Transumbilical single incision laparoscopic sigmoidectomy for benign disease

Background  Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease.
Method  Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m²) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization.
Results  Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery.
Conclusion  Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.     

The evolution of postoperative ileus after laparoscopic cholecystectomy

Summary Our study is prompted by the arrival of laparoscopic cholecystectomy in connection with the evolution of postoperative ileus (PI) and by its avoidance of the intraabdominal handling implied in conventional cholecystectomy.With this aim a prospective, controlled, randomized, and blind clinical trial was designed using 100 patients divided into five groups (n=20): I, conventional cholecystectomy (CC); II, CC + injection of 20 ml bupivacaine 0.5% into the mesentery root; III, CC + 7.5 mg propanolol i.v. and 0.5 mg neostigmine s.c., postoperatively until the first defecation; IV, II + III; and V, laparoscopic cholecystectomy.The shortest period of PI was observed in group V. This period increases notably in group IV (53 h), group II (72 h), and group III (84 h) relative to the control group with (89 h). This reduction in PI time runs parallel with an improvement in the patient's general state of well-being.We concluded that after laparoscopic cholecystectomy PI is nonexistent. Furthermore, this study confirms the correlation between the avoidance of intraabdominal manipulation and the evolution of postoperative ileus.     

腹腔镜超声检查和超声刀在胃肠外科诊治中的应用

目的:探讨腹腔镜超声检查技术（LUS）和腹腔镜超声刀在腹腔镜胃肠外科手术中的应用价值。方法:对50例胃肠道肿瘤等病变采用腹腔镜超声进行前瞻性肿瘤分期诊断,结合腹腔镜超声刀开展腹腔镜胃肠手术治疗。结果:经腹腔镜和腹腔镜超声分期诊断,47例肿瘤患者均明确诊断,淋巴结穿刺活检与病理结果符合率为87.5％（7/8）;其中2例转开腹手术,6例避免了剖腹探查术,39例肿瘤患者成功地完成了腹腔镜手术。本组50例患者中42例在腹腔镜下成功完成姑息性或根治性胃肠切除术。平均手术时间190min,术中出血量平均120ml（20～250ml）,系膜淋巴结清除数平均6.5个（5～12个）,术后肠蠕动恢复时间平均36h,平均住院8.5d,无手术后并发症。术后随访3～36个月,未发现复发与转移及腹壁穿刺孔或切口转移。结论:腹腔镜胃肠手术中常规使用腹腔镜超声检查可准确为病变定位,完善肿瘤分期诊断,提高肿瘤可切除性的判断率,避免了不必要的剖腹探查;术中常规使用超声刀提高了手术安全性,扩大了腹腔镜手术范围。腹腔镜胃肠道病变切除术安全可行,近期效果良好,远期效果有待观察。腹腔镜胃肠手术将成为胃肠良恶性疾病的常规手术。     

Laparoscopic colostomy, indications and technical notes

The aim of this article was to review the main indications of laparoscopic colostomy. A series of 9 patients is reported, stressing the technical steps of laparoscopic colostomy. The laparoscopic approach in patients with unresectable colorectal cancer permit to avoidance mayor laparotomy. In conclusion this technique appears safe, feasible and effective.     

Back to basics--cutting the cord on umbilical infections

INTRODUCTION

Surgical site infections (SSIs) are a significant cause of postoperative morbidity with laparoscopic surgery associated with lower SSI rates. However, a departmental change in our unit to increased laparoscopic colorectal surgery resulted in increased wound infection rates at umbilical specimen extraction sites, the cause of which we attempted to elucidate.

SUBJECTS AND METHODS

Prospectively collected data over an 18-month period (April 2008 to September 2009) for laparoscopic colorectal operations in a busy teaching hospital were retrospectively analysed, focusing on operation performed, whether pre-operative skin cleansing was employed, nature of specimen extraction excision, and rate of umbilical wound infection. Comparison was made with open colorectal procedures performed in the preceding year.

