Transvaginal extraction of the laparoscopically removed spleen

Pneumatosis cystoides intestinalis in a trauma patient presenting with pneumoperitoneum: a case report

Background

Pneumatosis cystoides intestinalis is a rare and usually benign condition in which multiple thin-walled cysts develop in the submucosa or subserosa of the gastrointestinal tract. While usually asymptomatic, severe cases can result in pneumoperitoneum, which can be managed surgically or medically depending on circumstances. We present a case of a patient with pneumatosis cystoides intestinalis, which presented as pneumoperitoneum following trauma. To our knowledge, there are no other published cases in which a trauma patient with pneumoperitoneum was found to have radiologic evidence of pneumatosis cystoides intestinalis.

Case presentation

We present the case of a 37-year-old Hispanic male admitted to the hospital after being involved in a motorcycle accident. Computed tomography imaging of the abdomen and pelvis with oral and intravenous contrast demonstrated trace pneumoperitoneum, possibly originating from the splenic flexure of the colon without evidence of extravasation of oral contrast. Laparoscopy with conversion to exploratory laparotomy revealed bowel abnormalities at the distal transverse colon and splenic flexure, which were identified as pneumatosis cystoides intestinalis by pathology. There was no evidence of bowel perforation. A panel of abdominal radiologists attended the computed tomography interpretation to note that incidental atraumatic or traumatic rupture of the cysts could have caused the pneumoperitoneum. The patient had an uncomplicated postoperative course and was transferred to another facility per insurance request.

Conclusions

When presenting in the context of trauma, pneumatosis cystoides intestinalis can lead to difficult management decisions. To our knowledge, there are no existing evidence-based guidelines for the scenario of concurrent pneumatosis cystoides intestinalis, blunt abdominal trauma, and pneumoperitoneum in a patient with a benign abdominal exam. This patient’s pneumoperitoneum was likely caused by rupture of preexisting cysts rather than frank bowel perforation. Patients who are asymptomatic, lack signs of clinically worrisome disease, and have a low pretest probability will likely not benefit from surgery and can be medically managed. Thorough discussion between surgeons and radiologists can be helpful when evaluating the clinical significance of a patient’s pneumatosis cystoides intestinalis and aid in the decision to perform surgery.

Long-term outcomes after Natural Orifice Specimen Extraction versus conventional laparoscopy-assisted surgery for rectal cancer: a matched case-control study

Purpose

The aim of this study was to compare the long-term outcomes of total laparoscopic surgery with Natural Orifice Specimen Extraction (NOSE) with those for conventional laparoscopy (CL)-assisted surgery for treating rectal cancers.

Methods

We reviewed the prospectively collected records of 844 patients (163 NOSE and 681 CL) who underwent curative surgery for mid- or upper rectal cancers from January 2006 to November 2012. We applied propensity score analyses and compared oncological outcomes for the NOSE and CL groups in a 1:1 matched cohort.

Results

After propensity score matching, each group included 138 patients; the NOSE and CL groups did not differ significantly in terms of baseline clinical characteristics. The median follow-up was 57.7 months (interquartile range, 42.4–82.5 months). The combined 5-year local recurrence rate for all tumor stages was 4.1% (95% confidence interval [CI], 0.9%–7.4%) in the NOSE group and 3.0% (95% CI, 0%–6.3%) in the CL group (P = 0.355). The combined 5-year disease-free survival rates for all stages were 89.3% (95% CI, 84.3%–94.3%) in the NOSE group and 87.3% (95% CI, 81.8%–92.9%) in the CL group (P = 0.639). The postoperative mean fecal incontinence scores at 6, 12, and 24 months were similar between the 2 groups.

Conclusion

In our experience, NOSE for mid- and upper rectal cancer had acceptable long-term oncologic outcomes comparable to those of conventional minimal invasive surgery and seems to be a safe alternative to reduce access trauma.

