Endocatch Bag Research Articles

Minimizing Risks of Spillage during Laparoscopic Cystectomy

<h3>Study Objective</h3> Demonstrate cystectomy performed over an endocatch bag inserted through a posterior colpotomy. <h3>Design</h3> Video. <h3>Setting</h3> Hospital operating room. <h3>Patients or Participants</h3> 29yo G0 who presented with spotting at time of ovulation, found to have two ovarian dermoid cysts <h3>Interventions</h3> The patient had a laparoscopic cystectomy which was performed over an endocatch bag inserted through a posterior colpotomy. <h3>Measurements and Main Results</h3> The cystectomy was successfully performed via sharp and blunt dissection, along with a traction counter traction technique. The cysts were successfully removed without any spillage. <h3>Conclusion</h3> Inserting an endocatch bag vaginally is a minimally invasive technique to ensure that any spillage that occurs during a cystectomy is contained. It is a safe and feasible intervention.

PSAT333 Case Of a Large Adenomatoid Hyperplastic Thyroid Goiter

Abstract An 81-year-old woman presented to the emergency department for evaluation of shortness of breath, dysphagia and chest tightness. In the emergency department, imaging was obtained, with CXR showing complete opacification of R hemithorax. Follow up imaging with CT Chest showed large mediastinal mass contingent with the right lobe of the thyroid, along with large volume (transudative) pleural effusion. Patient underwent thoracentesis with improvement in her shortness of breath, but chest tightness persisted. IR biopsy was obtained, which confirmed the mass was indeed thyroid in origin. At this time, Endocrinology was consulted for concerns of thyrotoxicosis, along with the goiter, as lab work returned with suppressed TSH (&amp;lt;0.01 mcIU/mL), normal Free T4 (1.14 ng/dL). On examination, the Endocrinology team found the patient to be clinically euthyroid, with normal vital signs and only ongoing complaints of chest tightness with deep inspiration. Decision was made to go forward with resection of the mass, with a multidisciplinary approach involving ENT and Cardiothoracic Surgery. The ENT team began the procedure by dissecting the right lobe from the remaining thyroid tissue. The gland was noted to track inferiorly and posteriorly into the chest, and the decision was made to truncate the portion of the gland superior to the clavicle. At the time it was felt that further manipulation of the gland was a high risk from this position. The patient was then handed off to the cardiothoracic surgery team who, using robotic assistance, took a transdiaphragmatic approach. After roughly 3 hours of dissection, the goiter was placed in an endo-catch bag and was able to be removed through a transabdominal/diaphragmatic incision. The remainder of the left lobe was safely left in place. In the end the removed portion of the goiter was found to be 13.7 cm in length and weighed 532 g. Average thyroid weight in iodine replete populations remains roughly 20 g. Pathology returned as adenomatoid hyperplasia in all 4 specimens. Postoperatively the patient did well and follow up with Endocrinology was scheduled. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

