Laparoscopic single site adrenalectomy using a conventional laparoscope and instrumentation

Background and Objectives:

We present a case of Laparoendoscopic Single Site Surgery (LESS) left adrenalectomy performed with a conventional laparoscope and instruments.

Methods:

A 45-year-old male was diagnosed with hyperaldosteronism. Computed tomography detected a left adrenal nodule. Bilateral adrenal vein sampling was consistent with a left-sided source for hyperaldosteronism.

Results:

Total operative time for LESS left adrenalectomy was 120 minutes. The surgery was performed with conventional instruments, a standard 5-mm laparoscope, and a SILS port, with no additional incisions or trocars needed. No complications occurred, and the patient reported an uneventful recovery.

Conclusions:

LESS adrenalectomy is a feasible procedure. Although articulating instruments and laparoscopes may offer advantages, LESS adrenalectomy can be done without these.     

Laparoscopic Transumbilical Cholecystectomy: Surgical Technique

Background:

Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports.

Methods:

The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval.

Results:

Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m². The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours.

Conclusion:

Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.     

Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments

Background and Objectives:

We present 2 cases of laparoendoscopic single site surgery (LESS) splenectomy performed with a conventional laparoscope and instruments, and the use of a novel internal retraction device.

Methods:

One patient underwent LESS splenectomy for idiopathic thrombocytopenia purpura (ITP), and a pediatric patient with sickle cell disease underwent LESS splenectomy and cholecystectomy. In each case, a 2-cm vertical incision was made within the confines of the umbilical ring, and a SILS port (Covidien, Norwalk CT) inserted. A 5-mm, 30-degree laparoscope and standard 5-mm instruments were used. After isolation of the splenic hilum, one 5-mm trocar of the SILS port was upsized to 12mm, and a laparoscopic stapler was used to divide the splenic artery and vein. An internal retractor consisting of a laparoscopic bulldog clamp with a hook attachment was used to retract the gallbladder, and to secure the specimen retrieval bag during splenic extraction, which eliminated the need for a fourth trocar.

Results:

Total operative time was 160 minutes for the LESS splenectomy, and 216 minutes for the LESS splenectomy and cholecystectomy. Both procedures were successfully completed with conventional instrumentation and a SILS port, without the need for additional incisions or trocars. No complications occurred, and both patients had an uneventful recovery.

Conclusions:

LESS splenectomy is a feasible procedure that can be performed safely. Although articulating instruments and laparoscopes may offer advantages, they are not necessary for performing LESS splenectomy.     

Laparoscopic Resection of Solitary Adrenal Metastasis from Lung Carcinoma: A Case Report

Background and Objectives:

Patients with adrenal metastases from bronchogenic carcinoma are considered incurable and any surgical treatment is usually excluded. A review of the few cases of adrenalectomy for metastases from lung cancer that have been reported in the literature shows that good results can be achieved in selected patients. We propose a laparoscopic approach to perform the adrenalectomy in these patients.

Methods:

A right laparoscopic adrenalectomy for metastasis from lung adenocarcinoma was performed. The right adrenal was resected using the anterior transperitoneal laparoscopic approach.

Results:

The tumor was resected in total. The operating time was two hours. One year after surgery the patient remains well.

Conclusions:

The current indications for laparoscopic adrenalectomy can include the removal of small metastatic adrenal lesions in selected cases.     

Development of a Measurement System for Laparoendoscopic Single-Site Surgery: Reliability and Repeatability of Digital Image Correlation for Measurement of Surface Deformations in SILS Port

Objective:

Analysis of mechanical measurements in laparoendoscopic single-site surgery (LESS) is important for instrument design and surgical simulators. The aim of this study was to develop a measuring system for different instruments and manipulations in LESS using a single-incision laparoscopic surgery (SILS) port.

Methods:

The loads on the SILS port were applied and recorded by the universal material testing machine by the following method. The handle of the forceps inserted in the SILS port was connected with the machine by a fishing wire and pulled at a constant rate. The surface deformations (displacements and strains) of the SILS port were recorded with digital image correlation (DIC) simultaneously. The correlation between deformation measurements and loads were analyzed. This experiment was repeated 8 times.

Results:

Strong correlations existed between deformation measurements calculated by DIC and objective criteria “loads” applied and recorded by the universal material testing machine (r > 0.98). The correlation coefficients were statistically significant (P < .001). A high repeatability of the results appeared in all repetitions of the experiment.

