-
Combined Intraperitoneal Monitoring and Total Extraperitoneal Repair of McBurney’s Incisional Hernia
Background: McBurney’s incisional hernia after appendectomy is rare. Although the open surgical approach, either through direct suturing or through mesh repairs, mostly achieves a satisfactory outcome, postoperative wound pain usually impedes patient’s early ambulation. Accordingly, laparoscopic ventral hernia repair has emerged as a minimally invasive technique in modern surgical practice. We described a different approach of laparoscopic incisional hernia repair.
Case Report: A 76-year-old woman with a history of appendectomy presenting with a bulging mass over the right lower quadrant of the abdomen beneath the operation scar was admitted to our hospital. Computed tomography revealed defects in the abdominal muscle layers without evidence of bowel incarceration. The patient was diagnosed with postappendectomy incisional hernia for which laparoscopic hernia repair was performed through a combined intraperitoneal and extraperitoneal approach. The patient’s postoperative course was excellent.
Conclusions: Combined extraperitoneal approach and intraperitoneal monitoring for McBurney’s incisional hernia is feasible in selected cases.
-
Incidental Fetoscopy During Laparoscopy in Pregnancy: Management of Perforation of the Gravid Uterus
Introduction: Laparoscopy during pregnancy is safe and effective, but poses unique challenges because of alterations in the intra-abdominal anatomy induced by the gravid uterus.
Case: A 33-year-old female with an intrauterine pregnancy at 19 weeks’ gestation presented with symptoms of appendicitis. Diagnostic laparoscopy resulted in incidental uterine perforation and insufflation. Transition to midline laparotomy was made to suture uterine puncture sites from the trocar and Veress needle. Preterm premature rupture of membranes and abruption were diagnosed at 32 weeks’ gestation, and the patient was delivered. The child was alive and well at 12 months of age.
Conclusions: Lessons from the emerging field of minimally invasive fetal surgery regarding the management of surgical entry into the gravid uterus can be applied to the rare case of incidental uterine perforation at the time of laparoscopy during pregnancy.
-
Single-incision Laparoscopic Right Colectomy: An Efficient Technique
Purpose: Laparoscopic right colectomy has an established patient benefit. We sought to demonstrate that a single-incision approach to laparoscopic right colectomy is safe, reproducible, and efficient.
Methods: Photographs were acquired from cases to depict a step-by-step approach. We collected operative, pathologic, and postoperative outcomes from 8 patients who underwent a single-incision laparoscopic right colectomy.
Results: There were no intraoperative complications nor deaths and 3 complications postoperatively. The average return of bowel function and length of stay was 3 and 5 days, respectively. Pathologic assessment revealed negative margins and an average of 17 lymph nodes harvested from the specimens.
Conclusions: Single-incision laparoscopic right colectomy is an evolving technique and likely to supplant conventional laparoscopic colectomy because of its equivalent and reproducible outcomes and the ease of the procedure. We depict our preferred method and review the current literature of single-incision right colectomy.
-
Laparoscopic Sleeve Gastrectomy for a Large Gastrointestinal Stromal Tumor
The biological behavior of gastrointestinal stromal tumor (GIST) makes resection of the tumor with adequate margins, a mode of curative treatment. GIST does not have lymphatic permeation. Hence, the goal of therapy is complete resection of visible and microscopic disease, which can be achieved by adequate tumor-free margins. Laparoscopic management of large GIST tumors is discouraged because of the fear of spillage of the tumor or rupture of the tumor capsule while handling a large tumor and thus causing metastasis.
-
Linear-stapled Versus Circular-stapled Laparoscopic Gastrojejunal Anastomosis in Morbid Obesity: Meta-analysis
Background: The study aims to provide a pooled analysis of individual small trials comparing linear-stapled versus circular-stapled laparoscopic gastrojejunal (GJ) anastomosis in morbid obesity surgery.
Methods: A systematic literature search of Medline, Embase, and Cochrane library databases was performed. Primary outcomes were GJ leak and stricture. Secondary outcomes were operative time, length of hospital stay, postoperative bleeding, wound infection, marginal ulcers, and estimated weight loss. Pooled odds ratios were calculated for categorical outcomes and weighted mean differences for continuous outcomes.
Results: Nine trials were included comprising 9374 patients (2946 linear vs. 6428 circular). Primary outcome analysis revealed a statistically significant increase in the rate of GJ stricture associated with circular-stapled anastomosis. A significantly reduced rate of wound infection, bleeding, and operative time associated with linear stapling was also found. No significant differences appeared for the other outcomes.
Conclusions: This pooled analysis recommends the preferential use of the linear stapling technique over circular stapling.
