Balloon Dissection Research Articles

ETEP AND TRANSVERSUS ABDOMINIS RELEASE IN A M5W3 INCISIONAL HERNIA

Abstract A 59-year-old female who underwent hysterectomy and exploratory laparotomy secondary to seromucinous ovarian carcinoma presents with discomfort in a partially reducible M5W3 incisional hernia. The patient is operated using a full endoscopic minimally invasive extraperitoneal approach (e-TEP + TAR). A 2 cm incision on the right subcostal region is made, exposing and opening the anterior rectal sheath (ARS), medializing the right rectus muscle. A dissection balloon is introduced to release the retromuscular space on the right side. A 10 mm trocar is placed in the right flank and a 5 mm trocar in the right iliac fossa. First, we access the medial posterior rectus sheath (PRS) of the right side, which is then incised, and the preperitoneal dissection is performed doing the crossover above the umbilicus. Once the hernia is completely reduced we connect both the retrorectus space with the preperitoneal spaces on both sides of the hernia. A modified posterior components separation (TAR) is performed on the left side, sectioning the aponeurosis of the transverse muscle (TM) and accessing the preperitoneal space laterally without sectioning the TM. The posterior and anterior defects are then closed separately using a barbed suture. A wide pore mesh, covering both retrorectus and preperitoneal spaces is placed and fixated using glue. An aspiration drainage was placed and removed 24 h after surgery. The patient was discharged the day after and no complications, where reported. In the CT scan 6 months after surgery the correction of the defects where confirmed.

Telescopic dissection versus balloon dissection during laparoscopic totally extraperitoneal inguinal hernia repair: A prospective randomised control trial.

Totally extraperitoneal (TEP) repair involves creating a preperitoneal space. The preperitoneal space can be created by balloon or telescopic dissection (TD). Nevertheless, these techniques may have some complications. However, there are very few studies that compare these two techniques. This study aims to assess the impact and comprehensively compare the TD and balloon dissection (BD) methods in patients undergoing laparoscopic TEP inguinal hernia repair. This was a single-centre, double-blinded, prospective, randomised, controlled trial comparing BD and TD for the creation of the preperitoneal space. The primary end point was to compare the post-operative pain score, intraoperative complications and surgical site occurrence between the two groups. The secondary end point was to assess the impact of the dissection technique on operative time for the creation of extraperitoneal space during laparoscopic TEP inguinal hernia repair. A total of 46 patients were included in the study (23 in each group). Baseline parameters were comparable between the groups. The total operative time between the groups (120 min vs. 160 min; P < 0.005) was statistically significant. The incidence of the peritoneal breach was statistically less in the BD group (43% vs. 13%; P < 0.005). Other short-term and long-term complications were less in the BD group but not statistically significant. BD in TEP inguinal hernia repair reduces the operative time and peritoneal breach. When compared to TD in terms of operative time, routine use of BD can be proposed. It will be beneficial in the early part of the learning curve.

Evaluating a Single Surgeon's Learning Curve for Laparoscopic Totally Extraperitoneal Repair of Inguinal Hernia with Telescopic Dissection: A Cumulative Sum Control Chart Analysis.

Background: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair (IHR) reduces risk of injury to intraperitoneal structures. Balloon dissection is more costly and has theoretical risk of injury to the surrounding structures compared with telescopic dissection (TD). This study aims to evaluate the learning curve (LC) for TEP IHR with TD of a single surgeon. Methods: This is a 3-year retrospective cohort study from January 2020 to December 2022 on patients who underwent elective laparoscopic TEP unilateral IHR with TD. Exclusion criteria were recurrent inguinal hernia. Cumulative sum (CUSUM) analysis was performed to evaluate the number of cases required to surmount the LC, that is, NLC for operating time (OT) and open conversion. One way analysis of variance was used to perform groupwise comparison. Results: There were 69 patients who underwent laparoscopic TEP unilateral IHR with TD. The median age was 58.0 years (range 24.0-80.0) and body mass index was 23.0 (range 18.6-30.0). Majority of the hernia was indirect (n = 48, 69.6%). The median OT was 70 minutes (range 35-210). Three cases (4.3%) had open conversion. One-year recurrence was 4.2% (n = 1/24). CUSUM analysis showed improvement in OT after the eighth case. However, this was followed by multiple inflection points with no apparent stabilization in OT. Pairwise comparison showed a decrease in OT between cases 18-36 and cases 37-54. There was no incidence of open conversion until the 56th case. Conclusion: Laparoscopic TEP IHR using TD is safe in the absence of a practor. A minimum of 36 cases is required to surmount the initial LC.