Conclusions:

A DIC measurement system has been developed for LESS, and comprehensive mechanical parameters of a SILS port can be obtained precisely by using this system. It is reliable and repeatable for evaluation of instruments and manipulations in LESS.     

Single-Incision Laparoscopic Combined Cholecystectomy and Appendectomy

Background and Objectives:

Single-incision laparoscopic surgery is becoming more widely used, but few combined procedures have been reported. Herein we share our experience with single-incision laparoscopic combined cholecystectomy and appendectomy.

Methods:

We reviewed data from 26 patients who underwent single-incision laparoscopic combined cholecystectomy and appendectomy between May 1, 2009 and June 1, 2013 at Shengjing Hospital. All the procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus.

Results:

All the operations were successfully completed without conversion to conventional laparoscopic or open surgery. No intraoperative complications occurred. Patients were satisfied with the therapeutic and cosmetic outcomes.

Conclusions:

Single-incision laparoscopic combined cholecystectomy and appendectomy appear to be a technically feasible alternative to the standard laparoscopic procedure in simultaneous management of coexisting benign gallbladder and appendix pathologies. Larger studies are required to confirm these findings.     

Laparoscopic Duodenojejunostomy for Treatment of Superior Mesenteric Artery Syndrome

Background and Objectives:

Superior mesenteric artery (SMA) syndrome is a rare disorder, recognized as weight loss, nausea, vomiting, and post-prandial pain due to compression and partial obstruction of the third portion of the duodenum by the SMA. If conservative treatment fails, then laparotomy with duodenojejunostomy or lysis of the ligament of Treitz is indicated. Recently, laparoscopic division of the retroperitoneal attachments of the duodenum has been described. We report the first case of laparoscopic duodenojejunostomy as the definitive treatment of vascular compression of the duodenum.

Methods:

A very thin woman with a diagnosis of SMA syndrome was prepared for surgery after having failed medical therapy. The patient was placed in a supine position, and four laparoscopic ports were required to perform a 5 cm duodenojejunostomy.

Results:

The patient did well postoperatively. A gastrograffin study revealed no leak with patency of the duodenojejunal anastomosis. She was subsequently discharged home on a regular diet on postoperative day four.

Conclusion:

Laparoscopic duodenojejunostomy is a viable option to treat vascular compression of the duodenum. It provides definitive treatment while preserving the benefits of minimally invasive surgical techniques in the debilitated patient.     

Laparoscopic Resection of Giant Adrenal Cavernous Hemangioma

Background:

Large adrenal tumors were initially believed to be a relative contraindication to laparoscopic adrenalectomy.

Methods:

Here we discuss the case of a 42-year-old female with a 12-cm adrenal mass.

Results:

The patient underwent successful laparoscopic resection, and pathology revealed a cavernous hemangioma, a rare benign tumor of the adrenal gland.

Conclusion:

The following is a discussion of the case, laparoscopic resection technique, and brief review of adrenal hemangiomas. In experienced hands, adrenal mass size should not be considered a contraindication to laparoscopic intervention.     

Adrenal Schwannoma Treated With Laparoscopic Surgery

Objective:

We report a case of left adrenal schwannoma in a 62-year-old man, incidentally discovered on an abdominal computed tomography. It was successfully treated with laparoscopic adrenalectomy.

Methods:

On admission, no remarkable findings were recognized in the patient''s blood and urine examination, including adrenal function. Laparoscopic left adrenalectomy was performed with the diagnosis of a nonfunctioning adrenal tumor.

Results:

Macroscopically, the tumor (45 mm × 30 mm, 60 g) arose from the medulla of the adrenal gland with a clear border distinguishing it from surrounding tissues. Histologically, the tumor consisted uniformly of spindle cells that were positive for S-100. The cortex was compressed but showed no atrophy. The diagnosis of adrenal schwannoma was made.

Conclusion:

Although an increasing number of adrenal incidentaloma have been identified with the recent advances in imaging techniques, only a few cases of schwannoma of the adrenal gland have been reported. We reviewed the cases reported previously in an attempt to reveal the characteristic features of this rare disease.     

