Blunt Finger Dissection Research Articles

V-014 OPEN REPAIR OF PRIMARY LUMBAR HERNIA WITH PREPERITONEAL MESH

Abstract This video presents an open repair of a primary lumbar hernia with preperitoneal mesh performed at a high-volume hernia center. The patient was a 71-year-old female referred due to chronic pain from a primary hernia of the right superior lumbar triangle. The patient was positioned in the left lateral decubitus position with the bed slightly flexed. A skin incision was created sharply, and electrocautery used to dissect subcutaneous tissue and superficial fascia, revealing the hernia contents. Circumferential lysis of adhesions was performed with blunt and cautery dissection to release the hernia contents from the abdominal wall. Once the hernia contents were mobilized, they were then carefully reduced through the fascial defect. The hernia defect measured approximately 3.5×3.5 cm. Next, the preperitoneal space was circumferentially developed. This was done primarily with blunt finger dissection, using a rolling motion to direct pressure towards the abdominal wall and sweep the peritoneum and other attachments down. Larger attachments are gently retracted and divided with electrocautery. The preperitoneal space was measured at 20×19 cm and the mesh trimmed to those dimensions. The mesh was carefully laid flat in the preperitoneal space. No mesh fixation was required. Fascial edges were dissected free for 1–2cm surrounding the defect. Two running 1–0 PDS sutures were used to close the hernia defect. A closed-suction drain was placed superficial to the fascia to minimize seroma formation. The superficial fascia and dermis were closed in layers. The patient had a routine hospital course and was discharged on post-operative day 3.

Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina

To describe the surgical technique of laparoscopically assisted uterovaginal/vestibular anastomosis in patients with cervical atresia associated with partial or complete absence of the vagina. Surgical video article. Local institutional review board approval and written permission from the patients were obtained. Tertiary referral center. The surgical video presents surgical correction in 3 different patients with cervical agenesis. The first patient, aged 14 years, had a normoconformed uterus and total absence of the vagina. The second patient, aged 12 years, demonstrated a left unicornuate uterus and partial absence of the vagina. The third patient, aged 13 years, displayed a right unicornuate uterus and total absence of the vagina. Laparoscopic time and perineal time. During laparoscopy, the entire abdominopelvic cavity was assessed to evaluate the uterine morphology and size to exclude anomalies such as hematometra. The adnexa and adhesions were evaluated and any endometrial flare-ups were treated appropriately. A laparoscopic ultrasound probe was used to evaluate the size and location of the endometrial cavity. In cases with total absence of vaginas, an H-shaped incision in the hymenal dimple allowed a larger area of available tissue for the anastomosis. A tunnel was then created by blunt finger dissection between the bladder and rectum. Simultaneously, the uterus was pushed caudally by an assistant while the operator grasped it from below using an internal probe. A circular myometrial incision at the uterine caudal body allowed to reach the endometrial cavity and open it. The edges of the uterine cavity were then anastomized with the edges of the hymenal incision. In cases with partial absence of vaginas, the creation of the tunnel between the vagina and rectum was not necessary and the open uterus was anastomosed with the margins of the vaginal dome, engraved on the guide of a metal dilator. All patients received broad-spectrum antibiotics (i.e., cephalosporins of the last available generation) on the day before surgery and on the day of surgery. Intraoperative anatomic and ultrasound data, neovaginal length, and recovery of menstrual function 180 days after surgery. The surgical procedure was successful in all cases. No major complications were recorded, and in particular, no bladder or rectal injuries occurred. No stenosis of the neocervix was recorded. The main hospital stay of the patients was 3.5 ± 1.5 days. In each case, the neovagina developed gradually over time after surgery because of the upward traction action exerted by the uterus through its natural ligament apparatus (cardinal ligaments and ovarian vessels). This fact eliminated the requirement for the use of a mold after surgery. At the 15-week follow-up, vaginoscopy was performed, with mucus observed at the site of uterovaginal anastomosis in all cases. None of the patients developed infection after surgery because of the avoidance of molds or pessaries and the natural mucus production. Six months after surgery, the length of the neovagina was >4 cm in all 3 cases. Laparoscopic-assisted uterovaginal/vestibular anastomosis may be considered the treatment of choice for patients with cervical atresia associated with partial or complete absence of the vagina.