Retroperitoneoscopic Ureterolithotomy for the Management of Proximal Ureteric Stones: Initial Clinical Experience

Objective: Laparoscopic ureterolithotomy provides results equivalent to open ureterolithotomy for proximal ureteric stones, can be performed transperitoneally and retroperitoneally. The study aims to assess the efficacy of retroperitoneoscopic ureterolithotomy for managing proximal ureteral stones. Patients and Methods: It was a retrospective study carried out in the period from March 2018 to November 2021. 14 patients with proximal ureteric stones 16–26 mm (20.07± 02.8), all located above the upper border of the sacroiliac joint. Eleven (78.57%) patients underwent retroperitoneoscopy as a primary procedure, one (07.14%) had a history of failed ESWL, and two patients (14.28%) failed retrograde ureteroscopy. Retroperitoneoscopic ureterolithotomy was performed by lumbar approach with initial access conducted by open technique and creation of space by digital and homemade balloon dissection and secured 10 mm Hasson trocar at the primary port site, and 0° telescope advanced. Two 5-mm trocars were placed under visualization forming a triangle. The stone was removed from the primary port site while visualizing retrieval through the 5 mm. port using a fine 30° Cystoscope. Ureterotomy closure was performed by intracorporeal interrupted sutures of 4-0 polyglactin over 5 fr double-J stent, and a drain was left in the retroperitoneum. Results: Retroperitoneoscopic ureterolithotomy was accomplished in 11 out of 14 cases (78.58%). Three (21.42%) were converted to open surgery (2) and transperitoneal ureterolithotomy (1). The reason for open conversion was the failure to locate the ureter due to severe adhesion in 1 case, technical problems during dissection in 1 case, and another access problem, injury to the peritoneum, which was converted to the transperitoneal route. In 11 successful cases, the mean operative time was 126.5 ± 23.81 (90-170) min. There was no requirement for transfusions. There were no major perioperative and post-operative complications were observed. According to the modified Clavien classification, 07(63.63%) patients were reported to be grade I, whereas 04(36.36%) patients were reported to be grade II. One patient was managed with a course of antibiotics due to post-operative fever. Two patients who developed subcutaneous emphysema and superficial wound infection were treated conservatively. One urinary leakage was subsided by urethral re-catheterization. The drain was removed at 03.81 ±01.25(03-07) days. The mean hospital stay was 04.09 ± 01.13 (03-07) days. Conclusion: Retroperitoneoscopic ureterolithotomy has acceptable overall complication rates. It is an effective, low-morbidity alternative for the treatment of proximal ureter stones. Bangladesh J. Urol. 2022; 25(2): 84-92

V-015 ENDOSCOPIC MANAGEMENT OF AN INCARCERATED SPIGELIAN HERNIA

Abstract Introduction Spigelian hernias are abdominal wall hernias (incidence 0.12% to 2%). It is more common in women over the age of 60 years and occurs in individuals with raised intraabdominal pressure or weakening of the abdominal fascial layers. Several studies suggest that about 27% of Spigelian hernia will incarcerate and this will require immediate surgical intervention depending on the presentation. Presentation A 76-year-old lady presented with a painful lump at the right lower abdomen since a few days. No other constitutional symptoms were reported. She denied any comorbidities and was on no medication that would contraindicate a general anaesthetic. On Examination she had a 2cm tender non reducible lump at the right Spigelian line. A CT scan revealed a break in the right side of the abdominal wall consistent with a Spigelian Hernia. She underwent a repair using a laparoscopic, totally extraperitoneal technique (TEP). This was undertaken as a day case surgery with the hernia containing extraperitoneal fat only. The video demonstrates surgery with balloon dissection, medial to lateral dissection displaying the ilio-pectineal (cooper's) ligament and reduction of the hernia. The defect was covered with a mesh and fixated with Tisseel fibrin sealant. On her 4th week outpatient follow up she recovered well with only a small seroma at the previous site of the Spigelian hernia. Conclusion Our video demonstrates an efficient way to perform a Laparoscopic totally extraperitoneal (TEP) technique for an incarcerated Spigelian Hernia.