Robotic-Assisted Fertility-Sparing Surgery for Early Ovarian Cancer

Objective:

To show the feasibility and safety of robotic-assisted laparoscopic fertility-sparing surgery for early-stage ovarian cancer in women of reproductive age.

Methods and Design:

The first patient was a 29-year-old para 0 woman with well-differentiated endometrioid adenocarcinoma of the ovary and complex endometrial hyperplasia with marked atypia. The second patient was a 31-year-old para 0 woman with an immature grade 1 teratoma. Both patients underwent robotic-assisted laparoscopic surgical staging.

Results:

In the first patient, there were no intra- or postoperative complications. Operative time was 5 hours 43 minutes and estimated blood loss was 100 mL. She was discharged home on postoperative day 1. She received 3 cycles of carboplatin and paclitaxel, as well as medroxyprogesterone acetate for the duration of chemotherapy. She conceived twice spontaneously since surgery and had two successful deliveries. She currently has no evidence of disease.In the second patient, there were no intra- or postoperative complications. Operative time was 2 hours 52 minutes and estimated blood loss was 200 mL. She was discharged home on postoperative day 1. She declined adjuvant chemotherapy with bleomycin, etoposide, and cisplatin. She conceived spontaneously 4 months later and had a normal vaginal delivery. She currently has no evidence of disease.

Conclusions:

Because fertility-sparing surgery is now accepted as a viable option in young women with early-stage ovarian cancer, less invasive techniques are being used. With the advent of robotic-assisted surgery and its advantages over conventional laparoscopy, we show that it is a safe and feasible approach in select patients. This is the first reported series on robotic fertility-sparing surgery, but more research is needed.     

The Effect of Product Safety Courses on the Adoption and Outcomes of LESS Surgery

Background and Objectives:

As technology in surgery evolves, the medical instrument industry is inevitability involved in promoting the use and appropriate (ie, effective and safe) application of its products. This study was undertaken to evaluate industry-supported product safety courses in laparoendoscopic single-site (LESS) surgery, by using the metrics of surgeons'' adoption of the technique, safety of the procedure, and surgeons'' perception of the surgery.

Methods:

LESS surgery courses that involved didactic lectures, operative videos, operation observation, collaborative learning, and simulation, were attended by 226 surgeons. With Florida Hospital Tampa Institutional Review Board approval, the surgeons were queried before and immediately after the course, to assess their attitudes toward LESS surgery. Then, well after the course, the surgeons were contacted, repeatedly if necessary, to complete questionnaires.

Results:

Before the course, 82% of the surgeons undertook more than 10 laparoscopic operations per month. Immediately after the course, 86% were confident that they were prepared to perform LESS surgery. Months after the course, 77% of the respondents had adopted LESS surgery, primarily cholecystectomy; 59% had added 1 or more trocars in 0–20% of their procedures; and 73% held the opinion that operating room observation was the most helpful learning experience. Complications with LESS surgery were noted 12% of the time. Advantages of the technique were better cosmesis (58%) and patient satisfaction (38%). Disadvantages included risk of complications (37%) and higher technical demand (25%). Seventy-eight percent viewed LESS surgery as an advancement in surgical technique.

Conclusion:

In multifaceted product safety courses, operating room observation is thought to provide the most helpful instruction for those wanting to undertake LESS surgery. The procedure has been safely adopted by surgeons who frequently perform laparoscopies. The tradeoff is in performing a more difficult technique to obtain better cosmesis for the patient. We must continue to conduct critical evaluations of product safety courses for the introduction of new technology in surgery.     

Percutaneous Ureteral Elevation in Laparoendoscopic Single-Site Radical Nephrectomy

Background and Objectives:

To describe our technique of suture-assisted ureteral retraction during Laparoendoscopic Single-Site (LESS) radical nephrectomy.

Materials and Methods:

A healthy, 39-year-old woman with an incidental 5-cm enhancing left renal mass elected to undergo radical nephrectomy. A 2-cm skin incision was made in the left upper quadrant of the abdomen, and a Covidien SILS port was introduced using standard Hasson techniques. Straight and angled laparoscopic instruments were used to mobilize the kidney outside of Gerota''s fascia. To place the renal vessels on stretch and facilitate hilar dissection, the ureter and lower pole attachments were encircled with a 0-Vicryl suture inserted percutaneously via a disposable fascial closure device. The kidney was bagged and removed intact.

