12-mm Trocar Research Articles

Use of a multi-instrument access device in abdominoperineal resections.

BACKGROUND:Laparoscopic colorectal surgery results in less post-operative pain, faster recovery, shorter length of stay and reduced morbidity compared with open procedures. Less or minimally invasive techniques have been developed to further minimise surgical trauma and to decrease the size and number of incisions. This study describes the safety and feasibility of using an umbilical multi-instrument access (MIA) port (Olympus TriPort+) device with the placement of just one 12-mm suprapubic trocar in laparoscopic (double-port) abdominoperineal resections (APRs) in rectal cancer patients.PATIENTS AND METHODS:The study included 20 patients undergoing double-port APRs for rectal cancer between June 2011 and August 2013. Preoperative data were gathered in a prospective database, and post-operative data were collected retrospectively.RESULTS:The 20 patients (30% female) had a median age of 67 years (range 46-80 years), and their median body mass index (BMI) was 26 kg/m2 (range 20-31 kg/m2). An additional third trocar was placed in 2 patients. No laparoscopic procedures were converted to an open procedure. Median operating time was 195 min (range 115-306 min). A radical resection (R0 resection) was achieved in all patients, with a median of 14 lymph nodes harvested. Median length of stay was 8 days (range 5-43 days).CONCLUSION:Laparoscopic APR using a MIA trocar is a feasible and safe procedure. A MIA port might be of benefit as an extra option in the toolbox of the laparoscopic surgeon to further minimise surgical trauma.

Robot-assisted real-time magnetic resonance image–guided transcatheter aortic valve replacement

BackgroundReal-time magnetic resonance imaging (rtMRI)-guided transcatheter aortic valve replacement (TAVR) offers improved visualization, real-time imaging, and pinpoint accuracy with device delivery. Unfortunately, performing a TAVR in a MRI scanner can be a difficult task owing to limited space and an awkward working environment. Our solution was to design a MRI-compatible robot-assisted device to insert and deploy a self-expanding valve from a remote computer console. We present our preliminary results in a swine model. MethodsWe used an MRI-compatible robotic arm and developed a valve delivery module. A 12-mm trocar was inserted in the apex of the heart via a subxiphoid incision. The delivery device and nitinol stented prosthesis were mounted on the robot. Two continuous real-time imaging planes provided a virtual real-time 3-dimensional reconstruction. The valve was deployed remotely by the surgeon via a graphic user interface. ResultsIn this acute nonsurvival study, 8 swine underwent robot-assisted rtMRI TAVR for evaluation of feasibility. Device deployment took a mean of 61 ± 5 seconds. Postdeployment necropsy was performed to confirm correlations between imaging and actual valve positions. ConclusionsThese results demonstrate the feasibility of robotic-assisted TAVR using rtMRI guidance. This approach may eliminate some of the challenges of performing a procedure while working inside of an MRI scanner, and may improve the success of TAVR. It provides superior visualization during the insertion process, pinpoint accuracy of deployment, and, potentially, communication between the imaging device and the robotic module to prevent incorrect or misaligned deployment.

Robot-assisted thoracoscopic bronchoplasty.

Robotic systems have been used to enhance the surgeon's dexterity and visualization in endoscopic surgery and thus facilitate refined dissection, suturing, and knot tying. We describe use of the da Vinci surgical system for robotic-assisted thoracoscopic bronchoplasty in patient with centrally located lung cancer. We used three robotic ports (a 12-mm trocar for the 30°-down camera and two 8-mm trocars for the robotic instrument arms) and one utility incision for assistance and specimen retrieval. Lung isolation were achieved using double-lumen endotracheal tube without carbon dioxide inflation. The bronchoplasty was performed by using 4/0 polydioxanone suture (PDS). Three cases of robotic-assisted thoracoscopic bronchoplasty (n=3) were performed. Case 1: right upper lobe lobectomy with right main bronchus primary closure; case 2: right upper lobe lobectomy with the anterior wall of the right main bronchus re-anastomosis; case 3: left upper lobe sleeve lobectomy. The surgery and post-operative course were smooth without complication. We suggest that robotic-assisted thoracoscopic surgery offers specific advantages over conventional thoracoscopic surgery with accuracy and safety when doing bronchoplasty.

A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning: A Bulldog Clamp Technique and Description of Modified Port Placement.

