Additional Port Research Articles

Emergency single-incision laparoscopic cholecystectomy for acute cholecystitis: A multi-center study.

Single-incision laparoscopy is accepted as a safe alternative to multiple port laparoscopy for elective cholecystectomy; however, there are limited data on its use in patients with acute cholecystitis. The present multi-center study evaluated the outcomes of emergency single-incision surgeries for acute cholecystitis in hospitals in Belgium, Jamaica, and Trinidad and Tobago over a 5-year period. Standardized definitions of uncomplicated and complicated acute cholecystitis were used and the data were compared using SPSS software. The results revealed that over the 5-year period, 108 patients with a mean age of 48±15 years and a mean body mass index of 27±4.2 kg/m2 underwent emergency single-incision cholecystectomies. The surgeries were successful in 92.1% of cases without supplemental trocars being used. The overall morbidity rates (9.3%) were also comparable to the historic controls with multiple port cholecystectomy. As was expected, the complicated cholecystitis group required a significantly longer operating time (86.11±30.16 vs. 66.79±16.8; P<0.00194), as well as supplemental trocars (7.9%) vs. 0; P=0.0413). On the whole, the present study demonstrates that emergency single-incision cholecystectomy is a technically feasible and safe procedure for patients with acute cholecystitis. These findings advocate a low threshold to place additional ports to assist with dissection and exposure.

Technique and perioperative outcomes of single-port robotic surgery using the da Vinci SP platform in urology

To describe surgical technique for single port robotic surgery using the da Vinci SP system and report the perioperative outcomes. Between Jan 2019 and Jan 2021, single-port robotic urologic surgeries were performed in 120 patients by a single surgeon. Clinicopathologic data and perioperative outcomes were collected. All surgical procedures were performed with a transperitoneal approach through an umbilical single port. Additional assistant port was used in complex procedures for malignant disease. Surgeries were carried out using both above and below camera position for effective retraction. For reconstructive surgery using intestine, an extra-intracorporeal hybrid method was used. Surgical procedures involving both kidney and pelvis were performed without change of patient position or trocar placement. Mean age was 62.7 years and 102 patients were male. For oncologic indication, 105 patients underwent surgeries including 66 radical prostatectomy, 25 partial nephrectomy, six radical nephrectomies, five nephroureterectomy and three radical cystectomy with urinary diversion. Fifteen cases with benign indication included four ureterolithotomy, seven uretero/pyeloplasty, three ureteroneocystostomy, and one ileal ureter reconstruction. All surgeries were performed successfully without conversion to other surgical approach. Clavien-Dindo grade III complication occurred in two patients. The da Vinci SP system provides a new robotic surgical platform for single port surgery while maintaining the major features of robotic surgery similar to multi-port surgery. Various single port urologic surgeries can be safely performed with this platform.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for rectosigmoid or upper rectal cancer.

Single-incision laparoscopic surgery (SILS) for rectal cancer is technically challenging, and its clinical impact is unclear. The aim of this study was to evaluate clinical outcomes of SILS for rectal cancer compared with multi-port laparoscopic surgery (MPLS). We retrospectively analyzed 357 consecutive patients with stage I-III rectal cancer located in the rectosigmoid or upper rectum who underwent SILS or MPLS between January 2012 and December 2016, using propensity score-matched analysis. After propensity score-matching, we enrolled 204 patients (n = 102 per group). Before matching, significant group-dependent differences were observed in tumor location (p < 0.001). After matching, preoperative clinical factors were similar between groups. SILS was successful in 73.5% of cases, an additional port was required in 23.5%, and 2.9% were converted to open surgery. Compared to the MPLS group, the SILS group showed shorter operative time (192 vs. 211min, p = 0.015) and shorter postoperative hospital stay (9 vs. 11days, p = 0.038). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the SILS group (24) than in the MPLS group (27, p = 0.008). Postoperative recurrence did not differ between groups, either before or after matching. No significant differences in 3-year disease-free, 3-year local recurrence-free, or 5-year overall survival were found between groups. SILS is safe, is feasible, and offers satisfactory oncological outcomes in selected patients with rectosigmoid or upper rectal cancer.

A Transition Toward a Faster Recovery in Single-Port Transvesical Simple Prostatectomy.

