Use of Palmer's Point for Insertion of the Operative Laparoscope in Patients with Severe Pelvic Adhesions: Experience of Seventeen Cases

Laparoscopic Cystectomy for a 20-Centimetre Ovarian Endometrioma in a Subfertile Patient: Α Case Report

Large ovarian endometriomas may cause severe pressure symptoms and often require surgical management. The laparoscopic approach, although challenging, is feasible and safe when performed by surgeons with advanced minimal access skills, provided that certain rules are respected. We report a case of a 40-year-old, nulliparous patient with a history of endometriosis, low ovarian reserve, and subfertility who presented with a 20-cm left ovarian endometrioma and associated symptoms, managed successfully by laparoscopic cystectomy. Compared to non-excisional surgical methods, endometrioma cystectomy likely causes a more profound decline in post-operative ovarian reserve, which is particularly important in the context of subfertility. We discuss the technical aspects of this challenging procedure, potential alternative approaches, and clinical decision-making as to why cystectomy was preferred.

An Observational Comparative Study of the Impact of Accidental Pneumoperitoneum in Understanding the Learning Curve for Totally Extraperitoneal and Extended Totally Extraperitoneal Inguinal Hernia Repair

BACKGROUND

Abdominal wall hernia repair is among the fundamental procedures in general surgical practice. Subsequent to the advent of minimally invasive repair, there have been efforts to find the most reliable technique, with easily reproducible results that can be practiced by surgeons worldwide. From an analytical point of view, this study aimed to highlight the advantages and disadvantages of two techniques.

MATERIALS AND METHODS

A total of 60 participants were divided into two groups of 30 patients: the totally extraperitoneal (TEP) and the extended TEP (eTEP) hernia repair groups. Covariates and outcomes were analyzed using the chi-square and Mann-Whitney U tests. The study was carried out at a tertiary postgraduate teaching hospital in the western zone of Maharashtra, Pune, India, by a single surgeon. The operative procedures were as per standard surgical practice for both groups. The study was conducted to understand types of difficulties observed in the early implantation stages and the learning curve of these procedures.

RESULTS

Ten percent of the procedures in the TEP group and 6.7% of procedures in the eTEP group required Veress needle use to manage accidental pneumoperitoneum (P=0.64). The mean operative time in the eTEP group was significantly shorter than that of the TEP group (P=0.031).

CONCLUSION

Compared with the TEP approach, eTEP repair is associated with shorter operative times, owing to a shorter learning curve, a wider-angle view, a wider range of motion for instrument manipulation, and an ergonomically superior operative experience.

Safety considerations in laparoscopic surgery: A narrative review

Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.

Indications, evolving technique, and early outcomes with robotic retroperitoneal lymph node dissection

PURPOSE OF REVIEW

Examine and discuss indications, technique, and outcomes for robotic retroperitoneal lymph node dissection (RPLND) for testicular cancer.

RECENT FINDINGS

Open RPLND has been the longstanding standard of care for both primary and post chemotherapy RPLND. Recently, robotic RPLND has been an attractive option with the intent of reducing the morbidity associated with open surgery while providing identical oncologic efficacy. Naysayers of robotic RPLND suggest it is often inappropriately used as a staging procedure and consequently can compromise oncologic efficacy.

SUMMARY

Robotic RPLND is being evaluated as a therapeutic equivalent to open RPLND. On the basis of limited published data with modest follow-up from experienced centers, robotic RPLND appears to provide effective staging and therapeutic data mirroring that of open surgery.

Transperitoneal Subcostal Access for Urologic Laparoscopy: Experience of a Large Chinese Center

Objective. To present our experience of using transperitoneal subcostal access, Palmer's point (3 cm below the left costal margin in the midclavicular line), and its right corresponding site, in urologic laparoscopy. Methods. We used Palmer's point and the right corresponding site for initial access in 302 urologic surgeries (62 cases with prior surgeries). The record of these cases was reviewed. Results. Success rate of initial access is 99.4%, and complication rate of puncturing is only 3.4% with no serious complication. In the cases with prior surgeries, there were only two cases with access complication on the right side (minor laceration of liver). For people with BMI more than 30 kg/m² (12, 3.9%), the success rate was also 100 percent. Conclusions. Palmer's point and the corresponding right location are feasible, effective, and safe for initial access in urologic laparoscopic surgeries. This entry technique should be used routinely in urologic laparoscopic surgeries.

Robot-assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer: Evolution of the Technique

BACKGROUND

Retroperitoneal lymph node dissection (RPLND) is an accepted staging and treatment option for nonseminomatous germ cell tumor. Robotic surgery offers technical advantages and is being increasingly used in urologic procedures.

