Low anterolateral incision for single-port extraperitoneal robot-assisted pyeloplasty: description of technique and initial experience

PURPOSE

This study aims to describe the surgical steps for the single-port low anterolateral extraperitoneal approach to pyeloplasty, report its feasibility, and share the initial outcomes of our experience.

METHODS

We analyzed all consecutive patients who underwent single-port low anterolateral extraperitoneal pyeloplasty due to ureteropelvic junction obstruction (UPJO). The surgical steps included a pure single-port approach through a 3.5 cm low anterolateral incision two fingerbreadths above the superior pubic ramus. The ureter was localized and followed cranially, a dismembered pyeloplasty was performed, and a running ureteropelvic anastomosis was completed. No drains were placed. The urinary catheter was removed upon discharge, and the ureteral stent after 3-5 weeks.

RESULTS

A total of eight cases (two adults and six children) were completed successfully, without complications or conversions. Median operative time, console time, and estimated blood loss were 208.5 min, 114.5 min, and 10.0 ml, respectively. All patients were discharged within 24 h, except for one that required urinary output observation due to retention. There were no major postoperative complications. The median pain score at discharge was 0/10. Only one patient was prescribed PRN opioids at discharge. The readmission rate was 0.0%. All patients were asymptomatic on their last follow-up with no definitive obstruction on imaging, and no requirement for additional procedures or stents.

CONCLUSION

Single-port low anterolateral extraperitoneal pyeloplasty is a feasible alternative for surgical treatment of UPJO in adult and pediatric patients with improved recovery outcomes.

Transvaginal extraperitoneal single-port laparoscopic sacrocolpopexy for apical prolapse after total/subtotal hysterectomy: Chinese surgeons' initial experience

BACKGROUND

To introduce a novel technique of transvaginal extraperitoneal single-port laparoscopic sacrocolpopexy (ESLS) for apical prolapse and to evaluate the feasibility and short-term outcomes of this technique.

METHODS

Sixteen patients were enrolled to undergo ESLS between January 2020 and May 2021. Perioperative outcomes were included. Short-term results were assessed by Pelvic Floor Distress Inventory-20 (PFDI-20), Pelvic Organ Prolapse Quantification (POP-Q) scores, mesh exposure and prolapse recurrence.

RESULTS

A total of 14/16 cases (87.5%) were successfully completed. The mean operation time was 118 min (range 85-160), and the mean blood loss was 68 ml (range 20-100). The mean postoperative visual analog scale (VAS) pain score at 24 h was 0.7. No intraoperative complications occurred except for one patient who developed subcutaneous emphysema. All patients gained a significant improvement in both physical prolapse and quality of life at 12 months after surgery, and there was no mesh exposure or prolapse recurrence.

CONCLUSIONS

Our experience showed that transvaginal ESLS is a feasible and effective technique for apical prolapse with a previous hysterectomy. However, this technique should be performed by surgeons with extensive experience both in vaginal surgery and laparoscopic single-port surgery.

The application of Foley catheter traction technique in extraperitoneal robot-assisted radical prostatectomy

OBJECTIVES

To describe a technique to improve exposure of prostate during extraperitoneal robot-assisted radical prostatectomy (EP-RARP).

MATERIAL AND METHODS

From March 2020 to June 2022, a total of 41 patients with prior intra-abdominal surgery underwent EP-RARP. Twenty-three patients improved exposure by traction of prostate through urinary catheter. The catheter traction prostatectomy (CTP) group was compared with the standard prostatectomy (SP) group using three robotic arms (18 patients) in terms of estimated blood loss (EBL), operative time, positive surgical margin rate, the recovery rate of urinary continence, Gleason score and postoperative hospital stays. Differences were considered significant when P < 0.05.

RESULTS

The operative time was lower in the CTP group (109.63 min vs. 143.20 min; P < 0.001). EBL in the CTP group was 178.26 ± 30.70 mL, and in the standard prostatectomy group, it was 347.78 ± 53.53 mL (P < 0.001). No significant differences with regard to postoperative hospital stay, recovery rate of urinary continence, catheterization time and positive surgical margin were observed between both groups. No intraoperative complications occurred in all the patients. After 6 months of follow-up, the Post-op Detectable prostate specific antigen was similar between the two groups.

CONCLUSION

CTP is a feasible, safe, and valid procedure in EP-RARP. Application of CTP improved the exposure of prostate, reduced operative time and blood loss in comparison with the conventional procedure.

Extraperitoneal robot-assisted radical prostatectomy with the Hugo™ RAS system: initial experience of a tertiary center with a high background in extraperitoneal laparoscopy surgery

PURPOSE

The Hugo™ RAS system is a novel robotic platform with innovative features. However, there are currently no available data on extraperitoneal robot-assisted radical prostatectomy (RARP) performed using this system. The objective of this study is to describe the surgical setup and assess the safety and feasibility of the extraperitoneal approach in robotic radical prostatectomy with the Hugo™ RAS system.

METHODS

Sixteen consecutive patients diagnosed with localized prostate cancer underwent extraperitoneal RARP ± lymph node dissection at our institution, between March and May 2023. All RARP procedures were performed extraperitoneal with a modular four-arm configuration. The focus was to describe the operative room setup, trocar placement, tilt and docking angles and evaluate the safety and feasibility of this approach with this robotic platform. Secondary outcomes recorded included, total operative time, console time, estimated bleeding, intra- and postoperative complications, and length of stay after surgery. A descriptive analysis was conducted.

RESULTS

We report on the first sixteen cases of extraperitoneal robot-assisted radical prostatectomy performed with the new Hugo™ RAS system. All procedures were completed, without the need for conversion or placement of additional ports. No intraoperative complications or major technical failures that would prevent the completion of surgery were recorded. The median operative time was 211 min (IQR 180-277), and the median console time was 152 min (IQR 119-196). The mean docking time was 4.6 min (IQR 4.1-5.2). The median estimated blood loss and the median time to remove the vesical catheter were 200 mL (IQR 150-400) and 8 days (IQR 7-8), respectively. The median length of stay was 2 days (IQR 2-2). Only one minor complication was registered in the first 30 days.

CONCLUSION

This study provides evidence of the safety and feasibility of the extraperitoneal approach in RARP with the Hugo™ RAS system. The description of the surgical setup in terms of trocar placement, arm-cart disposition, tilt and docking angles offers valuable information for surgeons interested in adopting this surgical approach with the Hugo™ RAS platform.

The first experience with the Dextile anatomical mesh in laparoscopic inguinal hernia repair

BACKGROUND

The Dextile Anatomical mesh (Medtronic) is a polypropylene heavyweight mesh and has a 3D patented anatomical shape which adapts to the contours of the extra-peritoneal inguinal region without the need for fixation, potentially reducing the risk of hernia recurrence and chronic post-operative pain. This retrospective study will be the first study to assess the outcomes of the Dextile Anatomical mesh compared to another three-dimensional mesh, the 3DMax mesh (Bard).

METHODS

Between 2019 and 2022, all patients who underwent an elective unilateral inguinal hernia repair were assessed. 416 patients in the Dextile Anatomical mesh group and 540 patients in the 3DMax mesh group were included. Outcomes were intra- and post-operative complications, inguinal hernia recurrence and chronic post-operative inguinal pain.

RESULTS

No significant differences were found between the two groups regarding intra- and post-operative complications including wound infection, antibiotic use, hematoma, seroma, urinary retention and delayed wound healing. 1-year recurrence rate was comparable for the Dextile Anatomical mesh group and the 3DMax mesh group, respectively, 3.8% and 3.0%, P = 0.45. Chronic post-operative inguinal pain was similar for the Dextile Anatomical mesh (3.4%) and the 3DMax mesh (3.0%), P = 0.72.

CONCLUSION

This retrospective study comparing the relatively new Dextile Anatomical mesh (Medtronic) with the 3D Max mesh (Bard) in unilateral inguinal hernia repair showed that both meshes are safe and effective to use. There were no significant differences in intra-operative outcomes, recurrence rates and chronic post-operative inguinal pain.

