Conventional Laparoscopic Instruments Research Articles

Robotic transanal surgery: perspectives for application

Transanal minimally invasive surgery (TAMIS) is a surgical technique which allows the local excision of rectal benign tumors and early stage cancers measuring up to 4 cm and lying within 6-8 cm from the anal verge. It is performed by means of a disposable transanal platform and conventional laparoscopic instruments, proving to be effective and easily available. Hence, TAMIS soon became a valid alternative to other transanal resective procedures, especially transanal endoscopic microsurgery, and rapidly spread. Moreover, soon after its introduction, TAMIS started to be performed also using robotic technologies, but no clear advantages were found to date. This review is intended to provide a general overview on TAMIS, with a special focus on its association with robotic systems and the perspectives of this approach.

Needlescopic Appendectomy in Children and Adolescents Using 14G Needles: A New Era.

Purpose: We are presenting a new very minimally invasive technique for laparoscopic appendectomy (needlescopic appendectomy [NAP]) in children and adolescents using suture grasper device, epidural needle, and homemade isolated long diathermy probe without any conventional laparoscopic instruments. Patients and Methods: NAP was attempted in 48 patients with uncomplicated acute appendicitis at Al-Azhar, Tanta University Hospitals and other allied hospitals during the period from May 2017 to November 2018. The study included patients with acute appendicitis and patients scheduled for interval appendectomy. Exclusion criteria were patients with concealed appendix, patients with appendicular abscess or appendicular mass, patients with acute appendicitis complicated with generalized peritonitis, and patients unfit for laparoscopy. The appendix was brought outside through the umbilical port and the operation was completed extracorporeally. In cases of appendicitis with tethered cecum, the whole procedure was completed intracorporeally. Results: Forty-eight patients with acute uncomplicated appendicitis were treated by NAP. They were 36 males and 12 females with a mean age 9 ± 3.7 years (range = 4-15 years). Two cases with concealed appendix and one case with appendicular mass were diagnosed during initial laparoscopy and excluded from the study. Thirty-two cases (71.11%) were completed intracorporeally and 13 cases (28.89%) were completed by extracorporeal NAP. Mean operative time was 33.29 ± 3.95 minutes (range = 27-40 minutes) for intracorporeal NAP and 20.9 ± 7.01 minutes (range = 14-40 minutes) for extracorporeal NAP. Degrees of cosmetic satisfaction of the patients and parents were excellent in 93.33% (N = 42/45 patients), and very good in 6.67% (N = 3/45 patients) of patients. Conclusion: NAP using needles only is a new technique that is very minimally invasive, very cheap, safe, reproducible, and easy to be done with outstanding cosmetic results.

Intraoperative neuromonitoring of the RLNs during TOETVA procedures

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) is now being performed in increasing frequency and getting more and more attention. TOETVA is carried out through three incisions in the oral vestibular area. Thyroidectomy is performed endoscopically using conventional laparoscopic instruments, an energy based device and neuromonitoring instruments. Intraoperative neuromonitoring is one of the tools of utmost importance, used for navigation and confirmation of the functional integrity of the recurrent nerve during TOETVA. The aim of this study is to give information about the standards and technique of intraoperative neuromonitoring of the recurrent laryngeal nerves during TOETVA procedures. TOETVA is a safe technique with no visible scarring and hence resulting in an excellent cosmetic effect. We believe that neuromonitoring of the recurrent laryngeal nerves also minimizes the risk of nerve damage and is an essential safety component in this technique.

Transoral endoscopic thyroidectomy using the vestibular approach with an endoscopic retractor in thyroid cancer: experience with the first 132 patients.