Objectives: To present the updated technique and evaluate the perioperative and postoperative outcomes of single-port transvesical simple prostatectomy (SP TVSP) Patients and Methods: Forty-two consecutive patients with benign prostatic hyperplasia indicated for surgery underwent SP TVSP in a single institution. Through direct suprapubic bladder access, the SP robot was docked. Prostatic enucleation was performed using the prostatic capsule as a landmark. Then a complete vesicourethral mucosal advancement flap was accomplished. Demographics, perioperative, and postoperative data were prospectively collected. Mean follow-up period was 12 months. Results: All procedures were effectively performed with no conversion, additional port placement, or intraoperative complication. The median prostatic volume was 170 cc. Ninety-five percent of the patients did not require opioids analgesia after discharge. Excluding planned admissions, 92% (21/23 patients) were discharged after a median (interquartile range) of 4.6 (4.1-5.7) hours after surgery. The median Foley catheter duration for all cohort was 7 days, and decreased to 3 days after technique adjustment for the last 19 consecutive patients. The median international prostate symptom score decreased from 23 before surgery to 2.5 after surgery. All patients had a significant postoperative improvement in maximum flow rate with a 200% improvement over baseline (19 vs 6.5 mL/sec). Conclusion: In our initial series, SP TVSP allows for favorable perioperative and early postoperative outcomes including low complication same-day discharge, short Foley catheter stay, minimal opioids use, and quick recovery.

Initial experience of transurethral-assisted laparoendoscopic single-site nephroureterectomy

PurposeWe describe a new transurethral technique for distal ureter management and the improvement of intraoperative exposure during LESS-NU. MethodsA total of 20 transurethral assisted LESS-NU were performed between May 2018 and December 2020 in our institution. The access route for the operation was via a single-port, with four channels placed through a transumbilical incision. After the lower ureter was separated from the bladder wall, a 1470 laser working channel was placed through the urethra to precisely cut the ureteral orifice. Following this, a self-made urethra auxiliary port was inserted through the bladder cuff opening to facilitate a resection of the ureter and kidney. The peri-operative and postoperative data were then retrospectively collected and analysed. ResultsAll procedures were completed successfully and one patient needed an additional port. The mean operative time was 196.8 ± 45.8 min and the mean estimated blood loss was 58.9 ± 32.0 ml. The days required for the surgical drain removal and the hospital stay were 4.6 ± 4.6 and 11.1 ± 6.4 days, respectively. One patient developed a fever following surgery but there were no major complications. During the average follow-up period, which lasted 25.5 months, one patient developed spinal cord metastasis and died 8 months after surgery. No obvious abnormalities were found in any of the other patients. ConclusionThe tansurethral approach of the distal ureter for LESS-NU is deemed safe and efficient. The technique used offers accurate control of the distal ureter and good exposure of LESS.

An additional port in difficult laparoscopic cholecystectomy for surgical safety.

Tokyo Guidelines 2018, clinical practice guidelines for acute cholangitis and cholecystitis, recommend bailout procedures to prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC) for difficult gallbladder. We first insert an additional port (AP) for difficult gallbladder that may require bailout procedures. Because the usefulness of an AP during LC is unclear, we therefore examined the efficacy of the AP during LC in this study. Data were collected from 115 patients who underwent LC for acute cholecystitis in our department. The indications for AP were excessive bleeding, scarring, and poor visual field around Calot's triangle. AP was inserted into the right middle abdomen so as not to interfere with other trocars and was used by the assistant. Surgical outcomes were evaluated based on AP use during LC. AP was inserted in 19 patients during LC (AP group). The indications for AP were excessive bleeding in nine patients, scarring around Calot's triangle in seven patients, and poor visual field around Calot's triangle in three patients. Open conversion was performed in two patients in the non-AP group. BDI occurred in one patient in the non-AP group. In patients with Difficulty Score 3, operation time was significantly shorter (P=.038) and Critical View of Safety (CVS) score was significantly higher in the AP group (P=.046). AP is useful in patients with excessive bleeding to shorten operation time and increase the CVS score. AP may be one useful option for difficult gallbladder.