Abdominal Hernias, Giant Colon Diverticulum, GIST, Intestinal Pneumatosis, Colon Ischemia, Cold Intussusception, Gallstone Ileus, and Foreign Bodies: Our Experience and Literature Review of Incidental Gastrointestinal MDCT Findings

Incidental gastrointestinal findings are commonly detected on MDCT exams performed for various medical indications. This review describes the radiological MDCT spectrum of appearances already present in the past literature and in today's experience of several gastrointestinal acute conditions such as abdominal hernia, giant colon diverticulum, GIST, intestinal pneumatosis, colon ischemia, cold intussusception, gallstone ileus, and foreign bodies which can require medical and surgical intervention or clinical follow-up. The clinical presentation of this illness is frequently nonspecific: abdominal pain, distension, nausea, fever, rectal bleeding, vomiting, constipation, or a palpable mass, depending on the disease. A proper differential diagnosis is essential in the assessment of treatment and in this case MDCT exam plays a central rule. We wish that this article will familiarize the radiologist in the diagnosis of this kind of incidental MDCT findings for better orientation of the therapy.

A Rare Complication of Composite Dual Mesh: Migration and Enterocutaneous Fistula Formation

Introduction. Mesh is commonly employed for abdominal hernia repair because it ensures a low recurrence rate. However, enterocutaneous fistula due to mesh migration can occur as a very rare, late complication, for which diagnosis is very difficult. Presentation of Case. Here we report the case of an enterocutaneous fistula due to late mesh migration in a mentally retarded, diabetic, 35-year-old male after umbilical hernia repair with composite dual mesh in 2010. Discussion. Mesh is a foreign substance, because of that some of the complications including hematoma, seroma, foreign body reaction, organ damage, infection, mesh rejection, and fistula formation may occur after implantation of the mesh. In the literature, most cases of mesh-associated enterocutaneous fistula due to migration involved polypropylene meshes. Conclusion. This case serves as a reminder of migration of composite dual meshes.

[Reducing invasiveness of laparoscopic surgery using natural orifices and abdominal wall defects for extraction of the specimen]

INTRODUCTION

Due to significant technical evolution complex surgeries can be performed laparoscopically nowadays. However, laparotomy is needed frequently for the extraction of the specimen, which decreases the advantages of laparoscopy.

AIM

The aim of the authors was to analyse and present their experience on the use of natural orifices and abdominal wall defects for extraction of the surgical specimen.

METHOD

From 2009 the authors used natural orifices (stomach, vagina, rectum) when viscerotomy was an obligate part of laparoscopic surgery and, in a special gastrointestinal laparoscopic operation, the gate of the inguinal hernia for specimen extraction.

RESULTS

In 3 patients benign lesions of the stomach were extracted using gastroscope. In 6 patients with bowel endometriosis, in whom the wall of the vagina was completely infiltrated, the resected bowel was extracted transvaginally, and in 5 patients transrectal extraction of the specimen was performed. In 2 patients the inguinal hernia was used for the surgical specimen extraction after laparoscopic sigmoid resection, and in one patient a single-port was inserted into the gate of the hernia during laparoscopic cholecystectomy. Complications occurred only after transvaginal specimen extraction (rectovaginal fistula in 2 patients).

CONCLUSIONS

Use of natural orifices and abdominal wall defects for surgical specimen extraction further decreases the invasiveness of laparoscopic surgery, if indications made appropriately.

Pneumatosis cystoides intestinalis after cetuximab chemotherapy for squamous cell carcinoma of parotid gland

Pneumatosis intestinalis, defined as gas in the bowel wall, is often first identified on abdominal radiographs or computed tomography (CT) scans. It is a radiographic finding and not a diagnosis, as the etiology varies from benign conditions to fulminant gastrointestinal disease. We report here a case of pneumatosis intestinalis associated with cetuximab therapy for squamous cell carcinoma of head and neck. The patient underwent laparotomy based on the CT scan and the result was pneumatosis intestinalis without any signs of necrotizing enterocolitis.

Primary pneumatosis intestinalis of small bowel: a case of a rare disease

Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts are located in the bowel wall; it can represent a wide spectrum of diseases and a variety of underlying diagnoses. The present report describes the case of an 86-year-old man with symptomatic primary PI of small bowel treated with surgical approach after periodic episodes of cysts rupture and superimposed inflammation revealed on the basis of a clinical suspicion thanks to abdominal computed tomography. Moreover, after one year of followup, there has been no recurrence of digestive symptoms.

Laparoscopic incidental finding of pneumatosis intestinalis in acute appendicitis

Pneumatosis intestinalis (PI) is a rare condition where the gas trapped inside the bowel wall. It is commonly found as an incidental finding on routine abdominal imaging or scans. We present a case of incidental laparoscopic finding of pneumatosis intestinalis on a 32-year-old male, who underwent a laparoscopic appendectomy for an acute appendicitis. Laparoscopic appendectomy was performed and pneumatosis intestinalis managed conservatively. Patient did well and was discharged home. Management of PI depends on clinical presentation; asymptomatic PI can be managed adequately by treating underlying causes. We report a case of incidental laparoscopic finding of Pneumatosis intestinalis, which was adequately managed by treating underlying appendicitis.