V10-12 COMPLEX PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY

You have accessJournal of UrologyCME1 May 2022V10-12 COMPLEX PARTIAL NEPHRECTOMY IN SOLITARY KIDNEY Nimrod Barashi Gozal, Brijesh Patel, Mark Biebel, Joseph Ippolito, and Robert Figenshau Nimrod Barashi GozalNimrod Barashi Gozal More articles by this author , Brijesh PatelBrijesh Patel More articles by this author , Mark BiebelMark Biebel More articles by this author , Joseph IppolitoJoseph Ippolito More articles by this author , and Robert FigenshauRobert Figenshau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002623.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of renal masses in solitary kidneys can pose a challenging dilemma. Important considerations include feasibility of mass resection with adequate renorrhaphy, limiting ischemia time, and preservation of nephrons to avoid dialysis. We present a complex robot-assisted partial nephrectomy (RAPN) in a 55 year-old female with a solitary left kidney, incidentally found to have a 5.7cm left renal mass that was centrally located, completely endophytic, with a R.E.N.A.L Nephrometry score of 11, and a baseline creatinine of 1.06 mg/dL. METHODS: The patient was placed in right lateral decubitus position with the left flank flexed. Pneumoperitoneum was achieved with a Veress needle, and four robotic 8 mm ports were placed in a straight line along the lateral edge of the rectus with a 12 mm assistant port in the midline. A remotely operated suction irrigation (ROSI) system was utilized. After the colon was medialized, hilar dissection was started with identifying the renal vein (RV), and immediately posterior and cephalad was the renal artery (RA). Intraoperative ultrasonography was performed to demarcate borders of mass excision, since the mass was completely endophytic. Approximately 50% of mass excision was performed with selective clamping of the artery supplying the tumor, but the main RA was eventually clamped to help control bleeding. The mass, along with a segment of tumor thrombus, was grossly excised to completion. Renorrhaphy was started with a 3-0 v-lock suture over-sewing the base of mass excision to control bleeding followed by simple interrupted 0-vicryl suture to bring edges of resection together. These were secured with two Hem-o-lok clips. Gerota’s fascia was re-approximated with a 3-0 v-lock suture, and the specimen was placed in a Endocatch bag for extraction through a Gibson incision. RESULTS: Procedure time was 5 hours and 13 minutes. Estimated blood loss (EBL) was 1,500 mL. Pathology showed clear cell RCC, Furhman grade 3, with lymphovascular invasion and a positive surgical margin at the RV. Post-operatively, the patient experienced a oliguric renal failure, with creatinine (Cr) peaking at 8.5 mg/dL on postoperative day 4. Following that, urine output increased to over 2 liters daily, and Cr fell to 5.5 mg/dL by POD#9, at which time the patient was discharged. At one month follow-up, Cr was 1.49 mg/dL. At no point did the patient have any dialysis needs. CONCLUSIONS: A number of difficult challenges exist for complex RAPN in solitary kidneys. Performing as much of the procedure as possible without clamping the main renal artery may increase blood loss but will also facilitate renal recovery. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e852 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nimrod Barashi Gozal More articles by this author Brijesh Patel More articles by this author Mark Biebel More articles by this author Joseph Ippolito More articles by this author Robert Figenshau More articles by this author Expand All Advertisement PDF DownloadLoading ...

Critical Steps to Performing a Successful Single-site Laparoscopic Myomectomy for Large Pedunculated Myoma during Pregnancy

To demonstrate tips and tricks for the successful use of single-site laparoscopic surgery for pedunculated myomectomy during pregnancy. Stepwise demonstration with narrated video footage. An academic tertiary care hospital affiliated with Baylor College of Medicine. Our patient is a 39-year-old pregnant G1P0010 with a symptomatic 12-cm degenerating pedunculated myoma refractory to conservative pain management. Recent literature has indicated that most laparotomic myomectomies performed during pregnancy showed overall positive pregnancy outcomes and low complications. This indicates that myomectomy in pregnancy is safe and can be used in cases unresponsive to conservative management [1]. However, cases in literature discussing the single-site techniques for laparoscopic myomectomy during pregnancy have been sparse [2]. Four case series were reviewed; a total of 62 pregnant patients underwent laparoendoscopic single-site surgery without any complications [3-6]. Using laparoscopy in myomectomy compared with laparotomy during pregnancy permits decreased postoperative pain, quicker recovery, and lowered risk of postoperative complications [5,7,8]. Single-site laparoscopic surgery also aids in improved patient cosmesis and can be used for the myoma removal. Literature has demonstrated that single-site laparoscopy is safe and feasible during all stages of pregnancy [3,4]. Nevertheless, this approach may be challenging for inexperienced surgeons owing to the lack of triangulation and crowding of instruments in single-site laparoscopy [5]. At 21 weeks and 3 days pregnancy, our patient underwent single-incision laparoscopic surgery myomectomy. A 2.5-cm skin incision was made at the umbilicus to the abdominal cavity, and a GelPOINT Mini was inserted. Through the laparoscope, we can observe that a 12-cm pedunculated myoma was protruding from the right uterine fundus on a 4-cm stalk. A 0-Vicryl suture was tied around the base of the stalk. The stalk was then cauterized with bipolar energy and transected with the harmonic scalpel, completely detaching the myoma. Subsequently, an Endo Catch bag was placed around the myoma and brought up to the umbilical incision. Using a scalpel, bag-contained morcellation was completed within 22 minutes and the contents removed. As a result, the estimated blood loss was 50 cc and the total operative time was 123 minutes. The extended operating time was caused by slow movements to avoid disrupting the fetus. She had an unremarkable postoperative course, no medications were needed for pain management, and she was discharged home on postoperative day 2. At 38 weeks, she successfully delivered with elective cesarean delivery with no complications. Histopathology showed fragments of leiomyoma with diffuse necrosis. Tips and tricks: 1. Single-site entry technique uses the open Hasson technique, which reduces the risk of injury to the pregnant uterus and dilated surrounding vessels. 2. Through a 2.5-cm incision, the surgeon placed a suture in the myoma stalk because other hemostasis agents such as vasopressin are contraindicated in pregnancy. 3. Owing to difficulties related to single-site surgery, the surgeon should possess extensive expertise in single-site surgery. 4. Manipulation of the uterus should be minimized to reduce the disturbance of the pregnant uterus. 5. V-loc suture allows for faster and simplified uterine incision closure. 6. If the surgeon encounters excessive difficulty during the surgery, a 5-mm accessory port can be placed. 7. During tissue extraction, gentle traction should be used to reduce provoking the pregnant uterus. 8. When transecting the myoma stalk, it is important to leave a stump of more than 1 cm to increase suturing ease and prevent accidental suturing of the uterus. Single-incision laparoscopic surgery myomectomy for pedunculated myoma may be a practical technique in women refractive to conservative management. When performed by an experienced surgeon, the patient may benefit from faster specimen removal and recovery.