Use of an Endoloop Ligature and a 2-Portal Coelioscopic Approach for the Removal of an Arrowhead Foreign Body in a Red-Tailed Hawk (Buteo jamaicensis).

A juvenile red-tailed hawk (Buteo jamaicensis) was presented to the Ontario Veterinary College from a wildlife rehabilitation facility for the assessment of an arrowhead foreign body injury. The hawk was found on the ground with the left wing in a dropped position. Radiographic images revealed an arrowhead foreign body superimposed over the left lung and thoracic air sacs, immediately medial to the ribs on the ventrodorsal view, and ventral to the scapulae on the right latero-lateral view. A coelioscopy was performed using a left lateral approach with a 2.7-mm rigid endoscope into the left caudal thoracic air sac, with an additional instrument port through the left abdominal air sac. The arrowhead was visualized adjacent to the left lung, separated from the cranial thoracic air sac cavity by a membrane of fibrous tissue. The tissue membrane was radiosurgically incised. Forceps were then used to guide an Endoloop around the arrowhead. The arrowhead was secured by tightening the Endoloop, and the body wall incision was extended to facilitate the arrowhead extraction.

V10-11 PARTIAL NEPHRECTOMY IN COMPLEX KIDNEY MASSES - TWO APPROACHES WITH THE DAVINCI SINGLE PORT ROBOT

You have accessJournal of UrologyCME1 May 2022V10-11 PARTIAL NEPHRECTOMY IN COMPLEX KIDNEY MASSES - TWO APPROACHES WITH THE DAVINCI SINGLE PORT ROBOT John Sheng, Chrystal Chang, Michael Stifelman, and Mutahar Ahmed John ShengJohn Sheng More articles by this author , Chrystal ChangChrystal Chang More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002623.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: - Performing partial nephrectomy on patients with complex hilar anatomy and/or posterior tumors can be challenging, sometimes requiring placement of an additional assistant port and/or mobilizing the entire kidney. - We demonstrate how the DaVinci Single Port Robot facilitates certain surgical approaches in performing partial nephrectomy on complex masses. - We show how the procedure can be performed with one incision with both a transperitoneal approach on a patient with complex hilar anatomy and an entirely retroperitoneal approach on another patient with a posterior mass. METHODS: Case - Transperitoneal Approach. - 41 year old male who was found to have an enhancing left 3cm hilar mass on workup for microhematuria. - He also has a duplicated collecting system on the same side as his mass. Case - Retroperitoneal Approach- 61 year old female who was found to have an enhancing 2cm left posterior kidney mass on workup for microhematuria. RESULTS: - For both approaches no additional assistant port was needed. - A single 15mm incision was made on the left side of the abdomen for the robotic instruments. No assistant port was used, making both true single port procedures. - For the retroperitoneal approach, we did not have to mobilize the entire kidney and then flip it medially which would have been needed with a multiport robotic approach. - We had quick access to the hilum and vasculature as well as the mass itself. - The patient had only one incision for both approaches, resulting in better cosmesis and possibly less post operative pain. CONCLUSIONS: - True single port partial nephrectomy can be performed via both a transperitoneal or retroperitoneal approach. This can be customized based on surgeon preference, comfort level and patient anatomy. - Its utilization can allow for the most minimally invasive approach, despite complex kidney anatomy. - However there is a learning curve in the use of the Da Vinci SP robot. - We hope to improve our techniques and surgical approaches further to keep our procedures as minimally invasive as possible. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e851 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Sheng More articles by this author Chrystal Chang More articles by this author Michael Stifelman More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement PDF DownloadLoading ...

PD54-08 SINGLE-PORT EXTRAPERITONEAL VS TRANSPERITONEAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: A MULTI-INSTITUTIONAL MATCHED-PAIR COMPARISON OF OUTCOMES

