Optimal instrument length for transumbilical laparoendoscopic single site (U-LESS) surgery

The aim of our study was to recommend a novel method for measuring the distance from the umbilicus to intra-abdominal organs, as well as recommend an instrument length that would accommodate transumbilical laparoendoscopic single-site (U-LESS) surgeries to these areas. From CT scans of 50 men and 50 women, we calculated the distance from the umbilicus to 11 intra-abdominal points of interest using two triangles oriented perpendicular to each other. Using known lengths of the triangles, we used the Pythagorean theorem to calculate distances with and without insufflation. Distances were measured from the umbilicus to the xyphoid process, superior most aspect of the spleen, neck of the gallbladder, bifurcation of the descending aorta, adrenal glands, superior pole(s) of the kidneys, inferior most aspect of the inguinal canal, suprapubic margin, and the apex of the prostate (or female bladder neck). We found that an instrument working length of 43 cm would be sufficient to facilitate U-LESS surgery for all of our patients to each of the measured points of interest. The technique described in this paper serves as a useful method by which to measure the distance from the umbilicus to any intra-abdominal point of interest. These measurements would allow surgeons to correctly select instruments with adequate length when planning to perform U-LESS surgery.

Transumbilical versus periumbilical incision for laparoscopic surgery: A meta-analysis

BACKGROUND

Whether a transumbilical or periumbilical incision is beneficial for the initial peritoneal access in laparoscopic abdominal surgery has been debated. Our aim is to determine whether a transumbilical or periumbilical incision is a better route for the initial umbilical trocar.

METHODS

PubMed, Embase, and Cochrane Library databases were searched for articles published before March 2020. The meta-analysis calculated the pooled effect size by using a random effects model.

RESULTS

Five trials involving 783 patients were reviewed. The transumbilical group significantly reduced operation time (mean difference: -7.73; 95% confidence interval: -13.10 to -2.35) when compared to the periumbilical group. The length of hospital stay, mean pain scores on operation day and postoperation day 1 did not differ significantly between the two groups. Moreover, the incidence of surgical site infection, cosmetic satisfaction, and complication rate did not differ significantly between groups.

CONCLUSION

A transumbilical incision is better than a periumbilical incision for laparoscopic surgery as it saves operation time. Hence, we suggest transumbilical incisions for the initial peritoneal access in laparoscopic abdominal surgery.

Transumbilical repair of umbilical hernia in children: The covert scar approach

BACKGROUND

Umbilical hernia repairs are one of the most commonly performed operations in children. The traditional repair involves an infraumbilical incision, which produces a visible scar. We report a novel technique of umbilical hernia repair through a transumbilical incision, which eliminates the scar by hiding it within the umbilicus.

METHODS

We performed a retrospective chart review of 134 patients who had undergone a transumbilical hernia repair at a single institution between 2008 and 2016. Satisfaction with cosmesis and the presence of complications were assessed through parental interviews during follow up visit or by telephone survey. These data were compared to a large volume retrospective analysis of the standard infraumbilical approach.

RESULTS

121 of the 134 patients were evaluated in the clinic or by telephone interview. The overall complication rate was 7.44%. Parents of 118 patients reported satisfaction with the cosmetic result (97.52%). In comparison to the largest study of pediatric infraumbilical repair, there was an improvement in subjective cosmesis without a significant increase in complications.

CONCLUSION

Transumbilical hernia repair is a safe and cosmetically appealing technique for umbilical hernia repair in children.

LEVEL OF EVIDENCE

Treatment study, level III.

Outcomes of extracorporeal, transumbilical versus intracorporeal laparoscopic appendectomy for acute uncomplicated appendicitis in children and adolescents: A retrospective observational cohort study

BACKGROUND

An extracorporeal (ECA), transumbilical appendectomy has been proposed as a treatment for appendicitis. This study assessed the 30-day perioperative outcomes and cost between ECA and traditional intracorporeal (ICA) techniques for acute uncomplicated appendicitis.

METHODS

IRB approval was obtained for this retrospective cohort study of acute uncomplicated appendicitis in children aged 4 to 17 between April 2014 and April 2017. Patients were grouped based on ICA versus ECA. Operative time, length of stay, and complication rates were recorded.