RESULTS

In total, 275 laparoscopic colorectal operations were performed. Over the first 8 months there was a significant increase in infection rates when compared with open procedures over a similar time period (23.5% vs 8.0%; P = 0.0001). Changing practice to use pre-operative skin cleansing and an incision that skirted around, as opposed to traversing, the umbilicus reduced umbilical infection rates significantly from 23.5% to 11.6% (P = 0.01). Patients undergoing right hemicolectomy benefitted more (reduction of 30.0% to 6.9%; P = 0.04) than those undergoing anterior resection (26.8% vs 15.6%, P = 0.13).

CONCLUSIONS

Umbilical incisions, when extended for specimen extraction, are particularly prone to infection following colorectal surgery but rates can be reduced by simple measures such as pre-operative umbilical cleansing and avoidance of the umbilicus in the incision, without the need for drastic and costly changes in technique or antibiotic prophylaxis.     

Rare bile duct anomalies

Anomalies of the biliary ductal system are not uncommon, and are of variable clinical significance. A case is reported of an extremely unusual variation, with the cystic duct entering the left hepatic duct. Preoperative delineation of the anomaly in this patient by endoscopic retrograde cholangiography assisted in the subsequent performance of a safe laparoscopic cholecystectomy. Awareness of potential biliary variations is one factor in avoidance of ductal injuries during laparoscopic surgery.     

Laparoscopic retroperitoneal adrenalectomy

Laparoscopic adrenalectomy has largely replaced open adrenalectomy for resection of adrenal tumors, which are not adrenocortical cancer or malignant pheochromocytoma. Laparoscopic retroperitoneal adrenalectomy is a particularly useful technique in patients with tumors <7 cm and body mass index <45 kg/m2. When compared with laparoscopic transabdominal adrenalectomy, the laparoscopic retroperitoneal technique leads to reduced operating times, avoidance of intra-abdominal adhesions and irradiated fields, potentially less postoperative pain, and improved intraoperative hemostasis and visualization. The technique involves placement of 3 ports, dissecting the retroperitoneal space, identifying and ligating the adrenal vein, and removing the attachments to the adrenal gland. See the video, Supplemental Digital Content 1, http://links.lww.com/SLE/A38.     

An Evaluation of the Effect of Anesthetic Technique on Reproductive Success after Laparoscopic Pronuclear Stage Transfer: Propofol/Nitrous Oxide Versus Isoflurane/Nitrous Oxide

Background: Laparoscopic pronuclear stage transfer (PROST) is the preferred method of embryo transfer after in vitro fertilization in many infertility programs. There are scant data to recommend the use or avoidance of any particular anesthetic agent for use in women undergoing this procedure. The authors hypothesized that propofol would be an ideal anesthetic for laparoscopic PROST because of its characteristic favorable recovery profile that includes minimal sedation and a low incidence of postoperative nausea and vomiting. The purpose of the study was to compare propofol and isoflurane with respect to postanesthetic recovery and pregnancy outcomes after laparoscopic PROST.

Methods: One hundred twelve women scheduled for laparoscopic PROST were randomized to receive either propofol/nitrous oxide or isoflurane/nitrous oxide for maintenance of anesthesia.

Results: Visual analog scale scores for sedation were lower in the propofol group than in the isoflurane group at all measurements between 30 min and 3 h after surgery. More women experienced emesis and were given an antiemetic during recovery in the isoflurane group than in the propofol group. However, the percentage of pregnancies with evidence of fetal cardiac activity was 54% in the isoflurane group compared with only 30% in the propofol group (P = 0.023). Also, the ongoing pregnancy rate was greater in the isoflurane group than in the propofol group (54% vs. 29%, P = 0.014).     

Drain-Associated Intestinal Obstruction after Laparoscopic Gastric Bypass

A rare cause of intestinal obstruction after laparoscopic Roux-en-Y gastric bypass (RYGBP) is reported. A 42-year-old woman developed nausea, vomiting and dilated loops of small bowel upon commencing oral intake the day after RYGBP surgery. A CT scan demonstrated a loop of bowel twisting around the abdominal drainage catheter. After removal of the catheter, the patient’s symptoms immediately resolved and her subsequent course was uneventful. We suggest avoidance of drainage catheters after uncomplicated laparoscopic RYGBP.     