Primary Breast Augmentation Using Axillary Skin Incision, Submuscular Implants, and Intraoperative Tissue Expansion

Background:Primary breast augmentation in small, pointed, or tubular breasts using axillary skin incision, submuscular cohesive gel implants, and intraoperative tissue expansion dramatically reduces complications.Methods:A 2.5- to 3.5-cm-long incision is made in the hair-bearing part of the axillae beside a natural fold. Incisions are opened using dissection away from the axillae, and an opening is made underneath the muscle on top of the thoracic cage. Blunt finger dissection is performed, and temporary breast expanders and special dissectors are inserted. The expanders create volume and desired breast shape. Sterility is ensured by entering implant pockets only with expanders and elevators and changing gloves before placing implants. No irrigation or antibiotic solution is used on implants or in the pockets. One thousand three hundred ten breast augmentations were performed between 2004 and 2019 (including a 2-year follow-up) using textured, cohesive round implants. Patients were followed up 3–4 months postoperatively. The parameters analyzed were size, shape, firmness, scars, and sensation in the nipple areola complexes. Patients contacted the clinic if problems occurred.Results:Of the 1,310 patients, only 2 had a Baker grade 3–4 capsular contraction. We also found 2 cases of implant rupture at the end of the 10-year guarantee period. Implants were replaced with identical ones. No infections were seen. Six cases of implant malposition were corrected by surgery. The total number of reoperations was 10 (0.8%).Conclusions:The axillary skin incision is an extremely efficient technique with few complications. The lymphatic drainage system is preserved, and implant pockets are left in a virgin state.

Entry into the anterior cul-de-sac during vaginal hysterectomy.

We present a video reviewing the key steps involved in safe anterior cul-de-sac entry during vaginal hysterectomy, including tips for troubleshooting difficult cases such as: uterine procidentia, cervical elongation, and multiple prior cesarean sections. Anterior cul-de-sac entry is a critical step in performing a vaginal hysterectomy. In this video, we review our approach to anterior entry in patients with normal anatomy, followed by a discussion of techniques that may be useful in cases with challenging anatomy. To start, we drain the bladder, set up exposure with Deaver retractors, and make a circumferential incision at the cervicovaginal junction. In cases with normal anatomy, using sharp, followed by broad blunt finger dissection, the vesicocervical space is opened, and the peritoneal reflection is identified and sharply entered. If this is not possible, additional techniques such cystoscopic bladder illumination, posterior entry first, securing pedicles with extraperitoneal ties, or additional sharp dissection may be utilized. With all techniques, proper intraperitoneal entry should be verified by the visualization of small bowel or fat. This video reviews technical considerations for anterior cul-de-sac entry during vaginal hysterectomy in patients with normal anatomy and provides tips for troubleshooting challenging cases.

V5-07 PERINEAL ARTIFICIAL URINARY SPHINCTER (AUS) WITH HIGH SUBMUSCULAR (HSM) PLACEMENT OF PRESSURE REGULATING BALLOON (PRB)