Enhanced-view totally extraperitoneal access for repair of ventral hernias: Advantages and liabilities

The concept of enhanced-view totally extraperitoneal (eTEP) access was developed while exploring ways to facilitate the TEP approach for inguinal hernia repair. Surgeons soon noticed that the surgical space was ideal for repair of other abdominal hernias. The "crossover" maneuver, designed as a technique to cross from one retrorectus space to the other, permitted application of eTEP access to most hernias. eTEP access has the general advantage of working in the extraperitoneal space and the specific advantage of hernia repair allowing implementation of the modern principles of ventral hernia reconstruction and providing flexibility to address different types of hernias in different locations. The technique requires formal training and has inherent complications and limitations. The remarkable widespread acceptance and encouraging early results of this complex technique emphasize the responsibilities of proper training, judicious use, and evaluation of our own and others' results.

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study

INTRODUCTION

Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position.

METHODS

The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure.

RESULTS

Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures.

CONCLUSIONS

This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

Laparoscopic Extraperitoneal Hernia Repair Versus Open Repair in Boys with Inguinal Hernia: A Meta-analysis

OBJECTIVE

Pediatric inguinal hernia is a common surgical problem in boys. Open hernia repair surgery (OH) has been traditionally used to treat this condition, but it leads to complications, such as testicular complications. Laparoscopic hernia repair by using the extraperitoneal method (LHE) is performed through the percutaneous insertion of sutures and extracorporeal closure of patent vaginalis processus; thus, injury to spermatic cord structures is avoided. However, a meta-analysis comparing LHE and OH is lacking.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. A meta-analysis of the retrieved studies was performed, and a random-effects model was used to calculate the pooled effect size. The primary outcome was testicular complications, including ascending testis, hydrocele, and testicular atrophy. The secondary outcomes were surgical metachronous contralateral inguinal hernia (MCIH), ipsilateral hernia recurrence, and operation time.

RESULTS

In total, 6 randomized controlled trials (RCTs) and 20 non-RCTs involving 17,555 boys were included. The incidence of ascending testis (risk ratio [RR]: 0.38, 95% confidence interval [CI]: 0.18-0.78; p = 0.008) and MCIH (RR: 0.17, 95% CI: 0.07-0.43; p = 0.0002) was significantly lower in LHE than in OH. The incidence of hydrocele, testicular atrophy, and ipsilateral hernia recurrence did not differ between LHE and OH.

CONCLUSION

Compared with OH, LHE led to fewer or equivalent testicular complications without increasing ipsilateral hernia recurrence. Moreover, MCIH incidence was lower in LHE than in OH. Hence, LHE could be a feasible choice with less invasiveness for inguinal hernia repair in boys.

LEVEL OF EVIDENCE

Treatment study, LEVEL III.

Retrospective analysis of bladder perforation risk in patients after augmentation cystoplasty using an extraperitoneal approach

BACKGROUND

Initial management of pediatric patients with neurogenic bladder is focused on clean intermittent catheterization and medical therapies. Those with more hostile or small capacity bladders require surgical intervention including bladder augmentation that can result in significant clinical sequelae. This study examines a rarely described approach wherein the bladder reconstruction is extraperitonealized by bringing bowel segments through a peritoneal window and then closed.

OBJECTIVE

The aim of this study was to determine if the rate of bladder rupture and subsequent morbidity differed between patients who have undergone an intraperitoneal versus extraperitoneal bladder augmentation. We hypothesized that an extraperitoneal approach reduced the risk of intraperitoneal bladder perforation, downstream Intensive Care Unit (ICU) admission, small bowel obstruction (SBO) requiring exploratory laparotomy, and ventriculoperitoneal (VP) shunt-related difficulties as compared to the standard intraperitoneal technique.

METHODS

A retrospective chart review was conducted to assess surgical approach and outcomes in patients who underwent bladder augmentation performed between January 2009 and June 2021. Patients were identified through an existing database and manual chart review was conducted to extract data through imaging studies, operative notes, and clinical documentation. The primary outcome was bladder perforation. Secondary outcomes were ICU admission, exploratory laparotomy, and VP shunt externalization, infection, or revision for any cause. Nonparametric statistical analyses were performed.

RESULTS

A total of 111 patients underwent bladder augmentation with 37 intraperitoneal and 74 extraperitoneal procedures. Median follow up was 5.8 years [IQR 3.0-8.6 years] and did not vary between groups (P = 0.67). Only one patient was found to have a bladder perforation in the intraperitoneal group (log-rank P = 0.154). There were no significant differences in time to post-augmentation ICU admission, exploratory laparotomy, or VP shunt events between the two groups (log-rank P = 0.294, log-rank P = 0.832, and log-rank P = 0.237, respectively). Furthermore, a Kaplan-Meier analysis assessing time to composite complication demonstrated no significant difference between the two techniques (log-rank P = 0.236).

DISCUSSION

This study provides important data comparing the rate of bladder perforation and subsequent morbidity between intraperitoneal and extraperitoneal bladder augmentation. As expected, with a complex procedure, both groups suffered complications, but these data showed no difference between the two procedures. Rates of prior (abdominal) surgery may influence the decision to perform this procedure extraperitoneal.

CONCLUSIONS

Outcomes related to bladder perforation and secondary consequences do not differ significantly between patients who had bladder augmentation performed with an intraperitoneal versus extraperitoneal approach. Given the low number of adverse events in this study, larger studies are warranted.

Extraperitoneal laparoscopic radical cystectomy with intracorporeal neobladder: a comparison with transperitoneal approach

Background

Bladder cancer is one of the most common genitourinary cancers. Traditional transperitoneal radical cystectomy is the gold standard treatment for muscle-invasive bladder cancer. Our study was to compare the perioperative and oncological outcomes of extraperitoneal laparoscopic radical cystectomy (ELRC) with intracorporeal neobladder versus transperitoneal urinary diversion for bladder cancer.

Method

A total of 113 patients who underwent laparoscopic radical cystectomy performed at our center were included in this retrospective study. The perioperative data of the extraperitoneal laparoscopic radical cystectomy (ELRC) with intracorporeal urinary diversion (ICUD) and transperitoneal laparoscopic radical cystectomy (TLRC) with ICUD groups were compared. The demographic, perioperative, oncological, and complication data were collected and analyzed.

Results

In total, 113 patients were enrolled for the final analysis. The median follow-up period was 22 months. The ELRC group had shorter interval to flatus (p < 0.001), solid food (p < 0.001), shorter length of hospital stay (p < 0.01), and fewer early gastrointestinal complications (p < 0.05). Furthermore, urinary continence, recurrence-free, cancer-specific, and overall survival rates and recurrence patterns did not significantly differ.

Conclusions

Surgical technique of ELRC with ICUD can achieve the established oncologic criteria of TLRC, and such technique can improve perioperative and early postoperative outcomes.

Super-veil nerve-sparing extraperitoneal pure single-port robotic-assisted radical prostatectomy on da Vinci Si robotic system

OBJECTIVES

To investigate the safety profile and short-term outcome of super-veil nerve-sparing extraperitoneal single-port robotic-assisted radical prostatectomy (espRARP) on da Vinci Si platform.

METHODS

From December 2018 to March 2021, 106 consecutive patients with treatment-naive prostate cancer were prospectively included. espRARP was performed on da Vinci Si surgical platform. Operative time, estimated blood loss, Clavien-Dindo complication classification, continence, potency recovery, quality-of-life scores, and postoperative prostate-specific antigen (PSA) were documented.

RESULTS

Patients aged 52-79 years (mean ± SD, 64.8 ± 6.15 yrs), with a median PSA of 9.2 ng/ml (IQR: 6.70, 16.83) and median prostate volume of 31.9 ml (IQR: 30.01, 38.54). 95.28% (101/106) were clinically localized. All patients underwent espRARP successfully with no open conversions. Operative time was 94.2 ± 30.26 min with an estimated blood loss of 68.5 ml (range, 50-120 ml). No Grade III complications or above were documented. Positive surgical margin was 17.9% (19/106). Median pain score at discharge was 0 (IQR: 0, 1.75) without use of opioid narcotics. Postoperative length of stay was 3 days (IQR: 1, 3), in which 28 patients were discharged within 24 h. Instant, 1-, 3-, and 6 month continence recovery was 18.9, 45.3, 79.2, 93.4, and 96.4%, respectively. Of the 43 patients who received nerve-sparing procedures, 13 (30.23%) resumed potency 6 months postoperatively. 12 month biochemical recurrence-free survival was 92.77% (77/83).