Transgastric synthetic mesh migration, 9 years after liver resection

Complications of synthetic mesh have been described in various hernia procedures including migration and erosion, but no previous report mentions this complication after liver resection. This case describes a patient who had undergone a left hepatic resection with mesh pledgets sutured along the cut edge of the liver. He remained complication-free until nine years later when he presented with weight loss and early satiety, and endoscopy revealed mesh within the lumen of the stomach. While still attached to the liver, the mesh had eroded into the lumen of the stomach and he ultimately required surgery to remove this. The use of synthetic mesh in hepatectomies and other abdominal procedures may require further consideration by surgeons regarding its relatively unknown tendency for migration and erosion.

Euro-NOTES Status Paper: from the concept to clinical practice

BACKGROUND

The concept of natural orifice transluminal endoscopic surgery (NOTES) consists of the reduction of access trauma by using a natural orifice access to the intra-abdominal cavity. This could possibly lead to less postoperative pain, quicker recovery from surgery, fewer postoperative complications, fewer wound infections, and fewer long-term problems such as hernias. The Euro-NOTES Foundation has organized yearly meetings to work on this concept to bring it safely into clinical practice. The aim of this Euro-NOTES status update is to assess the yearly scientific working group reports and provide an overview on the current clinical practice of NOTES procedures.

METHODS

After the Euro-NOTES meeting 2011 in Frankfurt, Germany, an analysis was started regarding the most important topics of the European working groups. All prospectively documented information was gathered from Euro-NOTES and D-NOTES working groups from 2007 to 2011. The top five topics were analyzed.

RESULTS

The statements of the working group activities demonstrate the growing information and changing insights. The most important selected topics were infection issue, peritoneal access, education and training, platforms and new technology, closure, suture, and anastomosis. The focus on research topics changed over time. The principle of hybrid access has overcome the technical and safety limitations of pure NOTES. Currently the following NOTES access routes are established for several indications: transvaginal access for cholecystectomy, appendectomy and colon resections; transesophageal access for myotomy; transgastric access for full-thickness small-tumor resections; and transanal/transcolonic access for rectal and colon resections.

CONCLUSIONS

NOTES and hybrid NOTES techniques have emerged for all natural orifices and were introduced into clinical practice with a good safety record. There are different indications for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication.

Pneumatosis intestinalis as the initial presentation of systemic sclerosis: a case report and review of the literature

Introduction. Pneumatosis intestinalis (PI) is an uncommon pathology characterised by the presence of gas within the intestinal wall. It has been associated with various conditions, including connective tissue diseases. This is the first report of PI being the initial presentation of systemic sclerosis. Case Presentation. The patient, a 75-year-old female, presented with an 8-month history of worsening dysphagia and epigastric pain, as well as other nonspecific symptoms. Initial investigations with an oesophagogastroduodenoscopy diagnosed Candida oesophagitis and also identified an extrinsic compression of the gastric antrum. Subsequently a CT scan of the abdomen and pelvis showed moderately dilated small bowel loops and PI. Due to the patient's stability, non-critical clinical condition, conservative management was instituted. More detailed investigations confirmed the diagnosis of systemic sclerosis with positive anticentromeric and antinuclear antibodies. The patient improved on methotrexate and was discharged with appropriate outpatient follow-up. Discussion. PI is a rare but well-documented pathology associated with connective tissue diseases, such as systemic sclerosis. In most cases, conservative management is preferable to surgical intervention, depending on the patient's clinical presentation and progress. This is the first report of PI being the initial presentation of a patient with systemic sclerosis responsive to conservative management.

Transvaginal specimen extraction after laparoscopic colectomy

BACKGROUND

Despite the advantages of laparoscopic colon surgery, the need for an incision in the abdominal wall to remove the surgical specimen is a morbidity factor. The objective of this article is to introduce transvaginal specimen extraction after laparoscopic colectomy, in order to avoid an abdominal incision.