To describe a novel and pure laparoscopic approach using a custom-made bulldog clamp with modified port placement for management of distal ureter during laparoscopic nephroureterectomy. Between October 2013 and December 2014, 31 patients found to have upper tract urothelial carcinoma were treated using this technique. After finishing a standard laparoscopic transperitoneal nephrectomy in a 45° to 60° recumbent position, an additional 12-mm trocar was inserted at the lower abdomen to allow the surgeon to continue dissecting the ureter caudally toward the bladder wall without repositioning the patient. The intramural ureter was separated from the surrounding detrusor muscle and down to the bladder mucosa, until a tent-shaped bladder cuff and intramural ureter could be formed by retraction in the superior and lateral directions. Then, a custom-made laparoscopic bulldog clamp was placed at the bottom of the tent-shaped structure to prevent urine spillage, and the bladder was closed by two-layer running closure using a barbed suture. All surgeries were completed uneventfully. The mean operative time and estimated blood loss were 146.6 minutes and 47.3 mL, respectively. The median duration of the postoperative hospital stay was 6 days. No complications were noted. There were no positive margins in any specimen. No patients experienced stone formation or local or bladder recurrence during the 10.5-month follow-up period. Our novel technique fully replicates the open excision technique and conforms to the strictest oncologic principles while avoiding patient repositioning and the use of staplers (EndoGIA or Hemolock) to prevent stone formation.

Extracorporeal ureteral tailoring during HIDES laparoscopic robotic-assisted ureteral reimplantation for megaureter

Although laparoscopic robotic-assisted intracorporeal ureteral tailoring is feasible and several authors have reported doing it, it adds a level of complexity to the surgery that many robotic surgeons are uncomfortable with. Also, some techniques for tailoring the ureter, like the one described by Ossandon, would be very difficult to perform intracorporeally or violate principles of hidden incision endoscopic surgery (HIDES) by adding extra ports in visible locations. Extracorporeal ureteral tapering is performed by extracting the ureter through a 10-mm step trocar placed in the midline at the level of the biking line. Once the ureter is tapered and a stent has been secured, the 10-mm trocar is replaced and the rest of the reimplant is performed in a way very similar to when performing a robotic apendicovesicostomy. Extracorporeal ureteral tailoring can be added to the bag of tricks that robotic surgeons can resort to when faced with the situation of a dilated ureter without compromising cosmesis.

Robotic single docking total colectomy for ulcerative colitis: First experience with a novel technique

IntroductionWe describe a novel technique that could aid the surgeon to perform a total proctocolectomy with a single docking position of the da Vinci Si HD System. MethodsPatients were positioned in 20° Trendelenburg lithotomy split legs position. A 12-mm trocar was for camera and 3 more trocars were placed: two robotics on left and right flanks and one laparoscopic in left iliac fossa. The robot was docked between the legs of the patients. ResultsFour proctocolectomies were performed. Mean operative time was 235 min (range 215–255); mean blood loss was 100 cc (range 50–200). Median post-operative stay was 6 days. Overall morbidity was 75%, whereas major complications occurred in 25%. Post-operative mortality was null. ConclusionsThe robotic single docking approach to perform total proctocolectomy for ulcerative colitis is a time-saving technique respect to the multiple docking approach.

Palpable Undescended Testes: 15 Years of Experience and Outcome in Laparoscopic Orchiopexy.

Most of the current literature concerning laparoscopy in patients with cryptorchidism reports on those with nonpalpable testes. The purpose of this study is to share our experience and outcome in laparoscopic orchiopexy on patients with palpable undescended testes. From January 1999 to July 2014, 240 cryptorchid testes were treated of which 192 (155 patients) were palpable and were operated on by laparoscopy. Before starting, the bladder is emptied with a Foley catheter. Four trocars are used: One 5 mm for the lens (45 degree), one 10 mm (transscrotal), and two 3 mm placed at the subcostal midclavicular line for the instruments. We localize the deep inguinal ring and open the peritoneum. The spermatic vessels and vas deferens are dissected in a cephalic direction. The epigastric vessels are dissected and sectioned to facilitate the localization of the testicle inside the canal. Once found, the testis is dissected and taken into the abdominal cavity where the gubernaculum testis is cut. A 10-mm trocar is introduced through the scrotal sac into the peritoneal cavity. The testicle is grabbed and pulled down to the scrotum where it will be fixed with a 5-0 polypropylene suture in the usual manner. Of 192 cryptorchid palpable testes treated with laparoscopy, only one procedure was converted to conventional open orchiopexy because of an ectopic testicle (above the aponeurosis of the oblique muscle). The rest of the testicles could be moved down to the scrotal sac. Our follow-up ranges from 6 months to 15 years, and we have not found atrophy in any of the testicles. To date, only two (0.4%) testicles have reascended. Laparoscopy is a great and safe option for patients with palpable undescended testes, regardless of its position in the inguinal canal.