You have accessJournal of UrologyBPH and Voiding Dysfunction1 Apr 2017V5-07 PERINEAL ARTIFICIAL URINARY SPHINCTER (AUS) WITH HIGH SUBMUSCULAR (HSM) PLACEMENT OF PRESSURE REGULATING BALLOON (PRB) Billy Cordon and Allen Morey Billy CordonBilly Cordon More articles by this author and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1412AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In patients undergoing Artificial Urinary Sphincter (AUS) placement, with a history of major pelvic surgery, avoidance of the Space of Retzius with traditional placement of the Pressure Regulating Balloon (PRB) may be beneficial. This video presents perineal AUS placement with high submuscular placement (HSM) of the PRB. METHODS A perineal incision provides excellent exposure of the bulbar urethra for proximal bulbar urethral cuff placement. Via a separate 2cm high scrotal incision the external inguinal ring is identified. A pediatric Deaver is placed within the superficial ring and blunt finger dissection used above the transversalis fascia develops a space below the rectus that accommodates the PRB. Using one's index finger the PRB is then easily placed in the HSM space without any additional instrumentation. Finally through this same incision a subdartos pouch is created for pump placement. The AUS is cycled and deactivated and the wound is closed in multiple layers. RESULTS There is no difference in revision rates between HSM PRB placement versus Space of Retzius placement. CONCLUSIONS HSM placement of the PRB at the time of AUS implantation avoids the Space of Retzius with associated potential bladder, bowel, or vascular injury and/or complications. HSM placement avoids peritoneal placement post-robotic prostatectomy. HSM placement is safe, effective, can easily be learned and implemented, and may be used with concomitant IPP placement. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e601 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Billy Cordon More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Seperation of dorsal vein complex from the urethra by blunt finger dissection during radical retropubic prostatectomy.

We present our initial experience on the isolation of dorsal vein complex by blunt finger dissection in 26 patients with localised prostate cancer who underwent open retropubic radical prostatectomy. Loss of blood was between 300 and 500 mL (mean 350 mL). Two of 26 patients (7.6%) required blood transfusion. There was no positive surgical margin at prostatic apex in the patients. Twenty four of our patients (92.4%) were continent on the 3(rd) month. Control of dorsal vein complex is very important to decrease blood loss and to improve intraoperative exposure of retropubic area in order to get negative margin of prostatic apex and to provide the urethra long enough for a nice urethrovesical anastomosis. According to our initial experience, this technique seems to provide these aims.

Retroperitoneal Laparoendoscopic Single-Site Adrenalectomy for Pheochromocytoma: Our Single Center Experiences

To evaluate the feasibility and safety of retroperitoneal laparoendoscopic single-site adrenalectomy for pheochromocytoma (LESS-PHEO) and summarize our initial experience. Between June 2009 and June 2013, 21 patients with adrenal pheochromocytoma underwent adrenalectomy by means of LESS-PHEO in our department. Fifty-three patients with pheochromocytoma underwent conventional retrolaparoscopic adrenalectomy (RLAP-PHEO) between March 2001 and June 2013, of whom 42 were selected as a control group for a retrospective serial case-control analysis (1:2 matched-pair cohort). In the operation, the retroperitoneal space was created and dilated by blunt finger dissection and the pneumoperitoneal pressure was maintained below 10 mm Hg. As the first step, ligation of the adrenal central vein was performed. Intraoperative hemodynamic parameters, operating time, estimated blood loss, transfusion requirement, incidence of perioperative complications, visual analog pain scale (VAPS) score, time to resumption of oral intake and ambulation, and postoperative hospitalization were compared between the groups. All the operations were technically successful, without reoperations or conversion to open procedures. The 24-hour postoperative VAPS score was lower in the LESS-PHEO group than in the control group (5 vs 7; p<0.001). Despite a longer median operative time (167.4 minutes vs 125.5 minutes; p<0.001), the patients in the LESS-PHEO group resumed oral intake sooner (1 day vs 2 days; p<0.001), ambulated sooner (1 day vs 2 days; p<0.001), and were discharged earlier (4 days vs 7 days; p<0.001). No perioperative complications occurred in both the groups. No statistically significant differences in hemodynamic parameters or estimated blood loss were found between the groups. Although more training and practice are needed to shorten its operative time, LESS-PHEO, as performed by an experienced laparoscopic urologist, is a feasible and safe procedure associated with less postoperative pain and faster recovery.

