Single incision laparoscopic spigelian hernia repair--an approach with standard instrumentarium

Spigelian hernia is a rare type of abdominal wall ventral hernia caused by defect in the spigelian fascia and presented with pain and/or palpable mass. This diagnosis is an indication for surgical procedure due to the high risk of incarceration. There are two surgical approaches (open and laparoscopic), both using two methods of repair (mesh-free primary closure and tension-free mesh repair), depending on the hernia ring size. We present a case of a 62-year-old woman with a palpable mass localized in the left spigelian hernia belt, verified by ultrasonography as a spigelian hernia. A single incision intra-abdominal laparoscopic approach with a tension-free underlay mesh-repair technique was used to treat the condition. Operating time was 40 minutes and the procedure was completed without complications. Postoperative recovery was uneventful as well as 1-week and 2-month follow up. To our knowledge, this is the first report of spigelian hernia repair by single incision laparoscopic surgery. Although this approach is more demanding in comparison to multiport laparoscopy, it proved to be safe and feasible for experienced laparoscopic team. Besides cosmetic improvement, the single incision approach reduces to minimum the risk of bleeding, organ injury and incisional postoperative hernia. To determine optimal indications and limits of this approach, further data collection and follow up are required.

First case of single incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair

Laparoscopic approach to inguinal hernia repair is indicated for recurrent and bilateral hernias or as patient choice in unilateral primary hernias. Totally extraperitoneal (TEP) approach has some advantages over transabdominal preperitoneal (TAPP) approach, but has proved to be more technically demanding. It cannot be emphasized enough that every incision and trocar placement poses a risk of bleeding, organ damage, incisional hernia and less favorable cosmetic effect. Single incision laparoscopic (SILS) TEP hernia repair has reduced the number of incisions to minimum. A 60-year-old male patient presented with unilateral right sided primary indirect inguinal hernia. Laparoscopic SILS TEP repair was performed: a single 2.5-cm infraumbilical incision was made, the anterior rectus sheath was incised and a balloon dissection device was inserted over the posterior rectus sheath, guided to the pubic symphysis and inflated, resulting in separation of the peritoneum from the rectus muscle. This creation of the extraperitoneal space allowed for laparoscopic dissection to take place. We used a 10-mm optical trocar and two 5-mm trocars placed 1 cm laterally from the optical port. The operation was free from complications and the operative time was 90 minutes. Postoperative recovery was uneventful. We report on, to our knowledge, the first case of SILS TEP hernia repair. Based on this experience, we believe that SILS TEP is feasible. Adjacent placement of trocars in SILS reduces triangulation which, along with frequent crossing of instruments, renders this approach more demanding. Cosmetic benefit is clear; however, it remains to evaluate patient recovery, postoperative pain and complications in comparison to standard TEP.

Single incision laparoscopic surgery (SILS) cholecystectomy: where are we?

Laparoscopic cholecystectomy has become gold standard for cholecystectomy. The tendency of minimizing surgical trauma encourages the use of new approaches in laparoscopic surgery. Single incision laparoscopic surgery (SILS) cholecystectomy was first performed ten years ago; however, it is only recent technologic development that has enabled its wider acceptance. We report on a case of a 69-year-old female patient scheduled for elective laparoscopic cholecystectomy due to symptomatic ultrasonography verified cholelithiasis. A single 2.5-cm long semicircular supraumbilical skin incision was used. Pneumoperitoneum was established with the Veress access needle. Abdominal cavity was entered through three trocars: 10-mm trocar for camera and two 5-mm trocars, each placed 1 cm laterally and cranially from the 10-mm trocar. Antegrade cholecystectomy was performed without stay suture placement. Postoperative course was uneventful. The benefits of transition from standard laparoscopic approach to SILS will not be as obvious as was the transition from open to laparoscopic cholecystectomy. However, it cannot be overstated that every additional incision and trocar placement poses a risk of bleeding, organ damage and incisional hernia. SILS approach is feasible with standard and slightly modified instruments for standard laparoscopic cholecystectomy, thus posing minimal additional challenge to the laparoscopic surgeon. Accordingly, we believe that the use of this approach for cholecystectomy is worthwhile.

Splenic rupture following idiopathic rupture of the urinary bladder presenting as acute abdomen

Idiopathic rupture of the urinary bladder is an uncommon condition and represents less than 1% of all bladder rupture cases. In most of the cases the main etiological factor was heavy alcohol ingestion. A combined injury of the spleen and bladder is a very rare condition that is almost often associated with trauma and foreign bodies. In this paper we present the extremely rare clinical course of acute abdomen caused by a combined spontaneous intraperitoneal injury; spontaneous rupture of the urinary bladder and spleen. According to our opinion, spontaneous bladder rupture caused by bladder distension due to alcohol ingestion led to urinary ascites and abdominal distension. Finally, repeated minor abdominal blunt trauma during everyday life, to a moderately distended abdomen caused a spontaneous splenic rupture in the patient with abnormal coagulation studies.