Natural orifice transluminal endoscopic surgery (NOTES) salpingectomy for ectopic pregnancy: a first series demonstrating how a new surgical technique can be applied in a low-resource setting

This paper demonstrates the feasibility of a salpingectomy for ectopic pregnancy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Conventional, reusable laparoscopic instruments were used and inserted through an inexpensive, self-constructed single port device. The self-constructed single port device was made by assembling a surgical glove, a wound protector, one reusable 10-mm trocar and four reusable 5-mm trocars. We report on five patients who underwent a vNOTES salpingectomy between September 2014 and February 2015. All procedures were successfully performed, without conversion to multi-incision laparoscopy or laparotomy. This demonstrates that it is possible to perform a vNOTES salpingectomy without any financial investment in expensive ports, disposable instruments or sealing devices (Video 1). Patient and perioperative data were analysed (Table 1). NOTES salpingectomy is a novel technique requiring further validation. It could be a less invasive alternative to a laparoscopic salpingectomy. A better cosmetic result, by avoiding abdominal incision scars, and less port-related complications, can be expected.

Adnexectomy by poor man’s transvaginal NOTES

The purpose of this study was to demonstrate the feasibility and safety of adnexectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign adnexal masses. Conventional, reusable laparoscopic instruments were used, inserted through aninexpensive, self-constructed single port device. Between November 2013 and November 2014, 20 adnexectomies by vNOTES were performed by a single surgeon (BJ). Only conventional, reusable laparoscopic instruments were used. The self-constructed single port device was made by assembling a surgical glove, a wound protector, one reusable 10-mm trocar, and four reusable 5-mm trocars. The adnexectomy was performed according to the technique for standard laparoscopic surgery, and the specimen was removed through the colpotomy incision. Patient and perioperative data were analysed. Twenty patients underwent adnexectomy by vNOTES, and no conversion to standard laparoscopy or laparotomy was necessary. Mean operation time was 32 min (20–50 min); mean drop in hemoglobin level was 0.9 g/dl (0–2.1 g/dl). There were no operative complications. Post-operative pain scores were very low. The mean size of the removed adnexal mass was 51.8 mm (35–110 mm). Adnexectomy by vNOTES is feasible even for masses up to 110 mm and even when performed with reusable, conventional laparoscopic instruments. The main advantages of vNOTES are better cosmetics, low postoperative pain scores and easy removal of the specimen without spillage. This frugally innovative technique also enables surgeons to perform adnexectomies by vNOTES in low resource settings.

Comparison of surgical intervention and non-surgery result in early prostate cancer