Comparison of balloon dissection and telescopic dissection of the preperitoneal space in laparoscopic totally extraperitoneal hernia repair: a systematic review and meta-analysis.

Safety in creating a preperitoneal space is crucial in laparoscopic totally extraperitoneal (TEP) hernia repairs. In this systematic review and meta-analysis, we compared the outcomes of balloon dissection and telescopic dissection in patients with inguinal or femoral hernias who underwent TEP hernia repair. We searched PubMed, Embase, Web of Science, and Cochrane databases for randomized controlled trials (RCTs) and prospective and retrospective studies published from inception to July 2022. Meta-analysis was performed using a random-effects model. The treatment outcome was measured using operation time, incidence of intraoperative hemorrhage, peritoneal laceration, conversion to other approaches, surgical site infection (SSI), hematoma, seroma formation, hernia recurrence, and postoperative pain. Five RCTs, one prospective study, and two retrospective studies (in total, 936 patients) were included. No significant between-group differences were noted in operation time, SSI, hematoma, seroma, recurrence rate, and postoperative pain on days 1 and 7. The conversion rate was significantly lower in the balloon group than in the telescopic group (odds ratio, 0.34; 95% confidence interval, 0.15-0.81). Both balloon dissection and telescopic dissection are viable techniques for creating preperitoneal space in laparoscopic TEP hernia repair and have similar operation time, complication rate, and postoperative pain. Nevertheless, the conversion rate was lower in patients undergoing balloon dissection than in those undergoing telescopic dissection.

V-017 TOTALLY ENDOSCOPIC APPROACH TO MODIFIED SUGARBAKER PARASTOMAL HERNIA REPAIR BY TRANSVERSUS ABDOMINIS RELEASE (ETEP-PAULí). ADVANTAGES OF RETROMUSCULAR/PREPERITONEAL MESH PLACEMENT

Abstract Several studies published have shown that TAR is an effective technique for reconstructing midline hernias and lateral hernias. In 2016, Pauli et al. described a novel technique for parastomal hernioplasty using open TAR combined with a modified Sugarbaker repair.A 56-year-old woman operated on 5 years earlier due to rectum adenocarcinoma by laparoscopic resection. A parastomal hernia was diagnosed. CT revealed a 5 cm wide parastomal hernia associated with an umbilical hernia.Patient is placed in the supine position. Identification by ultrasound of the lateral junction of right rectus sheaths. incision on subcostal region 1 cm medial to said juntion. An incision is made on the anterior lamina and retromuscular space is created with a dissection balloon. With the placement of two 11–5 trocars, the medial aspect of the posterior rectus sheath muscle is incised at the epigastric level and the Crossover is carried out. Left retromuscular dissection is performed. The hernia content is reduced. the left arcuate ligament is identified and the transverse abdominis muscle is released. Anterior defect closure with barded suture. An horizontal peritoneal incision is performed with the aim of lateralizing the colonic stump, the peritoneum and posterior aspect of the rectum sheath are closed.Placement of PPL mesh of 25×30 cms covering the dissected space.Patient was discharged on postoperative day 2. No complications or hernia recurrence were identified. Conclusions This technique offers some advantages; Coated mesh is unnecessary,The retromuscular positioning permits the integration on both sides.However several drawbacks; lack of long-term outcomes and technically challenge.

Laparoscopic Totally Extraperitoneal (TEP) Groin Hernia Repair in Patients After Contralateral TEP Groin Hernia Repair.