98 A NOVEL PENOPLASTY TECHNIQUE FOR SEVERE PARAFFINOMA: MODIFIED BILATERAL SCROTAL FLAPS

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201298 A NOVEL PENOPLASTY TECHNIQUE FOR SEVERE PARAFFINOMA: MODIFIED BILATERAL SCROTAL FLAPS Gyung-woo Jung, Sung Jin Park, Juhyung Seo, Sung Chul Kam, Jung Mo Do, See Min Choi, and Jae Seog Hyun Gyung-woo JungGyung-woo Jung Busan, Korea, Republic of More articles by this author , Sung Jin ParkSung Jin Park Busan, Korea, Republic of More articles by this author , Juhyung SeoJuhyung Seo Busan, Korea, Republic of More articles by this author , Sung Chul KamSung Chul Kam Jinju, Korea, Republic of More articles by this author , Jung Mo DoJung Mo Do Jinju, Korea, Republic of More articles by this author , See Min ChoiSee Min Choi Jinju, Korea, Republic of More articles by this author , and Jae Seog HyunJae Seog Hyun Jinju, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.145AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although worldwide incidence is not well known, foreign-body injection is often attempted in order to augment the penis. Complications usually follow, such as penile deformity, skin necrosis, limited erectile function, and the inability to have intercourse. Definitive treatment of these patients includes complete removal of the involved tissue and repair of the denuded penis. The scrotal skin, which has highly elasticity, seems to be a good material for penile coverage. We tried a new technique comprised of modified bilateral scrotal flaps to provide reliable and stable coverage in such cases. METHODS Eighty three patients with penile foreign-body granuloma underwent reconstructive surgery by author from November 2001 to December 2011. Twenty seven patients had paraffinoma and 56 patients had vaselinoma. Most of them showed severe deformity from corona of penis to penoscrotal junction due to foreign-body granuloma. Necrosis and ulceraton of penile skin were seen in 16 patients. Foreign-body granuloma partly invaded the scrotum in 7 and the infrapubic area in 18 patients. The average age of the patients was 38 years. Complete removal of involved skin and subcutaneous tissue was performed under spinal anesthesia. After the preoperative design, flap elevation started with a midscrotal incision. The scrotal skin flap, including Dartos fascia, was elevated from the underlying tunica vaginalis using a blunt finger dissection. Finally, the inferior sides of flaps were incised and the bilateral scrotal flaps were completely elevated. The upper angles of each side of scrotal flaps were sutured together and fixed at middorsal portion of the corona. The lower angles of flaps were also sutured at the frenulum of penis. Two large Z-plasties were inserted into the dorsal and ventral suture lines. After the completion of penile resurfacing, the remaining scrotal skin was advanced forward and sutured. RESULTS All the flaps survived completely. Delayed wound healing was seen in 14 patients and the wound were healed with conventional treatments, except in 5 patients who underwent surgical intervention. Fourteen patients complained of decreased scrotal size. Eight patients showed mild scar contracture at the penoscrotal junction. The part of the scrotal hair-bearing area was moved to the penile shaft, After 6-month recovery period, satisfactory sexual activity was possible for all patients. CONCLUSIONS In our experience, penile resurfacing with modified bilateral scrotal flaps is an effective and reliable method for repair of completely denuded penis. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e40 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gyung-woo Jung Busan, Korea, Republic of More articles by this author Sung Jin Park Busan, Korea, Republic of More articles by this author Juhyung Seo Busan, Korea, Republic of More articles by this author Sung Chul Kam Jinju, Korea, Republic of More articles by this author Jung Mo Do Jinju, Korea, Republic of More articles by this author See Min Choi Jinju, Korea, Republic of More articles by this author Jae Seog Hyun Jinju, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Minimizing bladder injury in laparoscopically assisted vaginal hysterectomy among women with previous cesarean sections