Transoral endoscopic thyroidectomy using the vestibular approach (TOETVA) is a novel technique for thyroid cancer surgery. We aimed to review our initial experiences with TOETVA for the management of thyroid carcinoma, using retrospective analyses of a larger single-center case series. From September 2016 to April 2018, 132 patients with thyroid cancer underwent TOETVA. A three-port technique through the oral vestibule was used to perform endoscopic thyroidectomy with ipsilateral central compartment dissection using conventional laparoscopic instruments, and an endoscopic retractor that we developed. All patients had papillary thyroid carcinoma. Less-than total or total thyroidectomy with ipsilateral central compartment node dissection was performed (124 vs. 8). The mean operation time was 87.6min (range 56-213min). The average number of lymph nodes resected was 2.6 (range 1-12). Six patients experienced transient hoarseness, which was resolved within 3months. Most of the patients were discharged within 3days after surgery. In this large series from a single center, we found that TOETVA with the endoscopic retractor can be performed safely and radically in selected patients with thyroid cancer.

Single‐Port Laparoscopic Repair of Perforated Duodenal Ulcers

Laparoscopic single-port surgery has widely been introduced for the treatment of various abdominal conditions. But controversies still exist regarding its potential advantages and risks, especially for emergency surgery. The aim of this study was to evaluate the results of a single-port laparoscopic repair using straight laparoscopic instruments for the treatment of perforated duodenal ulcers. A prospective consecutive case series was conducted including all patients with a perforated duodenal ulcer who underwent a laparoscopic single-port repair at a single institution from January 2012 to June 2018. The operation was performed through a single port using conventional straight laparoscopic instruments and intra-corporeal knot tying techniques. Out of 75 patients, simple closure of the perforation without omental patch was accomplished in 96% of cases. Conversion to an open operation was required in one patient (1.3%) due to a posterior duodenal perforation, and additional trocar placement was needed in another patient (1.3%). The mean incision length was 2.0 ± 0.2cm. The mean operation time was 63.0 ± 26.6min. Meantime a nasogastric tube remained in place was 2.9 ± 0.8days. Mean duration of analgesic use was 2.8 ± 0.8days. The rate of postoperative complications was 2.7%, including two patients with wound infections. There were no instances of intestinal leak or abscess. The postoperative hospital stay was 5.7 ± 1.2days. Laparoscopic single-port repair using conventional straight laparoscopic instruments with intra-corporeal knot tying technique was safe and feasible for patients with perforated duodenal ulcers with low risk factors. This method offers results comparable to those expected with the standard multiport laparoscopic approach with the addition of improved cosmetic outcomes.

Outcome of Gynecologic Laparoendoscopic Single-Site Surgery with a Homemade Device and Conventional Laparoscopic Instruments in a Chinese Teaching Hospital.

Objective To demonstrate various benign gynecologic diseases that can be performed by laparoendoscopic single-site surgery (LESS) with conventional laparoscopic instruments. Method Patients with benign gynecologic diseases that need ovarian cystectomy, fallopian tube resection, or myomectomy were divided into experimental group and control group, and perioperative outcomes of these patients were analyzed. Results From November 2017 to May 2018, 65 LESS gynecological surgeries were performed, among which there were 25 ovarian cystectomies, 28 unilateral fallopian tube resections, and 12 myomectomies. All the surgeries were completed smoothly, and only one surgery needed one more additional port. No patients have severe complications. Operative time, intraoperative blood loss, and perioperative complications have no difference between the two groups. The LESS laparoscopy group had less postoperative pain scores and longer bowel recovering time, compared with the conventional laparoscopy group (<0.05). Conclusion Compared with traditional laparoscopy, LESS surgery with conventional laparoscopic instruments is feasible and safe, but postoperative exhaust time is longer than the control group.

Single-port laparoscopic appendectomy using a needle-type grasping forceps for acute uncomplicated appendicitis in children: Case series