The totally extraperitoneal (TEP) repair for groin hernia is considered difficult in patients with a healed surgical scar in the lower abdomen. We reported the feasibility of repair in those patients and found that the most frequent previous procedure in patients for whom the procedure was changed intraoperatively was a contralateral TEP after TEP repair. We now report an expanded patient cohort with a suggested unified treatment strategy. From 2006 to 2020, 443 patients underwent laparoscopic TEP groin hernia repair. A contralateral TEP after TEP repair was performed in 35 patients. The conversion rate after TEP was compared with that after other operations. Patients were divided into completed contralateral TEP after TEP repair (N=28) and changed procedure groups (N=7). Clinical characteristics were compared including age, body mass index, location and type of hernia, and interval after previous surgery. Multivariate analysis was performed to evaluate risk factors for conversion of the TEP procedure. Patients undergoing contralateral TEP after TEP repair were significantly overrepresented among patients for whom the procedure was changed compared with other previous operations (P<0.01), with an odds ratio of 19.91. Comparing completed TEP after TEP repair and changed procedure groups, there were no significant differences regarding age (mean: 67 vs. 69 y old), body mass index (22.4 vs. 22.5 kg/m2), type of hernia (indirect or direct), or duration after previous TEP repair (median: 642 vs. 470 d) and identified no significant risk factors. The contralateral TEP after TEP repair for groin hernia is feasible. However, dense adhesions may be present if balloon dissection was performed at the previous TEP repair, and it is necessary to carefully dissect being ready to convert to other procedures such as TAPP repair or an anterior approach.

Comparison of Balloon Trocar versus Telescopic Dissection Method for TEP Inguinal Hernia Repair.

To compare the outcomes between two methods of dissection (balloon trocar vs. telescopic dissection) used in total extra-peritoneal (TEP) inguinal hernia repair. Comparative study. Department of General Surgery, Faculty of Medicine, Sakarya University, conducted between January 2018 and January 2020. The study included patients who underwent elective TEP inguinal hernia repair. Preoperative and early postoperative results were compared, after the patients had been divided into a balloon trocar group (Group 1) and telescopic dissection group (Group 2). The technique performed depended on equipment availability. Permission was obtained from the Institutional Review Board. The study data are presented as descriptive statistics (mean, standard deviation, median, first quartile, third quartile, frequency and percentage); p-value <0.05 was considered significant. A total of 189 patients were included; 95 patients in Group 1 and 94 patients in Group 2. No significant differences in age, gender, body mass index, body weight, ASA performance status, operating time, duration of hospitalisation or postoperative bleeding values were observed between the groups (p >0.05). European Hernia Society Quality of Life pain score values ​​ were higher in Group 2 than Group 1 (p = 0.016). Telescopic dissection was cheaper than balloon dissection. The bleeding values and operating time were similar between the two methods, but telescopic dissection caused more postoperative pain. Key Words: Inguinal hernia, Telescopic dissection, Balloon dissection, Total extra-peritoneal (TEP) surgery.

Pneumothorax as a rare complication during laparoscopic total extra-peritoneal inguinal hernia repair: A case report and review of the literature.

Totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal repair are the two most commonly performed types of laparoscopic hernia repair procedures. Herein, we present a rare case of pneumothorax and pneumomediastinum that ensued during a TEP inguinal hernia repair. A 73-year-old man presented for elective laparoscopic right-sided hernia repair. After intubation, a 10-mm and two 5-mm trocars were placed in the peri-umbilical and midline area, respectively. A balloon dissector was inserted from the 10-mm trocar to develop the retro-rectus space and carbon dioxide was insufflated up to a pressure of 14 mmHg. About 55 min after insufflation, the patient presented subcutaneous emphysema, oxygen saturation dropped from 100% to 96% and pCO2 increased to 55 mmHg. Due to concerns for pulmonary embolism, he immediately underwent a chest computed tomography, which revealed pneumothorax, pneumomediastinum and subcutaneous emphysema extended throughout the neck, thorax and upper abdomen. The patient was successfully treated conservatively with oral analgesia and supplemental oxygen and was discharged on the 4th post-operative day without any further complications.

The Comparison of Balloon and Camera Dissection of the Preperitoneal Space in Totally Extraperitoneal Repair Hernia Repair. Our Initial Experience!

