Difficulty Of Dissection Research Articles

Determinaton of eligibility for laparoscopic cholecystectomy of elective patients

We defined possible complications and difficulty grade of surgery at frequent symptomatic cholelithiasis cases and laparoscopic cholesistectomy surgeries which is accepted exclusive cure technique with evaluating a number of preoperative parameters. Fifty patients who applied to Ataturk University Medical Faculty Department of General Surgery with cholelithiasis diagnosis and planned to undergo laparoscopic cholesistectomy were included in this study. These patient’s volume of gallbladder, the extreme dimensions, thickness of wall, count of gallstone and dimensions of the biggest stone, length of cystic canal, measured by magnetic resonance cholangiopancreatography; preoperative ages, genders and preoperative endoscopic retrograde cholangiopancreatography story were recorded.To detect difficulty of patients’ surgery, a grading system was established based on surgery time, count surgery port, difficulty of Callot dissection, difficulty of bad dissection, intraoperative injury of bile duct, intraoperative gallbladder perforation, applying drainage and passing to open procedure parameters. The statical relationship of preoperative data and surgery points were analysed. The difficulty of surgery was not statically related with age, gender, thickness of wall of gallbladder, count of gallstone and dimensions of the biggest stone, length of cystic canal, and preoperative endoscopic retrograde cholangiopancreatography story (p>0.05). A meaningful relationship was found between surgery difficulty and gallbladder volume over 30 cm³ or extreme dimension over 40 mm (p<0.05). In conclusion, it is discovered that surgery difficulty degree increases when gallbladder volume is over 30 cm³ or it’s extreme dimension is over 40 mm. We suggest that surgeans must be careful at laparoscopic surgeries on gallbladders which have high volume or extreme dimention to decrease possible complications. J. Exp. Clin. Med., 2013; 30:331-334

Laparoscopic ablative and reconstructive surgeries in genitourinary tuberculosis.

Background and Objectives:Laparoscopy is the present standard of care for urologic diseases. Laparoscopy in renal tuberculosis (genitourinary tuberculosis) is difficult because of inflammation and fibrosis associated with the disease. We present the outcome of our experience of laparoscopy in genitourinary tuberculosis, both ablative and reconstructive.Methods:The detailed data of patients with genitourinary tuberculosis who underwent laparoscopic surgeries between January 2011 and September 2012 were reviewed. Indications, type of surgery, duration, blood loss, intraoperative problems, postoperative outcomes, and follow-up details were noted.Results:Overall, 7 laparoscopic procedures were performed: 5 nephrectomies, 1 ureteric reimplantation with psoas hitch, and 1 combined nephrectomy and laparoscopy-assisted Mainz II pouch reconstruction. The mean operative time was 192 minutes for nephrectomy, 210 minutes for ureteric reimplantation, and 480 minutes for nephrectomy with Mainz II pouch reconstruction. There were no conversions to open surgery. The mean amount of blood loss was 70 mL for the nephrectomies, 100 mL for ureteric reimplantation, and 200 mL for nephrectomy with Mainz II pouch reconstruction. In 5 of 6 patients who underwent nephrectomy, there was severe perinephric and peripelvic fibrosis posing difficulty in dissection. However, the renal vessels could be controlled individually. The mean postoperative hospital stay was 3 days for the nephrectomies, 5 days for the ureteric reimplantation, and 10 days for the nephrectomy with Mainz II pouch reconstruction. In all cases the recovery was uneventful.Conclusions:Laparoscopy, though technically more demanding, is a feasible and safe option for ablative and complex reconstructive procedures in genitourinary tuberculosis. It offers the benefits of minimally invasive surgery. The difficulty with this procedure is mostly because of peripelvic and perinephric fibrosis, whereas the lower ureter and bladder are relatively easier to dissect.

