Umbilical stalk elevation technique for safer Veress needle insertion in obese patients: a case-control study

Tips and tricks in gynaecological robotic surgery

It was the dawn of a new era for robotic surgery when the Food and Drug Administration (FDA) approved da Vinci robotic surgical system for general laparoscopic procedures in 2000. The surgical practice saw a transformative breakthrough towards minimally invasive approach with the ever-increasing uptake of advanced robots proven to benefit patients and surgeons in various ways. However, these innovative machines only complement and enhance a surgeon's operating skills, and with such privilege come responsibilities and new challenges. Heavy reliance on such advanced devices while operating on humans necessitates thorough training and supervision to ensure safe and efficient applications. It is the surgeon's responsibility to direct the procedure constantly and lead other team members who assist during the surgery. In this chapter, we provide miscellaneous tips and tricks that can help beginners navigate through robotic surgery with more confidence and enthusiasm.

Abdominal access in laparoscopic surgery of obese patients: a novel abdominal access technique

BACKGROUND

An important step in laparoscopic surgery is abdominal access. Several abdominal access techniques have been described to reduce complications. We compare our novel abdominal access technique (MESAD) with other abdominal access techniques, particularly to reduce complications in obese patients.

OBJECTIVE

Compare the MESAD method and other methods we use for abdominal access in gynecologic laparoscopic surgery of obese patients DESIGN: Retrospective SETTING: Gynecology department in university hospital PATIENTS AND METHODS: Patients who underwent abdominal access by the MESAD technique, the Veress needle technique, and the Hasson technique were included in our study. In addition to demographic data, minor and major complications, number of unsuccessful attempts, conversion to another technique, and abdominal access times were collected from all patient files.

MAIN OUTCOME MEASURES

Clinical data and complications SAMPLE SIZE: 66 patients, 26 by MESAD technique, 24 by the Veress needle technique, and 16 by the Hasson technique.

RESULTS

There were two major complications (one in the Veress group and one in the Hasson technique group) and 7 minor complications. No significant difference was found between the groups in terms of complications (P=.477, P=.476, respectively). The fastest technique for abdominal access was in the MESAD technique whereas the slowest was in the Hasson (P<.001). The failure of abdominal access and subsequent conversion to another technique was most common in the Veress group. However, no significant difference was found between the groups (P=.092).

CONCLUSIONS

The MESAD technique is an easy method to both learn and teach. We think that the low major-minor complication rates in the MESAD technique will allow surgeons to reduce their anxiety at the first entry and to perform a more comfortable operation.

LIMITATIONS

Retrospective CONFLICT OF INTEREST: None.

Large bowel injuries during gynecological laparoscopy

Laparoscopy is one of the most frequently preferred surgical options in gynecological surgery and has advantages over laparotomy, including smaller surgical scars, faster recovery, less pain and earlier return of bowel functions. Generally, it is also accepted as safe and effective and patients tolerate it well. However, it is still an intra-abdominal procedure and has the similar potential risks of laparotomy, including injury of a vital structure, bleeding and infection. Besides the well-known risks of open surgery, laparoscopy also has its own unique risks related to abdominal access methods, pneumoperitoneum created to provide adequate operative space and the energy modalities used during the procedures. Bowel, bladder or major blood vessel injuries and passage of gas into the intravascular space may result from laparoscopic surgical technique. In addition, the risks of aspiration, respiratory dysfunction and cardiovascular dysfunction increase during laparoscopy. Large bowel injuries during laparoscopy are serious complications because 50% of bowel injuries and 60% of visceral injuries are undiagnosed at the time of primary surgery. A missed or delayed diagnosis increases the risk of bowel perforation and consequently sepsis and even death. In this paper, we aim to focus on large bowel injuries that happen during gynecological laparoscopy and review their diagnostic and management options.