-
Major Bile Duct Injuries During Cholecystectomy in Children: Conservative Laparoscopic Approach is Possible
Major bile duct injury is an inherent complication in cases of both open and laparoscopic cholecystectomies. In case of choledochal lesion, conservative treatment or internal derivation by a Roux-en-Y can be proposed. We report the case of a 5-year-old boy referred to our center for an iatrogenic choledochal ligation after open cholecystectomy (performed 20 d before) for asymptomatic gallbladder stone. We performed a laparoscopic conservative treatment with a consistent good result 5 years after the procedure.
-
Postpolypectomy Bleeding: Incidence, Risk Factors, Prevention, and Management
Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.
-
Minimally Invasive Myotomy for the Treatment of Esophageal Achalasia: Evolution of the Surgical Procedure and the Therapeutic Algorithm
Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.
-
Single-incision Laparoscopic Cholecystectomy: Comparison Analysis of Feasibility and Safety
To maintain operative safety, patient selection criteria for single-incision laparoscopic cholecystectomy (SILC) are more stringent than that for traditional laparoscopic cholecystectomy (TLC). No other method could demonstrate the same feasibility and safety as TLC because the patient selection criteria were too restrictive for SILC to compare with TLC. In this study, we conducted a comparative study between our original SILC and TLC for demonstrating similar feasibility and safety among patients who had the same selection criteria as that for TLC. A statistical comparison between 114 patients of SILC and 201 patients of TLC was conducted during the same time period. The preoperative patient characteristics for SILC and TLC showed no statistical difference. In the operative result analysis, a significant disadvantage of SILC was the prolongation of operative time by only 15 minutes. The original SILC was as feasible and safe as TLC and virtually scarless cholecystectomy could be performed without any selection criteria. This was performed using only 2 trocars from an umbilical incision and 2 incisionless extracorporeal retraction devices.
-
Laparoscopic Transcutaneous Closure of Central Defects in Laparoscopic Incisional Hernia Repair
Purpose: The aim of this technical report is to investigate the safety, efficacy, and outcome of transcutaneous closure of central defects (TCCD) for laparoscopic incisional hernia repair (LIHR).
Methods: Twenty-two patients with incisional hernias underwent a LIHR-TCCD repair. After clearance of the abdominal wall from adhesions, laparoscopic central closures were performed transcutaneously with 0-polypropelene sutures placed every 1 cm of the defect starting at the cranial-most edge of the hernia and ending at the caudal-most edge of the hernia. A standard LIHR was performed with coated polyester mesh placed with at least 6 cm of overlap with mesh on all borders. Transfascial sutures with 0-polypropelene sutures were placed every 4 cm circumferentially, and titanium tacks were used to secure the mesh to the peritoneum every 1 cm.
Results: The mean age was 52 years and the mean body mass index was 35 kg/m2. The mean hernia defect was 4.7 cm×7.2 cm with a mean area of 37 cm2. There were no mortalities and no major perioperative morbidities. Minor complications included 2 (9%) cases of pneumonia/pneumonitis. There were no clinically significant seromas, no radiographic or clinical eventrations, and no hernia recurrences with a mean follow-up of 21 months.
Conclusions: LIHR-TCCD is safe and technically feasible in incisional hernias of width <10 cm. By closing the central defect, seromas and eventrations can be reduced.
-
Single-incision Laparoscopic Cholecystectomy Learning Curve Experience Seen in a Single Institution
Introduction: Single-incision laparoscopic surgery (SILS) is laparoscopic surgery done by one incision through the umbilicus. Cholecystectomy lends itself well to a SILS approach. As these procedures have become more widely adapted, it is important to determine the approximate learning curve to decrease two surgical endpoints: (1) time to completion of the procedure; and (2) decreased incidence of conversion.
Methods: We prospectively reviewed our series of 50 cholecystectomies done using the SILS approach between May 2008 to September 2008. All cases were performed by two advanced laparoscopic surgeons at a single institution. Data was collected immediately after the case and entered into an Excel database. Cases were performed by insufflating the abdomen with a Veress needle through the umbilicus followed by placement of 5-mm ports at the umbilicus.
Results: Patient ages ranged between 21 and 82 years with a median age of 45 years. Body mass index (BMI) range was 21 to 42 kg/m2 with a mean of 30 kg/m2. Average length of time for cases was 1 hour 9 minutes with a range between 55 minutes and 120 minutes. The average length of time for the first 25 cases was 80 minutes. When compared with cases 26 to 50 the average length of time was 60 minutes (P<0.05). The conversion rate to conventional laparoscopic cholecystectomy was 10%. Conversion was accomplished through the addition of a 5-mm port elsewhere on the abdominal cavity. After the tenth case, the incidence of conversion went down to zero. When conversions were further stratified, they occurred within each individual surgeon’s first ten cases.
Conclusions: The learning curve for successful consistent completion of SILS cholecystectomy cases appears to be after 25 cases. In addition, conversion rates drop dramatically after the first ten cases.