s / Urological Science 26 (2015) S50eS81 S57 The operation began with 7ecm midline incision above the umbilicus. A small hole of cystic wall was created and more than 6 L of yellowish clear fluid was drained. The hand-assisted device was placed in midline wound. While other two 10-mm trocar were placed in left lower abdomen and left anterior axillary line subcostally. The membrane of cyst was dissected as much as possible. Nephropexy was done to attach migrating left kidney to the back of the abdominal wall. The postoperative course was uneventful and the patient was discharged 3 days after the operation. Intravenous urography done 3 months later showed normal kidney position and bilateral patent ureters. Discussion: A huge renal cyst measuring more than 15 cm is an extremely rare. Cases presenting simply with progressive abdominal distention can lead to misdiagnosis, such as obesity or ascites. In our case, huge left renal cyst caused left kidney migration to right side, leading to initial misdiagnosis of right acute pyelonephritis. Surgery has been considered the mainstay of treatment for giant cyst. We performed hand assisted laparoscopic renal cyst unroofing and nephropexy with uneventful postoperative course and good outcome. NDP028: UNUSUAL URETHRAL FOREIGN BODIES Wei-Chung Hsiao , Sung-Lang Chen , Yu-Lin Kao , Wen-Jung Chen , Tzuo-Yi Hsieh , Shao-Chuan Wang . Division of Urology, Chung Shan Medical University Hospital, Taichung, Taiwan; 2 Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan Purpose: Urethral foreign bodies are uncommon clinical conditions. Most of the foreign bodies are self-introduced under the circumstances of autoerotic impulses, sexual curiosity, psychiatric illness, or rarely migration from adjacent organs. Retrieval of the urethral foreign body is casespecific due to wide variety of foreign bodies. Materials and Methods: A 75-year-old man was sent to emergency department after a motorcycle accident. Serial examinations including pelvic radiography and computed tomography discovered 5 fishhooks within the urethra unexpectedly. Ingrowth into urethral mucosa of the fishhooks with related inflammatory process was noted. Due to complexity of the fishhook position and pelvic fracture condition, cystourethroscopic retrieval of the foreign bodies was performed successfully in a two-step manner. Results: Self-inflicted urethral foreign bodies have a very low incidence. Major complications of urethral foreign bodies include trauma, infection, urine retention, and urethral stricture. Most of the foreign bodies of lower urinary tract can be treated with endourological modalities. The key point of urethral foreign body extraction relies on its physical attributes and morphology with the purpose of minimal urothelial injury. Conclusion: The urethral foreign bodies could be removed successfully by cystourethroscopic procedure without any complication, even in the presentation of mucosal ingrowth.

Transperitoneal Laparoscopic Adrenalectomy in Children

Introduction: The use of a minimally invasive approach for adrenalectomy is poorly defined in pediatric patients, although laparoscopic adrenalectomy is considered a standard procedure in adults.1–4 The aim of our video is to describe the safety and feasibility of transperitoneal lateral laparoscopic adrenalectomy in children based on surgical skills and results. Surgical Procedure: The patient was placed in a reverse Trendelenburg semilateral position over a flank lift. A 10 mm Hg pneumoperitoneum was created using a 10- to 12-mm Hasson's trocar and three 5-mm trocars were inserted, as shown in the video. Left Adrenalectomy: A plane along the anterior surface of the kidney, lateral and dorsal to the spleen and tail of pancreas, was established and the splenic ligaments were divided. The dissection proceeded along the anterior surface of the kidney and adrenal gland until the inferior and medial border. The main adrenal vein and artery were isolated and sectioned. The dissection proceeded in a superolateral direction until complete mobilization of the gland. Right Adrenalectomy: The liver was retracted and the right lobe was mobilized, thus revealing the anterior surface of the adrenal gland. The lateral border of the inferior vena cava was isolated to identify the adrenal vein transacted. The dissection proceeded in a mediolateral and superoinferior direction, until complete mobilization of the gland. Materials and Methods: This is a retrospective study of four pediatric laparoscopic adrenalectomies (two right and two left) performed at our center. Preoperative workup included endocrinologic and radiologic investigation to determine the secretory activity, size, and local extent of the lesion. Results: The mean age was 87 months. Indications for surgery were two neuroblastomas, one aldosterone-secreting adrenocortical tumor, and one adrenocortical nodular hyperplasia. The mean size of the lesions was 3.23 cm at the pathologic examination. No intraoperative complications or conversions occurred. The average operating time was 85 minutes for right and 125 minutes for left adrenalectomies. The mean hospital stay was 3.75 days. At 15 months, the follow-up was negative. Conclusions: Transperitoneal laparoscopic adrenalectomy is a safe, feasible, and reproducible approach for the treatment of benign and malignant adrenal masses in children. Furthermore, this approach offers many advantages, including shortening of operating times and postoperative hospital stays, as well as reduction of blood loss and complications; also, a large working space with a clear view of the structure that permitted to perform a controlled resection.5,6 The authors have nothing to disclose. Runtime of video: 8 mins