CONCLUSIONS

Extraperitoneal single-port robotic-assisted radical prostatectomy is a safe and feasible technique. Combined with super-veil nerve-sparing procedures, it may provide satisfactory outcome in short-term functional recovery.

Intraperitoneal versus extraperitoneal mesh in minimally invasive ventral hernia repair: a systematic review and meta-analysis

PURPOSE

The ideal location for mesh placement in minimally invasive ventral hernia repair (VHR) is still up for debate. We undertook a systematic review and meta-analysis (SRMA) to evaluate the outcomes of patients who received intraperitoneal mesh versus those that received extraperitoneal mesh in minimally invasive VHR.

METHODS

We searched PubMed, EMBASE, Cochrane, and Scopus from inception to May 3, 2021. We selected studies comparing intraperitoneal mesh versus extraperitoneal mesh placement in minimally invasive VHR. A meta-analysis was done for the outcomes of surgical site infection (SSI), seroma, hematoma, readmission, and recurrence. A subgroup analysis was conducted for a subset of studies comparing patients who have undergone intraperitoneal onlay mesh (IPOM) versus extended totally extraperitoneal approach (e-TEP).

RESULTS

A total of 11 studies (2320 patients) were identified. We found no statistically significant difference between patients who received intraperitoneal versus extraperitoneal mesh for outcomes of SSI, seroma, hematoma, readmission, and recurrence [(RR 1.60, 95% CI 0.60-4.27), (RR 1.39, 95% CI 0.68-2.81), (RR 1.29, 95% CI 0.45-3.72), (RR 1.40, 95% CI 0.69-2.86), and (RR 1.22, 95% CI 0.22-6.63), respectively]. The subgroup analysis had findings similar to the overall analysis.

CONCLUSION

Based on short-term results, extraperitoneal mesh does not appear to be superior to intraperitoneal mesh in minimally invasive ventral hernia repair. The choice of mesh location should be based on the current evidence, surgeon, and center experience as well as individualized to each patient.

Extraperitoneal laparoscopy for para-aortic lymphadenectomy in endometrial carcinoma staging: an approach with higher efficiency

Background

Removing more inframesenteric nodes is not only significantly increases the likelihood of finding metastasis for endometrial cancer, but also can add survival advantage. As most patients diagnosed with endometrial cancer are overweight or obesity, a high efficiency approach is important. Aim of this study was to compare the surgical outcomes of extraperitoneal laparoscopic, transperitoneal laparoscopic, and laparotomic para-aortic lymphadenectomy in endometrial carcinoma staging.

Methods

We retrospectively reviewed data of all patients diagnosed with primary endometrial carcinoma who were treated at the Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center from 1 January 2017 to 31 December 2019. The numbers of para-aortic lymph nodes, surgical time, complications, blood loss and hospital stay were compared. The patients’ medical records and pathological reports were carefully reviewed. Statistical significance was defined as p < 0.05.

Results

We retrospectively compared patients who underwent extraperitoneal laparoscopy (Group E, n = 20), transperitoneal laparoscopy (group T, n = 21), and laparotomy (group L, n = 135). The median number of para-aortic lymph nodes was significantly higher in group E than in groups T and L (9.5, 5, and 6, respectively; p = 0.004 and 0.0004, respectively). All patients in group E underwent successfully dissection to the renal vessel level. The median operation time was significantly shorter in group L than in groups T and E (94, 174, and 233 min, respectively; p < 0.0001). The median estimated blood loss volume was higher in group L than in groups T and E (200, 100, and 142.5 ml, respectively; all comparisons p < 0.001), and the length of hospital stay was significantly longer in group L than in Groups T and E (6, 5, and 6 days, respectively; all comparisons p < 0.001).

Conclusion

The extraperitoneal laparoscopic approach for staging endometrial carcinoma harvested higher numbers of para-aortic lymph nodes which could be considered for endometrial carcinoma staging, especially for para-aortic lymph node harvest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02416-x.

Laparoscopic Extraperitoneal Approach to Bilateral Pelvic Lymph Node Dissection in Low Rectal Cancer: Technique with Video and 3D Modeling

BACKGROUND

Lateral pelvic lymph node dissection for rectal cancer is a difficult technique due to the complex pelvic anatomy. Recent series have underlined the importance of lateral lymphadenectomy in selective patients to prevent local recurrence of rectal cancer.

METHODS

A 65-year-old woman was diagnosed with locally advanced rectal adenocarcinoma of the low rectum with right and left lateral pelvic lymph nodes of respectively 9 and 13 mm. After chemotherapy followed by radiotherapy, the size of the right internal iliac lymph nodes remained enlarged to 5 mm. A laparoscopic extraperitoneal approach was used for total mesorectal excision, complete mesocolic excision, and bilateral lateral lymph node dissection. The extraperitoneal space was divided into the subperitoneal space dissected by a transanal approach and the retroperitoneal space dissected by a transabdominal approach.

RESULTS

The operating time was 303 min, and the estimated blood loss was 270 ml. No intraoperative adverse events occurred. Bilateral lymph node dissection was performed with obturator nerve and neurovascular bundle sparing. A postoperative complication classified as Clavien 3a arose with a pelvic infection but no anastomotic leakage. Final pathology disclosed T3N1M0 adenocarcinoma with free surgical margins. The patient never had urinary dysfunction.

CONCLUSIONS

The laparoscopic extraperitoneal approach to lateral pelvic lymph node dissection is feasible. For lateral lymph node dissection, the transanal approach may have some advantages over the standard transabdominal approach, with better visibility of and access to the distal internal iliac area. This video may help oncological surgeons to perform this new and complex procedure.

Extraperitoneal Laparoscopic Radical Cystectomy With Preservation of Fertility for the Treatment of Ewing Sarcoma: The First Report of a Reliable Surgical Method

OBJECTIVE

To improve the complications of traditional laparoscopic radical cystectomy (LRC), a novel technique of extraperitoneal laparoscopic radical cystectomy (ELRC) with preservation of fertility was described.

MATERIALS AND METHODS

Selected patients with bladder cancer were treated with the ELRC technique. The seminal vesicles and the vas deferens were preserved. Patient's perioperative conditions, tumor prognosis, and follow-up data were analyzed retrospectively.

RESULTS

We successfully completed ELRC surgery in dozens of patients. The orthotopic ileal neobladder was placed in the extraperitoneal area, completely preserving the peritoneum. The postoperative complications caused by postoperative peritoneal loss were reduced. Moreover, the perioperative period was strictly managed with the concept of enhanced recovery after surgery (ERAS). We described the operation process in detail through a typical case of a child. All patients were free of complication at short-term follow-up, and reported satisfied sexual function with normal erections.

CONCLUSION

The ELRC technique has benefits in terms of decreased ileus, reoperation rates, hospital stay, ease of management of urinary leaks, and improves the patient quality of life. ELRC is also an oncologically safe approach with excellent significant functional outcomes in carefully selected transitional cell carcinoma (TCC) or non-TCC patients who expect to maintain sexual function and fertility, especially for young patients. In addition, more patient groups and longer follow-ups are needed to further understand the safety and practicality of the ELRC technology.

Laparoscopic repair of combined extra- and intraperitoneal bladder ruptures in a patient with blunt trauma: Use of the bladder suspension method

Urinary bladder rupture is commonly due to blunt abdominal trauma rather than penetrating trauma. Intraperitoneal bladder rupture (IBR) is a concrete indication of surgical management. On the other hand, surgeons should perform surgeries in patients with extraperitoneal bladder rupture (EBR) solely in complicated cases. Uncomplicated EBR is managed conservatively. Laparoscopic repair is safe and effective for the treatment of IBR. However, there are no contemporary guidelines on the application of laparoscopy for the management of EBR. Herein, we describe a case of combined EBR and IBR in a hemodynamically stable 45-year-old patient who sustained injuries after falling. Intravesical repair of EBR and intracorporeal repair of IBR with the bladder suspension method were successfully performed with laparoscopy. This is a rare case describing the feasibility of laparoscopic suturing for combined EBR and IBR in a patient with blunt trauma.