Results:

The procedure was performed without complication with a total operative time of 265 minutes. EBL was minimal at 25mL. The patient was discharged home on postoperative day 1, and final pathology revealed stage pT1b chromophobe renal cell carcinoma with negative surgical margins.

Conclusion:

LESS radical nephrectomy is feasible in select patients. Suture-assisted retraction of the ureter and lower pole attachments using a fascial closure device facilitates safe dissection and control of the renal hilum.     

Laparoscopic adrenalectomy for unsuspected unilateral primary adrenal lymphoma

Background:

Rarely, a patient presents to a surgeon for evaluation of an adrenal incidentaloma where the final pathology is primary malignancy. For primary adrenal lymphoma, fewer than 100 cases have been reported in the literature.

Case Report:

We report a case of unilateral primary adrenal aggressive B cell lymphoma discovered incidentally in a 41-year-old female. Preoperative testing demonstrated the 6-cm mass to be biochemically silent. Subsequently, the patient underwent a laparoscopic adrenalectomy. Following pathologic diagnosis of B cell lymphoma, a metastatic workup was negative, and she underwent treatment with systemic chemotherapy. She is currently disease free 6 months postoperatively.

Conclusion:

Primary adrenal lymphoma should be considered in patients with unilateral adrenal incidentaloma. We believe that adherence to guidelines of resection of incidentalomas allowed for early surgical intervention and possible cure.     

Laparoscopic Adrenalectomy for Pheochromocytoma Versus Other Surgical Indications

Objective:

Laparoscopic adrenalectomy is widely recognized as the preferred technique for surgical removal of adrenal masses. This study aimed to evaluate the outcomes of consecutive laparoscopic adrenalectomies performed at a high-volume referral center and compare operative results for pheochromocytomas with that of other adrenal diseases.

Materials and Methods:

We retrospectively reviewed a single surgeon''s experience with laparoscopic adrenalectomy performed between July 2002 and June 2007. Patient records were analyzed in regards to demographics, pathology diagnoses, operative time, postoperative complications, tumor size, hospital stay, among others.

Results:

Seventy-two consecutive laparoscopic adrenalectomies were performed on 70 patients, including 2 bilateral adrenalectomies and one partial adrenalectomy. Surgical indications included pheochromocytoma (n=11), aldosteronoma (n=26), malignant adrenal disease (n=4), nonfunctioning adenomas (n=17), Cushing''s disease (n=6), and other adrenal disease (n=8). No mortality was observed. Perioperative complications occurred in 7 cases (9.7%). When a comparison between pathological diagnosis groups was made, no statistical differences were seen between pheochromocytomas and other adrenal neoplasms with respect to estimated blood loss, open conversion rate, length of stay, preoperative and postoperative hemoglobin values, blood transfusion rates, peri-operative complication occurrence, tumor size, and ASA class.

Conclusion:

Laparoscopic adrenalectomy is a safe and appropriate surgical technique for most adrenal lesions, including pheochromocytomas.     

Transperitoneal Laparoscopic Adrenalectomy in Children

Purpose:

The use of a minimally invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults. The aim of our study was to describe the safety and feasibility of minimally invasive adrenalectomy in children on the basis of surgical skills and results.

Materials and Methods:

This was a retrospective study of 4 pediatric laparoscopic adrenalectomies performed at our center between 2009 and 2012. All patients underwent transperitoneal lateral laparoscopic adrenalectomies (2 right and 2 left adrenalectomies).

Results:

Four laparoscopic adrenalectomies were performed. Indications for surgery were neuroblastoma in 2 patients, secernent adrenocortical tumor in 1 patient, and adrenocortical nodular hyperplasia in 1 patient. Patients had a mean age of 87 months (range, 17–156 months) at diagnosis, and the average lesion size was 3.23 cm (range, 0.7–6.4 cm). All laparoscopic adrenalectomies were successful, no conversions to open surgery were required, and no postoperative complications or deaths occurred. The average operating time was 105 minutes (range, 80–130 minutes), blood loss during surgery was minimal, and the mean postoperative hospital stay was 3.75 days (range, 3–5 days). None of the patients showed signs of recurring disease at 15-month follow-up.