Purpose. To perform totally extraperitoneal repair of a hernia, it is essential to create a working space for the placement of instruments. In this study, we aimed to compare balloon dissection (BD) and camera or telescopic dissection (CD) with respect to the surgical outcomes, without considering the cost-effectiveness. Methods. Forty consecutive, healthy, unilateral inguinal hernia patients who underwent Totally Extraperitoneal Repair hernia repair were randomized into 2 groups according to whether they received BD or CD. The perioperative demographic characteristics were recorded. All the operations were video recorded from the beginning to the end of each procedure. The virtually constructed periods of the procedures were evaluated by another surgeon who watched each video. The time spent for each period, the severity score assigned by the surgeon, the total operation time, the peritoneal laceration rate, the presence of early and late postoperative pain, the number of postoperative visits, the total analgesic requirements, and the complications were recorded. Results. The demographic properties of the patients, the perioperative and postoperative complications, and the severity scores in the BD and CD groups were statistically similar. The total operating time and the time from the dissection of the peritoneum to the reduction of the hernia sac were significantly longer in the CD group. Post-discharge analgesic consumption, Visual Analog Scale scores, and the number of visits were similar between the groups. Conclusions. The dissection of the working space in the preperitoneal area can be achieved using camera dissection without the risk of common complications associated with balloon dissection, particularly balloon rupture.

Retrorectal space creation with the «stick trick» technique in totally extraperitoneal hernia repair, a cost-effective way to substitute the trocar balloon dissector device

Revista monográfica de cirugía de la pared abdominal, digital y en lengua española. Artículos originales de investigación, editoriales, imágenes clínicas, cartas al director, reseñas de publicaciones, etc.

An Approach to Retroperitoneoscopic Urological Surgery

Objectives: To determine the safety and efficacy of retroperitoneoscopic surgery for renal, ureteral and adrenal diseases. Methods: Since October 2013, 62 patients (22 to 65 years old) have undergone retroperitoneoscopic renal, ureteral and adrenal surgery. Patients were included according to the inclusion criteria depending on the specifying disease and operation. Patient were appropriately evaluated and counseled before operation. The retroperitoneal space was created by handmade balloon dissection. Results: Average kidney size was 85 mm (range 50 to 1720) in simple nephrectomy cases, and average renal tumor size was 64 mm (range 48 to 73). Simple nephrectomy in 10, radical nephrectomyin 09, nephrouretectomy in 8, adrenalectomy in 1,decortication of renal cyst in 11, pyeloplasty in 06, transposition of retrocaval ureter in 06 and ureterolithotomy in 11 cases. Operating time varies from 35 min to 221 min, depending upon the procedure.Hospital stay varies from 2 to 7 days in different cases. Conversion from the laparoscopic procedure to open surgery was required in 3 cases. Peritoneal rent occurred in only 2 patients. Conclusions. The laparoscopic retroperitoneal approach is safe and effective for different types of renal, ureteral and adrenal surgery. Perioperative morbidity and hospital stay are reduced. Bangladesh Journal of Urology, Vol. 19, No. 1, Jan 2016 p.3-12

Laparoscopically Assisted DIEP Flap Harvest Minimizes Fascial Incision in Autologous Breast Reconstruction.

Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction. The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction. Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis. Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction. Therapeutic, IV.

Prone posterior retroperitoneoscopic access to the kidney in children: the controlled optical trocar approach

Conventional access for renal surgery through the retro-peritoneum includes the blind percutaneous approach using a haemostatic clip and the Gaur balloon dissection technique or alternatively the open cut-down approach. The authors present a video detailing the technique of optical access into the retro-peritoneum. Demonstration of the optical access technique into the retroperitoneal space using the optical trocar. Video describing the technique is carried out. With the patient in the prone position the optical trocar is introduced posteriorly traversing the different layers under vision to safely enter the space just outside gerota's fascia. Blunt dissection with the telescope tip and positive pressure aids creation of the working space. A total of 35 renal surgeries including nephrectomy and nephro-ureterectomy were performed via optical access to the retro-peritoneum. Ages ranged from 6 months to 14 years, and kidney sizes ranged from 1.6 cm to 15 cm, with operating times being 66-137 min. No complications or conversions were encountered. Optical access as described previously is achieved with a small incision, with complete control at every stage of the access with no room for error or subjective feeling. At all points, the operator recognises the different layers and is able to predictably reach the right space very quickly and safely. In contrast, the percutaneous technique was blind and the open cut-down required a bigger incision and was practically quite challenging in obese patients with leakage around the port and surgical emphysema. Optical access overcame all these drawbacks and made it reliable, predictable and reproducible. Access to the retroperitoneum in the prone posterior approach is achieved safely under vision and is reproducible. Every step in this access is performed in a controlled way and is therefore more predictable as compared to conventional techniques.

Protection from injury of organs adjacent to a renal tumor during percutaneous cryoablation.