•

Laparoscopic repair of extra- and intraperitoneal bladder rupture is feasible.

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The bladder suspension method is recommended in such repair.

•

Knowledge of the indications for surgical repair of bladder is required.

[Para-arortic lymhadenectomy and pelvic gynecological cancers: Extraperitoneal or transperitoneal laparoscopy?]

INTRODUCTION

Para-aortic lymphadenectomy plays a fundamental role in the surgical management of pelvic gynecological cancers. Two laparoscopic approaches exist: the transperitoneal (TP) and the extraperitoneal (EP). The aim of this study was to compare these 2 approaches in terms of surgical outcomes, specially the number of removed lymph nodes according to the surgical technique, and morbidity.

MATERIALS AND METHOD

A single-center retrospective study was carried out at the Lariboisiere University Hospital between January 2011 and March 2020 including all patients who underwent para-aortic lymphadenectomy for the management of a pelvic gynecological cancer (cervix, endometrium, ovary). Univariate and multivariate analysis (logistic regression) were performed to compare the TP and the EP groups.

RESULTS

143 patients were included: 74 in the TP group and 69 in the RP group. The total duration of surgery was 220.8minutes in the TP group and 166.4minutes in the EP group (P<0.001 in multivariate analysis). No significant difference between groups were found in the average total number of lymph nodes removed but there was a statistically significant difference in the average latero-aortic number of lymph nodes removed: 8.5 lymph nodes in the TP group and 11.3 lymph nodes in the group RP (P<0.001 in multivariate analysis). There was no difference between groups in peri and postoperative morbidity.

CONCLUSION

EP para-aortic lymphadenectomy reduces duration of surgery and increases the average latero-aortic number of lymph nodes removed with same morbidity compared to TP para-aortic lymphadenectomy, this confirming its preferred indication in endometrial and in cervical cancers.

Transperitoneal versus extraperitoneal laparoscopic aortic lymph nodal staging for locally advanced cervical cancer: A systematic review and meta-analysis

Cervical cancer is the fourth most common neoplasm in women. In locally advanced cervical cancers, the international guidelines recommend nodal aortic assessment. Two techniques have been described to perform laparoscopic aortic lymphadenectomy: transperitoneal laparoscopic lymphadenectomy (TLL) and extraperitoneal laparoscopic lymphadenectomy (ELL). This meta-analysis aims to compare the surgical outcomes of TLL and ELL for staging purposes. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). Two hundred and twenty studies were analyzed, and 19 studies were included in the review (7 for TLL and 12 for ELL group). 1112 patients were included in the analysis: 390 patients were included in group 1 and 722 patients in group 2.38 patients (9.7%) in the TLL group and 69 (9.5%) patients in the ELL group developed major complications. The analysis of all complications (intraoperative and postoperative) rate through pooled analysis did not show a significant difference between the two groups (p = 0.979), although a significantly higher intraoperative complication rate (p = 0.018) occurred in the TLL group compared to ELL. No significant differences were found between groups for BMI (p = 0.659), estimated blood loss (p = 0.889), length of stay (p = 0.932), intraoperative time (p = 0.932), conversion to laparotomy rate (p = 0.404), number of lymph node excised (p = 0.461) and postoperative complication (p = 0.291). TLL approach shows a higher rate of intraoperative complications, while no significant difference was found between the two techniques when postoperative complications were analyzed.

Extraperitoneal versus transperitoneal approach for robot-assisted radical prostatectomy: a contemporary systematic review and meta-analysis

We aim to evaluate the differences in peri-operative characteristics, surgical complications, and oncological and functional control between the extraperitoneal RARP (EP-RARP) and transperitoneal RARP (TP-RARP). A comprehensive database search was performed up to March 2021 for eligible studies comparing outcomes between EP-RARP versus TP-RARP. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO. A leave-one-out sensitivity analysis was performed to control for heterogeneity and risk of bias. A total of 16 studies were included with 3897 patients, including 2201 (56.5%) EP-RARPs and 1696 (43.5%) TP-RARPs. When compared to TP-RARP, EP-RARP offers faster operative time (MD - 14.4 min; 95% CI - 26.3, - 2.3), decreased length of post-operative stay (MD - 0.9 days, 95% CI - 1.3, - 0.4), and decreased rates of post-operative ileus (RR 0.2, 95% CI 0.1, 0.7) and inguinal hernia formation (RR 0.2, 95% CI 0.1, 0.5). There were no significant differences in total complications, estimated blood loss, positive surgical margins, or continence at 6 months. In this review, EP-RARP delivered similar oncological and functional outcomes, while also offering faster operative time, decreased length of post-operative stay, and decreased rates of post-operative ileus and inguinal hernia formation when compared to TP-RARP. These findings provide evidence-based data for surgical approach optimization and prompts future research to examine whether these findings hold true with recent advances in single-port RARP and outpatient RARP.

Laparoscopic intraperitoneal versus enhanced-view totally extraperitoneal retromuscular mesh repair for ventral hernia: a retrospective cohort study

BACKGROUND

Laparoscopic enhanced-view totally extraperitoneal retromuscular repair (eTEP-RM) was recently introduced as a new technique for ventral hernia repair. The aim of the current study was to examine the outcomes of laparoscopic eTEP-RM compared with laparoscopic IPOM for patients with primary ventral and incisional hernia.

METHODS

This was a retrospective cohort study of patients undergoing laparoscopic ventral hernia repair at a single University Hospital from June 2017 to November 2020. Medical charts of all patients subjected to IPOM and eTEP-RM were evaluated to identify patient- and procedure related variables, as well as postoperative 30-day outcomes.

RESULTS

A total of 72 patients were included in the study, 43 and 29 of whom underwent IPOM and eTEP-RM repair, respectively. Patient demographics showed no differences in terms of gender, age, smoking and comorbidity. The median age was 57 years and body mass index 30.5 kg/m². The rate of patients with incisional hernia was higher in the IPOM group (39.5% vs. 20.7%, p = 0.154). There was no difference in horizontal and vertical hernia size defect. The duration of surgery was significantly shorter for IPOM (mean 82.4 vs. 103.4 min, p = 0.010), whereas the length of stay was significantly longer after IPOM (median 1 days vs. 0 days (p < 0.001). The rate of patients requiring postoperative transversus abdominis plane (TAP) block or epidural analgesia was significantly higher after IPOM (33% vs. 0%, p = 0.002). A subgroup analysis on patients undergoing primary ventral hernia showed similar results.

CONCLUSION

The study found laparoscopic eTEP-RM safe and effective compared to traditional laparoscopic IPOM. The patients undergoing eTEP-RM had significantly reduced need for additional analgesic treatment and length of stay.

Extraperitoneal Laparoscopic Kidney Transplantation: Preliminary Clinical Experiences from China

OBJECTIVE

To report on the pioneering clinical experiences of six cases of extraperitoneal laparoscopic kidney transplantation in China.

METHODS

For the first time in clinical practice, a customised, controllable double-circulation cooling device was used to protect the transplanted kidney. Of the six patients, two underwent an allograft renal transplantation because they had been diagnosed with uraemia and were on maintenance haemodialysis. The other four patients underwent kidney autotransplantation because of a central renal tumour.

RESULTS

The extraperitoneal laparoscopic kidney transplantations were successfully completed between 2017 and 2018. The operative time for the two patients undergoing the allograft transplantation was 3-3.5 h. The time for venous anastomosis was approximately 53-65 min, and the time for arterial anastomosis was approximately 25-30 min. The creatinine level was 90-80 μmol/L after surgery. The operative time of the four patients who underwent autotransplantation was 9.4-17.5 h. The times of venous and arterial anastomosis were 58-90 min and 35-48 min, respectively. The follow-up B-mode ultrasound after surgery showed good blood supply in the spared nephron. A renal graft was removed from one patient 6 months after surgery because of renal atrophy and dysfunction caused by poor blood supply. Five patients (two undergoing allografting and three undergoing autografting) completed the 12-month follow-up, and their renal graft function was good.