Hartmann's Reversal: Laparoscopic Technique

Introduction: Hartmann's procedure (HP) consists of sigmoidectomy, rectal stump closure, and terminal colostomy. It was originally designed for and performed only in case of neoplastic obstructions. However, over time, indications have expanded and nowadays include complicated diverticulitis, traumatic colonic lesions, volvulus, and perforated rectosigmoid tumors. So there have been a growing number of patients undergoing HP, especially due to the increasing prevalence of sigmoid diverticular disease in the general population. Potentially, all these patients are waiting for their continuity to be restored. The original aim of this procedure was to reduce mortality due to anastomotic dehiscence in an emergent operation for neoplastic obstruction. However, reestablishing continuity after Hartmann's procedure (Hartmann's reversal [HR]) is considered a major surgical procedure and carries serious risk of both morbidity and mortality, ranging from 5% to 50%.1,2 This surely explains why a large proportion of patients undergoing HP will not have their bowel continuity restored. Spreading of laparoscopic expertise along with the documented advantages of minimally invasive approach (decreased postoperative pain, morbidity, hospital stay, and faster return to daily activities) in colonic surgery have lead to its application to procedures, such as HR. Since the first report of laparoscopic HR (LHR), there have been a growing number of publications in the world literature.3–19 This video shows the technique of laparoscopic restoration of bowel continuity after HP. Surgical Technique: The first step of the technique involves mobilization of the colostomy site. This is excised at the mucocutaneous junction circumferentially, until the peritoneum is entered. The edge of the stoma is revised to take away excessive scar tissue. An appropriately sized anvil of a circular stapler is then inserted into the colonic lumen and secured with a purse-string reabsorbable suture. The colostomy site is now used as port site for the establishment of pneumoperitoneum and a trocar or a hand-assist device can be placed for the camera. Three operative trocars are used: a 12-mm trocar in the right lower quadrant, a 10-mm in the right upper quadrant, and a 10-mm in the umbilicus. With the patient in the steep reverse Trendelenburg position, the rectal stump is identified. This step can be facilitated by a suture thread placed at the first surgery (Hartmann) or by transanally inserting a circular stapler, Hegar, dilators, or a rigid sigmoidoscope at HR. Lysis of adhesions is performed with sharp scissor dissection and minimal use of electric current to prevent any injury to the bowel. It is also important to minimize the risk of vascular injury during pelvic dissection, in a subsequent step of the procedure. In case the rectal stump is too long and includes a few folding of the distal sigmoid colon, the latter can be excised using a linear stapler and the specimen brought out through the colostomy site where the hand-assist device can been placed. Subsequently, with the patient in the Trendelenburg position, mobilization of the left colon proximal to the colostomy and take down of the splenic flexure is accomplished, by freeing the lateral attachments, to ensure a tension-free anastomosis with the rectal stump. An end-to-end colorectal anastomosis is created with an appropriately sized endoluminal circular stapler, possibly avoiding a stapler with diameter less than 28–29 mm. The pelvic cavity is filled with the saline solution and the air leak test is done by insufflating the air in the rectum while visualizing the anastomosis. The stoma wound is left partially open. Results: During the 8-year study period, 20 patients underwent laparoscopic HR. The median age was 65.4 years. Ten patients (50%) had undergone surgery for perforated diverticulitis, 3 (15%) for cancer, 7 (35%) for other reasons (volvulus, post-traumatic perforation, sigmoid perforation from foreign body). Previous HP had been performed laparoscopically in only three patients. The median operative time was 162.5 minutes. All the procedures were completed laparoscopically. The intraoperative complication rate was nil. Postoperative mortality and morbidity were 0% and 10%, respectively (one pneumonia, one bowel obstruction from postanastomotic stenosis, which required resection and re-do of the anastomosis). The median time to first flatus was 3 days, to normal diet 5 days. The median hospital stay was 9 days without readmissions. We followed-up the patients for a median of 44 months: when asked, all 20 (100%) said they would undergo the operation (LHR) again; 3 (15%) had been re-operated of laparoscopic mesh repair for incisional hernia. Conclusions: When performed by experienced surgeons, LHR is a feasible, safe, and reproducible operation, which allows early return of bowel function, early discharge, and fast return to work for the patient. It has a low morbidity rate. Drs. Valentino Fiscon, Giuseppe Portale, Antonio Mazzeo, Giovanni Migliorini and Flavio Frigo have no conflicts of interest or financial ties to disclose. Runtime of video: 5 mins 30 secs

Friction characteristics of trocars in laparoscopic surgery.