IntroductionSingle-port laparoscopy has been used in any areas of surgery, including appendectomy, to reduce the operative stress and enhance postoperative recovery procedure. This paper introduces our attempt to perform single-port laparoscopic appendectomy using conventional laparoscoopic instruments and a needle-type grasping forceps (SLAN), which has dominant advantage in cosmetic appearance. MethodsWe report six pediatric patients who underwent SLAN for uncomplicated appendicitis from April to November 2019. SLAN was performed transumbilically, while conventional laparoscopic instruments and needle-type grasping forceps were both used. After routine intracorporeal appendectomy was completed, the pathological appendix was extracted through the single-port site, while a 10 mm trocar was used to avoid incision infectious. Clinical data and postoperative follow-up data were collected and analyzed to evaluate the feasibility, safety, and clinical outcomes of this novel technique. ResultsSLAN was successfully performed in all six pediatric patients. The median operative time, first exhaust time after surgery, pain score of postoperative day 1, and postoperative hospital stay were 69 (range, 50−85) min, 1.33 (range, 1–2) d, 0.83 (range, 0–3) score, 1.5 (range, 1–2) d, respectively. Neither intraoperative nor postoperative complications were noted, while no incision infectious, adhesive intestinal obstruction, and abdominal abscess were observed with 2–9 months follow up. DiscussionThough there are many methods to perform single-port laparoscopic appendectomy, the use of needle grasping forceps in laparoscopic appendectomy has been confirmed a new choice for uncomplicated appendicitis in children. ConclusionSLAN is a feasible and safe technique to treat acute uncomplicated appendicitis in children. To be emphasized, surgeons must strictly grasp the indications for this surgery.

Evaluation and comparison of basic gestures in ex vivo laparoscopic surgery using a robotic instrument and traditional laparoscopic instruments

The robotic Dextérité Surgical™ arm (DEX) is an instrument used in laparoscopy that provides 6 degrees of freedom and 360 degrees of rotation with a needle holder and scissors. To evaluate the benefits this instrument offers, we asked novice surgeons to use DEX and a conventional laparoscopic instrument on a pelvitrainer and compared the results. The participants were asked to perform two exercises with DEX and then with a conventional laparoscopic instrument on a pelvitrainer that contained a synthetic reproduction of a male pelvis. For the stitching exercise, the distance from the marked points and any tears caused were analyzed. For the cutting, the participants were judged by how well they respected the marked extremities, the form and the amount of "hacking" observed on a multi-criteria scale. The amount of time required to carry out the exercises was recorded. All twelve urology interns all succeeded in using DEX. Of the 36 stitches, seven were giving a failing grade (19.4%) when using the conventional laparoscopic needle holder and one (0.3%) was recorded when using DEX. All of the criteria (entry and exit points, tears and duration) for the results obtained were better when using DEX compared to the classic laparoscopic tool. This difference was statistically significant for horizontal stitches and tearing. Concerning the cuts made, the global score obtained, following a multi-criteria scale, favored the use of DEX for 10 out of 12 candidates (83.3%) with an average score of +2.6 (±2.1). No significant difference was recorded for the duration of each exercise. It does not take novice operators long to understand how to use DEX. It enables precise stitching and reduces tearing while improving the quality of cuts compared to conventional laparoscopic instruments, all without slowing the user down. 4.

Transanal Total Proctocolectomy with Ileal Pouch-Anal Anastomosis for Synchronous Triple Colorectal Cancer.