LRC术中膀胱侧、后韧带及前列腺侧血管蒂处理方法改进

目的 探讨腹腔镜根治性膀胱癌切除手术中膀胱侧韧带、后韧带及前列腺侧血管蒂的处理方法。方法 根治术前先结扎髂内动脉分支以减少膀胱及前列腺动脉血供及静脉回流,对膀胱侧、后韧带及前列腺侧血管蒂的内、外侧缘充分游离后再进行切断处理。结果 按设计的方法在56例手术中完成了对膀胱侧、后韧带及前列腺侧血管蒂的处理,根治手术时间平均170min,出血量平均160ml。其中每侧手术时间平均为4min,出血量10~20ml,无直肠损伤发生。结论 采用本手术改进方法处理膀胱侧、后韧带及前列腺侧血管蒂,能有效缩短手术时间、减少出血及避免直肠损伤。     

John Syng Dorsey --Writer of the First American Systematic Surgical Textbook

With the progress in laparoscopic techniques in recent years, there is an increased interest in laparoscopic hernia repair. The laparoscopic indirect inguinal hernia repair with simple closure of the internal ring seems feasible in childhood inguinal hernia repair; however, this technique carries the risk of postoperative patent processus vaginalis. In this study we investigated the possibility of avoidance of this complication by chemical obliteration of processus vaginalis with 6010 iodine solution in rats. The study population was comprised of three groups: simple suture of the internal ring, iodine application plus simple suture of the internal ring, and iodine application alone. While processus vaginalis was anatomically closed in 75% of the rats in the iodine plus simple suture of the internal ring group, it was closed in 10% of the iodine application alone group and was not closed in the simple suture of the internal ring alone group. No histopathologic injuries to the testis or cord were detected attributable to iodine. Our study showed that simple suture of the internal ring is not sufficient for hernia repair. Laparoscopic chemical agent application in addition to simple suture of the internal ring may be beneficial for successful laparoscopic indirect inguinal hernia repair in children.     

Learning curve on the TrEndo laparoscopic simulator compared to an expert level

Background

The aim of this study was to determine growth in trainee laparoscopic skill as recorded by the TrEndo laparoscopic simulator during a laparoscopic training course, compared to an expert level.

Methods

A prospective observational cohort study was conducted between February 1 and November 31, 2010. Trainees in laparoscopic surgery completed a basic laparoscopic suturing task on a laparoscopic box trainer at three successive assessment points during a laparoscopic training course. Experts were assessed only once to define an expert level. The TrEndo recorded four motion analysis parameters (MAPs) individually for each hand and the amount of time taken to complete the suturing task.

Results

Seventy-two residents and 56 experts were included in this study. Overall, the amount of time taken on the suturing task and seven out of eight MAPs significantly increased toward an expert level during the course, representing an improvement in task efficiency. During the first training day, the amount of time spent on the suturing task and five out of eight MAPs improved significantly. After the retention period, five out of eight MAPS demonstrated a significant improvement compared to the end of the first training day.

Conclusions

Laparoscopic skill of trainees as recorded by the TrEndo laparoscopic simulator grows toward an expert level during a laparoscopic training course in a large and heterogeneous study group. Construct validity of the TrEndo is established.     

Laparoscopic identification and removal of focal lesions in persistent hyperinsulinemic hypoglycemia of infancy

Background: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is a heterogeneous condition. A number of children have focal lesions, and removal of these lesions is curative. However, these lesions are difficult to detect, even during surgery. A laparoscopic approach is beneficial. Methods: Two children with PHHI underwent laparoscopic pancreatic inspection at 32 and 29 days of age, respectively. Results: In both children, a lesion was easily found in the head of the pancreas. The lesions looked more lobular, had a more pronounced blood supply, and appeared to have a firmer texture than the remaining pancreas. Enucleation was curative. Conclusion: A laparoscopic approach seems to be ideal for patients with PHHI not only because of the magnification but also because of the delicate surgery it allows and the avoidance of major abdominal wall problems.     

Assessing the impact of a 2-day laparoscopic intestinal workshop

Background

Surgical educators have responded to the demand for increased skills in minimally invasive surgery by offering short technique-focused workshops at academic centres. The purpose of this study was to determine the impact of a comprehensive laparoscopic intestinal workshop for the adoption of laparoscopic colonic surgery.