This study demonstrated a method to prevent bladder injury during laparoscopically assisted vaginal hysterectomy (LAVH) to patients with vesicocervical adhesion after previous cesarean deliveries. Between July 2004 and July 2005, 50 women with vesicocervical adhesion who had given birth by cesarean delivery underwent LAVH. To minimize the chance of bladder injury, transvaginal lateral intervention was used to enter the anterior cul-de-sac during laparoscopic intrafascial hysterectomy. The lateral windows of the vesicocervical space were opened first. Usually, the potential spaces lateral to the adhesions could be developed easily by blunt finger dissection. Once adequate lateral spaces were created, an index finger was swept medially to define the margin of the midline adhesions secondary to the cesarean delivery scar. Under direct vision and finger guidance, the dense adhesions were dissected with more confidence and safety. Subsequently, the bladder was pushed gently aside to avert unexpected tearing or injury along the intrafascial hysterectomy. Because the vesico-uterine fold had been cut open previously under laparoscopy, the anterior cul-de-sac could be entered without much resistance. The average age of the patients was 45 +/- 7 years, and the extirpated uterine weight was 323 +/- 170.8 g (range, 85-730 g). Intraoperatively, the mean operation time was 124.6 +/- 28.5 min (range, 80-235 min), and the average blood loss was 79.1 +/- 47.8 ml (range, 20-250 ml). The mean intramuscular meperidine requirements were 1.2 +/- 0.8 ampules (range, 0-2 ampules) (1 ampule = 50 mg), and the average hospital stay was 3.2 +/- 0.9 days (range, 2-5 days). Of these 50 patients, 24 (48%) had one, 22 (44%) had two, and 4 (8%) had three previous cesarean deliveries. No bladder injury occurred among the patients, and there was no other complication. Transvaginal lateral intervention may help to minimize bladder injuries during LAVH for patients with previous cesarean deliveries.

Surgery of the parapharyngeal adenomas

Pleomorphic adenomas are the most common tumors of the parapharyngeal space (PPS) and often grow to an enormous size before becoming visible or symptomatic. CT and MRI scans are important in both diagnosis and surgical treatment. There are basically four different surgical approaches (transoral-transpalatal, transcervical-submandibular, transparotid und transmandibular) to the anterior PPS. Wide and direct exposure of the PPS is provided by a midline mandibulotomy with transection of the floor of the mouth. Owing to its morbidity this approach is reserved exclusively for extended tumors. The transcervical-submandibular route with blunt finger dissection generally offers adequate access for total tumor removal. For adenomas arising from the parotid gland a transparotid approach may be utilized. Adenomas located medially are better be resected transorally by splitting the soft palate.

Extraperitoneal Laparoscopic Trigonoplasty for Treatment of Vesicoureteral Reflux: Novel Technique Duplicating its Open Counterpart

We describe a novel technique of extraperitoneal laparoscopic trigonoplasty for the treatment of vesicoureteral reflux. Three boys and 24 girls with 41 refluxing units underwent extraperitoneal laparoscopic trigonoplasty. A 10 mm incision was made below the umbilicus. With sharp, blunt finger dissection and balloon dilation an extraperitoneal space was created. The bladder was opened using a laparoscopic scissors. Two 3Fr ureteral catheters were inserted intracorporeally into the ureters. A transverse superficial incision was made in the epithelium between the ureteral orifices. The medial aspect of the ureters was cleared of the muscles and attachments, and sutured in the midline with 4-zero polyglactin sutures. Operative time ranged from 60 to 240 minutes (mean 147). Blood loss was less than 50 ml. Adequate extraperitoneal space, bladder opening, epithelial incision, ureteral approximation with secure suturing in the midline and bladder closure were carried out in all cases. Peritoneal perforation was noted in 4 patients while creating the extraperitoneal space, with suturing needed for 1 large perforation. Hospital stay was 1 to 6 days (mean 2.7). At 4 to 19 months of followup (mean 8.2) reflux had resolved in 38 units (93%). Extraperitoneal laparoscopic trigonoplasty is technically feasible. Results are comparable to open techniques. The major advantage of this procedure is the avoidance of peritoneum. Other advantages include a shorter hospital stay and good cosmesis. More followup is necessary to establish the long-term results.