This article investigates the friction characteristics of the instrument-trocar interface in laparoscopic surgery for varying linear instrument velocities, trocar seal design and material, and trocar tilt. Furthermore, the effect of applying lubrication at the instrument-trocar seal interface on friction was studied. A friction testing apparatus was designed and built to characterise the resistance force at the instrument-trocar interface as a function of the instrument's linear movement in the 12-mm trocar (at constant velocity) for different design, seal material, and angle of tilt. The resistance force depended on the trocar seal design and material properties, specifically surface roughness, elasticity, hardness, the direction of movement, and the instrument linear velocity, and varied between 0.25 and 8 N. Lubricating the shaft with silicone oil reduced the peak resistance force by 75% for all trocars and eliminated the stick-slip phenomenon evident in non-lubricated cases. The magnitude of fluctuation in resistance force depends on the trocar design and is attributed to stick-slip of the sealing mechanism and is generally higher during retraction in comparison to insertion. Trocars that have an inlet seal made of rubber/polyurethane showed higher resistance forces during retraction. Use of a lubricant significantly reduced frictional effects. Comparisons of the investigated trocars indicate that a low friction port, providing the surgeon with improved haptic feedback, can be designed by improving the tribological properties of the trocar seal interface.

Low-cost total laparoscopic hysterectomy by single-incision laparoscopic surgery using only reusable standard laparoscopic instruments

The purpose of this study was to demonstrate the feasibility and safety of total laparoscopic hysterectomy (TLH) by single-incision laparoscopic surgery (SILS) with conventional, reusable laparoscopic instruments, inserted through an inexpensive, self-constructed single-port device. Between June 2013 and April 2014, 15 TLHs by SILS were performed by a single surgeon (BJ). Only conventional, reusable laparoscopic instruments were used. The self-constructed single-port device was made by assembling a surgical glove, a wound protector, one reusable 10-mm trocar, and four reusable 5-mm trocars. The vaginal cuff was closed by intracorporeal suturing. Patient and perioperative data were analysed. Fifteen patients underwent TLH by SILS, and no conversion to standard laparoscopy or laparotomy was necessary. Mean operation time was 97 min (55–135 min), and mean drop in haemoglobin level was 1.2 g/dl (0–2.4 g/dl). There were no operative complications. Postoperative pain scores were low. The mean weight of the removed uterus was 118 g (50–208 g). TLH by SILS is feasible even when performed with reusable, conventional laparoscopic instruments. An inexpensive, self-constructed single-port device allows every surgeon worldwide to accomplish single-incision surgery without the need to invest in expensive ports, disposable instruments, sealing devices, or auto-locking sutures.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction

IntroductionUmbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages. Patient and methodWe present a 34-year-old patient with a solid mesorenal lesion measuring 8cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision. ResultsAfter the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications. ConclusionsUmbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

Positioning Trocars for Performing Sleeve Gastrectomy. Points of Controversy

Dear editor, As the number of trocars used for performing sleeve gastrectomy is variable [1, 2], the location of some ports should have already been standardized as it determines the angle between the stapler and the major axis of the stomach, which could influence the complication rate. We read with great interest the letter of Kassier et al. [3] about positioning trocars in sleeve gastrectomy and we would like to make some observations. We think that the two first cartridges are important because they affect the incisura angularis and guide the rest of the gastric section. We think it would be difficult to start the gastric section without using a 12-mm trocar on the patient’s right side, as the gastric antrum is normally found slightly to the right of the midline. Maximum articulation of the stapler head is required when we begin the section from the midline or the patient’s left side. In this case, the surgeon has to cross the instruments in order to pull out the surgical specimen to the left side; the stapler usually points directly to the incisura, creating an acute angle, which could result in complications such as stenosis [4, 5]. On the other hand, it is easier to continue the section upward from the patient’s right side as it allows for pushing the gastric tube with the stapler to the right while the surgeon pulls the specimen to the left at the same time. Finally, when the stapler is introduced from the patient’s right side, its direction makes the surgeon to get away from the angle of His, while the contrary occurs when the stapler is introduced from the patient’s left side. Conflict of Interest David Ruiz de Angulo has no conflicts of interests to declare in relation to this article. Vicente Munitiz has no conflicts of interests to declare in relation to this article. M. Angeles Ortiz has no conflicts of interests to declare in relation to this article. Luisa F. Martinez de Haro has no conflicts of interests to declare in relation to this article. Pascual Parrilla has no conflicts of interests to declare in relation to this article.

Simple and Easy Technique for the Placement of Seprafilm During Laparoscopic Surgery.