METHODS

Between 2008 and 2011, 21 selected women with benign and malignant colorectal pathologies underwent laparoscopic colectomy and the extraction of the surgical specimen was done through a transvaginal access route. Of these patients, 12 had symptomatic diverticular disease, four had rectal villous adenomas, two had severe chronic constipation, and three had adenocarcinomas. We describe the surgical technique and the short-term outcomes related to the transvaginal specimen extraction.

RESULTS

The procedure was successful in all cases. There were no immediate complications or mortality. At follow-up, between 2 and 34 months, there were no functional disorders associated with the transvaginal specimen extraction.

CONCLUSION

Specimen removal of laparoscopic colectomies via the transvaginal route avoids the abdominal wall incision and its potential complications. It is feasible, safe, and simple to perform, with no additional costs, and provides excellent cosmetic results.

Sashimi NOTES--extraction of bulky specimens in no-scar operations

A major obstacle in no-scar surgery is the extraction of large, bulky or rigid specimen. Thus, a method is needed that allows for extraction of large specimens without situs contamination in women and men. It should enable safe treatment of infectious or malignant disease while preserving pathologic workup. Five patients suffering from diverticulitis with expected bulky and rigid specimen were enrolled into this early series. Preparation was performed transumbilically in single-port technique. To prevent new scar formation, the incision was limited to the base of the umbilicus without extension onto the sound abdominal skin. A functionally and topologically extracorporeal compartment was created within the abdomen by introduction and insufflation of a tear-proof impermeable retrieval bag. The specimen was sliced in a controlled fashion inside the compartment along a pre-marked geometry. Controlled specimen dissection in a dedicated intraabdominal resection compartment was feasible. The dissected specimen could be retrieved through the 1.5 cm umbilical incision without spillage of material. The geometry of the extracted organ was reconstructed in detail allowing for uncompromised pathological workup. Extraction of bulky and rigid specimen is possible through natural orifices by the proposed controlled dissection method enabling the pathologist to reconstruct anatomical affiliation.

Transvaginal specimen extraction in colorectal surgery: current state of the art

BACKGROUND

The expected benefit of transvaginal specimen extraction is reduced incision-related morbidity.

OBJECTIVES

A systematic review of transvaginal specimen extraction in colorectal surgery was carried out to assess this expectation.

SEARCH STRATEGY

The following keywords, in various combinations, were searched: NOSE (natural orifices specimen extraction), colorectal, colon surgery, transvaginal, right hemicolectomy, left hemicolectomy, low anterior resection, sigmoidectomy, ileocaecal resection, proctocolectomy, colon cancer, sigmoid diverticulitis and inflammatory bowel diseases.

SELECTION CRITERIA

SELECTION CRITERIA included large bowel resection with transvaginal specimen extraction, laparoscopic approach, human studies and English language. Exclusion criteria were experimental studies and laparotomic approach or local excision. All articles published up to February 2011 were included.

RESULTS

Twenty-three articles (including a total of 130 patients) fulfilled the search criteria. The primary diagnosis was colorectal cancer in 51% (67) of patients, endometriosis in 46% (60) of patients and other conditions in the remaining patients. A concurrent gynaecological procedure was performed in 17% (22) of patients. One case of conversion to laparotomy was reported. In two patients, transvaginal extraction failed. In left- and right-sided resections, the rate of severe complications was 3.7% and 2%, respectively. Two significant complications, one of pelvic seroma and one of rectovaginal fistula, were likely to have been related to transvaginal extraction. The degree of follow up was specified in only one study. Harvested nodes and negative margins were adequate and reported in 70% of oncological cases.

CONCLUSION

Vaginal extraction of a colorectal surgery specimen shows potential benefit, particularly when associated with a gynaecological procedure. Data from prospective randomized trials are needed to support the routine use of this technique.

[Novel laparoscopic techniques in gynecologic surgery]

The practice of gynecologic surgery has been revolutionized by laparoscopic techniques in the past decades. Nowadays minimal invasive procedures are feasible and safe standard options in the management of most benign and malignant gynecologic diseases. Natural orifices transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed in an attempt to further reduce the morbidity and scarring with minimal invasive procedures. These techniques share a common conception that a reduction in the number of transcutaneous points of access may benefit patients in terms of port-related complications, risk of hernia formation, recovery time, pain and cosmetics by potentially performing scarless surgery. The development of LESS has been facilitated by the concept of scarless surgical procedures. Increasing experience revealed by recent publications have allowed for the expansion of NOTES and LESS techniques in the gynecologic surgery. Almost all laparoscopic procedures can be performed by acquiring these concepts. Although these surgical methods are feasible and safe, certain technical problems (e.g. loss of triangulation, problems of visualization, ergonomic considerations) has yet to be solved and several questions must be answered before LESS and NOTES could gain widespread acceptance as single procedures. Despite successful technical developments these methods remain investigational approaches and refinement of indications as well as further development of instrumentation are expected to define its area of future application.