Submucosal endoscopy with mucosal resection (SEMR): a new hybrid technique of endoscopic submucosal balloon dissection in the porcine rectosigmoid colon

We developed a technique, submucosal endoscopy with mucosal resection (SEMR) intended to make endoscopic submucosal dissection easier and safer. With this technique, the submucosal layer is balloon dissected in lieu of electrosurgical knife dissection. The aim of this study was to further evaluate SEMR in the porcine rectum and colon. Targeted sites in the rectum and the distal colon were marked by spot coagulation. Submucosal fluid cushions (SFC) were created followed by a circumferential mucosal incision. After isolation of the targeted mucosa, balloon dissection was initiated. The balloon catheter was inserted deep into SFC and the inflated balloon repeatedly pulled back toward the endoscope tip to disrupt the submucosa. Residual strands of submucosa were cut. Dissection difficulty scores (DDS) were used using a visual analogue scale ranging from 0 to 5 (failed). The entire study period was divided into three periods (first period, pigs 1-10; second period, pigs 11-20; third period, pigs 21-30). Sixty lesions in 30 pigs were resected using SEMR. The en block resection rate was 95%. There were three incomplete resections, two as a result of an errant site location and one as a result of a floppy prototype balloon catheter tip. The median resected size, procedure time, and DDS were 6.0 cm, 25 min, and 1. All three failed cases occurred in first period. The procedure time in third period was significantly shorter than the second period (P = 0.0017). The DDS in first period was significantly higher than the second (P = 0.0024) and third (P = 0.0155) periods. Two perforations, one muscularis propria catheter perforation, and one mucosal perforation were observed (3.3%). Large mucosal target sites in the rectum and distal colon could be safely removed en bloc by means of a hybrid technique, SEMR, with blunt submucosal balloon dissection.

Rethinking the superficial inferior epigastric artery flap in breast reconstruction: Video demonstration of a rapid, reliable harvest technique

Abdominal-based autologous free tissue breast reconstruction has undergone significant changes over the past decade. The evolution has focused on limiting morbidity of the donor site. The transition from the transverse rectus abdominus muscle free flap to the muscle-sparing transverse rectus abdominus muscle free flap to the deep inferior epigastric artery perforator free flap has markedly improved abdominal-based autologous breast reconstruction. However, all of these flaps involve an incision through the anterior rectus fascia and potential damage of intercostal motor and sensory nerves. The superficial inferior epigastric artery flap (SIEA) reliably perfuses the ipsilateral hemiabdomen, yet does not violate the fascia or any motor nerves. As a result, the incidence of hernia, abdominal wall weakness and bulging is essentially eliminated. Nevertheless, use of the SIEA flap remains marginal. Vessel size, dissection difficulties and lack of understanding of the relevant anatomy have limited its acceptance. The present article describes a rapid, reliable and safe dissection technique with an algorithm for harvesting the SIEA flap in autologous breast reconstruction.

Reconstruction tridimensionnelle informatisée du segment rétrohépatique de la veine cave inférieure d’un embryon humain de 20 mm

The subdiaphragmatic venous drainage of the embryo is provided by the two caudal cardinal veins to which is added the subcardinal vein system, draining the mesonephros, the perispinal supracardinal veins and the umbilical and vitelline venous system. The anastomosis of certain segments of the embryonic venous structures and the disappearance of others are at the origin of the inferior vena cava. Since the 19th century, three-dimensional reconstruction of solid models from histological sections were developed. At present, the development of computerized three-dimensional reconstruction techniques allowed to operate a multitude of techniques of image processing and modeling in space. Three-dimensional reconstruction is a tool for teaching and research very useful in embryological studies because of the obvious difficulty of dissection and the necessity of introducing time as the fourth dimension in the study of organogenesis. This method represents a promising alternative compared to previous three-dimensional reconstruction techniques including Born technique. The aim of our work was to create a three-dimensional computer reconstruction of the retrohepatic segment of the inferior vena cava of a 20mm embryo from the embryo collection of Saints-Pères institute of anatomy (Paris Descartes university, Paris, France) to specify the path relative to the liver and initiate a series of computerized three-dimensional reconstruction that will follow the evolution of this segment of the inferior vena cava and this in a pedagogical and morphological research introducing the time as the fourth dimension.

Cellular Intermingling Between Adrenal Gland and Liver: An Infrequent Cause of Incomplete Resection at Right Adrenalectomy

To assess the incidence of difficulty in complete dissection between the right adrenal gland and the liver at the time of laparoscopic surgery for adrenal tumor and to elucidate its cause histopathologically. Thirty-six patients underwent laparoscopic right adrenalectomy between 2004 and 2011 at our institution. Two reviewers independently assessed difficulty in dissection for the 36 nonedited video records of laparoscopic right adrenalectomy in blinded fashion. Twenty-seven records were evaluable for the judgment of difficulty in dissection between the lower surface of the liver and the right adrenal gland. On the other hand, the gross and microscopic relationship between the right adrenal gland and the surface of the liver was investigated in 32 cadavers. Incomplete resection of the adrenal gland was found in 11 of 27 (40.7%) patients. Difficulties in dissection because of adhesions between the liver and the adrenal gland were apparently recognized in 5 of 27 (18.5%) patients. Pathologic assessment for cadavers revealed that capsules between these two organs are partially fused in 10 of 32 (31.3%) cases. Histopathologically, intermingling of parenchymal cells (infiltration through the fibrous capsules) was observed in nine (28.1%) cases. The tight adhesion between the lower surface of the liver and the adrenal gland because of intermingling of parenchymal cells of both organs is a major cause of incomplete resection of right adrenalectomy. Surgeons have to keep this fact in mind during right adrenalectomy to avoid unnecessary adverse events.