Methods

A 2-day comprehensive laparoscopic intestinal surgery workshop included didactic teaching and supervised hands-on practice of numerous laparoscopic colon resections on a cadaveric model. Participants completed pre-, post- and 6-month postcourse questionnaires.

Results

The participants (n = 39) had been in practice for a mean of 10 (interquartile range 3–18) years. Fifty-one percent (n = 20) were already performing laparoscopic colectomies as part of their practices prior to the course. Regardless of whether they were performing laparoscopic colectomies prior to the course or not, attending the 2-day workshop improved their self-assessed preparedness to perform laparoscopic colectomies. Six months after the intestinal workshop, 10 of 16 respondents who were not performing laparoscopic colectomies prior to the course had performed at least 1 since the course. Seven of these individuals had a preceptor for their first case. Reasons cited for not performing a laparoscopic colectomy since the workshop included perceived inadequate surgical skill set, a lack of preceptor and the lack of an appropriate patient.

Conclusion

A comprehensive laparoscopic intestinal workshop contributed to the perceived acquisition of advanced laparoscopic surgical skills. Local laparoscopic preceptorship was an important adjunct to the workshop for the incorporation of laparoscopic colorectal surgery into practice.     

Single-Incision Versus Hand-Assisted Laparoscopic Colectomy: A Case-Matched Series

Background  

Single-incision laparoscopic colorectal surgery is an emerging modality. We incorporated this technique as an alternative to hand-assisted laparoscopic surgery. We investigated intraoperative and short-term outcomes following single-incision laparoscopic colectomy compared with hand-assisted laparoscopic colectomy.     

Laparoscopic splenectomy

Background: Elective splenectomy is often performed for hematological diseases, some of which cause only moderate enlargement of the spleen. The avoidance of an extensive upper abdominal incision is desirable in such cases and laparoscopic splenectomy offers significant potential advantages over the open operation if it can be performed safely and economically. Methods: Eight consecutive patients underwent laparoscopic splenectomy. The operation was carried out with the patient at 40° in the right lateral position so that rotating the operating table would make a full right lateral position possible. After fenestration of the gastrocolic omentum and division of the short gastric vessels, this position allowed the spleen to be pushed up under the diaphragm to facilitate access to the splenic vessels and the hilum. Vessels were divided individually between clips. Results: All eight cases were completed laparoscopically. Mean length of operation was 259 min (range 230–285). Postoperative stay ranged from 2 to 7 days (median 4 days). There was no mortality, although minor complications did occur in three patients. Conclusions: We found laparoscopic splenectomy to be a safe and feasible procedure for the elective removal of the moderately enlarged spleen.     

Laparoscopic versus open repair of inguinal hernia: a longitudinal cohort study

Background

Traditionally, repair of an inguinal hernia has been by an open method, but laparoscopic techniques have recently been introduced and are increasing in popularity. This study aimed to compare early and late outcomes following laparoscopic and open repair of inguinal hernia.

Methods

We performed an analysis of inpatient Hospital Episode Statistics. Early-outcome criteria studied include in-hospital mortality, length of hospital stay, complications (infection, bleeding, injury to an organ, and urinary retention), and readmission. Late outcome was assessed by the need for a further inguinal hernia repair on the same side.

Results

Between April 2002 and April 2004 there were 125,342 patients who underwent inguinal hernia repair and were included in the analysis. They were followed until April 2009. There were no differences in postoperative stay between the laparoscopic and open groups except for the laparoscopic bilateral hernia repair patients who had a shorter stay than the open group. Infection and bleeding were more common following open repair, whilst urinary retention and injury to an organ were more frequent after laparoscopic repair. Reoperation for another inguinal hernia was more common after laparoscopic (4.0 %) than after open repair of primary inguinal hernia (2.1 %), mostly in the first year after surgery. There was no difference in reoperation rate following repair of a recurrent inguinal hernia. Consultant caseload was strongly inversely correlated with reoperation following laparoscopic but not open repair of primary inguinal hernia.

Conclusions

Reoperation is more common after laparoscopic than after open repair of primary but not recurrent inguinal hernia. Surgeons with a low laparoscopic hernia repair caseload have an increased reoperation rate following laparoscopic repair of primary inguinal hernia. The increase in reoperation rate following laparoscopic repair is seen in the first year or two following the initial surgery.     