[The transvaginal approach in acute appendicitis]

INTRODUCTION

The purpose of this work is to present 8 minilaparoscopic-assisted transvaginal appendectomies using rigid instruments in patients with acute appendicitis.

MATERIAL AND METHODS

Eight minilaparoscopic-assisted transvaginal appendectomies were performed from the 10th of August 2009 to the 30th of June 2010. The inclusion criteria were women between 18 and 65 years of age with a diagnosis of acute appendicitis. The exclusion criteria were palpable masses, appendicular abscesses, ASA III and IV; morbid obesity (BMI > 35); gynaecological infections; virgin patients and pregnant women. The surgical intervention was performed with rigid instruments. Surgical time, the need for post-operative analgesics, and post-surgical complications.

RESULTS

The age range varied between 18 and 42 years, with a mean of 29.6 years. The mean surgical time was 48.3 minutes (37-75). Analgesics were given to 2 patients after surgery (1 parenteral and 1 oral). Five patients were discharged before 24 hours and 3 at 48 hours. There were no post-operative complications.

CONCLUSIONS

Minilaparoscopic-assisted transvaginal appendectomy with rigid instruments, in selected women is a feasible and safe method, and with better aesthetic results than laparoscopic appendectomy, but future studies will be required that can demonstrate its advantages.

Getting ready for surgery through natural orifice

The technical background of pure Natural Orifice Translumenal Endoscopic Surgery (NOTES) surgery has not been created yet, but ever more reports are being published on hybrid NOTES surgery and single-port surgical interventions, which have appeared as a result of device development inspired by NOTES. Surgery carried out through single ports only differ from pure NOTES in respect of the access orifice, which makes learning this technique extremely important for anyone whishing to implement a surgical intervention through a natural orifice. Numerous publications have appeared by now on the single port or hybrid NOTES surgery of various organs (gall bladder, kidney, large bowel). Based on these, most surgery is safely feasible through one port as well, but the surgery takes longer and it is not significantly less painful than a “traditional” laparoscopic intervention. Long-term results are still missing, primarily in what concerns the frequency of infections and post-operative hernia. We have received an answer to part of the dilemmas formulated in the White Paper. Besides specially bent laparoscopic devices robot technology and devices controlled by extracorporal magnets may both be a solution to the problem of triangulation. The transvaginal and transgastric paths do not seem to cause significant risks from the viewpoint of infections, but the closing of viscerotomy in the case of the stomach is far from being solved. In respect of learning and practicing new surgical techniques no method exists at the moment that could be considered the “gold standard”. Besides the earlier questions there are new ones as well awaiting partial solutions (e.g. necessity of drain following a NOTES surgery, oncologic principles).

Minimal Repair technique of sportsmen's groin: an innovative open-suture repair to treat chronic inguinal pain

BACKGROUND

Sportsmen's groin, also known as sportsman's hernia, sports hernia, (athletic) pubalgia or athletic hernia, especially in professional sportsmen, is a difficult clinical problem, and may place an athlete's career at risk. It presents with acute or chronic inguinal pain exacerbated with physical activity. So far, the diagnostic criteria and treatment modalities are inconsistently described and there is no evidence-based consensus available to guide decision-making.

OBJECTIVES

We developed an innovative open suture repair, called the "Minimal Repair" technique. With this technique, the defect of the posterior wall of the inguinal canal is not enlarged, the suture is nearly tension-free and the patient can, therefore, return to full training and athletic activity within the shortest time.

METHODS

In September 2008, we started a prospective cohort study to evaluate the outcome of patients undergoing operations under the Minimal Repair technique for sportsmen's groin. Between September 2008 and May 2009, 129 patients were included in the study and were questioned at entry and 4 weeks after the operation. The primary endpoints were time to complete freedom of pain and time to resumption of exercise and sport. Here, we present the results observed 4 weeks after operation under the Minimal Repair technique.