Rectum compression by a gluteal lipoma

A 56-year-old patient presented with swelling in the left gluteal region. Clinical history showed only occasional problems with defecation. Anteroposterior and transverse MRI showed a large fat-density soft tissue tumour arising from the left gluteal region penetrating into the pelvis minor through the greater sciatic notch. The rectum was displaced to the right (fi gure). Because of the tumour size, MRI was also done on posteroanterior projection. Percutaneous biopsy failed to diff erentiate between lipoma and liposarcoma. Elective surgery was done through a classic posterior Kocher-Langenbeck pelvic approach. Tumour penetration into the pelvis minor through the greater sciatic notch was easily seen and dissected off by tilting the operating table together with blunt fi nger dissection. Diagnosis of lipoma was made peroperatively and confi rmed postoperatively. 10 years after operation the patient remains well with no pathological fi ndings on MRI. Lancet 2006; 368: 1893

Successful Video-Assisted Mediastinoscopic Drainage of Descending Necrotizing Mediastinitis

Descending necrotizing mediastinitis is an uncommon form of mediastinitis that can rapidly progress to septacemia. To date, the optimal surgical approach has remained controversial. We report a case of descending necrotizing mediastinitis that was treated successfully through a transcervical approach with video-assisted mediastinoscopy. In our case, because the abscess was separated into small compartments, especially in the paratracheal space, the abscess was drained using video-assisted mediastinoscopy. This less-invasive approach may be an option in the treatment of descending necrotizing mediastinitis, especially when the abscess in the paratracheal space is separated into small compartments.

P47. Minimally invasive XLIF fusion in the treatment of symptomatic degenerative lumbar scoliosis

BACKGROUND CONTEXT: Surgical treatment of degenerative scoliosis in the elderly typically involves large, morbid reconstructive surgeries that are often poorly tolerated. The authors have developed a minimally invasive eXtreme Lateral Interbody Fusion (XLIF) approach, which they have applied in the treatment of degenerative scoliosis. The XLIF is accomplished through two 1–2 inch incisions and incorporates a posterolateral blunt finger dissection of the retroperitoneal space, finger-guidance of an initial dilator to the surface of the psoas muscle, EMG-guidance of the dilator through the psoas, and expansion of a split-blade retractor system that provides a working channel and direct visualization of the lateral disc.

Dissection with a Metal Dissector: A Useful Adjunct to Transhiatal Oesophagectomy

Intraoperative cardiovascular instability is frequently observed during blunt finger dissection for transhiatal oesophagectomy. We conducted a prospective study using a metal ring dissector for blunt dissection of the oesophagus to overcome this problem. Dissection with a metal ring dissector was used in 30 consecutive patients undergoing transhiatal oesophagectomy for carcinoma of the lower oesophagus (n=26) and oesophagogastric junction (n=4). Dissection of the oesophagus proximal to the growth was quick and straightforward in all instances. The procedure appeared less traumatic than the conventional manual technique and was not associated with any intraoperative cardiovascular instability or intramediastinal bleeding. None of the patients had tracheal injury or recurrent laryngeal nerve paralysis. There was one anastomotic leak and no deaths. Oesophageal blunt dissection with a metal ring dissector is safe, easy and quick. The correct plane of dissection minimizes the risk of intramediastinal bleeding and inadvertent trauma to neighbouring structures.