-
Single-port Laparoscopic Appendectomy During Pregnancy
As a result of the increased demand for minimally invasive surgery, single-port laparoscopic surgery performed via a single incision was introduced and has been performed in various fields. Herein, we report our initial experience with single-port laparoscopic appendectomy (SP-LA) using Gelport access for the treatment of acute appendicitis in 2 pregnant women. SP-LA using Gelport access was performed successfully in these pregnant women without prolongation of operation time, and there was no need for ancillary trocar insertions or conversion to conventional laparoscopy. One woman spontaneously delivered at 39 weeks’ gestation approximately 20 weeks after the surgery and the other has maintained a healthy pregnancy. SP-LA can be considered a minimally invasive alternative to conventional laparoscopic appendectomy in pregnant women (Supplemental Digital Content 1, http://links.lww.com/SLE/A55 ).
-
Benefits of a Straight Laparoscopic Restorative Proctocolectomy With Ileal Pouch Anal Anastomosis for Ulcerative Colitis: A Retrospective Case-matched Study
Purposes: The aim of this study was to evaluate the benefit of straight laparoscopic restorative proctocolectomy (sLRP) with ileal pouch anal anastomosis for ulcerative colitis (UC).
Methods: Twenty patients underwent sLRP or open restorative proctocolectomy. The 2 groups were retrospectively well matched with respect to sex, body mass index, and American Society of Anesthesiologists’ score.
Results: The median operative time was longer in the sLRP group (P=0.0003). The median operative blood loss was significantly less in the sLRP group (P=0.0054). The median analgesic drug usage during the first 7 days after surgery was lower in the sLRP group (P=0.038). There were no differences in morbidity rates and long-term functional outcome measures between the groups.
Conclusions: An sLRP for UC has the advantage over an open restorative proctocolectomy of better short-term outcomes, and both groups have similar long-term outcomes. This procedure is acceptable for minimally invasive surgery in patients with UC.
-
Laparoscopic TME for Rectal Cancer: A Case Series
Purpose: Laparoscopic colonic resection for cancer is becoming well established within the surgical community. However, the current evidence for laparoscopic total mesorectal excision (TME) is scanty but does point toward a potential for improved short-term outcomes and oncological equivalency to open resection.
Methods: Patients undergoing laparoscopic TME for rectal cancer in 1 hospital between October 2003 and December 2010 were analyzed. Data were collated from a prospective database. Survival analysis was calculated using the Kaplan-Meier method.
Results: 79 patients were analyzed (96.3% of all TMEs). There was a median length of stay of 5 days, with no postoperative mortality. The 5-year overall survival was 70% and the 5-year disease-free survival was 65.5%. There was a conversion rate of 10.1%. The 5-year overall survival for completed laparoscopic cases was 70.6% versus 62.5% for converted cases (P=0.041).
Conclusions: There seems to be increasing evidence that laparoscopic TME is equivalent to open TME for rectal cancer. Conversion may be deleterious to overall survival.
-
The Applicability of Laparoscopic Gastrectomy in the Surgical Treatment of Giant Duodenal Ulcer Perforation
Purpose: The present study aims to provide an applicability of laparoscopic gastrectomy used in the treatment of giant duodenal ulcer perforation.
Methods: Between July 2010 and April 2011, laparoscopic distal gastrectomy with ROUX-EN-Y gastrojejunostomy and truncal vagotomy was performed in consecutive 5 patients with giant duodenal ulcer perforation.
Results: There was no conversion to open surgery. There was no severe postoperative complication. The days of normalization of leukocytosis were 3, 1, 2, 2, and 5, respectively. The times to first flatus were postoperative days 2, 3, 5, 2, and 3. The days of commencement of a soft diet were postoperative days 5, 5, 6, 5, and 5. They were discharged on postoperative days 9, 11, 20, 10, and 11.
Conclusions: We suggest that laparoscopic surgery may be a good surgical method to improve surgical outcomes and is worth a try in experts.
-
Laparoscopic Sleeve Gastrectomy in a Pediatric Patient
Laparoscopic sleeve gastrectomy (LSG) is a novel technique in pediatric bariatric surgery. The patient reported here participated in our pediatric weight management clinic for 2 years. His obesity was complicated by obstructive sleep apnea, acanthosis nigricans, and hypertension. His past medical history included 2 small bowel resections, bilateral nephrectomy and kidney transplantation for multicystic renal dysplasia, and 2 peritoneal dialysis-catheter infections. Gastric banding was contraindicated because of previous foreign body infections and chronic need of immunosuppression and steroids. Roux-en-Y gastric bypass was of higher risk given his previous abdominal operations and the resulting medication absorption issues. He underwent LSG without any complications. Five trocars were utilized and a gastroscope was placed during gastric resection. Presurgical body mass index was 44.8 kg/m2. At 18 months follow-up body mass index was 26.5 kg/m2. We concur that LSG can be a safe and effective alternative in bariatric surgery in well-selected adolescents.