RESULTS

At enrollment, all but three patients reported a significant restriction of physical activities due to severe groin pain (median duration of pain 142 days, interquartile range [IQR] 57-330 days). Four weeks after operation under the Minimal Repair technique, 96.1% had resumed training (median 7 days, IQR 5-14 days). At this time, there was a full return to pre-injury sports activity levels in 75.8% (median 18.5 days, IQR 11.75-28 days). Focusing on the group of professional athletes, 83.7% had returned to unrestricted sports activities (median 14 days, IQR 10-28 days). In this subgroup, the median time to complete pain relief was 14 days (IQR 6-28 days).

DISCUSSION

The surgical treatment of sportsmen's groin is common practice when non-surgical treatment has failed over a period of 6 weeks or more. However, there is no evidence-based data on the type of treatment. A wide variety of techniques with and without mesh are being performed. So far, laparoscopic repair is believed to enable a faster recovery and return to unrestricted sports activities. Our results, however, show that the outcome after operation under the Minimal Repair technique is very fast, without exposing the patient to possible risks related to mesh insertion or laparoscopic procedures.

CONCLUSION

The Minimal Repair technique is an effective and safe way to treat sportsmen's groin.

Transvaginal video-assisted cholecystectomy in clinical practice

BACKGROUND

Transvaginal video-assisted cholecystectomy with rigid instruments is a new procedure that combines natural orifice surgery (NOS) with classic laparoscopy. This hybrid technique requires conventional laparoscopy via an umbilical incision. To date it is unclear if this procedure is safe and feasible in routine practice.

METHODS

We report on a case series of 128 women who consented to transvaginal cholecystectomy. Data, including visual analog scores (VAS), were collected prospectively via a standard digital spreadsheet. Patients completed satisfaction questionnaires within 10 days after discharge from hospital. We report on outcomes, age, body mass index, operating time, complications, pain scores, and patient satisfaction.

RESULTS

In 115 (89.8%) patients the procedure was performed as a transvaginal operation. In 11 women (8.6%), we converted to standard laparoscopy, and in 2 cases (1.6%), we converted to an open procedure. Mean age was 52.4 years (range = 23-78 years) and mean body mass index was 27.8 (range = 18.8-42). Mean operating time was 60.6 min (range = 22-110 min). Other procedures were combined with hybrid cholecystectomy in six cases. Complications following transvaginal access included one vaginal bleeding, one perforation of the urinary bladder, and one superficial lesion of the rectum. In one case the hepatic duct had to be stented due to leakage after the procedure via endoscopic retrograde cholangiography. Mean VAS on day 1 was 2.26 (± 0.31 SEM) and on day 2 it was 1.53 (± 0.35 SEM). In a postoperative questionnaire, 95% of patients indicated that they would recommend this procedure to other patients.

CONCLUSIONS

Transvaginal cholecystectomy is a safe and easy-to-learn procedure. Possible complications are different than those of standard laparoscopic procedures. Trauma to the abdominal wall and scarring is minimal. Postoperative pain scores were not different than those of standard laparoscopy and a high percentage of patients are satisfied with the procedure.

Transvaginal specimen extraction in a laparoscopic anterior resection of a sigmoid colon neoplasia with en bloc right salpingo-oophorectomy

Laparoscopic colorectal surgery has well-known benefits. However, an abdominal incision, albeit much smaller than conventional surgery, is still needed. A transvaginal extraction of a sigmoid colon neoplasia with en bloc salpingo-oophorectomy and colorectal mechanical anastomosis is described. The technique is feasible and safe. The excellent recovery of the 86-year-old patient shows the potential future of the natural orifices endoscopic surgery.

Single-port access: a feasible alternative to conventional laparoscopic splenectomy

HYPOTHESIS

The laparoscopic approach has become the gold standard for splenectomy despite the fact that the spleen is a solid organ located deep in the splenic fossa. There is currently a trend to reduce the invasiveness of minimally invasive procedures. Transabdominal or transumbilical single-incision laparoscopic (SILS) approaches are an alternative to natural orifice transluminal endoscopic surgery techniques, but no reports of their use have yet been published in relation to the spleen.

AIM

To describe the SILS technique for splenectomy in 2 patients.

MATERIAL AND METHODS

Two patients were approached by SILS, a 26-year-old male diagnosed of autoimmune thrombocytopenia and a 45-year-old male with recurrent Hodgkin disease. In both cases 3 trocars (1 of 12 mm and 2 of 5 mm) were inserted through the umbilicus in one and in a left subcostal in the other, and a curved transanal endoscopic microsurgery instrument, a flexible-tip 10-mm scope, and the UltraCision were introduced. Visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transumbilicus stapling of the splenic hilum. The spleen was extracted through the umbilical incision, intact in one case and after morcellation in the other.