Robotic-assisted thoracoscopy thymectomy for juvenile myasthenia gravis

Abstract Introduction Juvenile myasthenia gravis (JMG) is a rare debilitating and potentially fatal autoimmune disease, with unclearify pathogenesis. Surgical immunomodulation with thymectomy has been repeatedly demonstrated to be a safe and effective treatment for JMG in both adult and pediatric patients. In the last few years, minimally invasive approach and above all robotic assisted thoracoscopy, replaced sternotomy which is widely used in adult patients. We report our experience in a case of robot-assisted thoracoscopic thymectomy approach in a 12 years old boy for juvenile myasthenia gravis (JMG). Case report Procedure was performed with the Da Vinci surgical robot (Xi) using left-sided approach. Left lung was kept out from mechanic ventilation. A 8 mm port for the 3-D camera was introduced on the V intercostal space on the anterior axillary line. Others two 8mm thoracic ports were placed under vision after the induction of a low-pressure pneumothorax, respectively on the midaxillary line on the III intercostal space and on the parasternal space on the V intercostal space. Bulk resection of gland was made using Maryland grasper and Harmonic scalpel, starting at level of the left pericardiophrenic angle and continuing cranially. Thymus was unstick from the posterior face of the sternum until the right pleura releasing lower thymic horns. After that, controlateral right-side thymectomy was continued into the neck to include the upper horns and finally it was removed with an endocatch bag. Histopathological examination showed a benign thymic hyperplasia. There were no perioperative and postoperative complications. The discharge was on IV post-operative day. After thymectomy, patient reported an improvement in symptoms and stopped medical therapy with pyridostigmine. Conclusions VATS and Robotic thoracoscopic thymectomy have increasingly taken hold in recent years. The surgical treatment offered to patient an improvement in clinical status. Surgery by robotic assistance has demonstrable advantages, including three-dimensional visualization and articulating instruments. Left lateral approach provided excellent visualization of the thymic veins, anonymous vases and phrenic nerves. Three-dimensional visualization as well as articulating arms greatly facilitated the dissection compared with standard thoracoscopic technique. In Literature very few series of robotic approach for surgical treatment of JMG in children are reported, for these reasons further studies are needed.