41 CELLULAR INTERMINGLING BETWEEN ADRENAL GLAND AND LIVER: AN INFREQUENT CAUSE OF INCOMPLETE RESECTION AT RIGHT ADRENALECTOMY

You have accessJournal of UrologyAdrenal1 Apr 201341 CELLULAR INTERMINGLING BETWEEN ADRENAL GLAND AND LIVER: AN INFREQUENT CAUSE OF INCOMPLETE RESECTION AT RIGHT ADRENALECTOMY Mikio Sugimoto, Hiromi Hirama, Yushi Hayashida, Shinsuke Shibuya, Nobufumi Ueda, and Yoshiyuki Kakehi Mikio SugimotoMikio Sugimoto Kagawa, Japan More articles by this author , Hiromi HiramaHiromi Hirama Kagawa, Japan More articles by this author , Yushi HayashidaYushi Hayashida Kagawa, Japan More articles by this author , Shinsuke ShibuyaShinsuke Shibuya Kagawa, Japan More articles by this author , Nobufumi UedaNobufumi Ueda Kagawa, Japan More articles by this author , and Yoshiyuki KakehiYoshiyuki Kakehi Kagawa, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1417AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess the incidence of difficulty in complete dissection between the right adrenal gland and the liver at the time of laparoscopic surgery for adrenal tumor and to elucidate its cause histopathologically. METHODS Seventy-nine patients underwent laparoscopic adrenalectomy during the period between 2004 and 2011 at our institution. Affected glands were right in 36, left in 41 and bilateral in 2. Two reviewers independently assessed difficulty in dissection for the 36 non-edited video records of laparoscopic right adrenalectomy in the blind fashion. Twenty-seven records (10 males, 17 females, mean age: 51.8 years) were evaluable for the judgment of difficulty in dissection between the lower surface of the liver and the right adrenal gland. Adrenal tumor types were classified into 3 types according to location of tumor in the adrenal gland (A: tumor in the upper pole, B: tumor apart from the liver, C: multiple small tumor foci). On the other hand, gross and microscopic relationship between right adrenal gland and surface of the liver was investigated in 32 cadavers. RESULTS Incomplete resection of adrenal gland was found in 11 of 27 patients (40.7%). Difficulties in dissection due to adhesions between the liver and the adrenal gland were apparently recognized in 5 out of 27 patients (18.5 %). Pathological assessment for cadavers revealed that capsules between these two organs are partially fused in 10 out of 32 cases (31.3%). Histopathologically, intermingling of parenchymal cells (infiltration through the fibrous capsules) was observed in 9 cases (28.1%).Partial absence (between open arrows) of the intervening fibrous capsule between the liver and the right adrenal gland are observed as shown in the figure. Adreno cortical cells are growing into liver tissue (closed arrow)(Fugure). CONCLUSIONS The tight adhesion between lower surface of the liver and the adrenal gland due to intermingling of parenchymal cells of both organs is a major cause of incomplete resection of right adrenalectomy. Surgeons have to keep this fact in mind during right adrenalectomy for avoiding unnecessary adverse events. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e16 Peer Review Report Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mikio Sugimoto Kagawa, Japan More articles by this author Hiromi Hirama Kagawa, Japan More articles by this author Yushi Hayashida Kagawa, Japan More articles by this author Shinsuke Shibuya Kagawa, Japan More articles by this author Nobufumi Ueda Kagawa, Japan More articles by this author Yoshiyuki Kakehi Kagawa, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intersphincteric resection for very low rectal cancer: clinical outcomes of open versus laparoscopic approach and multidimensional analysis of the learning curve for laparoscopic surgery