RESULTS

The postoperative course was uneventful. Both patients had minimal postoperative pain and scarring and were discharged on the second postoperative day.

CONCLUSIONS

SILS access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Pneumatosis intestinalis with complete remission: a case report

Introduction

Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Rarely, patients may experience symptoms secondary to the cysts. The pathogenesis of pneumatosis cystoides intestinalis is still unclear and many theories have been advocated to explain the exact origin. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation.

Case presentation

The author reported a male patient aged 56 years presented to the emergency department with acute upper abdominal pain. Widespread variable sized serosal intestinal air cysts were seen at the first look involving long segment of jejunum and ileum. Perforated duodenal ulcer, as the cause of generalized peritonitis, was repaired with direct closure and omental patch. A second laparotomy, was done and exploration was systematically performed and denoted hugely distended stomach with cicatrisation at the site of previous closure of perforated duodenal ulcer and the whole length of small gut was completely free from the already described pneumatosis cystoides intestinalis.

Conclusion

The pneumatosis cystoides intestinalis is a rare disease and suspicion of this disease process should be based on imaging and clinical finding. The therapy can be conservative or surgical in restricted situations.

[NOTES and other minimally invasive surgical techniques (hybrid NOTES, NOTUS, SPS, SILS), and their effect on surgical approaches]

A new surgical technique--called Natural Orifice Translumenal Endoscopic Surgery (NOTES)--evolved in 2004. Although numerous problems arose regarding this method--and most of them are unresolved yet--several new articles about the human application have been published. In order to find solutions of a certain extent, new techniques have been developed (hybrid NOTES, NOTUS, SPS, SLIS, etc). Although these could not eliminate difficulties completely, they do provide some solutions in many cases. It is very important for the surgeon of modern days to be familiar with these techniques and analyze them in a critically. Application of these methods requires a review of principles of surgery and flexible endoscopy. Although in many cases these are considered axioms, there data exist in literature of different management principles, as well. It is fundamental that critically review of the basic questions of NOTES (which natural orifice is the best, how to close the viscerotomy, how to avoid infection, who should carry out the NOTES surgery) is carried out in relation of the complications of the original 'gold standard' methods (e.g. frequency of infection or hernia after laparoscopy). Based on human data there is minimal postoperative pain after the NOTES procedure, and patients in general will leave the hospital on the same day. Is such a short postoperative stay enough and can we entirely dismiss drainage after cholecystectomy? Results of the human procedures are adequate to draw further conclusions regarding the new technique. Retrospective analysis of problems occurring during the evolution of laparoscopy can make it possible to avoid mistakes that can be made in the development of NOTES.

NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen

HYPOTHESIS

Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option.

MATERIAL AND METHODS

We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally.

RESULTS

The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day.

CONCLUSIONS

Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

[Transvaginal cholecystectomy in animal model: first series in Hungary]

INTRODUCTION

The Natural Orifice Transluminal Endoscopic Surgery (NOTES) is the newest trend in minimally invasive surgery. Based on clinical experiences, transvaginal cholecystectomy causes less pain and operative stress, requires shorter hospitalization and allows patients to return quicker to normal activity.

MATERIALS AND METHODS

A transvaginal cholecystectomy was carried out using hybrid technique in animal model first time in Hungary. A 5 mm umbilical trocar was used for preparation of cystic artery and duct, clip application and gallbladder dissection. A transvaginally inserted 10 mm trocar was used for laparoscopic camera to follow the procedure. Gallbladder was fixed and secured with a special curved instrument inserted also transvaginally during the procedure. At the end of procedure the gallbladder was removed transvaginally.

RESULTS

Six transvaginal cholecystectomies was performed on pigs. The mean time of operations was 78 min (40-145 minutes). During the operations and the follow up period (3 months) no complications and mortality was detected.

CONCLUSIONS

According to our experiences both procedures can be safely carried out on animal model, but further refinement of devices is necessary.

Transvaginal endoscopic cholecystectomy in human beings: preliminary results

INTRODUCTION

The exciting concept of performing surgery in the peritoneal cavity without abdominal incisions by means of flexible endoscopes introduced through natural orifices-natural orifice transluminal endoscopic surgery (NOTES) has been widely investigated in recent years in experimental settings. However, experience with this procedure in human beings is still lacking. In this paper, we report the preliminary results of a small consecutive series of transvaginal endoscopic cholecystectomies.