-
The Value of a Laparoscopic Interval Appendectomy for Treatment of a Periappendiceal Abscess: Experience of a Single Medical Center
Background: Interval appendectomy has been known to be an effective and safe treatment for a periappendiceal abscess, but there is no study on a laparoscopic approach for the treatment of a periappendiceal abscess. The aim of this study is to investigate the value of laparoscopic interval appendectomy.
Materials and Methods: We retrospectively studied 56 patients who had been admitted due to a periappendiceal abscess to Chungbuk National University Hospital from July 2005 to June 2010. Fifteen patients underwent an initial conservative treatment and interval appendectomy. Medical records were reviewed for the postoperative hospital course such as complications, time of initiation of diet, time since stopping antibiotics, symptoms’ relief period, and length of hospital stay.
Results: All patients received initial conservative treatment [percutaneous drainage insertion (1 case failed) and intravenous antibiotics], and the initial length of hospital stay was 11.6±4.3 days. Percutaneous drainage was removed a mean of 21.7±9.4 days after the initial treatment. Interval appendectomy was performed at a mean of 64.0±17.8 days after initial admission. The duration of use of intravenous antibiotics was a mean of 4.1±1.8 days after laparoscopic interval appendectomy. The complication rate was 1 (6.7%) and the open conversion rate was 1 (6.7%).
Conclusions: Our study revealed that initial conservative treatment and laparoscopic interval appendectomy represented a feasible and effective treatment for patients with a periappendiceal abscess.
-
Laparoscopic Insertion of Antegrade Continence Enema Catheter: A Technique Enabling Early Postoperative Usage
Aims: The Chait Trapdoor Caecostomy catheter was developed to allow the use of antegrade continence enemas without using the appendix. We describe a technique for its insertion under laparoscopic guidance.
Methods: Bowel is secured to the abdominal wall using nonabsorbable sutures. Technical details of the procedure are described.
Results: Five children underwent the procedure. Four had a left-sided procedure and tolerated the procedure well without complications. They have good results with daily antegrade enemas. One child who had a cecostomy had postoperative abdominal distension. He has ongoing soiling and constipation, but has problems with compliance.
Conclusions: We have used the technique in a small number of patients, but results have been favorable. The sutures prevent the risk of the bowel segment slipping from the tube when distended with fluid, provide a good seal around the tube to avoid leakage, and keep a smooth alignment of bowel without angulation.
-
Results From a Consecutive Series of Laparoscopic Incisional and Ventral Hernia Repairs
Introduction: Incisional hernia is a problematic complication of abdominal surgery and both late and early outcomes can be unsatisfactory. Laparoscopic repair has been gaining popularity for both incisional and ventral herniae. However, the perceived benefits have not been convincingly demonstrated by randomized-controlled studies or meta-analyses.
Methods: Case notes from 54 patients undergoing consecutive laparoscopic repairs of the abdominal wall hernia at a single center were reviewed. Demographic data, postoperative complications, length of stay, and recurrence rates were all recorded.
Results: The majority of the patients had incisional hernia, with de novo ventral hernia comprising 7.4% of the total. Forty percent of patients had undergone at least 1 previous repair of their incisional hernia. The median recorded diameter of the hernia defect was 5 cm. No recurrences were recorded over a median follow-up of 26 months. Complications were all minor and included seroma formation, hematoma, and wound infection (n=5 patients). Median operative duration was 45 minutes and median length of stay postoperatively was 1 day.
Conclusions: The results compare well with those in the published literature and would support the continued use of laparoscopic incisional/ventral hernia repair. Any benefits from this approach, however, are likely to be operator dependent. As a result, all units undertaking such repairs should regularly review their results and compare them with the reported standard.
-
How to Meet the Challenge of Flexible Exposure of the Calot Triangle in SILS Cholecystectomy
Single-incision laparoscopy was developed to further reduce the operative trauma in routine laparoscopic procedures. However, the method remains challenging because the exposure of the Calot triangle is more difficult as the use of a singular traction device does not allow the flexible 3-dimensional mounting of the structures. We introduce a technical improvement involving both exposure and traction. After installation of the technical devices for single-incision laparoscopy cholecystectomy, as usual, a suture on a Keith needle is inserted subcostally from the right side of the patient, passed midway through the infundibulum, and extracted subcostally on the left side of the patient. The suture is fixed with 2 metal clips on each side of the gallbladder. The gallbladder can be tilted both medially and laterally on a horizontal line and the Calot triangle can be dissected from medial and lateral aspects following the “critical view of safety” criteria used in conventional laparoscopy.
|