CONCLUSIONS

Extraperitoneal laparoscopic kidney transplantation, either allograft or autologous transplantation, is a safe and feasible procedure with a good chance of survival for the transplanted kidney. A customised cooling device is effective and practical during laparoscopic kidney transplantation.

Safety and efficacy in inguinal hernia repair: a retrospective study comparing TREPP, TEP and Lichtenstein (SETTLE)

BACKGROUND

This pilot trial investigates whether the trans rectus sheath extra-peritoneal (TREPP) mesh repair is a safe and effective procedure compared to the currently most performed inguinal hernia repair techniques TEP and Lichtenstein.

METHODS

Three hundred patients older than 18 years with unilateral inguinal hernia were included in this retrospective cohort study, of which 58 (19.3%) underwent TREPP, 190 (63.3%) TEP and 52 (17.3%) Lichtenstein. The primary outcome of this study was inguinal hernia recurrence rate within 1 year after surgery. Secondary objectives were chronic post-operative inguinal pain (CPIP) lasting more than 6 months, (major) complication rates and operating time.

RESULTS

Recurrence rate within 1-year post-operative was low overall in the study population and did not differ significantly between TREPP, TEP and Lichtenstein, respectively 1.7, 2.1, 0.0% (P = 0.591). The rate of CPIP for which the patient contacted the hospital was similar in the study groups: TREPP: 1.7%; TEP: 1.6%; Lichtenstein: 1.9%; (P = 0.591). The mean operating time in minutes (SD) was significantly shorter in the TREPP group compared with the two other patient groups (TREPP: 22.2 (± 5.7); TEP: 38.7 (± 14.8); Lichtenstein: 49.3 (± 17.1), P < 0.001). No major complications occurred in any patient of the study groups.

CONCLUSION

TREPP seems to be an effective and safe technique for unilateral primary inguinal hernia repair. It is found to be comparable to TEP and Lichtenstein in terms of recurrence rates, chronic post-operative inguinal pain, and clinically significant adverse events. This pilot study proves the need for future research into the TREPP technique.

Comparison between mesh fixation and non-fixation in patients undergoing total extraperitoneal inguinal hernia repair

Background

The most important advantages of laparoscopic hernia repair include less postoperative pain, good cosmetic results, and early return to daily activities. Different methods and mesh types are used in inguinal hernia repair.

Aims

The objective of this study was to evaluate the complications and recurrence rates in patients who underwent laparoscopic inguinal hernia repair with and without mesh fixation.

Subjects and Methods

A total of 183 patients who underwent total extraperitoneal (TEP) inguinal hernia repair in the general surgery clinic between January 2012 and January 2015 patients operated due to inguinoscrotal hernia and those lost to follow-up were excluded from the study. Patients were divided into two groups. Group 1 consisted of patients in whom 3D (Bard 3D Max) mesh was used and fixed with symphysis pubis absorbable tucker, while group 2 included patients without mesh fixation. All statistical analyses were performed using SPSS 22.0 statistical package software. The differences were considered statistically significant if the P value was less than 0.05.

Results

In the study, 178 patients were included. The median age was 48 years. Of all patients, 98 had right-sided, 72 left-sided, and eight bilateral hernias. The mean follow-up duration was 45 months. The demographic data between the groups were similar. Operation time was 51.82 ± 18.87 min in group 1 and 52 ± 19.92 in group 2 (P = 0.089). No statistically significant difference was found between both groups in terms of the development of early and late complications. Intraoperative complications, port-site hernia, and mortality were not seen in any patient.

Conclusion

TEP seems to be a safe and effective surgical approach in inguinal hernia treatment with acceptable operation times and postoperative results. It was determined that not performing mesh fixation in the TEP application did not cause a statistical increase in morbidity and recurrence rates.

Cross-sectional anatomy of the male pelvis

The visceral organs of the male pelvis have complex anatomic relationships with the surrounding extraperitoneal spaces, supplying arteries and adjacent pelvic musculature. Since various neoplastic, vascular, and traumatic pathologies can often involve multiple organs and spread into adjacent pelvic spaces, a keen understanding of this intricate anatomy can help radiologists to accurately characterize findings and improve recognition of the routes in which these conditions can spread. The purpose of this review is to examine the relationships between the anatomic compartments of the pelvic extraperitoneal space, summarize the pelvic arterial anatomy, and identify the pelvic muscles that support normal genitourinary function.

Fixation versus no fixation in laparoscopic totally extraperitoneal repair of primary inguinal hernia-a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The necessity of mesh fixation in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair remains controversial. We performed a systematic review and meta-analysis to compare the effectiveness of mesh fixation versus no fixation in laparoscopic TEP repair for primary inguinal hernia.

MATERIALS AND METHODS

PubMed, EMBASE, and Cochrane databases were searched for relevant articles from January 1992 until May 2020. All trials that compared fixation versus no fixation in TEP repairs for inguinal herniae were included. Recurrent and femoral herniae were excluded from the current analysis. The primary outcome measure was recurrence while secondary outcomes included postoperative pain at 24 h, mean operative time, urinary retention, and seroma rates. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also carried out.

RESULTS

Eight randomized controlled trials were included capturing 557 patients and 715 inguinal herniae. On random effects analysis, there were no significant differences between fixation and no fixation with respect to recurrence (RD 0.00, 95% CI = - 0.01 to 0.01, p = 1.00), operative time (MD 1.58 min, 95% CI = - 0.22 to 3.37, p = 0.09), seroma (OR = 0.70, 95% CI = 0.28 to 1.74, p = 0.44), or urinary retention (RD 0.09, 95% CI = - 0.18 to 0.36, p = 0.53). However, fixation was associated with more pain at 24 h (MD 0.93, 95% CI = 0.20 to 1.66, p = 0.01).

CONCLUSIONS

Mesh fixation in laparoscopic TEP repair for primary inguinal herniae is associated with increased postoperative pain at 24 h but similar recurrence, seroma, and urinary retention. Therefore, it may be omitted.

Robotic-Assisted Laparoscopic Ventral Hernia Repair

Robotic-assisted laparoscopic ventral hernia repair (RA-LVHR) has many options. Before applying these techniques, it is important to identify the patient's goals for hernia repair, align yourself with those goals, and apply a technique appropriate for the clinical scenario, and most likely to meet the goals. Fundamental principles of hernia repair must be maintained: avoiding thermal injury to hollow viscera, adequate dissection of abdominal wall, appropriate mesh:defect ratio, stronger fixation where overlap is limited, and more overlap where fixation points are weak. This manuscript will detail available techniques for RA-LVHR along with their their advantages and disadvantages.

Albumin for cirrhotic patients with extraperitoneal infections: A meta-analysis

BACKGROUND AND AIM

Bacterial infections are among the main causes of death in patients with cirrhosis. While there are unquestionable benefits of using albumin in patients with spontaneous bacterial peritonitis, the benefits of albumin are controversial for those with extraperitoneal infections. The aim was to compare the use of albumin associated to antibiotics and antibiotics alone in cirrhotic patients with extraperitoneal infections.

METHODS

A systematic review was performed using MEDLINE and Embase databases. Randomized controlled trials comparing albumin associated to antibiotics and antibiotics alone in cirrhotic patients with extraperitoneal infections were considered eligible, as long as at least one of the following outcomes was evaluated: mortality and renal dysfunction. Meta-analysis was performed using the random effects model, through the Mantel-Haenszel method. The study protocol was registered at PROSPERO platform (CRD42018107191).

RESULTS

The literature search yielded 812 references. Three randomized controlled trials fulfilled the selection criteria and were included in this meta-analysis. There was no evidence of significant difference between the groups regarding mortality in 30 days (risk ratio [RR] = 1.62, 95% confidence interval [CI]: 0.92-2.84, P = 0.09, I² = 0%) or in 90 days (RR = 1.27, 95% CI: 0.89-1.83, P = 0.19, I² = 0%). Regarding renal dysfunction, there was also no evidence of significant difference between the groups (RR = 0.55, 95% CI: 0.25-1.19, P = 0.13, I² = 0%).

CONCLUSION

There is no evidence of significant benefits of using albumin for cirrhotic patients with extraperitoneal infections regarding mortality or renal dysfunction.