RESULTS

A total of 289 patients were included, and of these 217 underwent ICA, and 72 underwent ECA. Median weight-for-age percentile was the only demographic characteristic different between groups (ECA 50 [0.1-100] vs. ICA 71 [0-100]; p < 0.01). Median operative time was significantly shorter in the ECA group (21.0 min [8.0-61.0] vs. 38.0 min [19.0-87.0]; p < 0.0001). Length of stay and complication rates were similar between groups. The median per case cost was significantly lower in the ECA group (CAD$ 593.05 range: 499.70-900.81 vs. CAD$ 858.78 range: 490.36-1106.29; p < 0.001).

CONCLUSIONS

Extracorporeal transumbilical laparoscopic appendectomy is associated with shorter operative times and no increased risk of 30-day postoperative complications in children and adolescents. This offers a new operative approach that may reduce hospital cost and resources.

LEVEL OF EVIDENCE

III.

A modified technique of single-incision laparoscopic hepaticojejunostomy for children with choledochal cysts

Background

To present a modified laparoscopic surgical technique that works to optimize the surgical view in laparoscopic total excision of choledochal cyst in pediatric patients.

Methods

From June 2015 to June 2017, a total of 48 pediatric cases of choledochal cyst were admitted. Their age ranged from 15 month to 8 years (average 3.5 years). The Todani types were: type I (n = 32) and type IVa (n = 16), according to the diagnostic criteria of ultrasound, abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP).

Results

Total cystic excision with hepaticoenterostomy was accomplished laparoscopically in 48 cases with our transumbilical single -incision method without conversion to open surgery. Average duration of operation was 200 min (range 170–240 min), average intraoperative blood loss was 9 ml (range 6–14 ml) without the need for blood transfusion. The 72-h postoperative ultrasound reported no abdominal effusion, when the intraperitoneal drainage tube was removed. There was no postoperative complication during the 6 months of follow-up.

Conclusions

We accomplished the same postoperative outcome in laparoscopic total cyst excision with our modified method as that with conventional laparoscopic surgery. This technique allows the operator to have a stabilized surgical view without needing to rely on an assistant to hold up the liver lobe for larger operative space.

Comparison of postoperative pain at umbilical wound after conventional laparoscopic cholecystectomy between transumbilical and infraumbilical incisions: a randomized control trial

BACKGROUND

Transumbilical incision has been applied in single-incision laparoscopy. Evidence for the effect of transumbilical incision on postoperative pain compared with infraumbilical incision is still lacking.

METHODS

A randomized controlled trial (RCT) was conducted in a university hospital. Patients who underwent conventional laparoscopic cholecystectomy were randomized to have transumbilical or infraumbilical incision. Postoperative pain was measured using visual analog score at 6, 24 h, and 7 days post operation. Secondary outcomes were analgesic usage, length of stay, superficial surgical site infection (SSI), wound numbness, and hypersensitivity. Risk ratio and mean difference (MD) along with their 95% confidence intervals (CIs) were estimated. Adjusted analysis was done, if clinical unbalanced characteristics presented. The study was registered at http://ClinicalTrial.gov (ID NCT02738710).

RESULTS

A total of 102 patients were enrolled in which 51 patients were randomized to each interventional group. Postoperative pain was not significantly different between the groups with the MD of - 0.07 (95% CI - 0.47, 0.35). Paracetamol usage was significantly 1 tab (95% CI - 1.9, - 0.1) less after transumbilical incision, but this was not significant after adjusting for unbalanced characteristics. Superficial SSI rate was much higher in the transumbilical than the infraumbilical group, i.e., 16 versus 4%, but this was not significant (p = 0.070). Satisfaction scores at 3 months were not different between the groups, with the corresponding means of 8.9 [standard deviation (SD) 1.3] and 9.0 (SD 1.0).

CONCLUSIONS

Transumbilical incision had non-significant different pain compared to infraumbilical incision. Most patients in both groups were satisfied with the operation at 3 months. A further large RCT is required for comparing SSI between the two incisions.