OBJECTIVE

To determine the feasibility and safety of robotic surgery for RPLND.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of robotic (R)-RPLND performed by a single surgeon from April 2008 to October 2014 using two approaches was performed. In total, 20 procedures in 19 patients were evaluated. Eleven men had clinical stage (CS) I disease, six had CS II, one of whom had prior chemotherapy, and two had CS III disease and had also undergone previous chemotherapy.

SURGICAL PROCEDURE

A lateral robotic approach was initially used; however, a supine robotic approach was developed to allow for bilateral dissection in one setting without repositioning. Template dissection with nerve sparing was performed for CS I patients and full bilateral dissection for patients with CS II or higher disease and for those who had active disease according to intraoperative frozen section results.

OUTCOME MEASUREMENTS

Mean operative time, estimated blood loss, hospital stay, and lymph node count were retrospectively reviewed, as was the presence of recurrence or the need for adjuvant therapy over median follow-up of 49 mo (interquartile range [IQR] 37.4-70.5). Intraoperative and postoperative complications were also reviewed.

RESULTS AND LIMITATIONS

R-RPLND was performed successfully in 20 procedures in 19 patients; 11 were performed from a lateral approach and nine from a supine approach. The median operating time (available for 19 of 20 cases) was 293min (IQR 257.5-317). Median estimated blood loss and length of stay were 50ml (IQR 50-100) and 1 d (IQR 1-2), respectively. Some 70% (14/20) of patients were discharged after one night. The median lymph node yield was 19.5 (IQR 13.8-27. 3). Eleven patients had pathologic stage I disease, and eight had residual disease on pathology. There was one ureteral transection that was repaired robotically at the time of surgery with no long-term sequelae. There were no open conversions or transfusions. Two patients had ejaculatory dysfunction following bilateral RPLND. There has been no evidence of retroperitoneal disease recurrence during the follow-up period. Limitations include the retrospective nature of the study and the single surgeon experience.

CONCLUSIONS

R-RPLND can be successfully performed and provides improved visualization and dexterity over conventional laparoscopy. Patients experience significantly reduced morbidity and the nodal yield is comparable to open surgical techniques.

PATIENT SUMMARY

We studied our experience with robot-assisted removal of lymph nodes from the abdomen among men with testicular cancer. This method was found to be safe and effective with a very short hospital stay.

Safety of laparoscopically assisted vaginal hysterectomy for women with anterior wall adherence after cesarean section

Objective

To evaluate the safety and surgical outcomes of laparoscopically assisted vaginal hysterectomy (LAVH) for women with anterior wall adherence after cesarean section.

Methods

We conducted a retrospective study of 328 women with prior cesarean section history who underwent LAVH from March 2003 to July 2013. The subjects were classified into two groups: group A, with anterior wall adherence (n=49); group B, without anterior wall adherence (n=279). We compared the demographic, clinical characteristics, and surgical outcomes of two groups.

Results

The median age and parity of the patients were 46 years (range, 34 to 70 years) and 2 (1 to 6). Patients with anterior wall adherence had longer operating times (175 vs. 130 minutes, P<0.05). There were no significant differences in age, parity, number of cesarean section, body mass index, specimen weight, postoperative change in hemoglobin concentration, or length of hospital stay between the two groups. There was one case from each group who sustained bladder laceration during the vaginal portion of the procedure, both repaired vaginally. There was no conversion to abdominal hysterectomy in either group.

Conclusion

LAVH is effective and safe for women with anterior wall adherence after cesarean section.

Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review

BACKGROUND

The aim of this study was to assess the prevalence, risks, and outcomes of injuries caused by the Veress needle described in the literature.

METHODS

Iatrogenic injuries caused by Veress needle insertion during diagnostic or therapeutic laparoscopies in humans were researched, with no language restriction, in the Medline, Lilacs, Embase, Scielo, and Cochrane Library databases. The following words were combined: "Veress" or "insufflation needle" or "pneumoperitoneum needle," and "complications" or "injuries" or "lesions." The bibliographic references of the selected articles were also analyzed. We considered the following: (1) number of injuries described in the literature, (2) relationship between number of injuries and number of patients who underwent Veress needle insertion in the studies that reported Veress needle injury, (3) organs and structures injured (retroperitoneal vessels, digestive tract, and self-limited, minor injuries), and (4) outcome (death, conversion to laparotomy, laparoscopic repair, spontaneous resolution).

RESULTS

Thirty-eight selected articles included 696,502 laparoscopies, with 1,575 injuries (0.23%), 126 (8%) of which involved blood vessels or hollow viscera (0.018% of all laparoscopies). Of the 98 vascular injuries, 8 (8.1%) were injuries to major retroperitoneal vessels. There were 34 other reported retroperitoneal injuries, but the authors were not specific as to which vessel was injured. Of the 28 injuries to hollow viscera, 17 were considered major injuries, i.e., 60.7% (0.0024% of the total cases assessed).