Conclusions:

Laparoscopic adrenalectomy is a safe, feasible, and reproducible technique offering numerous advantages, including shortening of operating times and postoperative hospital stays, as well as reduction of blood loss and complications. It also provides good visibility and easy access to other organs.     

SINGLE-INCISION VIDEOLAPAROSCOPIC APPENDECTOMY WITH CONVENTIONAL VIDEOLAPAROSCOPY EQUIPMENT

Background

Acute appendicitis is the most common surgical emergency in daily practice, and is approached laparoscopically in many centers. Efforts have been undertaken for the development of minimally invasive techniques that reduce tissue trauma and offer improved cosmetic results, one of such being the single-incision laparoscopic surgery (SILS).

Aim

To present a minimally invasive technique for appendectomy (SILS) undertaken with conventional instruments.

Method

Eleven patients were treated in the emergency care center presenting abdominal pain in the right iliac fossa that was suggestive of appendicitis. Diagnostic investigation was subsequently conducted, including physical examination, laboratory and imaging exams (CT scan with intravenous contrast or total abdominal ultrasound), and the results were consistent with acute appendicitis. Thus, after consent, these patients underwent SILS appendectomy under general anesthesia with three trocars (two 10 mm and one 5 mm), using conventional and optical laparoscopic tweezers (10 mm, 30º). The base and pedicle of the appendix were ligated with titanium LT 400 clips. The procedure occurred uneventfully. Inclusion criteria were absence of diffuse peritonitis, BMI (body mass index) less than 35 and absence of serious comorbidities or sepsis.

Results

Seven men and four women were operated with average age of 25.7 years and underwent appendectomy through this technique. Mean procedure duration was of 37.2 min. Regarding surgical findings, three had appendicitis in stage 1, four in stage 2 and four in stage 3. All patients improved well, without surgical complications, and did not require conversion to open surgery or conventional laparoscopy technique.

Conclusion

Appendectomy conducted through Single Incision Laparoscopic Surgery is a feasible and promising technique that can be performed with conventional laparoscopic instruments.     

Ergonomic and geometric tricks of laparoendoscopic single-site surgery (LESS) by using conventional laparoscopic instruments

Background

The aim of this study was to explore the feasibility and safety of performing laparoendoscopic single-site surgery (LESS) with conventional laparoscopic instruments.

Methods

We retrospectively reviewed our data from 175 patients who underwent various urological LESS procedures via the same ergonomic and geometric principles between 2008 and 2011. LESS procedures performed included adrenalectomy (N?=?23), radical nephrectomy (N?=?5), radical nephroureterectomy with bladder cuff resection (N?=?5), varicocelectomy (N?=?12), nephropexy (N?=?4), lumbar sympathectomy (N?=?4), orchiectomy for intra-abdominal testis (N?=?1), pyeloureterostomy (N?=?1), dismembered pyeloplasty (N?=?1), and adult inguinal hernia mesh repair (N?=?119).

Results

All procedures were completed successfully without the use of ancillary ports or articulating instruments except two cases that required laparoscopic conversion. The mean patient age was 48.9?years. Mean operative time was 99.7?min, mean estimated blood loss was 17.3?ml, and mean hospital stay was 2.1?days. There were no intraoperative complications.

Conclusion

According to our ergonomic and geometric principles, use of conventional laparoscopic instruments is feasible and safe in LESS procedures.     

Increased complication rate in obese patients undergoing laparoscopic adrenalectomy

Objectives:

Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses, with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with healthy weight patients.

Methods:

A retrospective chart review was performed on patients undergoing laparoscopic adrenalectomy between January 2000 and February 2010. Intraoperative and postoperative complications in the patients were compared. A patient with a body mass index >30kg/m² was considered obese.

Results:

Eighty patients underwent laparoscopic adrenalectomy between January 2000 and February 2010. Forty-nine patients (61%) were considered obese based on the body mass index criteria. Operative time, estimated blood loss, and length of stay did not differ significantly between the 2 cohort groups. There was no 30-day mortality in the population. There were 9 complications in the obese population and no complications in the healthy weight population (P<.011). Four obese patients had intraoperative complications, and 5 obese patients had postoperative morbidity.

Conclusions:

A significant increase occurred in intraoperative and postoperative complications for obese individuals undergoing laparoscopic adrenalectomy compared with healthy weight individuals. However, high body mass index should not preclude elective laparoscopic adrenalectomy.