BackgroundLaparoscopic rectal cancer surgery is regarded as more complex because of its technical difficulties in pelvic exposure, dissection, and sphincter preservation. This study therefore aimed to investigate the feasibility of laparoscopic resection for low rectal cancer using intersphincteric resection (ISR) and to assess its short-term oncological outcomes. Further, we intended to analyze the learning curve for laparoscopic surgery and identify the factors influencing the learning curve. MethodsPatients with low rectal cancer who received open or laparoscopic ISR were retrospectively chart reviewed. The surgical and oncological outcomes were evaluated. Comparisons of operating time, estimated blood loss, surgical outcomes, and histopathologic status were analyzed. Also, operating time was used as a technical indicator for learning curve analysis. ResultsThe mean estimated blood loss was 265 mL (range, 100–800 mL) in the open group and 104 mL (range, 30–250 mL) in the laparoscopic group. There was a significant difference between these two groups (P < 0.001). Operative experience analysis showed that the mean operating time was 402.1 min (range, 210–570 min) in the first stage and 331.4 min (range, 210–450 min) in the second stage, and on pathologic examination the mean number of lymph nodes harvested was 11.1 (range, 5–21) in the first stage and 18.3 (range, 11–31) in the second stage, with statistical differences between these two stages (P = 0.034 and P = 0.004, respectively). Multifactorial analysis showed that operating time was associated with surgeons’ experience (<18 or ≥18 cases) (odds ratio = 2.918, 95% CI 1.078–7.902). Protective stoma creation was also associated with surgeons’ experience (odds ratio = 3.999, 95% CI 1.153–13.86). ConclusionsOur data show that laparoscopic ISR for low rectal cancer is feasible and safe. Surgeons’ experience improved operating time and postoperative complications.

La néphrectomie laparoscopique pour rein polykystique est faisable et reproductible

The aim of our study was to report our experience of laparoscopic nephrectomy in patients with polycystic kidney disease.Between December 2007 and February 2012, we performed 39 consecutive laparoscopic nephrectomies in patients with polycystic kidneys. All patients were operated by a transperitoneal approach.Patients had a mean age of 55 with an average BMI of 25 kg/m(2). Eighty-seven percent were ASA III and 77% were on dialysis. In most of the cases, the indication concerned patients who were candidates to a renal transplantation to make space for graft implantation. Operative time was 167 minutes with a mean blood loss of 200 mL. Two open conversions were necessary (splenic injury and difficulty of dissection of the renal pedicle). Fifteen percent of patients were transfused. There were 11 complications (28%) among which five were major (Clavien ≥ 3). Mean length of stay was 5.2 days.Our study showed that laparoscopic nephrectomy for polycystic kidney is feasible and reproducible. We systematically offer it when indicated.

Prolonged use of the LMA Supreme™

To the Editor, The LMA Supreme (The Laryngeal Mask Company Limited, Le Rocher, Victoria, Mahe, Seychelles) is a disposable extraglottic laryngeal mask airway that features high airway sealing pressures and a channel for gastric decompression. We report the use of an LMA Supreme in an unexpected prolonged surgery. The patient gave written consent for the publication of this case report. A 74-yr-old male (weight 68 kg, height 168 cm) with a history of allergic rhinitis was admitted for re-intervention of a mixed tumour of the parotid gland. The physical examination and laboratory tests were normal, and no criteria were found to predict difficult airway management. Expected duration of surgery was two hours. The neurophysiologist requested avoidance of neuromuscular blockade and halogenated anesthetics to allow monitoring of facial nerve branches. Standard hemodynamic variables, urine output, and bispectral index (BIS) were monitored. Anesthesia was induced with propofol 2 mg kg and maintained with a continuous infusion of propofol (4-6 mg kg hr) and remifentanil (0.2-0.4 lg kg min), adjusted for a BIS target value 60. Nitrous oxide was not used. A size-4 LMA Supreme was inserted and the cuff was inflated with 20 mL of air. Volume-controlled ventilation was initiated with the following parameters: tidal volume 6 mL kg; inspiratory:expiratory ratio 1:2; and respiratory frequency 12 breaths min. Peak inspiratory pressure was 16 cm H2O during the procedure and the capnographic wave was normal. Once the airway sealing was assessed, we placed a 16G orogastric drain tube, decompressed the patient’s stomach, and connected the drain tube to a drainage bag on the floor. Due to dissection difficulties, the surgery lasted for seven hours and 20 min, and we left the LMA Supreme in place during all this time. There was no air leakage throughout the surgery, and the drainage bag collected only a few millilitres of bilious fluid. We administered dexamethasone 4 mg, acetaminophen 1 g, and dexketoprofen 50 mg iv before the end of surgery. We removed the LMA Supreme with the patient awake and breathing spontaneously. History and physical examination of the patient in the recovery room immediately after surgery and before discharge ruled out any side effects relating to prolonged use of the LMA Supreme. Most reported problems associated with the laryngeal mask airway (LMA) are related to the misuse of the device. Complications, such as mucosal ischemic injury, gastric insufflation, regurgitation, and aspiration, appear to be time-dependent. As a result, LMAs have been used chiefly for short surgical procedures. The risk of mucosal injury increases with cuff volume due to increased mucosal pressure. A well-placed LMA Supreme provides adequate airway sealing with minimal intracuff volume, which is important for prolonged use. A 20-mL volume of air for a size-4 LMA Classic does not produce elevated pressure on the pharyngeal mucosa, but we have a lack of corresponding data for the LMA Supreme. As we had no possibility of measuring intracuff pressure, we used 20 mL of air with good sealing pressure ([ 25 cm H2O). Although data are lacking on mucosal pressure applied by the LMA Supreme, it appears that a 20-mL volume is safe for prolonged use without nitrous oxide. Incorporating a drain tube with the LMA Supreme minimizes the likelihood of gastric insufflation and allows a route to vent regurgitated gastric contents. Publications investigating a safe time limit M. Kammah, MD (&) C. Anez, MD, PhD Servicio de anestesiologia y reanimacion, Hospital Universitario Joan XXIII, Rambla President Lluis Company, Tarragona, Spain e-mail: maryemane@gmail.com

Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial

BackgroundAfter an initial attack of biliary pancreatitis, cholecystectomy minimizes the risk of recurrent biliary pancreatitis and other gallstone-related complications. Guidelines advocate performing cholecystectomy within 2 to 4 weeks after discharge for mild biliary pancreatitis. During this waiting period, the patient is at risk of recurrent biliary events. In current clinical practice, surgeons usually postpone cholecystectomy for 6 weeks due to a perceived risk of a more difficult dissection in the early days following pancreatitis and for logistical reasons. We hypothesize that early laparoscopic cholecystectomy minimizes the risk of recurrent biliary pancreatitis or other complications of gallstone disease in patients with mild biliary pancreatitis without increasing the difficulty of dissection and the surgical complication rate compared with interval laparoscopic cholecystectomy.Methods/DesignPONCHO is a randomized controlled, parallel-group, assessor-blinded, superiority multicenter trial. Patients are randomly allocated to undergo early laparoscopic cholecystectomy, within 72 hours after randomization, or interval laparoscopic cholecystectomy, 25 to 30 days after randomization. During a 30-month period, 266 patients will be enrolled from 18 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite endpoint of mortality and acute re-admissions for biliary events (that is, recurrent biliary pancreatitis, acute cholecystitis, symptomatic/obstructive choledocholithiasis requiring endoscopic retrograde cholangiopancreaticography including cholangitis (with/without endoscopic sphincterotomy), and uncomplicated biliary colics) occurring within 6 months following randomization. Secondary endpoints include the individual endpoints of the composite endpoint, surgical and other complications, technical difficulty of cholecystectomy and costs.DiscussionThe PONCHO trial is designed to show that early laparoscopic cholecystectomy (within 72 hours) reduces the combined endpoint of mortality and re-admissions for biliary events as compared with interval laparoscopic cholecystectomy (between 25 and 30 days) after recovery of a first episode of mild biliary pancreatitis.Trial registrationCurrent Controlled Trials: ISRCTN72764151

Can cross-handed approach improve maneuver in transumbilical laparoscopic surgery?