Video-assisted Transcervical Thymectomy

Myasthenia gravis (MG) is an autoimmune disorder diagnosed clinically for the first time at the end of the 17th century. Intense research into the pathogenesis of the disease has led to the discovery of an antibody directed against the muscle nicotinic acetylcholine receptor (AchR) in 1973 and, more recently, to the finding of a new antibody directed against the muscle-specific receptor tyrosine kinase (MuSK) in a subgroup of patients that remain seronegative for AchR antibodies. 1 Blalock’s initial experience in the early 1940s and subsequently published series of surgically treated patients led to the widespread acceptance of thymectomy in the treatment of MG despite the absence of a prospective randomized trial comparing surgery with medical treatment alone. 2 Controversiesremain,however,withregardtothetimingandextent of surgery to be performed. Some authors recommend thymectomyearlyinthecourseofthedisease,whereasothers reserve surgery for when medical therapy fails or if a thymoma is suspected. Different surgical approaches have been recommended including transcervical, transsternal, and more recently a transthoracic thoracoscopic thymectomy. All procedures allow extracapsular resection of the thymus and vary somewhat in the extent of mediastinal fat removal, which may contain foci of thymic tissue. The most extensive resection combines the transcervical and transsternal thymectomy procedures and includes removal of all mediastinal fatty tissue, both sheets of mediastinal pleura along with a sharp dissection of the pericardium. The transcervical approach was first described in the late 19th century for thymic enlargement in children and consisted of an enucleation of the thymus from within its capsule. Although initially reported in an adult patient with MG by Sauerbruch in 1912, the transcervical approach was modified to completely remove the thymus with its capsule and reintroduced in the 1960s for patients with MG. Through this approach, Kark and his colleagues reported fewer postoperative complications when compared with the transsternal approach. 3 Consequently, their patients were operated on earlier in the course of the disease and were shown to have more rapid rate of improvement. To improve exposure and to facilitate removal of the thymic gland and extracapsular thymic tissue through the neck, Cooper and colleagues described the use of a special rightangle manubrial retractor to elevate the sternum (Cooper retractor, Pilling Company, Fort Washington, PA). Using the same retractor, we observed that the routine use of a videothoracoscope introduced through the cervicotomy further improves visualization of the mediastinum and permits teaching of the technique under direct supervision. 4 Currently, the combination of early surgical referral, optimization of medical status when necessary by plasmapheresis, video-assisted transcervical thymectomy, and careful perioperative management have led to optimized care for patients with MG.

Minimally Invasive Radical Prostatectomy

Minimally Invasive Radical Prostatectomy

Retroperitoneal Laparoscopic Living–Donor Nephrectomy

Purpose: Living–donor nephrectomy is performed via a standard flank approach during open surgery in contrast to laparoscopy where kidneys are procured transperitoneally. Being more familiar with retroperitoneal laparoscopy for the surgery of the upper urinary tract, we investigated the feasibility of live donor nephrectomy by this approach. Material and Methods: We performed laparoscopic retroperitoneal left–sided nephrectomy in 3 living donors. The patients were placed in lumbotomy position. The retroperitoneal space was developed with blunt finger dissection, through a 2–cm mini–lumbotomy under the 12th rib in the posterior axillary line. 5 trocars were inserted. After primary access to the renal artery and vein, these were dissected to their junctions with the aorta and inferior vena cava, respectively, before freeing the kidney of its perinephric attachments. The kidney was delivered manually, through the slightly enlarged initial subcostal incision. Results: The average duration of surgery was 83 min; warm ischemia time less than 5 min. Average blood loss was 120 cm³. Donors did not present any postoperative morbidity and were discharged after an average of 2.3 days. Mean analgesic requirement was 5 mg morphine sulphate equivalent (0–15). Average convalescence was 13.3 days (10–18). All 3 kidneys harvested laparoscopically had immediate function with urine production after graft revascularization; serum creatinine levels returned to normal within 1 week. The first patient presented ureteral stenosis 2 months after surgery. He underwent ureteropyeloplasty using his native ureter. Conclusions: Laparoscopic living–related–donor nephrectomy become a new standard for organ harvesting. Our data suggest that retroperitoneal laparoscopic donor nephrectomy may represent a reasonable option in centers in which more extensive experience has been accumulated with retroperitoneal than with transperitoneal laparoscopy for the surgery of the upper urinary tract.