Telescopic dissection versus balloon dissection for laparoscopic totally extraperitoneal inguinal hernia repair (TEP): a registry-based randomized controlled trial

OBJECTIVE

Laparoscopic totally extraperitoneal inguinal hernia repair (TEP) can be performed using either telescopic (TD) or balloon dissection (BD). The use of a disposable balloon dissector increases the cost of TEP. However, it remains unclear whether BD saves enough time to justify its cost. We hypothesized that BD would consistently save 15 min in operative time. To test this hypothesis, we designed a registry-based randomized controlled trial (RB-RCT) embedded into the Americas Hernia Society Quality Collaborative.

METHODS

A single-blinded, parallel, RB-RCT was conducted. Adults with inguinal hernias presenting for elective repair were screened. Patients with unilateral hernias deemed fit to undergo TEP were eligible; those with bilateral hernias (BIH) or undergoing open repair were excluded. Individuals were randomized to TD or BD with a disposable device. TEP was performed with synthetic mesh and tacks. Subjects were blinded and followed up for 30 day. Main outcome was operative time.

RESULTS

207 patients were screened: 166 were excluded and 41 were randomized (21 BD, 20 TD). One patient (TD group) was excluded due to the incidental finding of BIH. 40 patients were analyzed (median age 56, median BMI 26 kg/m², 98% males). Hernias were 72% indirect, 17% direct, 10% pantaloon, and 8% recurrent. Other than obesity (26.5% vs. 0, p = 0.018), there were no baseline differences between the groups. Median operative times were similar (TD 43 min, IQR 33-63; BD 46 min, IQR 35-90, p = 0.490). There were 2 seromas and 2 hematomas in the BD group, and none in the TD (p = 0.108).

CONCLUSIONS

BD does not consistently result in 15-min time saving during TEP. Use of a disposable balloon dissector can be deferred in the experienced hands.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03276871).

Extraperitoneal laparoscopic ventral hernia repair: one step beyond

PURPOSE

The objective of the study was to analyze the experience of the Department of Surgery of two institutions of high complexity in Colombia, with the extra peritoneal ventral hernia repair by laparoscopy during the last 2 years and characterize the clinical and surgical aspects most relevant in the procedures performed.

METHODS

Observational, descriptive, retrospective study, case series type: collection of data by clinical history and analysis thereof including calculation of frequency and central tendency measurements.

RESULTS

59 Cases of Ventral Hernia Repair by laparoscopy, 41 with Transabdominal Preperitoneal approach and 18 totally Extraperitoneal. In total, 7 complications were presented as follows: 1 Case of recurrence, 1 case of chronic pain, 2 complications Dindo-Clavien IIIa and 1 complication IIIb.

CONCLUSIONS

The repair of the ventral hernia by Extraperitoneal route is an innovative approach of increasing popularity, which avoids the contact of the mesh with the intestines, thus avoiding the potential complications that this situation generates with good outcomes and at a lower cost.

Single-port laparoscopic herniorrhaphy using a two-hooked cannula device with hydrodissection

BACKGROUND

Laparoscopic percutaneous extraperitoneal closure (LPEC) with variable devices seems to be one of the most simple and reliable methods. We described our modifications of single-port laparoscopic herniorrhaphy using an inner two-hooked cannula device with preperitoneal hydrodissection.

PATIENTS AND METHODS

1568 children with 2114 inguinal hernias were treated by single-port LPEC. Under laparoscopic visualization, the two-hooked cannula device carrying a silk suture was inserted at the point of the internal ring and could be readily kept in an identical path. The hernia orifice was completely lassoed extraperitoneally by the suture with the assistance of hydrodissection. Any huge hernias of more than 1.5 cm were repaired with the incorporation of medial umbilical fold flap as reinforcement.

RESULTS

All hernia repairs were successfully performed by LPEC. 1022 patients had unilateral inguinal hernia repair, and 546 patients underwent bilateral inguinal hernia repair. Of these, additional medial umbilical flap reinforcement was necessary in 68 cases, and an assisted grasping instrument was used in 19 cases owing to omental adhesion or sliding hernia. Mean operating times for unilateral and bilateral inguinal hernia repairs were 9.8 ± 2.1 min and 13.6 ± 2.2 min, respectively. There were no operative complications. Two recurrences and three hydroceles were observed during 6 to 30 months of follow-up.

CONCLUSIONS

One-puncture LPEC using the two-hooked cannula device with preperitoneal hydrodissection has proved to be a safe and effective procedure with excellent cosmetic results.

LEVEL OF EVIDENCE

IV.

The rare case of an extraperitoneal ureteral herniation into the inguinal canal of a 12-year-old boy

Ureteric herniation into the inguinal canal is a rare condition in adults and even more so in the paediatric population. These hernia types can be categorised as paraperitoneal or extraperitoneal. The former are the only varieties encountered in the paediatric literature, where patients are generally infants, while the latter phenomenon is seen in 20% of ureteric herniations in adults. We present a case of an extraperitoneal ureteric herniation into the inguinal canal in a 12-year-old boy with previous surgery for cloacal exstrophy, analyse the existing literature on the condition and make the speculation that the extraperitoneal variety is an adult variant seen in this child because of weakness in the surrounding structures as a result of previous surgery.

Left Lateral Endosurgical Extraperitoneal Total Hysterectomy with Para-Aortic and Pelvic Lymphadenectomy: A Novel Approach for the Obese Patient with Endometrial Cancer

STUDY OBJECTIVE

To describe the left lateral extraperitoneal approach to perform complete para-aortic and pelvic lymphadenectomy and transverse total hysterectomy from left to right as a novel approach to treat obese patients with endometrial cancer. Laparoscopic management of obese patients represents a challenge for the gynecologic surgeon. The extraperitoneal approach is technically easier in the obese patient because it naturally creates a bowel-free operative field.

DESIGN

A prospective pilot bicentric and descriptive study (Canadian Task Force classification III) evaluating the feasibility and reproducibility of the transverse total hysterectomy and complete lymphadenectomy through left endoscopic extraperitoneal approach in obese patients with endometrial cancer.

SETTING

A comprehensive cancer center in Toulouse and a teaching university hospital in Madrid.

PATIENTS

Sixteen consecutive overweight or obese patients (body mass index > 25 kg/m²) with high-risk endometrial cancer.

INTERVENTIONS

Currently, the left extraperitoneal approach is routinely used to perform complete para-aortic and pelvic lymphadenectomy. It provides direct access to the left ureter and uterine pedicle. This access can be extended to the right side when performing a transverse extrafascial hysterectomy from left to right. The procedure starts from the left extraperitoneal space, where the left uterine artery is sectioned and the vesicovaginal and rectovaginal septa are developed, without opening the peritoneum. Colpotomy is performed from the left to the right side. Once the right ureter is identified, the right uterine artery can be safely transected. Alternatively, the right uterine artery can be sealed and sectioned during the right pelvic lymphadenectomy. At the end of the procedure the peritoneum is opened to complete the surgery.

MEASUREMENTS AND MAIN RESULTS

Between May 2015 and February 2016, 16 consecutive obese patients were successfully treated using this technique. Median patient age was 62 years (range, 44-78), and median body mass index was 32.5 kg/m² (range, 26-42). In 3 cases the right uterine artery was sealed during the right pelvic lymphadenectomy, in 11 cases after completing vaginal opening, and in 2 cases after peritoneal opening. The median operative time was 137.5 minutes (range, 66-260). The median blood loss was 85 mL (range, 0-260), and no blood transfusion was required in any of our 16 patients. No significant complications occurred.

CONCLUSION

The full extraperitoneal approach represents an interesting alternative strategy for the surgical treatment of obese patients with high-risk endometrial cancer.

Laparoscopic extraperitoneal repair versus open inguinal hernia repair: 20-year follow-up of a randomized controlled trial

PURPOSE

This study compared the long-term recurrence rates of laparoscopic totally extraperitoneal (TEP) and open inguinal hernia repair in patients from a randomised trial completed in 1994. Laparoscopic inguinal hernia surgery, especially TEP repair, has gained widespread acceptance in recent years. There is still paucity of data on long-term follow-up comparing recurrence rates for open and laparoscopic techniques. This is the first study providing direct long-term comparative data about these techniques.