Transumbilical laparoscopic or laparoendoscopic singlesite surgery (LESS) is an emerging concept that has developed rapidly during the past 5 years. Almost all traditional laparoscopic surgeries can be performed transumbilically, including surgeries for morbid obesity, liver, splenic, or gastrointestinal diseases. It is estimated that 50–80 % of traditional laparoscopic surgery could be performed transumbilically in the next 5 years according to the LESSCAR consensus [1]. However, the procedure is more difficult than traditional laparoscopic surgeries due to associated technical challenges, including laparoscope and instruments crowding around the umbilicus, loss of triangulation between the two instruments in the operative field, and the required ambidexterity of the surgeons to adopt relatively difficult maneuvers. The enlarged end of the trocars is the main reason for external interference. Another factor is the instruments handles, which are usually very close to the ports. The crowding around the umbilicus can be effectively overcome by using our improved ports, because their maximum diameters are much smaller than those of commercially available trocars. The distance from the handles to the ports becomes longer when using the lengthened instruments, which results in longer distance between the instruments handles and can partly avoid external interference [2]. To overcome the problem of loss of ‘‘triangulation’’ caused by in-line viewing in transumbilical laparoscopic surgery, the articulated instruments have been developed. The problem is that when the tips of the instruments are bent in toward the target tissue, the surgeon’s hands tend to collide and the handles externally move toward one another. To avoid crossing the hands with this technique, the possible solution could be using the cross-handed approach, whereby the operator’s left hand operates the instrument on the right, and vice versa. Theoretically, cross-handed manipulation can overcome the problem of loss of triangulation under the circumstance of the in-line viewing system. Some people believe that it is an ideal solution to the most difficult problem in transumbilical laparoscopic surgery. Others consider that it can be uncomfortable and create additional difficulty in safe dissection of the target tissues. In addition, with the crossing of two instruments internally, they may compete for the same space in a vertical plane, which may limit their motion in the abdomen [3]. Do articulated instruments and cross-handed approach really benefit transumbilical laparoscopic surgery? To answer this question, it needs to be further evaluated objectively. Botden et al. [4] compared maneuver of curved instruments and cross-handed approach on standardized box trainer tasks and showed the results that the dissection task was performed faster and with less errors by using curved instruments than the crossed SPA setting. Their study also showed that the double-curved instruments were more potential for safe use than the cross-handed maneuver in conventional instruments in single-port laparoscopic surgery. However, other research concluded that crossed maneuver system gave a task performance equivalent to that of obtained with uncrossed system [5]. We recently set up a mechanical evaluation platform for single-port laparoscopic surgery on which a port (SILS Port, Covidien, Mansfield, MA) with two sensors around it was introduced. The instruments motion in the port can J. Zhu (&) A. A. Xu Department of General Surgery, East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong, 200120 Shanghai, China e-mail: zhujiangfan@hotmail.com

Laparoscopic cholecystectomy techniques with special care treatment in acute cholecystitis patients regardless of operation timing.

The optimal timing for laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) remains controversial. In this study, we aggressively performed three types of LC techniques in AC patients at different time with our care procedure. Forty-three patients with AC were retrospectively divided into two groups: Group one (n=16, within 72 hrs at the onset of symptoms) and Group two (n=27, beyond 72 hrs after the onset of symptoms). Standard, subtotal or prograde cholecystectomy were performed for all cases, depending on the fragility of gallbladder wall, difficulty of gallbladder dissection, assurance of Calot's triangle and quality of retraction over Hartman pouch. There were no statistical differences between both groups with regards to age, operation time, length of hospital stay and complications. Gangrenous cholecystitis was found in 6.3% of cases in Group one and 26.9% in Group two, although not statistically different. Four cases (two in each of groups) underwent prograde cholecystectomy and four cases in the group 2 received subtotal cholecystectomy; all with longer operation time and length of stay, as compared to standard cholecystectomy. None of the 43 patients was converted to open procedure. Complications in this study were minor. LC can be safely performed in patients with AC with special care, regardless of the duration between the onset of symptoms and operation. In addition to standard procedures, subtotal and prograde cholecystectomy could help to manage inflammatory gallbladder and obscured Calot's triangle.

Persistent Müllerian duct syndrome: lessons learned from managing a series of eight patients over a 10‐year period and review of literature regarding malignant risk from the Müllerian remnants