Renal cryoablation has become accepted as treatment for small renal tumors as an alternative to surgery. However, parallel with the increase in the use of this therapy, there also has been increases in the number of reports of complications related to renal cryoablation. One potential complication is injury to important non-renal structures adjacent to the ablated renal tumor, such as the colon, duodenum, ureter, psoas muscle and so on. To prevent injury of adjacent organs, separating organs from the tumor is desirable. Over the past 15years, several techniques have been developed to protect against injury of organs adjacent to renal tumors that are targets of cryoablation. The most commonly used technique for this purpose has been hydrodissection. Others include dissection with gas, balloon dissection and probe traction. To avoid injury of a ureter running near the renal tumor, pyeloperfusion is known to be useful. The rate of cases necessitating avoidance of organ injury by using these techniques is relatively high. In some cases, more than two techniques are combined. In the present review, we provided an overview of techniques currently available to protect against organ injuries, and discussed the advantages and disadvantages of each technique.

Randomized controlled trial comparing submucosal endoscopy with mucosal resection and endoscopic submucosal dissection in the esophagus and stomach: Animal study.

In Western countries, endoscopic submucosal dissection (ESD) has not prevailed as a result of training problems and a target patient population. We have previously reported a hybrid ESD technique, submucosal endoscopy with mucosal resection (SEMR), in which the submucosal dissection is carried out chiefly by blunt balloon dissection. We have also reported successful application in the porcine colon. In the present study, we compared the safety and efficacy of SEMR with ESD in the porcine esophagus and stomach. SEMR and ESD were carried out in eight domestic pigs under general anesthesia. Resection sites were marked by circumferential coagulation. After circumferential ESD knife mucosal incision, submucosal fluid cushion (SFC) was created. In the SEMR group, the balloon catheter was inserted deep into the SFC. The balloon was then inflated and pulled back toward the endoscope tip repeatedly, altering the direction, to disrupt the submucosa. Residual strands were cut with an IT-knife. Enbloc resection rates, procedure times, complications and dissection difficulty scales (DDS) were recorded prospectively. DDS were rated using a visual analog scale. Thirty-two resections (8 SEMR/8 ESD in the esophagus; 8 SEMR/8 ESD in the stomach) were done with no major adverse events. There was no statistical difference between the two techniques in either location in the above categories measured. SEMR and traditional ESD are comparable techniques in safety and effectiveness when carried out in the esophagus and stomach. SEMR may serve as a more appealing technical option for endoscopists who are unable to sustain a traditional ESD practice volume.

Laparoendoscopic Single-Site Plus One Robot-Assisted Extraperitoneoscopic Radical Prostatectomy for Prostate Cancer

Purpose: Pure laparoendoscopic single-site (LESS) radical prostatectomy is still a challenging procedure even in the robotic era. Herein, we present LESS plus one robot-assisted extraperitoneoscopic radical prostatectomy for prostate cancer. Materials and Methods: Three consecutive patients with prostate cancer had radical prostatectomy performed using this technique. The clinical stages are cT1cN0M0 in two and cT3aN0M0 in one patient. The patients were placed on low lithotomy without or with mild Trendelenburg position, which can avoid the complications caused by steep Trendelenburg position. The single-site port was placed on subumbilical 2.5 cm incision and the additional port was located on the cross of right anterior axillary line and umbilical level. We created the extraperitoneal space from posterior rectus sheath using balloon dissector. Three kinds of single-site platforms were used, including da Vinci single-site port, GelPOINT mini advanced access platform (Applied Medical), and homemade glove single port. Each one has its benefits and limitations. We performed radical prostatectomy using the anterior approach technique with da Vinci single-site instruments. Results: The operative time ranged from 320 to 400 minutes. No oral intake was limited after operation because of the extraperitoneal approach. Hospital stay was from 5 to 7 days. Blood loss was from 200 to 300 mL. All surgical margins are free of tumor cell. All patients are continent of urination in 3 months evaluation. Conclusions: Robot-assisted laparoendoscopic single-site surgery radical prostatectomy is still a challenging procedure. R-LESS plus one technique can be an alternative for a complicated procedure, for example, radical prostatectomy. This technique can reduce the port sites from six in a conventional technique to two with better cosmetic and postoperative pain control benefits. The major limitation of the extraperitoneal approach is lack of space for extended lymph node dissection. The use of da Vinci single-site instruments can keep the triangulation well during operation. Continuous refinement of instruments and technology is essential to allow it to become a routine practice. No competing financial interests exist. Runtime of video: 6 mins 53 secs