Transumbilical multi-port laparoscopic pyeloplasty versus transumbilical single-site laparoscopic pyeloplasty for ureteropelvic junction obstruction in children: A retrospectively comparative study

INTRODUCTION

Laparoscopic pyeloplasty has achieved good cosmetic and functional outcomes. Both transumbilical single-site and transumbilical multi-port approaches are currently being used. No comparison of transumbilical single-site laparoscopic pyeloplasty (TSLP) and transumbilical multi-port laparoscopic pyeloplasty (TMLP) has been reported in the literature.

OBJECTIVES

We present a retrospective comparison study to evaluate clinical outcomes of TSLP and TMLP for children with ureteropelvic junction obstruction (UPJO).

STUDY DESIGN

A retrospective study was carried out comparing TSLP and TMLP performed by a single surgeon between July 2012 and June 2014. The patient data of the two groups (90 in each group) were evaluated. All patients underwent urine analysis, ultrasonography, magnetic resonance urography, and diuretic renogram using 99Tc-diethylene triamine pentaacetic acid scan preoperative and postoperative follow-up. Data were analyzed using the SPSS 20.0 software package.

RESULTS

DISCUSSION: To our knowledge, our series is the first report in the literature that compares the outcomes of TSLP and TMLP in children. Our study suggested that there were no significant differences in start of oral feeding, drain removal, hospital stay, postoperative renal pelvic anteroposterior diameter and differential renal function at 6 months, postoperative complications, and success rate between the two groups. It demonstrated that TMLP is as effective and safe as TSLP. Although the cosmetic result of the TSLP group is satisfactory, TMLP requires three 0.5-cm ports around the umbilicus and does not change the shape of the umbilicus. Hence, the cosmetic result of the TMLP group is better than that of the TSLP group. TSLP involves some technical challenges. However, TMLP facilitates the procedure and renders the operation easier. Our findings confirmed that the operative time of TMLP group is shorter than that in TSLP group, and also showed that TMLP is relatively easy to perform compared with TSLP.

CONCLUSION

TMLP is a feasible and safe operation for pediatric UPJO. TMLP is shorter in operative time and has a better cosmetic result than TSLP. We propose TMLP as a more viable treatment option for pediatric UPJO.

[Is there an ideal patient for transumbilical laparoscopic assisted appendectomy?]

OBJECTIVES

To identify the factors that lead to postoperative morbidity in acute appendicitis patients treated using a TULAA (Transumbilical laparoscopic assisted appendectomy) approach.

MATERIAL AND METHODS

Retrospective review of patients treated through a TULAA approach between 2007 and 2014. Data concerning the location of the appendix, need for conversion, appendiceal abscess or perforation, surgical time and other complications were collected. Student's T test and Chi-squared test were used for statistical analysis.

RESULTS

A total of 111 appendectomies underwent TULAA. The average operating time was 79 minutes (45-150). Nonperforated appendicitis was found in 90% of patients with 10% having perforated appendicitis or appendiceal abscess. In 35,13% of cases, additional trocars were used, usually when the appendix was in a retrocecal position (89,5%). When the appendix was found in a pelvic or ileal position, a need for extra trocars decreased to 25.9% (p< 0.05). The surgery was converted to open surgery in 6,3% of the cases. The appendix in a retrocecal position had a conversion rate of 20,8% compared to 2,3% of cases with an appendix in a pelvic location (p< 0.05). A total of 3,6% reported postoperative wound infection, possibly caused by perforation of the appendix during extraction (p< 0.05). All the perforated appendixes were considered complicated appendixes.

CONCLUSIONS

The retrocecal location of the appendix is associated with the need to install additional trocars or conversion to open surgery. The TULAA approach is ideal for patients with nonperforated acute appendicitis in a pelvic or ileal location.

Risk Factors for Transumbilical Wound Complications in Laparoscopic Gastric and Colorectal Surgery

AIM

To investigate the risk factors of transumbilical incision for organ removal in laparoscopic surgery.

PATIENTS AND METHODS

We enrolled 643 consecutive patients undergoing laparoscopic surgery from 2010 to 2013. Superficial surgical site infection (SSI) and transumbilical port site hernia were recorded.

