Laparoscopic management of persistent mullerian duct syndrome

Persistent mullerian duct syndrome (PMDS), characterized by the presence of mullerian structures in a virilized male, frequently presents as undescended testis, either intraabdominal or within a hernial sac. We describe a 10-month-old infant with PMDS successfully managed by the laparoscopic approach. At the age of 1.5 months, the patient presented with a left inguinal hernia and bilateral nonpalpable gonads in another center and underwent left inguinal exploration. The uterus and a gonadlike structure along with the hernia sac were found in the inguinal canal. Left inguinal herniotomy was performed after reduction of the uterus and gonadlike structure. No gonadal biopsy was obtained. The patient was further investigated in the same center. His karyotype was 46,XY. Magnetic resonance imaging of the abdomen and pelvis revealed a uterinelike structure posterior to the urinary bladder, but neither testis nor ovaries were visualized. At 10 months of age, he was referred to our department for further management. A laparoscopic single-stage orchiopexy was performed. Both testes were identified and brought to the scrotum by splitting the uterus in the midline and then bringing the testes with the vas and attached uterine tissue into the scrotum. The aim of placement of well-vascularized testes in the scrotum was achieved as confirmed on follow-up color Doppler ultrasound study 6 months postoperatively, which showed normal vascularity. Laparoscopic surgical techniques for this condition are also discussed.     

Minimally invasive ventral herniorrhaphy: an analysis of 6,266 published cases

BACKGROUND: Over 300,000 ventral abdominal wall hernias are repaired each year in the United States; many of these operations are done with a minimally invasive approach. Despite these numbers, there are few controlled data that evaluate the minimally invasive method of ventral hernia repair. METHODS: A review of over 6,000 published cases of minimally invasive ventral herniorrhaphy was performed in order to determine major outcome statistics for this procedure. RESULTS: The mean follow-up period was 20 months. The operative mortality was 0.1%. The mean recurrence rate (weighted) was 2.7%, and the major complication rate (mostly bowel injury and infection) was 3%. CONCLUSION: The results from published cases of minimally invasive ventral herniorrhaphy appear to be competitive with the historical results of open ventral herniorrhaphy. The major caveats of this review are that most of the data are (1) retrospective/uncontrolled and (2) obtained from specialized centers.     

Antral resection versus antral preservation during laparoscopic sleeve gastrectomy for severe obesity: Systematic review and meta-analysis

Although laparoscopic sleeve gastrectomy is an established operation for severe obesity, there is controversy regarding the extent to which the antrum is excised. The objective of this systematic review was to investigate the effect on perioperative complications and medium-term outcomes of antral resecting versus antral preserving sleeve gastrectomy. MEDLINE, EMBASE, and Cochrane databases were searched from 1946 to April 2017. Eligible studies compared antral resection (staple line commencing 2–3 cm from pylorus) with antral preservation (>5 cm from pylorus) in patients undergoing primary sleeve gastrectomy for obesity. Meta-analyses were performed with a random-effects model, and risk of bias within and across studies was assessed using validated scoring systems. Eight studies (619 participants) were included: 6 randomized controlled trials and 2 cohort studies. Overall follow-up was 94% for the specified outcomes of each study. Mean percentage excess weight loss was 62% at 12 months (7 studies; 574 patients) and 67% at 24 months (4 studies; 412 patients). Antral resection was associated with significant improvement in percentage excess weight loss at 24-month follow-up (mean 70% versus 61%; standardized mean difference .95; confidence interval .35–1.58, P<.005), an effect that remained significant when cohort studies were excluded. There was no difference in incidence of perioperative bleeding, leak, or de novo gastroesophageal reflux disease. According to the available evidence, antral resection is associated with better medium-term weight loss compared with antral preservation, without increased risk of surgical complications. Further randomized clinical trials are indicated to confirm this finding.     

Celecoxib premedication in post-operative analgesia for laparoscopic cholecystectomy

The analgesic effect of celecoxib on postoperative laparoscopic cholecystectomy pain was studied in a prospective, randomized, placebo-controlled, double-blind study. Sixty ASA 1 and 2 patients were randomized to receive celecoxib 200 mg or placebo orally before the operation under a standardised general anaesthetic for the elective surgery. All patients had intravenous morphine via a patient-controlled analgesia device (PCA). Postoperative abdominal and trochar site pain, shoulder pain and morphine consumption were assessed hourly until the 6th hour, and then at the 12th and 24th hour. There was no statistical significance in the pain scores and morphine consumption for the two treatment groups. We conclude that the opioid-sparing effect of celecoxib in acute pain management for laparoscopic cholecystectomy is clinically not useful and a combination of analgesia techniques may be more effective in treatment of multi-factorial post laparoscopic cholecystectomy pain.     