Balloon Dissection for Extra Pleural Approach in Tracheoesophageal Fistula Repair; A Novel Technique

Objective: The extra-pleural approach for the tracheoesophageal fistula is preferred by most of pediatric surgeons because the possible substantial anastomotic leak will end in a fistula rather than an empyema. The problem with this technique that it is time consuming for pleural separation and liable for pleural tears. We studied a new method for using of Foley's catheter balloon to push the pleura away from the chest wall in an easier manner and shorter time. Method: A 25 neonate with tracheoesophageal fistula was managed with the extra-pleural approach using the Foley's catheter balloon as a method of pleural separation. Results: The mean time for pleural dissection was 4.5 m (266.4 sec) with a range of 2 m, 47 sec (167 sec) - 6 m, 18 sec (378 sec). Only 4 minor pleural tears were encountered (16%) that passed smoothly. 4 Anastomotic leaks occurred that were managed conservatively and 2 mild Anastomotic strictures (8%) occurred and were managed conservatively. Conclusion: Balloon dissection is a valuable addition to management of esophageal atresia. It accomplishes pleural separation from the rib cage in short time and easy manner with nearly 0% incidence of significant pleural tears. Moreover, it improves the outcome of possible postoperative anastomotic leak without adding to the patient's morbidity or the hospital cost.

Preliminary experience with the novel laparoendoscopic single-site extraperitoneal (LESS-EP) varicocelectomy

Minimally invasive varicocelectomy offers improved peri-operative pain and cosmesis as compared to standard microsurgical approaches(1-3).While standard multi-port laparoscopic varicocelectomy yields equivalent outcomes in terms of efficacy(4), an extraperitoneal approach decreases risk of bowel injury or post-operative gastrointestinal symptoms.(5, 6) We herein describe our initial results with an extraperitoneal approach coupled to single port laparoscopy (LESS-ep). We performed an IRB approved retrospective chart review of patients undergoing varicocelectomy (CPT codes 55550, 55530) at our center with a single surgeon between 3/1/2013 to 3/1/2016. Microsurgical and laparoscopic varicocelectomies were performed in standard previously described fashion. LESS-EP was performed as follows; a 2 cm infra umbilical incision was made. The anterior rectus sheath was anchored with 0 Vicryl sutures in parallel then divided. The rectus muscle was dissected laterally thereby exposing the posterior rectus sheath. The extraperitoneal space was developed bluntly using a balloon dissector under direct vision, and then the GelPort Mini Advanced Access (Applied Medical) was affixed. The GelPort was prepared with three trocars positioned in a tripod configuration as well as the Doppler probe. Varicocelectomy was performed under direct vision with a 5mm 30 degree bariatric laparoscope with dissection at the level of the internal inguinal ring. Manual chart review included patient history, lab values, and operative data. Data were analyzed with Student’s T-test. Of the 75 patients in our cohort, 32 underwent microscopic varicocelectomy, 18 had a standard laparoscopic varicocelectomy, and 25 underwent a less-ep repair. The average age was 39. There were no intraoperative complications in any group, nor EBL greater than 25 cc’s. There was no difference in operative times between groups (97 vs 84 vs 101 minutes, respectively; p=0.43). There were no instances of recurrent varicocele. In the LESS-EP cohort, there were no complications within 30 days; 2 patients received treatment for presumed epididymitis within the first 6 months of surgery. No statistically significant difference in change in sperm parameters was identified. Of 27 concomitant surgeries performed, all inguinal hernia repairs were performed with a standard laparoscopic technique and testicular sperm extraction was performed via microsurgical approach. LESS-EP is a novel approach to varicocelectomy. We have found LESS-EP to be comparable to established methods in terms of safety, operative time and efficacy. It may be most appropriate in patients with bilateral disease or prior inguinal surgery. A microsurgical approach may be most apropos in patients with unilateral disease and no prior groin surgery, and as well for whom concomitant surgeries are not required. Further study is ongoing to assess patient outcomes including long term improvement in semen analysis and pregnancy rates.