RESULTS

The participants underwent gastric (n=253) and colorectal (n=390) resections. SSI was observed in 17 cases (colorectal in 15; gastric in two) (2.64%) with colorectal resection having a high rate of SSI [odds ratio (OR)=5.020; p=0.022]. Hernia occurred in 23 cases (colorectal in 22; gastric in one) (3.53%), with a significantly higher rate for colorectal resection (OR=13.052; p<0.001). Female (OR=5.410; p=0.021) and history of diabetes mellitus (OR=4.437; p=0.009) contributed to the risk for developing a hernia.

CONCLUSION

Especially in relation to hernia, being female and having diabetes mellitus were considered independent risk factors.

Lung resection using transumbilical incision: an animal survival study

INTRODUCTION

Transumbilical single-port surgery is a potentially less invasive approach to many types of abdominal surgeries and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. It avoids the complication of intercostal neuralgia and may reduce the risk of pulmonary complications after video-assisted thoracic surgery. This study evaluated the feasibility of transumbilical lung wedge resection.

METHODS

Lung resection was performed in 11 beagle dogs weighing 5.9 to 8.5 kg. A 3-cm umbilical incision and one diaphragmatic incision were made, and an endoscopic stapler was used. The diaphragmatic incisions were repaired under video guidance using a V-Loc knotless suturing device (Covidien, Mansfield, Massachusetts). Animals were monitored daily for signs of postoperative infection. White blood cell count, C-reactive protein level, and IL-6 level were measured in all animals. Animals were euthanized 14 days after surgery and underwent necropsy evaluation.

RESULTS

Accurate lung resection was achieved in 10 of 11 animals during a median operative time of 98 minutes (range 60-165). In 1 animal, transumbilical lung resection was not possible and was converted to thoracotomy. All animals survived without major postoperative complications. At necropsy, evidence of uneventful healing of the stapled resection margin and diaphragmatic wound were found. There was no evidence of vital organ injury or intrathoracic infection.

CONCLUSION

A transumbilical approach to thoracic cavity exploration and stapled lung resection is technically feasible. Primary suturing of the diaphragmatic incision is a simple and effective means of diaphragmatic wound closure. This may be an alternative to video-assisted thoracic surgery for the management of simple thoracic disease.

Transumbilical thoracic sympathectomy: a single-centre experience of 148 cases with up to 4 years of follow-up†

OBJECTIVES

Thoracic sympathectomy is considered as the most effective method to treat palmar hyperhidrosis (PH). Here, we report our experience of transumbilical thoracic sympathectomy with an ultrathin flexible endoscope for PH in a series of 148 patients with up to 4 years of follow-up.

METHODS

A prospective database was used in this retrospective analysis of 148 patients (61 males, 87 females, with a mean age of 21.3 years) with PH who were operated on by the same surgeon in a single institution from April 2010 to March 2014. All procedures were performed under general anaesthesia involving intubation with a double-lumen endotracheal tube. Demographic, postoperative and long-term data of patients were recorded and statistical analyses were performed. All patients were followed up at least 6 months post procedure through clinic visits or telephone/e-mail interviews.

RESULTS

The procedure was performed successfully in 148 of the 150 patients. Two patients had to be converted to conventional thoracoscopic procedure because of severe pleural adhesions. The mean operating time was 43 min (ranging from 39 to 107 min) and the mean postoperative length of stay was 1 day (range 1-4 days). All patients were interviewed 6-48 months after surgery and no diaphragmatic hernia or syndrome was observed. The rate of resolution of PH and axillary hyperhidrosis was 98 and 74.6%, respectively. Compensatory sweating was reported in 22.3% of patients. Almost all of the patients were satisfied with the surgical results and the cosmetic outcome of the incision.

CONCLUSIONS

This preliminary human experience suggested that transumbilical thoracic sympathectomy was a safe and efficacious alternative to the conventional approach. This technique avoided the chronic pain and chest wall paraesthesia that are associated with the chest incision. In addition, this novel procedure afforded maximum cosmetic benefits.

Early experience of using transumbilical multi-stab laparoscopic pyeloplasty for infants younger than 3 months

OBJECTIVE

Minimally invasive surgery is increasingly being adopted in pediatric urology practice. The aim of this study is to investigate the feasibility and the safety of transumbilical multi-stab laparoscopic pyeloplasty (TMLP) as a treatment for infants younger than 3 months with severe hydronephrosis.