You have accessJournal of UrologyCME1 May 2022PD54-08 SINGLE-PORT EXTRAPERITONEAL VS TRANSPERITONEAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: A MULTI-INSTITUTIONAL MATCHED-PAIR COMPARISON OF OUTCOMES Mahmoud Abou Zeinab, Ethan Ferguson, Aaron Kaviani, Alp T. Beksac, Marcio Moschovas, Luca Morgantini, Sij Hemal, Susan Talamini, Jean Joseph, Moses Kim, Simone Crivellaro, Vipul Patel, Jeffrey Nix, and Jihad Kaouk Mahmoud Abou ZeinabMahmoud Abou Zeinab More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Aaron KavianiAaron Kaviani More articles by this author , Alp T. BeksacAlp T. Beksac More articles by this author , Marcio MoschovasMarcio Moschovas More articles by this author , Luca MorgantiniLuca Morgantini More articles by this author , Sij HemalSij Hemal More articles by this author , Susan TalaminiSusan Talamini More articles by this author , Jean JosephJean Joseph More articles by this author , Moses KimMoses Kim More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , Vipul PatelVipul Patel More articles by this author , Jeffrey NixJeffrey Nix More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002631.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The introduction of the ‘purpose-built’ Single-port (SP) robot successfully expanded the surgical approaches in the management of localized prostate cancer to include the extraperitoneal, in addition to the standard transperitoneal approach. We sought to perform a multi-institutional study to assess the perioperative, and functional outcomes between SP extraperitoneal (ERP) and SP transperitoneal (TRP) radical prostatectomy. METHODS: From February 2019 to October 2021, a prospective data collection from six different robotic centers was performed. Data of 412 patients who underwent ERP and 241 patients who underwent TRP were analyzed. All procedures were performed by surgeons with extensive robotic experience. A 1:1 matched-pair analysis for the National Comprehensive Cancer Network (NCCN) risk was performed. Baseline characteristics, intraoperative, postoperative and functional outcomes were evaluated. RESULTS: Before matching, there was a significantly higher percentage of NCCN high risk in the ERP group compared to the TRP group. After matching, patients in the ERP had a higher rate of previous abdominal surgery (p <.001). The median operative time was 203 vs 169 minutes, median estimated blood loss was 150 vs 87 cc for ERP and TRP, respectively (p <.001). TRP was more likely to include an additional surgical port (SP+1). 37.6% of the ERP group had more extraprostatic extension on pathology compared to 26.8% in the TRP, with no significant difference in the positive surgical margins (25.3% and 26.8%). The median lymph node yield was higher in the ERP group (6 vs 3 nodes, p=.017). ERP patients were more likely to be discharged the same day after the surgery (7 vs 14 hours, p <.001), and had their median Foley catheter stay for 7 days compared to 5 days In the TRP group (p <.007). There was no difference in the perioperative complications or continence rates after the surgery. Median follow-up was 6 months. CONCLUSIONS: Both SP ERP and TRP are comparable surgical options for the treatment of localized prostate cancer. ERP is more associated with same-day discharge and higher lymph node yield. TRP has a shorter operative time and less estimated blood loss. The two techniques have similar complications, positive surgical margin, and continence rates. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e918 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mahmoud Abou Zeinab More articles by this author Ethan Ferguson More articles by this author Aaron Kaviani More articles by this author Alp T. Beksac More articles by this author Marcio Moschovas More articles by this author Luca Morgantini More articles by this author Sij Hemal More articles by this author Susan Talamini More articles by this author Jean Joseph More articles by this author Moses Kim More articles by this author Simone Crivellaro More articles by this author Vipul Patel More articles by this author Jeffrey Nix More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF DownloadLoading ...

Single-port robot plus one port (SP + 1) distal pancreatectomy using the new da Vinci SP system.

Single-incision laparoscopic distal pancreatectomy has not been widely applied due to technical challenges and increased operative risks. The newly released da Vinci SP system has been introduced to overcome these limitations and offer improvements for established robotic single-site procedures. We report our experience of robotic single port plus one port distal pancreatectomy using the da Vinci SP system. We performed robotic distal pancreatectomy in three patients using the da Vinci SP surgical system with one additional port used for applying the energy device and stapling. Technical and clinical feasibility were examined. The mean age and body mass index were 70.7years and 27.8kg/m2, respectively. The mean operation time was 215min. The estimated blood loss was less than 500mL. All patients underwent combined splenectomy. The postoperative course of all patients was uneventful. Robotic distal pancreatectomy using the da Vinci SP system is safe and feasible, with acceptable perioperative outcomes.