Introduction: Transanal total mesorectal excision (TME) has been utilized as a minimally invasive surgery for colorectal cancer.1 Sylla et al. first reported the use of transanal TME and since then, various platforms have been applied for this procedure.2 The most widely used procedure is laparoscope-assisted transanal TME using a hybrid technique. de Lacy et al. introduced the Cecil procedure, which utilizes two teams (transabdominal and transanal).3 With regard to rectal cancer, a small group of authors attempted pure natural orifice transluminal endoscopic surgery (NOTES) transanal TME.4,5 The aim of this case report is to show that a transanal laparoscopic technique can be utilized for total colectomy. Except for rectal cancer, there are few reports regarding colon resection using NOTES. In this video, we perform a transanal total proctocolectomy with ileal pouch–anal anastomosis in a patient with synchronous triple colorectal cancer (ascending colon, rectosigmoid colon, and rectum).Methods: We performed transanal total proctocolectomy with ileal pouch–anal anastomosis in a patient with synchronous triple colorectal cancer (ascending colon, rectosigmoid colon, and rectum). On preoperative MRI, there was no pelvic lateral lymph node, so we did not need to perform chemoradiation therapy. After transanal dissection of the mesorectum, rectum was flipped into the intraperitoneal space for further dissection. In our setting, we used conventional laparoscopic instruments for most procedures and long-shafted instruments helped during mobilization of the splenic and hepatic flexures. The entire specimen was extracted transanally. The ileal pouch was constructed intracorporeally and ileal pouch–anal anastomosis was performed using a circular stapler. We did not create a defunctioning stoma.Results: The operating time was 328 minutes and blood loss was <50 mL. We harvested 61 lymph nodes, and 1 regional lymph node metastasis was found. The patient experienced temporary paralytic ileus and was discharged on postoperative day 10 and had no major complications. The patient had medications for loose stool but had no incontinence. The patient refused adjuvant chemotherapy. During the 24 months follow-up period, there were no recurrences or metastases in three colonoscopies and three CT scans. This operation was performed in February 2017 and transanal total colectomy has not been reported so far.Conclusion: This transanal laparoscopic technique is feasible for total colectomy and may be adapted to achieve colonic resection through a natural orifice in the future.No competing financial interests exist.Runtime of video: 9 mins 55 secsThis subject was previously presented at the International Society of University Colon and Rectal Surgeons (ISUCRS), August 29–September 1, 2018, in London, United Kingdom.

Outcome of Laparoscopic Deroofing of Renal Cyst- Our Experience

Introduction: To evaluate the outcome of laparoscopic deroofing of renal cyst for the management of symptomatic renal cyst.&#x0D; Materials &amp; Methods: This study was performed on 32 patients having symptomatic renal cyst at the Department of Urology, Shahid Sheik Abu Naser Specialized Hospital, Khulna and two other private hospitals in Khulna from January 2015 to December 2017. Patients having cyst size less than 5cm, previous abdominal surgery and sepsis were excluded from this study. Transperitoneal approach was adopted in all cases. All patients were diagnosed by ultrasonography and computed tomography to determine the Bosniak classification of the cyst. Pain and cyst recurrence were assessed during the follow-up.&#x0D; Results: Thirty-two patients (mean age=52.9±12 years) with large renal cyst (mean size=35±13) were included. All procedures were completed successfully, with no major intraoperative complications. The mean (range) operative duration was 56 (35–125) min, affected by the site and number of cysts unroofed. All patients were symptom-free except one, who had a recurrent large cyst, anteriorly located, and who underwent open cyst deroofing.&#x0D; Conclusion: Laparoscopic deroofing of symptomatic renal cysts should be the standard of care, especially after failed percutaneous aspiration, with reduced postoperative pain, short hospital stay and cost effective. It is feasible with conventional laparoscopic instruments and gives a better cosmetic outcome.&#x0D; Medicine Today 2019 Vol.31(2): 114-116

Handheld laparoscopic robotized instrument: progress or challenge?

Handheld laparoscopic robotized instruments have been developed to combine the advantages of a robotic operation system and conventional laparoscopic instruments. Direct objective standards are needed to quantify surgeons' skill level and validate the advantages of new instruments. This study describes and objectively evaluates the use of a robotized instrument using a force-sensing test platform. The test platform consists of 12 rings on a hypersensitive force sensor. Forty volunteers were recruited: the expert group included 20 laparoscopic experts and the novice group included 20 medical students in their 4th year without laparoscopic skills. The baseline of the two groups was identified using a conventional needle holder. Participants then repeated the test with the robotized needle holder after training. The maximum force and impulse of each ring were analyzed for each group. Institutional review board approval is not needed for this study. Significantly lower maximum force and impulse were observed in the expert group than in the novice group during the baseline test (all P < 0.05). After training, a significant difference remained in maximum force and impulse between the two groups using the robotized needle holder (all P < 0.05). Within each group, there was no difference in maximum force or impulse using the robotized needle holder after training compared to that on using the conventional needle holder (all P > 0.05). The maximum force and impulse recorded by a test platform can accurately identify participants' laparoscopic skill level. Six hours' training can ensure that experts master the use of the robotized needle holder, but this training session is too short for novices to improve their performance with a new instrument. The force-sensing test platform can reflect the suturing characteristics of users based on the skill level and is useful for laparoscopic suture training.