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Approximately 200 cases of persistent Müllerian duct syndrome have been reported over the last 50 years and most authors suggest leaving the Müllerian remnant in situ because of the difficulty in dissection and the presumed absence of risk of malignancy. However, with increasing reports of Müllerian malignancies emerging, we report our 10-year experience of managing patients with persistent Müllerian duct syndrome, with removal of müllerian remnants. This case series shows that there is an increased risk of Müllerian malignancy that was previously unknown. With the laparoscopic approach, orchidopexy with simultaneous removal of Müllerian remnants could be accomplished with minimal surgical trauma and the benefit of no malignancy risk in the future. This is a new technique that has not been previously performed. Considering the current evidence of malignancy in the Müllerian remnant, surgeons would need to discuss with families about removal of remnants or long-term monitoring. • To describe the presentation and management of eight patients with persistent Müllerian duct syndrome (PMDS) seen over a 10-year period at our tertiary centre. • To review the literature of Müllerian malignancies reported in PMDS. • The hospital records of eight patients with PMDS were retrospectively reviewed between 2001 and 2011. • Extensive PubMed searches for PMDS and Müllerian malignancy were performed. • Eleven cases with PMDS and malignancy of the Müllerian remnants were identified. • From our own PMDS series: five males presented with bilateral undescended testes and three had unilateral undescended testis. • We found that the Müllerian remnants could be removed by laparoscopy and three patients had simultaneous laparoscopic removal of the Müllerian structures and laparoscopic orchidopexy. • The principle aim of orchidopexy with simultaneous laparoscopic removal of the Müllerian structures can be accomplished with minimal surgical trauma and the benefit of no malignancy risk in the future. • Surgeons should consider excision of the Müllerian remnants where possible.

The Impact of Obesity on Perioperative Outcomes After Laparoscopic Colorectal Resection

It is commonly perceived that surgery in obese patients is associated with worse outcomes than in nonobese patients. Because of the increasing prevalence of obesity and colonic diseases in the world population, the impact of obesity on outcomes of laparoscopic colectomy remains an important subject. The aim of this review was to evaluate the feasibility and safety of laparoscopic colectomy for colorectal diseases in obese patients compared with nonobese patients. We conducted a comprehensive review for the years 1983-2010 to retrieve all relevant articles. A total of 33 studies were found to be eligible and included 3 matched case control studies and 1 review article. Obesity, often accompanied by preexisting comorbidities, was associated with longer operative times and higher rates of conversion to open procedures mainly because of the problem of exposure and difficulties in dissection. Although some studies showed obesity was associated with increased postoperative morbidity including cardiopulmonary and systemic complications, or ileus leading to longer hospital stay, there was no evidence about the negative impact of obesity on intraoperative blood loss, perioperative mortality, and reoperation rate. Whether obesity is a risk factor for wound infection after laparoscopic colectomy remains unclear. Though sometimes in obese patients, additional number of ports were necessary to successfully complete the procedure laparoscopically, obesity did not influence the number of dissected lymph nodes in cancer surgery. Lastly, the postoperative recovery of gastrointestinal function was similar between obese and nonobese patients. Laparoscopic colorectal surgery appears to be a safe and reasonable option in obese patients offering the benefits of a minimally invasive approach, with no evidence for compromise in treatment of disease.

Robotic surgery for gastric cancer

Minimally invasive surgery (MIS) for gastric cancer has been gaining popularity. Although many surgeons have reported the feasibility of MIS for gastric cancer, difficulties in standard lymph node dissection and anastomoses during laparoscopic procedures have hindered the widespread use of this technique. To overcome these difficulties, a robotic system has been adopted and its feasibility and safety have been shown. However, robotic surgery for gastric cancer has shown few definite advantages over conventional laparoscopy so far. In addition, longer operation time and much higher cost for this procedure are consistently noted. Recently, some retrospective comparative studies have reported benefits of robotic surgery over laparoscopic gastrectomy such as more complete D2 lymph node dissection for advanced gastric cancer, less blood loss, and shorter learning curves. For the wider spread of robotic surgery for gastric cancer, well designed studies are required to verify patients' secondary advantages, the cost benefit trade-off, and oncologic outcomes.

Anterolateral thigh free flap for the reconstruction of through and through defect of cheek following cancer ablation

The anterolateral thigh flap is a highly versatile and reliable flap for use in the reconstruction of various soft-tissue defects of the head and neck. This flap has gained great popularity due to its versatility, ability for a two-team approach, and minimal donor site morbidity. However, it has not met the same enthusiasm in the armamentarium of Maxillofacial Surgeons due to its relative difficulty in perforator dissection, reported variations of the vascular anatomy, and the presumed increased thickness of the anterolateral thigh tissue. These obstacles may be overcome by increased surgical experience and by the ability to create a thinner suprafacial flap or thinning the flap after it has been obtained. We have described the versatility of this flap for the reconstruction of the through and through defect of cheek following cancer ablation along with difficulties in raising flap.

Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: early results of a randomized prospective study

BackgroundStandard laparoscopic colectomy (SLC) for cancer is a safe, feasible, and oncologically effective procedure with better short-term and similar long-term results of open colectomy. Conversely, owing to technical difficulties in colonic resection and full mesenteric dissection, single-incision laparoscopic colectomy (SILC) has been considered unsuitable for oncologic purposes. We compared the technical feasibility and early clinical outcomes of SLC and SILC for cancer. MethodsIn this prospective randomized clinical trial, 16 (50%) patients underwent SLC (10 left and 6 right) and 16 (50%) patients underwent SILC (8 left and 8 right). ResultsDemographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 16 ± 5 in the SLC and 18 ± 6 in the SILC group (P = NS). Surgical time was 124 ± 8 minutes and 147 ± 5 minutes, respectively (P = NS). Surgical mortality was nil and the major morbidity rate was 6.3% in both groups. ConclusionsSILC for cancer is a technically feasible and safe oncologic procedure with short-term results similar to those obtained with a traditional laparoscopic approach.

Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial

Background In recent years, new devices providing multiple channels have made the performance of laparoscopic cholecystectomy through a single access site not only feasible but much easier. The potential benefits of laparoendoscopic single-site (LESS) cholecystectomy may include scarless surgery, reduced postoperative pain, reduced postoperative length of stay, and improved postoperative quality of life. There are no comparative data between LESS cholecystectomy and standard laparoscopic cholecystectomy (LC) available at present with which to quantify these benefits. Methods This study was a prospective, randomized, dual-institutional pilot trial comparing LESS cholecystectomy with standard LC. The primary end point was postoperative quality of life, measured as length of hospital stay, postoperative pain, cosmetic results, and SF-36 questionnaire scores. Secondary end points included operative time, conversion to standard LC, difficulty of exposure, difficulty of dissection, and complication rate. Results No significant differences in postoperative lengths of stay were found in the two groups. Postoperative pain evaluation using a visual analogue scale showed significantly better outcomes in the standard LC arm on the same day of surgery ( P = .041). No differences in postoperative pain were found at the next visual analogue scale evaluation or in the postoperative administration of pain-relieving medications. Cosmetic satisfaction was significantly higher in the LESS group at 1-month follow-up (mean, 94.5 ± 9.4% vs 86 ± 22.3%; median, 100% vs 90%; P = .025). Among the 8 scales of the SF-36 assessing patients' physical and mental health, scores on the Role Emotional scale were significantly better in the LESS group (mean, 80.05 ± 29.42 vs 68.33 ± 25.31; median, 100 vs 66.67; P < .0001). Conclusions In this pilot trial, LESS cholecystectomy resulted in similar lengths of stay and improved cosmetic results and SF-36 Role Emotional scores but performed less well on pain immediately after surgery. A larger multicenter trial is needed to confirm and further investigate these results.

A Prospective Phase II Evaluation of Esophageal Stenting for Neoadjuvant Therapy for Esophageal Cancer: Optimal Performance and Surgical Safety

Many surgeons are reluctant to use esophageal stents during neoadjuvant therapy for esophageal cancer because of concerns about nutritional status, stent-related complications, or added difficulties during esophagogastrectomy. We hypothesized that esophageal stenting during neoadjuvant therapy allows for optimal nutritional intake without adversely affecting perioperative outcomes. This study is a prospective, dual-institution, single-arm, phase II evaluation of esophageal cancer patients undergoing neoadjuvant therapy before resection. All patients had a self-expanding polymer stent placed before neoadjuvant therapy. We monitored dysphagia symptoms, nutritional status, stent-related complications, and perioperative complications during the course of therapy and 90 days postoperatively. We enrolled 32 patients with dysphagia and weight loss who were eligible for neoadjuvant therapy. After stent placement, 2 patients had stent migrations requiring replacement. No erosive complications were observed. During the course of neoadjuvant therapy, we noted improvement in dysphagia, mild weight loss, and maintenance of performance status. At a median of 50 days (range 18 to 92 days) after completion of neoadjuvant therapy, 20 patients underwent margin-negative esophagogastrectomy (16 Ivor Lewis, 4 minimally invasive) without problems with stent removal or difficulty in surgical dissection. Twelve patients did not undergo resection due to development of metastases (n = 8) or rapid decline in functional status (n = 4). Major perioperative complications included pulmonary embolism (n = 2), chyle leak (n = 1), and bronchial injury (n = 1). No surgical complications were attributed to stent placement. Use of esophageal stents during neoadjuvant therapy is safe and results in resolution of dysphagia, mild weight loss, and maintenance of performance status without an effect on intraoperative dissection, perioperative complications, or delay in resection after neoadjuvant therapy.