Application of tiny-TIM as a mechanistic tool to investigate the in vitro performance of different itraconazole formulations under physiologically relevant conditions

The increasing number of poorly water-soluble compounds in drug development is one of the major challenges in oral drug delivery nowadays. For rational formulation development, biopharmaceutical tools are needed that closely simulate the conditions present within the human gastrointestinal (GI) tract in order to early predict the potential effect of important factors like meal intake or acid-reducing agents on oral bioavailability. The tiny-TIM system equipped with the advanced gastric compartment is one of the most realistic in vitro models for the simulation of the physiological processes occurring in human stomach and small intestine. In the present study, this model was applied to study the in vitro performance of an ASD-based formulation of itraconazole under different clinically relevant conditions. Apart from the assessment of the bioaccessible fraction (i.e., the fraction available for drug absorption), the implementation of two additional sampling ports enabled the measurement of intraluminal concentration profiles. Along with solubility experiments in biorelevant media, deeper mechanistic insights into drug product performance in different prandial states as well as in case of gastric pH modification could be generated. The comparison of the in vitro data with published in vivo data revealed that the model successfully predicted the effect of food intake as well as of modified gastric pH conditions on the bioavailability of itraconazole from this formulation. In contrast, the negative food effect observed for an oral solution formulation could not be predicted. For this cyclodextrin-based formulation, the formulation effect on permeation needs to be considered. Nonetheless, the data presented in this study showed that tiny-TIM is an interesting tool to mechanistically study the impact of different physiological conditions on drug release from oral drug products.

Robotic total gastrectomy with thrombectomy and portal vein reconstruction for gastric cancer and portal vein tumor thrombus

BackgroundGastric cancer with portal vein tumor thrombus (PVTT) is poor prognosis, and the treatment remains challenging. Regarding surgery, there are only reports of highly invasive laparotomy. We report some techniques of the completely robotic total gastrectomy with thrombectomy and portal vein reconstruction for the patient with gastric cancer and PVTT for the first time.Case presentationA 79-year-old man was diagnosed with a 5-cm gastric cancer on the side of the lesser curvature from the middle of the gastric body to the cardia. Computed tomography revealed a massive PVTT extending from the left gastric vein to the portal trunk (28 x 16 mm). There were no other distant metastases. After 3 cycles of the chemotherapy, the PVTT shrank to 19 x 12 mm. After obtaining informed consent from the patient, robotic total gastrectomy with regional lymphadenectomy and thrombectomy were performed. We used the da Vinci Xi Surgical System. A 3-cm incision was made at the umbilicus, and a wound retractor was placed. Five additional ports were placed. The right side suprapancreatic lymph nodes were performed at the time of the thrombectomy. It was important to identify the precise extent of the PVTT with intraoperative ultrasonography before the thrombectomy. After PVTT identification, the portal trunk was clamped above and below the tumor thrombus with vascular clips. The membrane on the anterior wall of the portal trunk around the PVTT was carefully incised with da Vinci Scissors. The tumor thrombus was completely enucleated without separation. The incised part of the portal trunk was reconstructed with continuous 5-0 synthetic monofilament nonabsorbable polypropylene sutures. After removing the vascular clamps, we made sure there was no leakage from the portal vein and no tumor thrombus remnants with intraoperative ultrasonography. Robotic total gastrectomy with lymphadenectomy and Roux-en-Y reconstruction were performed. The patient was discharged without complications. The patient has remained alive for 30 months after surgery.ConclusionsRobotic total gastrectomy with thrombectomy and portal vein reconstruction is a safe, minimally invasive, and precise surgery. It may contribute to improved prognosis of gastric cancer with PVTT when combined with chemotherapy.

Single Incision Cholecystectomies for Acute Cholecystitis: A Single Surgeon Series from the Caribbean.