METHODS

We retrospectively reviewed 63 infants younger than 3 months with severe hydronephrosis who underwent TMLP from June 2010 to March 2013. The operative indications included: 1) prenatal diagnosis of hydronephrosis with anteroposterior renal pelvic diameter greater than 3 cm and Society of Fetal Urology (SFU) Grade 4 hydronephrosis; 2) ipsilateral differential renal function being less than 40%. Patients were followed up with physical examinations, ultrasound and radionuclide scans.

RESULTS

The operations were successfully performed in all 63 patients. There was no conversion, no requirement of additional trocar placement and no intraoperative complication. The median age was 54 (47-87) days. The median operative time was 75 (53-118) minutes. The patients were followed up for 12 (6-36) months. The anastomoses were proved to be patent and the renal parenchymal thickness increased. The renal pelvic anteroposterior diameters were reduced and the renal functions were improved (p < 0.01). In addition, the scars were barely noticeable.

CONCLUSIONS

TMLP for infants younger than 3 months with severe hydronephrosis is feasible, safe and minimally invasive. The cosmetic results are excellent.

Single-incision laparoscopic appendectomy for treating appendicitis in a patient with gastrointestinal malrotation

INTRODUCTION

Intestinal malrotation is a rare congenital anomaly, and acute appendicitis associated with intestinal malrotation is extremely rare. PRESENTATION OF CASE We report a rare case of a 47-year-old Japanese woman diagnosed with barium-related perforated appendicitis associated with intestinal malrotation. We used a transumbilical single-incision laparoscopic approach to resect the appendix, and the procedure was completed successfully without perioperative complications.

DISCUSSION

To our knowledge, single-incision laparoscopic surgery for appendicitis associated with intestinal malrotation has not been reported yet. In cases with mobile cecum such as this one, mobilization from inflammatory adhesion of the surrounding structures is easy.

CONCLUSION

We conclude that transumbilical single-incision laparoscopic appendectomy is a simple and less invasive method for treating appendicitis associated with intestinal malrotation.

Transumbilical laparoscopic-assisted appendectomy in children: Clinical and surgical outcomes

The aim of this paper is to present and describe transumbilical laparoscopic-assisted appendectomy in children, focusing on its technical aspects and clinical and surgical outcomes. The surgical charts of all patients aged between 0 and 14 years treated with transumbilical laparoscopic-assisted appendectomy admitted to the authors’ institution from January 2009 to September 2013 with a diagnosis of suspected appendicitis following clinical, laboratory and ultrasound findings were reviewed. Operating time, intraoperative findings, need for conversion or for additional trocars, and surgical complications were reported. During the study period, 120 patients aged between 6 and 14 years (mean age: 9.9 years), 73 females (61%) and 47 males (39%), were treated with transumbilical laparoscopic-assisted appendectomy. There were 37 cases of hyperemic appendicitis (subserosal and retrocecal), 74 cases of phlegmonous appendicitis and 9 cases of perforated gangrenous appendicitis. It was not possible to establish a correlation between grade of appendicitis and mean operating time (P > 0.05). Eleven cases (9%) needed the use of one additional trocar, while 8 patients (6%) required conversion to the standard laparoscopic technique with the use of two additional trocars. No patient was converted to the open technique. Transumbilical laparoscopic-assisted appendectomy is a safe technique in children and it could be used by surgeons who want to approach other minimally invasive techniques.

Feasibility of endoscopic transumbilical thoracic sympathectomy in a porcine model

OBJECTIVES

Thoracoscopic sympathectomy is an effective treatment for palmar hyperhidrosis. Current methods are associated with risks of chronic neuropathic pain and a visible chest scar. We developed a novel surgical technique for the performance of sympathectomy by embryonic natural orifice transumbilical endoscopic surgery with a flexible endoscope in a porcine model.

METHODS

Transumbilical flexible endoscopic thoracic sympathectomies were performed in seven farm pigs (three acute and four 4-week survivals). Under general anaesthesia, animals were intubated and mechanically ventilated with a dual lumen endotracheal tube through tracheostomy. A newly developed long transabdominal trocar was placed through the umbilicus. After insertion of a gastroscope through this trocar, a small incision was created on both sides of the diaphragm by a needle-knife. Then the gastroscope was inserted into the thoracic cavity, and the sympathetic chain was identified at the desired thoracic level and ablated. Operation time, safety and feasibility were recorded in all animals.