EP1.17-03 New Approach to Complete Video-Assisted Thoracoscopic Lobectomy in T2 and T3 Non-Small Cell Lung Cancer

The advantages of complete video assisted thoracoscopic surgery(c-VATS) include less postoperative pain and early cosmetic benefit because of the small incision recured. If large tumors can be successfully removed without need for a long thoracic incision or extensive costal rib resection, c-VATS may be performed in patients with stage II or III NSCLC. We herein repot our experience with a novel c-VATS technique that involves removal of resected lung tissu from an abdominal incision in patinets with T2 and T3 NSCLC. Fifteen patients with T2 and T3 NSCLC who underwent surgical treatment. Five patients underwent c-VATS lobectomy, and 10 patients under went hybrid VATS(h-VATS), which is performed mainly by direct visualization using video assistance. The tumour large perpendicular was 60 to 140mm in the c-VATS group and 52mm to 82mm in the h-VATSgroup. Surgical procedure. For lobectomy, the ports were placed in the 3rd, 5fh, and 7th intercostal spaces on the anterior axillary line for the operator and camera pole and in the 6th and 8th intercostal spaces on the infrascapular line for the assistant. An abdominal skin incision of <5cm was then created just below the xiphoid in Fig1. A forceps was inserted through this incision into the intrapleural cavity through the preperitoneal space to remove the resected lung tissu by grabbing the endocatch bag. the resected lung tissue was remoed with the forceps through this route. Comparison between c-VATS and h-VATS groups. Significantly fewer patients in the c-VATS than h-VATS group developed severe pain in Table1.table 1View Large Image Figure ViewerDownload Hi-res image Download (PPT) The present study suggests that the indications for c-VATS lobectomy in patients with T2 and T3 NSCLC can be expanded by implementation of our approach, which involves removal of the free lobe through an abdoninal incision.

Diagnosis and Management of an Adenomatoid Uterine Tumor: Ultrasound, Magnetic Resonance Imaging, Surgical Appearance, and Pathology Correlation.

Adenomatoid uterine tumors are rare, and their appearance on medical imaging modalities is not well established. We present a case of an adenomatoid uterine tumor reviewing a unique sonographic presentation, magnetic resonance imaging (MRI), gross surgical appearance of the tumor, and microscopic pathology images. A 29-year-old gravida 0 Caucasian woman presented with dysmenorrhea, menorrhagia, and desire to conceive. Transvaginal ultrasound revealed a 2.7 cm round, well-circumscribed posterior intramural uterine mass. The mass was hyperechoic centrally with a thin hypoechoic rim. Color Doppler imaging revealed a prominent vascular rim around the periphery of the mass as well as central vascularity not typical for a leiomyoma. MRI, with and without intravenous gadolinium, was obtained showing a 2.7 cm posterior fundal mildly enhancing uterine mass suggestive of leiomyoma. The mass had a heterogeneous signal pattern on T2-weighted images, and no fat component was noted within the mass. Repeat transvaginal ultrasound showed interval growth of the mass to 3.5 cm with a lipomatous appearance. Adenomatoid uterine tumors are rare and may be mistaken for uterine leiomyomata. Unique features include sonographic appearance of central hyperechogenicity with a hypoechoic rim and prominent peripheral and central vascularity in conjunction with MRI revealing a heterogeneous signal pattern on T2-weighted images without fat component. Gross surgical appearance reveals a nondiscrete capsule and secretion of mucoid material when the mass is exposed. We present a case of adenomatoid tumor providing sonographic, MRI, surgical, and pathological correlation. The patient subsequently conceived spontaneously and delivered at term by cesarean section. The patient underwent a preoperative evaluation with complete blood count, comprehensive metabolic panel, blood type with antibody screen, and pregnancy test. She underwent laparoscopic excision with robotic assistance for removal of the tumor. Grossly, the uterine mass had a very soft consistency atypical for a uterine leiomyoma making dissection more challenging. During dissection the mass diffusely secreted a mucoid material although the capsule was not disrupted. The lesion was excised intact and was removed from the peritoneal cavity in an endocatch bag without internal morcellation. Microscopic examination revealed an adenomatoid tumor.