Introduction Single incision laparoscopic surgery (SILS) is accepted as a safe alternative to conventional multiport laparoscopic (MPL) cholecystectomy for benign gallbladder disease. Since many surgeons carefully select patients without inflammation, there are limited data on SILS for acute cholecystitis. We report a single surgeon experience with SILS cholecystectomy for patients with acute cholecystitis. Materials and Methods After securing ethical approval, we performed an audit of all SILS cholecystectomies for acute cholecystitis by a single surgeon from January 1, 2009, to December 31, 2019. The following data were extracted: patient demographics, intraoperative details, surgical techniques, specialized equipment utilized, conversions (additional port placement), morbidity, and mortality. Data were analyzed using SPSS 12.0. Results SILS cholecystectomy was performed in 25 females at a mean age of 35 ± 4.1 (SD) years and a mean BMI of 31.9 ± 3.8 (SD) using a direct fascial puncture technique without access platforms. The operations were completed in 83 ± 29.4 minutes (mean ± SD) with an estimated blood loss of 76.9 ± 105 (mean + SD). Three (12%) patients required additional 5 mm port placement (conversions), but no open operations were performed. The patients were hospitalized for 1.96 ± 0.9 days (mean ± SD). There were 2 complications: postoperative superficial SSI (grade I) and a diaphragmatic laceration (grade III). No bile duct injuries were reported. There were 9 patients with complicated acute cholecystitis, and this sub-group had longer mean operating times (109.2 ± 27.3 minutes) and mean postoperative hospital stay (1.3 ± 0.87 days). Conclusion The SILS technique is a feasible and safe approach to perform cholecystectomy for acute cholecystitis. We advocate a low threshold to place additional ports to assist with difficult dissections for patient safety.

Intra-/Extracorporeal Single-Incision Versus Conventional Laparoscopic Appendectomy in Children: A Systematic Review and Meta-Analysis

Background: There are two approaches to single-incision laparoscopic appendectomy (SILA): intracorporeal (Intra) and extracorporeal (Extra). However, the differences in the efficacy between these procedures remain unclear. Thus, this systematic review and meta-analysis aimed to compare the safety and usefulness of these techniques with those of conventional laparoscopic appendectomy (CLA) in children. Methods: A systematic literature search was performed using the PubMed, CENTRAL, and Scopus databases. Studies comparing outcomes of "Intra-SILA and CLA" or "Extra-SILA and CLA" in children aged <18 years were included. Operative time, hospitalization duration, wound infection, intra-abdominal infection, conversion to open, additional ports, and narcotic doses were evaluated. Results: Overall, 20 studies (six randomized controlled trials [RCTs], one prospective non-RCT, and 13 retrospective cohort studies) (Intra-SILA: 322, CLA: 791 cases; Extra-SILA: 1318, CLA: 1313 cases) were included. Compared with CLA, Extra-SILA was associated with a shorter operative time (mean difference, -9.79 minutes; 95% confidence interval [CI], -18.34 to -1.24) and lower incidence of intra-abdominal infection (3.3% versus 4.6%, odds ratio [OR], 0.52; 95% CI, 0.33 to 0.82) and a higher rate of additional port (13.6% versus 0%, OR, 43.93; 95% CI, 14.79 to 130.50). Meanwhile, the outcomes of Intra-SILA were comparable with those of CLA. However, the participants in the Intra-SILA group received significantly lower doses of narcotics than those in the CLA group. Conclusion: Although the evidence was insufficient, both Intra- and Extra-SILA were comparable to CLA with respect to safety. Extra-SILA seems to have an advantage of a shorter operative time, but additional ports may be required.

Triple Intercostal Transthoracic Ports in Laparoscopic Hepatectomy for a Tumor in a Cranially Protruded Liver (with Video).

It is difficult to laparoscopically approach tumors of the anatomically anomalous right lobe of the liver, such as cranially protruded liver. The intercostal port has been useful for laparoscopic hepatectomy, especially for tumors located in the dome of the liver. PLoS One. 15:e0234919; Surg Endosc. 31:1280-1286; J Gastrointest Surg. 21:2135-2143; J Hepatobiliary Pancreat Sci. 21:E65-68; Surg Oncol. 38:101576; Thus, we introduce our technique using triple intercostal transthoracic ports for laparoscopic hepatectomy for hepatocellular carcinoma located in segment 8. The right lobe of the liver was cranially protruded and located at the same level of the heart. The patient was placed in left lateral decubitus position. After the pneumoperitoneum and adhesiolysis, the hepatoduodenal ligament was controlled. Three additional intercostal ports with balloons were introduced transdiaphragmatically for liver parenchymal resection after confirmation of the lung edge by mandatory ventilation. A 12-mm and a 5-mm port were inserted into the sixth and seventh intercostal space for the operator's hands, while a 5-mm port was inserted into the fourth intercostal space for the assist's right hand. The liver parenchymal resection was performed using a cavitron ultrasonic surgical aspirator (CUSA) through the 12-mm intercostal port, followed by its completion without exposing the tumor. The 12-mm port hole on the diaphragm was sutured and a 12-Fr chest tube was introduced in the right thoracic cavity. The operation time was 131 min, and the blood loss was 20 g. The patient was discharged on postoperative day 7 without any complication. Triple intercostal ports could be a feasible procedure for a tumor with limited laparoscopic access from the abdominal port due to the anatomically anomalous liver.