Laparoendoscopic Single-Site (LESS) Surgery in Pediatric Urology: A 4-Year Experience

Objective: The aim of the study was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single-site (LESS) surgery. Materials and Methods: We retrospectively collected charts of all patients who underwent LESS procedures in our department from January 2013 to December 2016. Data included demographic characteristics, type of procedures, intraoperative details, hospital stay, and complications. The umbilicus was used as the surgical site in all cases. All procedures were performed with a homemade glove port and standard straight 3- or 5-mm laparoscopic instruments. Results: Seventy-three patients (55 males, 18 females) were identifed. Procedures included 46 orchidop-exies, 21 pyeloplasties, 8 varicocelectomies, 3 nephrecto-mies, 3 nephroureterectomies, 3 orchiectomies, and 1 renal hydatid cyst treatment. Median operative time for the entire cohort was 47 min (range 26-156 min). There was no signifcant intraoperative blood loss. No conversion to conventional laparoscopy or open surgery was needed. All patients required paracetamol postoperatively. The mean follow-up was 18 months. Two patients had testicular atrophy after a Fowler-Stephens procedure and 1 patient had testicular reascension. Cosmetic results were excellent. Forty-five (62.5%) patients were discharged on the day of surgery. Conclusion: Our study demonstrated that LESS surgery using our glove port technique and conventional laparoscopic instruments is a feasible and safe technique for the surgical management of various pediatric urological conditions.

Significance of steerable laparoscopic instrument: usability-based evaluation in a simulation model

Background: Laparoscopic surgery had been developed for decades. The latest trend is to minimize the incision size and minimize the number of port incisions. When surgeons have to operate in the limited incision, interference between instruments will result in increasing difficulty of surgery. In the study, we tested the significance and efficacy of a newly developed laparoscopic instrument with conventional rigid laparoscopic instrument in an usability-based method. Methods: We used a standard laboratory setting for comparison of characteristics of the instruments. There are 10 surgeons participated in the study. The tests included common procedures that can be performed by these instruments. The efficiency and features are compared and analyzed. Results: The average time to learn to use the instrument is 3.8 minutes. In 6 tests of common laparoscopic techniques, including using instruments to moving a plastic tube in certain site, to throw a knot, to suture, to guide a string, to cut specimen and to open a candy with foil, performance of the two steerable laparoscopic instruments is similar but both performances are better than that of conventional rigid instrument. The benefits are much better in single port situation. Conclusions: Steerable design of the instrument is reasonable for clinical use. Steerable laparoscopic instrument can be an alternative to conventional rigid laparoscopic instrument.