V12-09 ANATOMIC ROBOT ASSISTED RADICAL CYSTECTOMY IN FEMALE: STEP BY STEP TECHNIQUE

You have accessJournal of UrologyBladder Oncology and Diversion1 Apr 2017V12-09 ANATOMIC ROBOT ASSISTED RADICAL CYSTECTOMY IN FEMALE: STEP BY STEP TECHNIQUE Giuseppe Simone, Salvatore Guaglianone, Leonardo Misuraca, Francesco Minisola, Gabriele Tuderti, Mariaconsiglia Ferriero, Giuseppe Romeo, and Michele Gallucci Giuseppe SimoneGiuseppe Simone More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Francesco MinisolaFrancesco Minisola More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Giuseppe RomeoGiuseppe Romeo More articles by this author , and Michele GallucciMichele Gallucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3215AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robot assisted radical cystectomy in female for bladder cancer is a challenging urologic surgical procedure. We describe step by step surgical technique and present perioperative outcomes of a single patient who underwent a robot assisted radical cystectomy (RARC) with totally intracorporeal orthotopic neobladder (iON). METHODS A 66 yr-old female patient with a cT1/N0/M0 high grade BCG refractory recurrent bladder cancer, underwent RARC and iON.?Key steps of surgery include: the ligation of gonadic pedicles, meticulous dissection of the umbilical and uterine artery and the ureter, dissection of the bladder pedicle, opening of the vagina and creation of the plane between vagina and bladder. Cut of the urethra and securing the Foley catheter with the entire specimen placed into an Endocatch bag to minimize any urine spillage. Removal of the specimen into an endocatch bag through the vagina. Extended pelvic lymph node dissection. Suture of the vagina and creation of a peritoneal flap as posterior neobladder support. RESULTS The procedure was successfully completed. Operative time was 295 minutes, EBL was 250 mL, time to flatus was 3 days, time to bowel was 7 days. Hemoglobin and creatinine at discharge were 10.3 g/dL and 0.76 mg/dL, respectively. The hospital stay was 8 days. The pathologic stage was pT0 pN0. The number of nodes removed was 26. Postoperative course was uneventful. The patient recovered daytime continence 45 days after surgery. CONCLUSIONS A meticulous dissection of vascular suppliers of the bladder, a natural orifice specimen retrieval and the ease of posterior neobladder support thanks to a perfect vision of the small pelvis anatomic structures may contribute to minimize invasiveness and to improve perioperative outcomes of radical cystectomy in female patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1374 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Giuseppe Simone More articles by this author Salvatore Guaglianone More articles by this author Leonardo Misuraca More articles by this author Francesco Minisola More articles by this author Gabriele Tuderti More articles by this author Mariaconsiglia Ferriero More articles by this author Giuseppe Romeo More articles by this author Michele Gallucci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic laser lithotripsy inside the endocatch bag: An alternative technique for removal of large post lap pyelolithotomy calculi

Large staghorn calculi in unascended pelvic kidneys and in normally located kidneys with anatomy unsuitable for percutaneous nephrolithotomy have to be treated via pyelolithotomy. When performed laparoscopically, the extraction of these staghorn calculi, without extending skin incision at the port site is challenging. We describe the successful use of laparoscopic laser lithotripsy, intracorporeally, with the entrapped calculus inside the endocatch bag, for fragmentation and retrieval without extension of skin incision.

Pure laparoscopic right anterior sectionectomy for hepatocellular carcinoma with great vascular exposure.

Laparoscopic hepatectomy is a common procedure that has been reported frequently [1-3]. However, laparoscopic resection of tumors located in hepatic segments 5 and/or 8 remains a technically difficult procedure as it requires two transection planes [4]. Furthermore, there are a greater number of hepatic vein and glissonian pedicle branches that require a division as compared to other hepatectomy operations. In this report, we present a pure laparoscopic right anterior sectionectomy (RAS) for hepatocellular carcinoma (HCC). Preoperative imaging showed HCC (3cm× 4cm) in segment 5 [5]. After selective anterior segment inflow occlusion, transection lines were demarcated. Complete Pringle maneuver was performed for 15min intervals five times during hepatic parenchymal transection. The Cavitron Ultrasonic Surgical Aspirator was used for the transection of the hepatic tissue. Small hepatic vein branches along the middle and right hepatic veins and small glissonian pedicles were clipped, sealed and divided with EnSEAL (TM) (Ethicon). iDrive (TM) Ultra Powered Stapling device (Medtronic) was used for the division of tertiary glissonian pedicles. Hanging maneuver was performed for transection of remaining liver parenchyma after complete division of hepatic venous branches. The specimen was removed through the lower abdominal transverse incision using the endocatch bag. Jackson-Pratt drain was left in the operative field. All work was performed with IRB approval. Pure laparoscopic RAS for HCC was performed successfully without intraoperative complications or transfusions. The operation time was 300min, and the estimated blood loss was <200ml. On postoperative day 5, computed tomography scan showed well-perfused hepatic parenchyma. Pathology specimen confirmed 3.2cm×3cm×2.2cm HCC without involvement of surgical resection margins. The patient was discharged on postoperative day 7 without complications. Pure laparoscopic RAS is a feasible operative procedure in patients with tumors located in hepatic segments 5/8.