Incidence and risk factors for umbilical incisional hernia after reduced port colorectal surgery (SIL + 1 additional port)—is an umbilical midline approach really a problem?

Umbilical midline incisions for single incision- or reduced port laparoscopic surgery are still discussed controversially because of a higher rate of incisional hernia compared to conventional laparoscopic techniques. The aim of this study was to evaluate incidence and risk factors for incisional hernia after reduced port colorectal surgery. A total 241 patients underwent elective reduced port colorectal surgery between 2014 and 2020. Follow-up was achieved through telephone interview or clinical examination. The study collective was examined using univariate and multivariate analysis. A total of 150 patients with complete follow-up were included into this study. Mean follow-up time was 36 (IQR 24-50) months. The study collective consists of 77 (51.3%) female and 73 (48.7%) male patients with an average BMI of 26kg/m2 (IQR 23-28) and an average age of 61 (± 14). Indication for surgery was diverticulitis in 55 (36.6%) cases, colorectal cancer in 65 (43.3%) patients, and other benign reasons in 30 (20.0%) cases. An incisional hernia was observed 9 times (6.0%). Obesity (OR 5.8, 95% CI 1.5-23.1, p = 0.02) and pre-existent umbilical hernia (OR 161.0, 95% CI 23.1-1124.5, p < 0.01) were significant risk factors for incisional hernia in the univariate analysis. Furthermore, pre-existent hernia is shown to be a risk factor also in multivariate analysis. We could demonstrate that reduced port colorectal surgery using an umbilical single port access is feasible and safe with a low rate of incisional hernia. Obesity and pre-existing umbilical hernia are significant risk factors for incisional hernia.

Single-Incision Laparoscopic Complete Mesocolic Excision With Central Vascular Ligation for Descending Colon Cancer.

Single-incision laparoscopic complete mesocolic excision with central vascular ligation for descending colon cancer is technically challenging. Standardization of the surgical procedures is therefore needed. In a Trendelenburg position with left side elevated, the sigmoid mesocolon is mobilized using a medial-to-lateral approach, and the left colic artery and inferior mesenteric vein (IMV) are divided after radical lymphadenectomy along the inferior mesenteric artery, preserving the superior rectal artery. The descending mesocolon is mobilized from the retroperitoneal planes up to the dorsal surface of the pancreas using medial and lateral approaches. Next, changing the surgical position to a reverse Trendelenburg position with left side elevated, the omental bursa is opened, and the transverse mesocolon is separated from the inferior border of the pancreas. The splenocolic ligament and lateral attachment are then divided, matching the previous medial dissection of the retroperitoneum, and the splenic flexure is fully mobilized. The IMV is divided again at the inferior border of the pancreas. The left branch of the middle colic artery is also divided. Forty-seven consecutive patients with DCC underwent single-incision laparoscopic CME with CVL. One patient required an additional port. Median operative time, blood loss, and number of harvested lymph nodes were 240min (interquartile range [IQR], 195-257min), 5mL (IQR, 5-52mL), and 21 (IQR, 13-29), respectively. Morbidity rate was 5.9%. Median duration of hospitalization was 9days (IQR, 7-11days). Single-incision laparoscopic CME with CVL is safe and feasible for DCC.