LAPAROSCOPIC BILATERAL HAND ASSISTED NEPHRECTOMY FOR AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE: INITIAL EXPERIENCE

The laparoscopic technique for bilateral nephrectomy in patients with autosomal dominant polycystic kidney disease is technically difficult. The procedure may be more acceptable if alterations to the technique made it safer and easier to perform. We describe our initial experience with, and the feasibility and potential benefits of hand assisted laparoscopic nephrectomy for approaching these large kidneys in patients with autosomal dominant polycystic kidney disease. This approach was successfully applied in 3 patients with end stage renal disease due to autosomal dominant polycystic kidney disease. After obtaining transumbilical pneumoperitoneum ports were placed in the umbilicus (12 mm.), sub-xiphoid in the midline (12 mm.) and subcostal in the midclavicular line on each side (12 mm.). The table was tilted 40 degrees away from the planned side of initial nephrectomy with the patient in the half lateral position. A 7 cm. midline incision was made that incorporated the umbilical port and a commercially available hand assistance device was positioned. One surgeon hand was inserted into the abdomen to serve as a retractor/blunt dissector, while the other operated the electrosurgical instruments. The right hand was inserted for left nephrectomy and the left hand was inserted for right nephrectomy. The laparoscope was passed via the sub-xiphoid port and the instruments were placed through the ipsilateral subcostal laparoscopic port. Nephrectomy was completed and the specimen was removed through the hand port incision by draining the cysts as they were exposed to view via the midline incision. When dissection was difficult, an additional port was placed in the anterior axillary line at the umbilical level. Some cysts were ruptured or aspirated to decrease overall kidney size and make extraction possible via the 6 to 7 cm. midline incision. All procedures were successfully completed. Mean operative time for bilateral hand assisted laparoscopic nephrectomy was 5.5 hours (range 4.5 to 6.6). Estimated blood loss was 200 cc or less. Patients resumed oral intake on postoperative day 1. The mean amount of parenteral analgesics required postoperatively was decreased. Mean hospital stay was 4.3 days but it was 3 days when considering nephrectomy only. Patients returned to normal activity after an average of 2 weeks. There was sustained resolution of preoperative discomfort based on pain analog scales. At 1 month or less all patients recorded absent pain. They uniformly noticed improved preoperative pulmonary and gastrointestinal symptoms Hand assisted laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease makes bilateral nephrectomy a reasonable option. The bilateral procedure may be performed as rapidly as laparoscopic only, unilateral nephrectomy in these cases. The advantages of the hand assisted approach include using tactile sensation to facilitate dissection, rapid blunt finger dissection, hand retraction and the application of immediate tamponade when needed. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay and rapid convalescence in this group of patients at high risk.

Percutaneous endoscopic external ring hernioplasty using Dundee inguinal canal retractor.

The percutaneous endoscopic external ring (PEER) hernioplasty is a novel technique that uses a minimal access approach to the inguinal canal by the anterior route and reproduces the conventional open tension-free mesh repair. The procedure consists of two stages: an open phase through a 2.5-cm incision over the external ring followed by an endoscopic repair of the defect. During the open stage, the spermatic cord is mobilized from the external ring, blunt finger dissection of the inguinal canal is used to create a space beneath the external oblique aponeurosis, and the hernial sac is dissected down to level of the preperitoneal fascia. The second endoscopic stage is performed after insertion of a telescope-mounted retractor through the external ring. The posterior wall of the inguinal canal is visualized and the hernial defect repaired by a tension-free mesh repair (Lichtenstein onlay mesh repair or mesh plug repair). The procedure provides an anatomic approach that is familiar to general surgeons. In a pilot study, the authors have established that the PEER hernioplasty is an easily learned, safe, and cost-effective operation that offers the benefits of minimal access surgery in terms of patient recovery and early return to work, and can be performed as a day case under local or regional anesthesia.