RESULTS

The transumbilical thoracic sympathectomies were successfully completed in all pigs with a mean operation time of 66.7 ± 9.4 min. Intraoperative bleeding occurred in one pig during the electrosurgical incision of diaphragm tissue, which was successfully controlled by hot biopsy forceps. No other acute intraoperative complications were observed in any cases. In the acute group, the length of the diaphragm incision ranged from 4 to 5 mm in three pigs. In the survival group, the animals recovered promptly from surgery. In three pigs, a small pneumothorax was found in the postoperative chest X-ray, but all of them were completely resolved with conservative treatment. Autopsy showed all bilateral T3 sympathetic chains were successfully ablated and no evidence of vital structure injury or diaphragmatic hernia.

CONCLUSIONS

Transumbilical flexible endoscopic thoracic sympathectomy is technically feasible, simple and safe in a porcine model. This technique can be used as a novel experimental platform for studies of natural orifice transluminal endoscopic surgery (NOTES) for intrathoracic surgery.

Transumbilical single port laparoscopic appendectomy using basic equipment: a comparison with the three ports method

PURPOSE

Single port laparoscopic surgery is a rapidly evolving laparoscopic surgical approach. We report a comparison of transumbilical single port laparoscopic appendectomy (TUSPLA) and conventional laparoscopic appendectomy (CLA) in a Korean military hospital.

METHODS

This single-center retrospective study of 63 patients who received laparoscopic appendectomy was conducted between May 2011 and October 2011. Nineteen patients received TUSPLA and 44 patients received CLA. Clinical outcomes such as operation time, hospital stay, postoperative pain, diet, and postoperative complication were reviewed.

RESULTS

There were no statistically significant differences between TUSPLA and CLA patients, respectively, in operation time (58.9 minutes vs. 52.3 minutes, P = 0.262), duration of hospitalization (10.2 days vs. 10.6 days, P = 0.782), mean visual analogue scale score (2.6 vs. 2.5, P = 0.894), and return to diet (1.6 days vs. 1.7 days, P = 0.776). There were two cases (10.5%) of short-term complications in the TUSPLA group and four cases (9.1%) of short-term complications in the CLA group. All patients were fully recovered at discharge.

CONCLUSION

TUSPLA is a feasible alternative for CLA. When a glove port is used, no special instruments are needed. Thus, it can be performed in a hospital equipped with basic laparoscopic surgical instruments.

Transumbilical endoscopic surgery: History, present situation and perspectives

Transumbilical endoscopic surgery or laparo-endoscopic single site (LESS) surgery has become an exciting area of surgical development as innovation continues to move in the 21^st century to minimally invasive surgery. The history, present situation and perspectives are reviewed and the nomenclature of this technique is discussed in this article. The range of this technique has been applied in almost all abdominal diseases, surgeries for morbid obesity, hernia and so on, in recent years. It is estimated that 50%-80% of traditional laparoscopic surgery could be performed transumbilically in the next five years according to the LESSCAR consensus. Although the concept of transumbilical laparoscopic surgery is gaining traction rapidly and the instruments have been improved greatly, we should not advocate for slightly improved cosmetic value over safety. Multicenter, randomized and clinical trials are necessary to further elucidate the safety and efficiency of this new technique. Research that examines the efficacy of the new instruments on the market may be helpful to simplify the confusing landscape of new and novel products designed for this purpose.

Single access laparoscopic surgery: Complementary or alternative to NOTES?

In recent years, single access laparoscopic surgery (SALS) and natural orifice translumenal endoscopic surgery (NOTES) have gained interest from both clinical and industrial point of view, with the increased development of different laparoscopic instruments, production of various access ports, and improvement of operative endoscopes. The main advantages stimulating these two approaches are the cosmetic result, the rapid recovery of the patient, and the reduced need for pain killers. SALS and NOTES are in part complementary and in part alternative techniques. Currently, SALS is much simpler and technically easier than NOTES.