Bikini laparoscopic cholecystectomy: a replica of notes cholecystectomy

Background: Conventional four port laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis. Single incision lap. chole, Needloscopic cholecystectomy, NOTES Lap. chole. and Robotic cholecystectomy has been described primarily to further minimize the trauma and to improve cosmetic outcome. However, the cosmetic benefit is offset by expenses, non ergonomic approach and a steep learning curve. A new economic and an aesthetic approach of laparoscopic removal of gall bladder through bikini incisions is described. The purpose of this study is to find out the feasibility and safety of this technique. Methods: Non obese Patients (BMI <25) with normal gall bladder wall thickness were included. Informed consent for conversion was obtained. Intra operative bladder decompression was done by urinary catheterization. Surgery was performed by standard operative steps in split leg position. Both legs were placed at 200 below the level of torso. The surgeon stood in middle of legs. Long bariatric instruments were used. The first assistant on left side and the scrub nurse was positioned on the right side of patient. A 10 mm camera port was inserted in mid line 2 cms above pubic symphysis and two 5 mm working ports in both mid clavicular lines in lower iliac fosse. Fourth 3 mm port to retract fundus was made in right hypochondrium if required. Results: Eighteen patients were operated with this technique as day care surgery from Nov. 2017–Sept. 2018. Patients of acute cholecystitis, abdomino pelvic surgery, Pancreatitis and endoscopic retrieval of CBD stones were excluded. Sixteen were female and two were male patients. Majority of them, 88.9% were young (24–40 years). Operative steps were similar to conventional laparoscopic cholecystectomy. Surgery was completed by three ports in ten patients. Eight patients (44.44%) required fourth 3 mm port in right hypochondrium to retract gall bladder fundus. Mean duration of surgery 50.6 minutes (35–75). Specimen was retrieved through supra pubic port under vision by putting a camera from one of the 5 mm port. No conversion or complications was observed. Patients were discharged on the same day. Mean Post op followed up was 6.8 months. All patients are doing well and none developed port site infection or hernia. Conclusion: Bikini laparoscopic cholecystectomy is feasible, safe, and can be successfully performed with conventional long laparoscopic instruments. Learning curve is minimal. Like NOTES hybrid cholecystectomy, this technique leaves an invisible scar hidden under garments and there is no escalation of the cost from conventional four ports Laparoscopic Cholecystectomy.

Is the Human Brain Capable of Controlling Seven Degrees of Freedom?

BackgroundConventional rigid laparoscopic instruments offer five degrees of freedom (DOF). Robotic instruments add two independent DOFs allowing unconstrained directional steering. Several nonrobotic instruments have been developed with the additional DOFs, but with these devices, surgeon's wrist movements are not intuitively transmitted into tip movements. In this study, a new articulated instrument has been evaluated. The aim of the study was to compare learning curves and performances of conventional laparoscopic instruments, the da Vinci system and Steerable devices in a crossover study. Materials and methodsA total of 16 medical students without any laparoscopic experience were trained for 27 h to operate all of a rigid, a robotic, and a new Steerable instrument in a random order. Learning curves and ultimate experience scores were determined for each instrument. Strain in wrist and shoulders was assessed with a visual analog score. ResultsPerforming the suturing task with rigid and robot instruments required 4 h of training, compared with 6 h to master the Steerable instrument. After 9 h of training with each instrument, completing the complex suturing pattern required 662 ± 308 s with rigid instruments, 279 ± 90 s with the da Vinci system, and 279 ± 53 s with the Steerable instrument. Pain scores were significantly higher after using the rigid instruments compared with the Steerable instruments. ConclusionsTransmission of torque and the presence of additional two DOFs in combination with reduced crosstalk significantly improved the instrument dexterity where the Steerable platform is concerned. Although the learning curve is longer, once mastered, it provides enhanced surgical freedom.

Transoral endoscopic thyroidectomy using vestibular approach: A single center experience.

Background:Thyroid Natural Orifice Transluminal Endoscopic Surgery (NOTES) or transoral endoscopic thyroidectomy using vestibular approach is a recent advance embraced by the surgical community because of its potential for a scar-free thyroidectomy. In this article, we present our initial experience with this technique.Materials and Methods:We used a three-port technique through the oral vestibule, one 10 mm port for the laparoscope and two additional 5 mm ports for the endoscopic instruments required. The carbon dioxide insufflation pressure was set at 12 mm of Hg. Anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch, and the thyroidectomy was done using conventional laparoscopic instruments and a harmonic scalpel.Results:From May 2016 to December 2017, we have performed ten such procedures in the Department of General Surgery in our hospital, which is a tertiary referral center. Six patients had solitary thyroid nodules, for which a hemi-thyroidectomy was done. Four patients had multi-nodular goiter and total thyroidectomy or near-total thyroidectomy was done. The preoperative fine-needle aspiration cytology (FNAC) was suggestive of Bethesda class 2 lesions in all the patients with multinodular goiter and in five of the six patients with solitary nodular goiter. Only one patient with solitary nodular goiter had a Bethesda class 3 lesion on FNAC. The final histopathological report of the specimen was benign, either colloid goiter, or degenerative nodule in all cases of multinodular goiter and in four cases of solitary thyroid nodule. In one Bethesda class 2 solitary nodule, the histopathological report was suggestive of follicular carcinoma; in the Bethesda class 3 solitary nodule, the histopathological report was suggestive of follicular variant of papillary carcinoma. No complication such as temporary or permanent vocal cord paralysis, hypoparathyroidism, subcutaneous emphysema, pneumomediastinum, tracheal injury, esophageal injury, mental nerve palsy, or surgical site infection was found postoperatively. However, two patients developed small hematomas in the midline.Conclusion:Transoral endoscopic thyroidectomy is a safe, feasible, and minimally invasive technique with excellent cosmetic results.