METHODS

A randomised controlled trial was conducted between 1992 and 1994 on patients undergoing a laparoscopic TEP or an open inguinal hernia (Shouldice) repair at our institution. Of the original 104 participants, contemporary follow-up data could be obtained for 98 patients with regards to long-term recurrence. These data were collected with the help of questionnaires, telephone calls and retrieval of case records. Medical records were reviewed for all patients. Data were analysed using a Cox proportional hazards model.

RESULTS

There were 7/72 (9.7%) recurrences in the open group and 9/35 (25.7%) recurrences in the laparoscopic group. This difference in recurrence rates was statistically significant (HR = 2.94; 95% CI 1.05-8.25; p = 0.041.) CONCLUSION: Laparoscopic TEP inguinal hernia repair performed in 1992-1994 had a higher recurrence rate than open Shouldice inguinal hernia repair during the same period. The original study was undertaken in the inceptive days of laparoscopic surgery and results need to be interpreted considering the technology and expertise available at that time.

Critical appraisal of literature comparing minimally invasive extraperitoneal and transperitoneal radical prostatectomy: A systematic review and meta-analysis

Objectives

To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP).

Methods

The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be ≥6 months.

Results

In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of −0.30 days (95% confidence interval [CI] −0.35, −0.24) for the laparoscopic group and 1.09 days (95% CI −1.47, −0.70) for the robotic group (P < 0.001). Early continence rates favoured the E-RP group, although this was statistically significant only in the laparoscopic group (odds ratio [OR] 2.52, 95% CI 1.72, 3.70; P < 0.001). There was no statistically significant difference between the E-RP and T-RP cohorts for 12-month continence rates for both the laparoscopic (OR 1.55, 95% CI 0.89, 2.69; P = 0.12) and robotic groups (OR 3.03, 95% CI 0.54, 16.85; P = 0.21). The overall complication and ileus rates were significantly lower in the E-RP cohort for both the laparoscopic and robotic groups. The symptomatic lymphocele rate favoured the T-RP cohort, although this was statistically significant only in the laparoscopic group (OR 8.69, 95% CI 1.60, 47.17; P = 0.01).

Conclusion

This review suggests that the extraperitoneal approach is associated with a shorter hospital stay, lower overall complication rate, and earlier return to continence when compared to the transperitoneal approach. The transperitoneal approach has a lower lymphocele rate.

Totally extraperitoneal approach for ventral hernia

BACKGROUND

In open surgery, extraperitoneal sublay mesh implantation is generally preferred to intraperitoneal placement, following the same principles as in "giant prosthetic reinforcement of the visceral sac" described for inguinal hernia repair [1, 2]. Miserez and Penninckx in 2002 described an endoscopic totally preperitoneal ventral hernia repair in a small cohort of 15 cases [3]. Unfortunately, this technique has not spread, probably because of the technical difficulties that require, but not for effectiveness.

METHODS

This video demonstrates the detailed operative technique and feasibility for performing extraperitoneal mesogastric hernia repair endoscopically. After insufflation of CO₂ in Retzius space, 3 trocars were introduced on semilunar line once identified the correct retromuscular plane. Blunt dissection was done up to midline. Above arcuate line, linea alba was incised in order to open the contralateral posterior rectus sheath and dissection proceeded laterally until the contralateral semilunar line. Hernia sac was reduced and the defect of posterior rectus sheath and peritoneum was closed with continuous suture. A composite mesh was placed without fixation.

RESULTS

Operative time was 150 min without blood loss. Interruption of pain medication was in the first post operative day and discharge in second post operative day. One week after surgery, an ultrasound assessment was done to evaluate presence of seroma.

CONCLUSIONS

Although this approach will not become the gold standard, certainly it presents some innovative elements such as non-exposure of the mesh with the abdominal viscera and the improvement of the comfort avoiding fixing system such as tacks. Comparison between the current endoscopic techniques is required. Totally extraperitoneal (TEP) approach for ventral hernia is safe and feasible.

Single-port endoscopic mesocolic and mesorectal excision using an extraperitoneal approach

BACKGROUND

The extraperitoneal rectal dissection via a transanal approach facilitates the mesorectal dissection. The retroperitoneal approach for mesocolic excision may also offer some similar advantages. To complete the lymphadenectomy of extraperitoneal mesorectal resection, we developed an innovative approach for upper rectal and mesocolic excision via an exclusive retroperitoneal dissection using a single-port access at the site of the future stomy.

METHODS

This study was a prospective pilot study and was conducted between 2013 and 2015 at two oncologic centers. Five consecutive patients, with ano-rectal cancer requiring permanent stoma, underwent this procedure.

RESULTS

The bowel was never touched or mobilized to perform the lymphadenectomy, and no Trendelenburg was required. The median operative duration was 300 min (range 205-310). The quality of the surgical plane was classified as good (mesorectal) in the five patients. The median circumferential and distal margins were, respectively, 5 mm (range 1-20) and 20 mm (range 5-25). The median number of harvested lymph nodes was 11 (range 5-18). No laparotomy or multiport laparoscopy was required. There was no death. Two patients had perineal wound dehiscence (one minor and one major).

CONCLUSIONS

The mesocolic excision via a retroperitoneal approach is feasible, completes naturally the transanal mesorectal excision and may confer several advantages including no morbidity of small bowel manipulation or Trendelenburg position. Further studies are required to analyze this approach.

Teaching the transrectus sheath preperiotneal mesh repair: TREPP in 9 steps

BACKGROUND

The preperitoneal mesh position seems preferable to reduce the number of patients with postoperative chronic pain after inguinal hernia surgery. The transrectus sheath preperitoneal mesh repair (TREPP) is gaining popularity. Teaching a new technique requires a standardized approach to achieve an optimal learning curve. The aim of this paper was to provide a step-by-step teaching module for hernia surgeons learning the TREPP.

METHODS

Literature was critically reviewed and the forthcoming nine surgical steps of the new TREPP technique and its rationale are described in this article. The TREPP hernia repair technique is illustrated with an online education video and three photos of the anatomical landmarks and the proposed mesh position of TREPP.

RESULTS

The nine steps of TREPP are described extensively and the critical steps are presented in a standardized way for surgical educational purposes. Also the rationale and technical considerations of inguinal hernia experts are presented.

DISCUSSION

TREPP may be a promising technique for groin hernia surgery. To date there have been no major complications with the TREPP repair which is currently the subject of a RCT. The learning curve of TREPP is being investigated and teaching of this technique requires standardization for trainee surgeons.

CONCLUSION

TREPP potentially merges the advantages of a preperitoneal positioned mesh with an open technique. Initial results are promising and TREPP seems to be applicable in different hospitals in the Netherlands. Since the start of an active teaching program, TREPP has been introduced and accepted well by dedicated hernia surgeons in other hospitals in the Netherlands and Europe.

[Complicated diverticular disease debuting as necrotising fasciitis of pelvic limb. A case report]

BACKGROUND

Diverticular disease, and the diverticulitis, the main complication of it, are widely studied diseases with multiple chronic cases reported in the literature, but there are no atypical presentations with extra-abdominal symptoms coupled with seemingly unrelated entities, such as necrotising fasciitis.

CLINICAL CASE

Female 52 years old, was admitted to the emergency department with back pain of 22 days duration. History of importance: Chronic use of benzodiazepines intramuscularly. Physical examination revealed the presence of a gluteal abscess in right pelvic limb with discoloration, as well as peri-lesional cellulitis and crepitus that stretches across the back of the limb. Fasciotomy was performed with debridement of necrotic tissue. Progression was torpid with crackling in abdomen. Computed tomography showed free air in the cavity, and on being surgically explored was found to be complicated diverticular disease.

DISCUSSION

It is unusual for complicated diverticular disease to present with symptoms extra-peritoneal (< 2%) and even more so that a diverticulitis is due to necrotising fasciitis (< 1%). The absence of peritoneal manifestations delayed the timely diagnosis, which was evident with the crackling of the abdomen and abdominal computed tomography scan showing the parietal gaseous process.

CONCLUSION

All necrotising fasciitis needs an abdominal computed tomography scan to look for abdominal diseases (in this case diverticulitis), as their overlapping presentation delays the diagnosis and consequently the treatment, making a fatal outcome inevitable.