CONCLUSION

The insertion of the Veress needle in the abdominal midline, at the umbilicus, poses serious risk to the life of patients. Therefore, further studies should be conducted to investigate alternative sites for Veress needle insertion.

Direct visual or blind insertion of the primary trocar

BACKGROUND

We set out to assess the difference in complication rates between primary umbilical insertion by a blind trocar and insertion with an optical surgical obturator.

METHODS

In a retrospective survey, we investigated the rate of severe complications by primary umbilical trocar entry. Of 1546 patients undergoing gynecological laparoscopies at a tertiary-care university hospital, 1000 cases were operated by blind umbilical insertion with a conventional primary trocar whereas 546 used an optical primary trocar.

RESULTS

The rate of major complications during insertion of the primary trocar in the blind insertion group was five of 1000 (0.5%), whereas there were no major complications in the optical-guided insertion group (0.0%).

CONCLUSIONS

In comparison with the blind insertion of a sharp trocar, optical guidance provides a safe and functional primary insertion method that allows to detect adhesions to be detected at an early stage, thus preventing injuries to the bowel and abdominal vessels.

Laparoscopic cholecystectomy and choledocholithotomy in patients with a previous gastrectomy

BACKGROUND

An increased incidence of cholelithiasis has been widely reported after truncal vagotomy and after gastric resection. In the early phase of patient selection, previous gastrectomy has been considered a relative contraindication to laparoscopic cholecystectomy (LC). In this study, we examined the management of LC in patients with previous gastrectomy.

STUDY DESIGN

LC was attempted on 1,260 consecutive patients. Of these patients, 29 had a previous gastrectomy. Surgical procedures that had been performed included Billroth I gastrectomies (15), Billroth II gastrectomies (10), and total gastrectomies (4). There were 23 cases of cholelithiasis, 4 chronic cholecystitis, 2 gallbladder polyps, I porcelain gallbladder, and I gallbladder cancer. Nine patients were diagnosed with stones in their common bile duct or common hepatic duct.

RESULTS

Preoperatively, seven of nine patients with common bile duct stones were subjected to endoscopic sphincterotomy, and the stones were removed successfully from five of these patients. In the remaining two patients, common bile duct stones were removed by laparoscopic choledocholithotomy by choledochotomy. The LC was completed in 26 patients (90%) who had undergone previous gastrectomy. In 449 patients who had previous abdominal surgery without a gastrectomy, only 4 patients (0.9%) required open surgery. In contrast, three patients (10%) with previous gastrectomy required open surgery. No major complications were recorded in this study series, and no residual or retained stones were seen during a followup period of 3 months.

CONCLUSIONS

Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe LC in these patients. We conclude that in our study patients, a previous gastrectomy is considered an indication for LC and laparoscopic choledochotomy.

Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion

OBJECTIVE

To determine the frequency of peritoneal and visceral adhesions to the umbilical region according to past surgical history and to estimate the risk of bowel injury with blind insertion of the principal trocar-cannula.

DESIGN

Prospective, unicentric study by a single operator.

SETTING

Clinique Saint-Sernin and Polyclinique de Bordeaux, Bordeaux, France.

PATIENT(S)

Eight hundred fourteen patients undergoing diagnostic or operative laparoscopy were classified into four groups based on their history of abdominal surgery: group I (n = 469), no previous abdominal surgery; group II (n = 125), prior laparoscopic surgery; group III (n = 131), previous laparotomy with a horizontal supra-pubic incision; group IV (n = 89), previous laparotomy with a midline incision.

INTERVENTION(S)

Initial microlaparoscopy performed through the left upper quadrant of the abdomen, inspection of the anterior abdominal wall and particularly the umbilical area for the presence of adhesions. Patients who had adhesions were assessed as to whether or not they were at significant risk of injury from blind insertion of the principal trocar.

MAIN OUTCOME MEASURE(S)

Incidence of umbilical adhesions and the potential risk of bowel injury with blind insertion of the umbilical (principal) trocar.

RESULT(S)

Umbilical adhesions were found in 9.82% of the 814 cases. The rates of umbilical adhesions were as follows: group I, 0.68%; group II, 1.6%; group III, 19.8%; and group IV, 51.7%. Severe adhesions with potential risk of bowel injury with blind insertion of the umbilical trocar in the four groups were 0.42%, 0.80%, 6.87%, and 31.46%, respectively.

CONCLUSION(S)

Women with previous laparotomy have a higher incidence of umbilical adhesions, especially in case of midline incision. Preliminary inspection of the umbilical area with a microlaparoscope and insertion of the umbilical trocar under direct vision are recommended for patients at risk for adhesions to reduce complications associated with insertion of the principal (umbilical) trocar.