AB002. 76. First experience of trans oral endoscopic thyroidectomy—vestibular approach (TOETVA) in Ireland &amp; UK at Cork University Hospital

Background: Many patients requiring thyroidectomy are concerned regarding scar caused by incision in the neck. Various techniques of minimally invasive thyroidectomy, including endoscopic and robotic thyroidectomy, have been developed to address this issue. TOETVA has been successfully used in the recent past worldwide, with few complications and excellent results. Moreover, recent literature comparing TOETVA with open thyroidectomy has confirmed that the TOETVA is performed as safely as traditional open thyroidectomy, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for selected patients.

Robotic pelvic reconstruction for a case of multiple uterine myomas with acute urinary retention combined with pelvic organ prolapse and occult stress urinary incontinence

Pelvic organ prolapse (POP) is the descent of the female organs that result in a protrusion of the vagina and/or uterus. Women often present with multiple complaints including bladder, bowel, and pelvic symptoms. Urinary retention was the symptom that woman presents uncommonly. Treatments of urinary retention were including removing the etiology of compression of the urethra and rescuing the normal position of pelvic organs. Surgery may be by abdominal, vaginal, or laparoscopic or robotic approach according to doctor's skillfulness, patient's need, and involving pelvic organs. Robotic technology has advantages of minimally invasive surgery such as reduced postoperative pain, shorter hospital stay, and quicker recovery times. It also has advantages of faster performance times, increased accuracy, enhanced dexterity, more accessible and more comfortable suturing, and a lower number of errors when compared to conventional laparoscopic instrumentation. Hence, it could be performed complex surgery such as this case. We present a case of multiple uterine myomas with compression symptoms and occult stress urinary incontinence. At the case of paravaginal wall defect with stress incontinence, she underwent robotic Burch colposuspension and paravaginal repair. Robotic pelvic reconstruction can be accomplished safely and efficiently and should be considered as an option for patients who had POP with urinary incontinence and who are prepared undergoing robotic surgery.

A comparative study of single incision laparoscopic cholecystectomy with conventional laparoscopic instruments versus multiple port laparoscopic cholecystectomy

Background: Treatment of gall stones have evolved markedly since open cholecystectomy was first described by Lange Buch in 1881. Management has progressed through eras of nonsurgical management, laparotomy, minilaparotomy and now laparoscopic cholecystectomy which is the gold standard for the treatment of gall stone disease today. Laparoscopic surgery is the procedure of choice for most benign gall bladder diseases unless obvious contraindication exists. There has been a trend toward minimizing the required number and size of ports to reduce postoperative pain with better cosmetic results.Methods: Comparative randomized study was conducted in Department of Surgery, SDM College of Medical Sciences and Hospital between February 2017 to July 2018. 60 patients who fit into the inclusion criteria were included in the study. 30 patients were included in the multiport cholecystectomy and 30 in the SILC. Random allocation of patients presenting with symptoms suggestive of gall bladder disease with confirmatory USG study. Group1: single incision laparoscopic cholecystectomy, Group2: multiple port laparoscopic cholecystectomy.Results: Majority of presenting patients were in age group 41-50 years. No significant difference in the mean age of patients, surgical complication, conversion rates and SSI operated by the two techniques. Median time required to complete cholecystectomy by SILC technique was not significantly higher than that required for multiport cholecystectomy. Statistically significant lower postoperative pain score was seen in patients with SILC compared to Multiport laparoscopic cholecystectomy. Patients operated by SILC technique had a postoperative hospital stay of mean 4.04 days, almost same as for patients operated by multiport technique.Conclusions: Difference of Conversion rates and time required for SILC is not significantly higher than that required for multiport cholecystectomy. No rise in intra and post-operative complications occurred in the single port surgery. Postoperative pain is significantly lower in patients undergoing SILC Length of postoperative hospital stay and incidence of SSI for single port cholecystectomy is almost as same as for multiport cholecystectomy.