Extraperitoneal Robotic-Assisted Para-Aortic Lymphadenectomy in Gynecologic Cancer Staging: Current Evidence

We reviewed the current evidence on the safety, effectiveness, and applicability of extraperitoneal robotic-assisted para-aortic lymphadenectomy (ExtRA-PAL) as the staging procedure of gynecologic malignancies. PubMed (MEDLINE), Scopus, Web of Science databases, and ClinicalTrials.gov were searched for original studies reporting outcomes of ExtRA-PAL. Quality of the included studies and their level of recommendation were assessed using the Grading of Recommendations, Assessment, Development, and Evaluation and the American College of Obstetricians and Gynecologists guidelines, respectively. Overall, 62 studies were identified; after a process of evidence acquisition 5 original investigations were available for this review that included 98 patients undergoing ExtRA-PAL. The main surgical indication was staging for cervical cancer (n = 71, 72%). The mean (SD) number of para-aortic node yielded was 15.4 (±4.7) nodes. Blood transfusion and intraoperative complication rates were 2% and 6%, respectively. ExtRA-PAL was completed in 88 patients (90%). Six (6%) and 4 (4%) patients had conversion to other minimally invasive procedures and open surgery, respectively. Success rate was 99% among patients undergoing ExtRA-PAL without concomitant procedures. Overall, mean (SD) length of hospital stay was 2.8 (±0.5) days. Twenty-four patients (24%) developed postoperative events. According to the Clavien-Dindo grading system, grades IIIa and IIIb morbidity rates were 12% and 2%, respectively. No grades IV and V morbidity occurred. ExtRA-PAL is associated with a high success rate and a relative low morbidity rate. However, because of the limited data on this issue, further studies are warranted to assess the long-term effectiveness of this procedure.

Laparoscopic percutaneous inguinal hernia repair in children: review of technique and comparison with open surgery

INTRODUCTION

Minimally-invasive approaches for inguinal hernia repair have evolved from conventional laparoscopy requiring placement of three ports and intracorporeal suturing to simple, one and two port extraperitoneal closure techniques. We utilize a single port laparoscopic percutaneous repair (LPHR) technique for selected children requiring operative intervention for inguinal hernia. We suspect that compared to open surgery, LPHR offers shorter operative duration with comparable safety and efficacy. Our objectives are to (1) illustrate this technique and (2) compare operative times and surgical outcomes in patients undergoing LPHR versus traditional open repair.

METHODS

We reviewed operative times, complications, and recurrence rates in 38 patients (49 hernias) who underwent LPHR at our institution between January 2010 and September 2013. These data were compared with an age-, gender-, weight-, and laterality-matched cohort undergoing open repair during the same 3 year period. All cases were performed by a pediatric urologist or pediatric surgeon.

RESULTS

Thirty-eight patients with a median age of 21.5 months underwent LPHR, and 38 patients with a median age of 23 months underwent open repair. In both groups, 27/38 patients (71%) had unilateral repairs, and 11/38 patients (29%) had bilateral repairs. For unilateral procedures, average operative duration was 25 min for LPHR and 59 min for OHR (p < 0.001). For bilateral procedures, average operative duration was 31 min for LPHR and 79 min for OHR (p < 0.001). There were no intraabdominal injuries in either group. In the LPHR group, there were no vascular or cord structure injuries and no conversions to open technique. Median follow-up was 51 days for the LPHR group and 47 days for the OHR group (p = 0.346). No hernia recurrence was observed in either group.

CONCLUSIONS

In select patients, LPHR is an efficient, safe, and effective minimally invasive alternative to OHR, with reduced operative times but without increased rates of complications or recurrences. The technique has a short learning curve and is a practical alternative to OHR for pediatric urologists who infrequently utilize pure laparoscopic technique.

Robotic retroperitoneal lymph node dissection in gynaecological neoplasms: comparison of extraperitoneal and transperitoneal lymphadenectomy

OBJECTIVE

The main aim of our study is to review the till now available literature data on the role of robotic retroperitoneal lymph node dissection in gynaecological cancers by comparing the extraperitoneal versus the transperitoneal approach.

METHODS

A thorough and systematic search was performed in electronic databases of PubMed and Scopus.

RESULTS

The extraperitoneal approach is described in 148 patients. The age of the patients ranged from 26 to 78 years. The indications included cervical, endometrial and ovarian carcinoma in 113, 22 and 12 patients, respectively. The operative time ranged between 45 and 410 min. The number of dissected lymph nodes ranged from 3 to 25, while only 13 of them were found to be positive. The mean estimated blood loss during the operation was 77 ml (range <50-200 ml). Seven cases were converted to open. The duration of hospital stay ranged from 2 to 14 days. The transperitoneal approach is described in 898 patients. The age of the patients ranged from 15 to 89 years. Cervical, endometrial and ovarian carcinomas were the principal neoplasias present in 248, 449 and 164 patients, respectively. The operative time ranged from 19 to 633 min. The number of dissected lymph nodes ranged from 1 to 54, while the total number of patients with positive lymph nodes dissected was 56 patients. The estimated blood loss during the operation varied between 20 and 1800 ml. Only 9 out of 898 patients were converted to open. The duration of hospital stay ranged from 1 to 40 days.

CONCLUSION

A reliable definition of the "kind" of lymphadenectomy used in each study is the first step in order to reach safe conclusions. The lack of comparative studies, especially the randomized ones, cannot help us draw any safe conclusion regarding both the clinical outcomes and the possibility of any superiority of these different approaches (extraperitoneal and transperitoneal).

Laparoscopic assisted extraperitoneal hernia sac high ligation vs traditional surgery for inguinal hernia in preschool children

AIM: To compare the clinical effects of laparoscopic assisted extraperitoneal hernia sac high ligation with traditional surgery in the management of inguinal hernia in preschool children.

METHODS: Preschool children with inguinal hernia treated at Suqian People's Hospital from March 2013 to January 2015 were divided into two groups to receive either laparoscopic assisted extraperitoneal hernia sac high ligation (observation group, n = 53) or traditional surgery (control group, n = 49). Operative time, hospital stay, and postoperative complications were compared for the two groups.

RESULTS: All surgical procedures were successful in the two groups. The mean operation time and hospital stay were significantly better in the observation group than in the control group (15.35 min ± 2.11 min vs 20.45 min ± 3.74, 2.0 d vs 3.5 d, P < 0. 05). The postoperative follow-up duration was 6 mo, during which no postoperative recurrence was observed in the observation group. One case of contralateral hernia developed in patients with unilateral inguinal hernia in the observation group. In the control group, 7 cases of contralateral hernia appeared.

CONCLUSION: Laparoscopic assisted extraperitoneal hernia sac high ligation treatment of inguinal hernia in preschool children is feasible and convenient, with shorter hospital stay and fewer postoperative complications.

A pseudo-TEP repair of an incarcerated obturator hernia

INTRODUCTION

Obturator hernia (OH) is a rare condition and difficult to diagnose. While they account for as few as 0.073% of all hernias, mortality can be as high as 70%. The typical clinical presentation for OH is small bowel obstruction. Computed tomography is the diagnostic tool of choice. Surgical repair is mandatory in virtually all cases of OH and traditionally consists of performing an exploratory laparotomy.

PRESENTATION OF CASE

A 90-year-old female was admitted to our surgical service with signs of small bowel obstruction and a CT scan revealing incarcerated fatty tissue and small bowel within a left OH.

DISCUSSION

The role of laparoscopic surgery in the management of OH has been limited to elective repairs; most reports detail that the OH was found serendipitously during laparoscopic inguinal hernia operations or other pelvic procedures. A few reports describe the use of laparoscopy to treat OH associated with bowel obstruction in an emergency setting using a TAPP approach. A strict TEP hernia repair is not indicated for all patients with OH, and should rarely be performed in emergency situations given its limitation to assess or resect bowel if necessary. In selected cases, a formal exploratory laparoscopy that is negative for compromised bowel can be safely followed by a TEP repair using the same umbilical access as shown in our patient.

CONCLUSION

A 90-year-old female with a small bowel obstruction related to an incarcerated OH was treated effectively with an extraperitoneal laparoscopic approach.