METHODS

A standard double-channel gastroscope introduced into the abdominal cavity through a posterior colpotomy was used to perform the cholecystectomy. The introduction of a 5-mm trocar in the left-upper abdominal quadrant was mandatory to create and monitor the pneumoperitoneum and allow the application of the standard laparoscopic clips. This port was also used to introduce a grasper that assisted in the exposure of the gallbladder. The gallbladder was removed through the vagina and was protected in a plastic bag.

RESULTS

Since July 2007, 3 patients were successfully operated on by this approach, including 1 morbidly obese woman with a body mass index (BMI) of 45. The mean operative time was 136 minutes (range, 110-190). No postoperative complications occurred, and the patients did not complain of pain at both access sites. At the 1-month follow-up, none of the patients complained of dyspareunia.

CONCLUSIONS

The transvaginal cholecystectomy is feasible, safe, and reproducible in women within a wide range of BMI. NOTES might dramatically change the way surgery will be conceived and performed in the future, as it holds the potential to abolish the historic association of surgery with pain and scars.

[New generation of abdominal surgery: the Natural Orifice Transluminal Endoscopic Surgery]

Minimal invasive surgical techniques, namely laparoscopic procedures to the abdominal surgery have been introduced more than 20 years ago. In view of clinical results, the majority of these are considered as routinely performed procedure today. Natural Orifice Transluminal Endoscopic Surgery can be considered as a new generation of abdominal surgery. It means a method directed through natural orifices, and abdominal surgery operated by transluminal endoscopic techniques (transgastric, transcolonic, transvaginal) to reach diagnostic and therapeutic goals. Theoretically, this method allows the possibility to decrease invasiveness and postoperative pain, to prevent postoperative hernias and to improve cosmetic results. At present numerous researchers work worldwide to receive scientifically based answers to arising questions (surgical technique, indication, contraindication, complications, monitoring) and concerns in this area. The present paper gives an overview of the national and international literature on experimental results and clinical approaches in the field of this new surgical technique.

[Natural orifice transluminal endoscopic surgery]

In Natural Orifice Transluminal Endoscopic Surgery (NOTES) a flexible endoscope is passed through a natural orifice of the body and intra-abdominal procedures can be performed through a transvisceral (transgastric, -colonic, -vaginal or -vesical) incision. Principally, this state-of-the-art technology decreases invasiveness and postoperative pain, prevents postoperative hernia formation and improves cosmetic results. However, numerous questions regarding the technique are unanswered yet. Further research is necessary to extend the armamentarium of minimally invasive surgery. This article reviews the current state of experimental results and clinical approaches of NOTES.

Splenic retrieval after laparoscopic splenectomy: a new bag

BACKGROUND

Laparoscopic splenectomy has become the gold-standard surgical approach for patients undergoing elective splenectomy. Little data exist concerning the technical difficulties of splenic retrieval. When the spleen is large, popular commercial retrieval bags are often too small to facilitate removal. The aim of this study was to compare our clinical experience utilizing two different retrieval bags, the Endocatch II (Autosuture, London, UK) and the developing E200 (Espiner Ltd., Bristol, UK).

MATERIALS AND METHODS

We performed a retrospective review of all laparoscopic splenectomies performed at Hull Royal Infirmary, Kingston upon Hull, from March 1997 to July 2003. Patient demographics, morbidity, mortality, and clinical outcome had been entered prospectively into a database. Two patient groups were examined, depending on the type of retrieval bag utilized. Complications and instrument failure during splenic retrieval were analysed.

RESULTS

A total of 83 laparoscopic splenectomies were performed. No retrieval bag was used in 8 cases (10%). The Endocatch retrieval bag was used for 45 (60%) patients and the E200 for 30 (40%) patients. The mean operative time for the former group was 65 minutes (range, 50-127 minutes) and for the latter, 120 minutes (range, 80-180 minutes) (P < 0.05). Bag-related complications were 2 (4%) perforations and 2 (4%) failures to deploy while using the Endocatch bag.

CONCLUSION

The Endocatch bag is easy to deploy but is associated with perforation and cannot be used for large spleens. The E200 bag is more useful for large spleens but is associated with prolonged operative time due to poor maneuverability. Improved technology is still required.