术前超声检查预测急性胆囊炎腹腔镜胆囊切除术的技术难度

目的评价术前超声检查预测急性胆囊炎腹腔镜手术技术难度.方法对73例因急性胆囊炎行腹腔镜胆囊切除术的患者行超声检查,超声检测参数:胆囊容积、胆囊壁厚度、胆囊壁增厚类型、结石大小、结石移动性、胆囊与胆囊床的粘连、肝与胆囊间的脂肪厚度、胆囊窝液体、总胆管扩张、总胆管结石、胆囊壁彩色和脉冲多普勒征像、邻近肝脏内的彩色和脉冲多普勒信号.腹腔镜胆囊切除手术分5步,每步根据难易程度记分:困难记1分,容易记0分,总分相加为总的难度分数.评价术前超声表现与总的难度分数、每一步难度分数、手术时间长短是否有显著关系.结果胆囊容积≥50 cm3、胆囊壁厚度≥3 mm、胆囊壁内丰富彩色血流信号与手术总难度分数显著相关;胆囊容积增大使粘连胆囊及Calot'三角分离困难;胆囊壁增厚及胆囊粘连者胆囊取出腹腔时较难;胆囊壁彩色血流丰富、邻近肝脏血流增加与手术时间延长有显著关系.结论术前测定胆囊容积、胆囊壁厚度、胆囊壁彩色血流丰富程度有助于预测急性胆囊炎腹腔镜胆囊切除手术中的技术难度.     

腹腔内局麻药和丁丙诺啡对腹腔镜术后镇痛效果观察

目的 :评价腹腔内给予局麻药物和丁丙诺啡对腹腔镜胆囊切除术后镇痛效果。方法 :腹腔镜胆囊手术结束 ,90例病人被随机分配到 3组 ,每组 30例病人 ,组 1在腹腔内注射 0 .2 5 %布比卡因 30ml,组 2在腹腔内注射 0 .2 5 %布比卡因 30ml+丁丙诺啡 0 .15mg ,组 3注射 0 .2 5 %布比卡因 30ml+丁丙诺啡 0 .3mg。分别在术后的 1、2、6、12h记录病人在安静和咳嗽状态下的模拟镇痛评分 ,记录术后镇痛时间和各种不良反应。结果 :术后 6和 12h ,在安静和咳嗽状态下 ,组 3对切口和腹腔内疼痛的镇痛效果均较其余两个组好 (P <0 .0 5 ) ,组 3的肩膀疼痛的发生率较其余两个组明显降低 (P <0 .0 5 ) ,术后镇痛时间 3组依次分别是 4 .6± 2 .3h ,15 .3± 5 .4h和 2 3.6± 5 .6h ,组 3较其他两组明显延长 (P <0 .0 5 ) ,组 2较组 1亦明显延长 (P <0 .0 5 )。术后恶心、呕吐的发生率在组 2和组 3之间没有差异 ,但较组 1明显增加 (P <0 .0 5 ) ,其余并发症无明显差异。结论 :在腹腔镜胆囊切除术后的病人 ,腹腔内给与局麻药和丁丙诺啡的术后镇痛效果较单纯使用腹腔内局麻药效果更加明显 ,同时可以明显减少术后肩膀疼痛的发生 ,但应注意恶心、呕吐的发生。     

腹腔镜下应用复合补片行食管裂孔疝修补手术的配合

腹腔镜下应用复合补片行食管裂孔疝修补及胃底折叠抗反流术是一种新型的手术方式,对手术配合要求较高。术前了解病情和充分的器械准备是开展此项手术的前提。术中及时的器械传递和与术者良好配合是手术成功的关键。总结此项手术经验,以促进新技术、新业务的提高和应用。     

The correlation between fundamental characteristics and first-time performance in laparoscopic tasks

Background

The ability of characteristics to predict first time performance in laparoscopic tasks is not well described. Videogame experience predicts positive performance in laparoscopic experiences but its mechanism and confounding-association with aptitude remains to be elucidated. This study sought to evaluate for innate predictors of laparoscopic performance in surgically naive individuals with minimal videogame exposure.

The inflammatory response to stress and angiogenesis in liver resection for colorectal liver metastases: a randomized controlled trial comparing open versus laparoscopic approach

Background: This study evaluates the surgical stress response following laparoscopic and open liver resection for colorectal liver metastasis (CRLM).

Methods: Patients with CRLM were prospectively randomized to receive open or laparoscopic liver resection (NCT03131778). Blood samples were drawn preoperatively and 24?h after resection. The serum interleukin-6 (IL-6) and IL-8 levels were measured. Furthermore, the mRNA levels of angiogenesis-related factors (vascular endothelial growth factor [VEGF] and HIF-1) and inflammation-related factors (COX-2 and MMP-9) in both tumor tissue and normal liver parenchyma were detected.

Results: Twenty patients for each arm were included. Size of metastasis, type of resection, and neoadjuvant therapy were comparable between groups. Postoperative stay was shorter in the laparoscopic group. Higher levels of IL-6 were observed after the operation in both open and laparoscopic groups, although no differences in the post-operative levels between the groups was noted. Similarly, there were no significant differences in the mRNA expression of VEGF, HIF-1, MMP-9, and COX-2 between the treatment groups. No differences were observed in terms of overall survival and disease free survival.

Conclusions: The immunological effects of treatment were similar between the groups. Thus, the laparoscopic approach does not seem to significantly influence the surgical stress and tumor related factors in patients suffering from colorectal liver metastases.