Extraperitoneal laparoscopic trigonoplasty for treatment of vesicoureteral reflux: novel technique duplicating its open counterpart

PURPOSE: We describe a novel technique of extraperitoneal laparoscopic trigonoplasty for the treatment of vesicoureteral reflux. MATERIALS AND METHODS: Three boys and 24 girls with 41 refluxing units underwent extraperitoneal laparoscopic trigonoplasty. A 10 mm incision was made below the umbilicus. With sharp, blunt finger dissection and balloon dilation an extraperitoneal space was created. The bladder was opened using a laparoscopic scissors. Two 3Fr ureteral catheters were inserted intracorporeally into the ureters. A transverse superficial incision was made in the epithelium between the ureteral orifices. The medial aspect of the ureters was cleared of the muscles and attachments, and sutured in the midline with 4-zero polyglactin sutures. RESULTS: Operative time ranged from 60 to 240 minutes (mean 147). Blood loss was less than 50 ml. Adequate extraperitoneal space, bladder opening, epithelial incision, ureteral approximation with secure suturing in the midline and bladder closure were carried out in all cases. Peritoneal perforation was noted in 4 patients while creating the extraperitoneal space, with suturing needed for 1 large perforation. Hospital stay was 1 to 6 days (mean 2.7). At 4 to 19 months of followup (mean 8.2) reflux had resolved in 38 units (93%). CONCLUSIONS: Extraperitoneal laparoscopic trigonoplasty is technically feasible. Results are comparable to open techniques. The major advantage of this procedure is the avoidance of peritoneum. Other advantages include a shorter hospital stay and good cosmesis. More followup is necessary to establish the long-term results.     

Strategies in the management of renal tumors amenable to partial nephrectomy

Purpose  The laparoscopic approach to radical and partial nephrectomy is becoming the standard of care for treating patients with renal tumors. Hand-assisted laparoscopic partial nephrectomy (HALPN) provides some advantages over the pure laparoscopic approach which include manual manipulation of the kidney, tactile feedback, and timely specimen removal. Materials and methods  We describe our technique for HALPN and emphasize the implementation of an in-room pathologist to examine gross margins during the period of renal arterial occlusion. Between 2004 and 2007, 46 patients underwent HALPN performed by the same surgeons. Mean patient age was 59.5 years and mean tumor size was 2.55 cm. Twelve of these patients underwent significant concomitant procedures. Results  Our mean operating time was 173.26 min (range 90–306 min) and our mean warm ischemic time was 28.32 min (range 14–54 min). Average estimated blood loss was 116.82 ml (range 10–1000 ml) with no transfusions. Thirty-six (78%) tumors were renal cell carcinoma, seven (15%) were oncocytomas, and three (7%) were angiomyolipomas. The average length of stay was 5.17 days (range 3–9 days) and there were no positive margins. There was one postoperative bleed (2%) and two postoperative urine leaks (4.3%). Discussion  In our institution, the hand-assist approach to laparoscopic partial nephrectomy has resulted in favorable perioperative outcomes. The use of an in-room pathologist to provide real-time assessment of gross tumor margins has allowed us to achieve a 0% positive final margin rate. We believe that the use of an in-room pathologist during the timely extraction of the specimen made possible by the hand-assisted approach provides a great advantage over pure laparoscopic partial nephrectomy. This low positive margin rate is also the result of maintaining a bloodless field of resection with temporary renal arterial occlusion as well as the avoidance of visual tissue distortion with cold, sharp scissor dissection. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

843例腹腔镜胆囊切除术手术体会

目的　总结分析腹腔镜胆囊切除术 (laparoscopiccholecystectomy ,LC)中Calot三角的解剖并探讨如何预防LC中胆管损伤。方法　回顾性分析 2 0 0 1年 3月～ 2 0 0 1年 8月完成的LC手术 84 3例。结果　完成LC手术 82 6例 ,手术成功率 97.98% ,中转开腹 17例 ,中转率 2 .0 2 % ,迟发性胆囊管残端胆漏 1例 ,无胆管损伤、术后腹腔内出血等其它并发症。结论　良好的胆道外科意识、科学的解剖方法和精细的手术操作是避免LC术中胆管损伤的关键。