Hybrid transgastric approach for the treatment of gastroesophageal junction pathologies.

Flexible endoscopy has evolved to the point that it includes many endoluminal procedures that once required open or laparoscopic surgery, for instance, antireflux surgery, pyloromyotomy, mucosal and submucosal tumor resections, and even full-thickness resection. However, these procedures remain technically demanding due to flexible technology issues: difficult imaging, limited energy devices, lack of staplers, unsatisfactory suturing abilities, and so on. Transgastric laparoscopy or hybrid laparoscopy/flex endoscopy has been described for almost two decades as an alternative to a pure endoluminal approach, mainly for pancreatic pseudocyst drainage and full-thickness and mucosal resection of various lesions. The approach has never been widely adopted mostly due to cumbersome and difficult to maintain methods of gastric access. We propose to expand the indications of transgastric laparoscopy by using novel endoscopically placed ports to replicate endoscopic procedures particularly in the difficult to access proximal stomach such as endoluminal antireflux surgery. Under general anesthesia, five female pigs (mean weight: 27.6 kg) had endoscopic placement of 3, 5 mm intragastric ports (Endo-TAGSS, Leakwood KS, USA) using a technique similar to percutaneous endoscopic gastrostomy. A 5-mm laparoscope was used for visualization. Laparoendoscopic-assisted plication of the gastroesophageal junction (GEJ) was performed using 3-0 interrupted sutures (Polysorb®, Covidien, Mansfield, MA, USA). A functional lumen imagine probe (EndoFLIP®, Crospon, Inc., Galway, Ireland) was used to measure diameter, cross sectional area (CSA), distensibility, and compliance of GEJ before and after intervention. Once the TAGSS ports were removed, the gastrotomies were closed by using endoscopic over-the-scope clips. At the end of the procedure, animals were euthanized. Five laparoendoscopic-assisted endoluminal plications were performed. The mean operative time was 65.6 min (Endoscopic evaluation: 3.2 min, TAGSS Insertion: 11 min, EndoFLIP evaluation+GEJ Plication: 43.25 min, gastric wall closure: 15 minutes). In all cases, this technique was effective and allowed to achieve an adequate GEJ plication by endoscopic grading and EndoFLIP measurements. Median pre-plication GEJ diameter (D) and median pre-plication GEJ cross-sectional area (CSA) were 11.42 mm (8.6-13.6 mm) and 104.8 mm2 (58-146 mm2). After the procedure, these values were decreased to 6.14 mm (5.7-6.6 mm) and 29.8 mm2 (25-34 mm2) respectively (p=0.0079). Median pre-plication distensibility (d) and compliance (C) were 7.87 mm2/mmHg (2.4-22.69 mm2/mmHg) and 190.56 mm3/mmHg (70.9-502.8 mm3/mmHg). After the procedure, these values decreased to 1.5 mm2/mmHg (0.7-2.2 mm2/mmHg) and 52.17 mm3/mmHg (21.9-98.7 mm3/mmHg) respectively (p=0.0317). No intraoperative events were observed. Endoscopically, all valves were felt to be transitioned from a Hill grade 3 (normal state for the animal model) to a Hill grade 1 at the procedure completion. A hybrid laparoendoscopic approach is a feasible alternative for performing intragastric procedures with the assistance of conventional laparoscopic instruments; especially in cases where the intervention location limits the access to standard endoscopy or where endoscopic technology is inadequate. Further evaluation is planned in survival models and clinical trials.