Laparoscopic surgery is a minimally invasive surgery, and the incidence of postoperative small bowel obstruction (SBO) is not high. However, SBO is a disease that detracts from the benefits of laparoscopic surgery due to the need for additional therapies or prolongation of hospital stay. Seprafilm is effective in reducing adhesions and preventing the occurrence of SBO. However, it is very difficult to place the Seprafilm during laparoscopic surgery compared to open surgery. Herein, we report a simple and easy method. The Seprafilm including the holder paper is divided into six pieces; each piece is wound around the end of the forceps and the reduction sleeve is slid over it. The forceps with the reduction sleeve is inserted through a 12-mm trocar and moved closer to the target place. Then, the reduction sleeve is slid down the forceps to expose the Seprafilm. This method does not require any special preparation or training. Based on our experience, this method can easily overcome the problems that the Seprafilm is vulnerable to tear and is difficult to spread out in the abdominal cavity.

A Simple Approach to Specimen Retrieval via Posterior Colpotomy Incision

Introduction:Posterior colpotomy incision for specimen retrieval is infrequently used in gynecologic laparoscopic surgery unless a concomitant hysterectomy is performed. We aim to describe a simple and unique technique for creating the colpotomy incision and to describe intraoperative and postoperative outcomes.Methods:Fifty patients underwent adnexal specimen retrieval through a posterior colpotomy incision. After devascularization and detachment of the adnexal specimen, the posterior cul-de-sac was visualized. The colpotomy incision was created by introducing a 12- or 15-mm laparoscopic trocar through the vagina into the posterior vaginal fornix under direct visualization. Specimens were placed into laparoscopic bags and removed through the vagina. The colpotomy incision was closed vaginally. Charts were reviewed for intraoperative and postoperative outcomes.Results:Twenty-nine women underwent adnexal surgery for an adnexal mass, 14 women underwent surgery for pelvic pain, and 7 women underwent adnexal surgery for primary prevention of malignancy. The specimens removed ranged in size from 2 to 16 cm (mean 5.7). The mean time patients were under anesthesia was 103 minutes (SD 57.3). There were no operative complications related to the colpotomy incision and no cases of postoperative vaginal cellulitis or pelvic infection were reported. Only 1 woman with a prior vaginal delivery reported dyspareunia postoperatively.Conclusion:This simple technique for posterior colpotomy incision can easily be added to the gynecologic surgeon's armamentarium and can be safely used for most women.

Total Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Mucinous Adenocarcinoma of the Appendix

Abstract Open cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as the procedure of choice for mucinous adenocarcinoma of the appendix (MAA); however, it is associated with substantial morbidity. We present a case of a total laparoscopic R0-CRS-HIPEC for MAA. CRS included right hemicolectomy, omentectomy, cholecystectomy, bilateral salpingo-oophorectomy, excision of the round and falciform ligaments, and stripping of the peritoneum of the right diaphragm, followed by HIPEC through single inflow and outflow catheters. The operative time was 380 minutes, and the estimated blood loss was 100 mL. There was no postoperative morbidity. The patient was discharged on postoperative day 8. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has emerged as the procedure of choice for selected patients with MAA.1 Usually performed through a large midline incision, CRS-HIPEC is associated with a substantial rate of morbidity and mortality.2–3 The ...

Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography (ERCP) After Roux-en-Y Gastric Bypass: Technical Features

Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The exclusion of stomach and duodenum after this operation makes the access to the biliary tree, in order to perform an endoscopic retrograde cholangiopancreatography (ERCP), very difficult. This procedure could be more often required than in overall population due to the increased incidence of gallstones after bariatric operations. Among the different techniques proposed to overcome this drawback, laparoscopic access to the excluded stomach has been described by many authors with a high rate of success reported. We herein describe our technique to perform laparoscopic transgastric ERCP. A gastrotomy on the excluded stomach is performed to introduce a 15-mm trocar. Two stitches are passed through the abdominal wall and placed at the two sides of the gastrotomy for traction. The intragastric trocar is used to pass a side-viewing endoscope to access the biliary tree. In patients with a past history of Roux-en-Y gastric bypass (RYGB), the present technique allows us a standardized, safe, and reproducible access to the major papilla and the biliary tree using a transgastric access. This will lead to simplify the procedure and reduce the risk of peritoneal contamination.