Single-Incision Laparoscopic Cholecystectomy: a Single-Centre Experience of 1469 Cases

BackgroundDespite having once been extensively used for cosmetics or pain reduction, the use of single-incision laparoscopic cholecystectomy (SILC) has declined in recent years due to technical difficulties and a reported increase in complications. Since the introduction of SILC in 2009, our hospital has been actively involved with this technique. Our experience suggests that SILC is not a difficult procedure and can be safe and useful, with particularly excellent cosmetic outcomes. This study retrospectively details the outcomes of SILC at our hospital. MethodData on 1469 cases of SILC performed on a waitlist basis at Osaka Police Hospital from May 2009 to December 2020 were collected and retrospectively analysed. ResultsThe median operative time and blood loss were 96 min and 0 mL, respectively. A total of 46 patients (3.1%) required conversion surgery, including 36 needing additional ports and 10 requiring laparotomy. Intraoperative complications included common bile duct injury in 1 patient (0.07%) and right hepatic artery injury in 1 patient (0.07%), with no other organ injury. Postoperative Clavien-Dindo 3 or higher complications were observed in 18 patients (1.2%). Incisional hernias occurred in 15 patients (1.0%). The median postoperative hospital stay was 3 days. ConclusionThis study showed that SILC can be performed safely without any increase in complications, as reported previously. Granted that it is performed safely, SILC may be a useful technique due to its superior cosmetic outcomes or pain reduction.

Mid- to long-term results of SuPerLap single-port treatment in inguinal hernia.

Laparoscopic treatment of inguinal hernia is gaining popularity in many hospitals, but the use of working channel scopes is not as widely extended. We present our long-term experience with the SuPerLap (laparoscopic-assisted percutaneous suture) technique described by Rosell et al.(1) for epigastric hernia repair in the percutaneous, single-port treatment of inguinal hernia using working channel scopes. A retrospective analysis of a series of male patients with congenital inguinal hernia undergoing surgery from February 2017 to December 2020 was carried out. A 5 mm-0º pleuroscope with a 3.5 mm working channel, a 20 G epidural needle, a 36 cm/3.5 mm laparoscopic Maryland dissector, and 3-0 polypropylene and polyester sutures were used. 384 inguinal hernia repairs using the SuPerLap technique were performed in 295 male patients - 206 unilateral repairs and 89 bilateral repairs. In 24 bilateral cases (26.95%), preoperative diagnosis had been unilateral. Mean age was two years (2 weeks-13 years). Mean operating time was 14 minutes (6-50 min) for unilateral repair, and 27 minutes (14-80 min) for bilateral repair. There were two cases of epigastric vessel damage, and one case of early recurrence in a newborn, who successfully underwent re-intervention using the SuPerLap technique. No late complications were recorded after a mean follow-up of 1-36 months. Working channel scopes using the SuPerLap technique avoid additional ports in inguinal hernia repair. They allow for excellent functional results, without visible scars, and minimize spermatic cord manipulation. Laparoscopy allows previously undiagnosed defects to be concomitantly treated.

Technical Feasibility of Single-Port Robotic Left Lateral Sectionectomy Using the da Vinci SP

The recent introduction of robot surgery system is bringing new innovation to the field of minimal invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. Well-known advantages of the robotic surgery such as improved vision of surgical field via three-dimentional vision, visual magnification , tremor suppression , and the flexibility and dexterity of the instruments have allowed precise and meticulous operation techniques. The da Vinci system has recently released a true single-port platform, the da Vinci SP system with 3 instrument which has the multi-joint (elbow and wrist) and flexible camera entering into one single port. We now present the first case of robotic liver resection using the da Vinci SP system, showing surgical technical feasibility. A 63-years old female presented with elevated liver function test(LFT) and abdominal pain. CT scan and MRCP shows that multiple intrahepatic duct stone at left lateral section and distal CBD stone near ampullar of vater. Thus, we removed distal CBD stone via ERCP. After performing ERCP, there were no biliary obstructive symptoms, so we doing operation after that. Docking time took 8 minites. The patient underwent successful da Vinci SP with a total operation time of 135 minutes. There was no significant intraoperative event. The patient was discharged post-operative 5 days after checking the CT scan without any surgical complication. We report a technique of left lateral sectionectomy without additional port. For active application of da Vinci SP in hepatobiliary surgery, more device development and further research are needed.