The Ovary-Sparing Laparoscopic Excision of a Benign Teratoma

Purpose: We demonstrate complete excision of a benign ovarian teratoma and combine the benefits of laparoscopy with ovary preservation and avoidance of tumor spillage. Case History: A 9-year-old female presented with 2 months of intermittent right lower quadrant abdominal pain. Physical examination was unremarkable with no palpable abdominal mass. Pelvic ultrasonography revealed an enlarged right ovary with no evidence of torsion on duplex scan. MRI revealed a calcified, 3.5 cm mass within the right ovary, consistent with a teratoma. Tumor marker blood studies, including beta-HCG, alpha-fetoprotein, and CA-125, were negative. Procedure: General anesthesia was administered. The patient was placed in Trendelenburg position with the monitor at the foot of the bed. Three 5-mm laparoscopic ports were placed, one for the 5-mm, 30° camera at the umbilicus and one each in the lower quadrants for dissection instruments. A 12-mm port was placed in the skin crease, directly above the ovary, for the endocatch bag. The abdomen was insufflated with carbon dioxide to 13-mm Hg pressure. Initial inspection revealed a normal-appearing abdomen, a normal contralateral ovary, and the serosa of the enlarged right ovary appeared intact. The dissection began at the pelvic edge by dividing the peritoneal attachments between the adnexal structures and the pelvic side wall with the harmonic scalpel. It proceeded toward the point between the bladder and the epigastric vessels. The ovarian and iliac vessels and ureter were avoided. The dissection extended under the adnexa. The ovary reached the 12-mm port without tension. It was placed in an endocatch bag to prevent spillage in case of rupture and carefully pulled through the 12-mm port site. The hydroplane technique of saline injection with a 30-gauge needle under the ovary serosa allowed dissection of the teratoma from normal ovarian tissue. The serosa was opened and the teratoma circumferentially excised.1,2 The preserved ovary serosa was closed with running suture of 3–0 chromic catgut. The adnexa were replaced in the abdominal cavity in the correct orientation. The abdomen was desufflated and port sites were closed. Results: The pathology analysis revealed a benign 3.0 cm teratoma, completely excised with intact margins and no immature elements. No complications occurred. The operative time was 70 minutes. The patient was discharged on postoperative day 2. Conclusion: We demonstrate complete excision of a benign ovarian teratoma and combine the benefits of laparoscopy with ovary preservation and avoidance of tumor spillage.3 For patients with negative tumor markers, an MRI with a teratoma contained in the ovary and a tumor diameter less than 5 cm are appropriate. The distance between bladder and epigastric vessels may limit the size of lesion that can be brought through the abdominal wall along the suprapubic skin crease. The hydroplane technique reveals a consistent plane between teratoma and normal ovary. However, this technique is also suitable for lesions where malignancy is suspected. The risk of suspicious histology, tumor rupture, and spillage increases with tumor diameter. In general, these risks increase with lesions more than 5 cm in diameter.4 Therefore, we promote the use of the endocatch bag. No competing financial interests exist. Runtime of video: 4 mins 55 secs

Vaginal Tissue Extraction Made Easy

The goal of this video is to demonstrate a new technique to improve vaginal tissue extraction. This video demonstrates the step by step process in obtaining and removing a specimen vaginally using an endocatch bag, Alexis ring, and hand stapler. This unique process avoids the need to extend any abdominal incision, which eliminates the need for fascial closure, thus risk of future hernia formation. We use the colpotomy (or one could create a colpotomy), which provides an extended incision ideal for extraction.

V9-06 TECHNICAL INNOVATIONS TO ROBOTIC LEVEL II AND III THROMBECTOMY: STEP BY STEP

You have accessJournal of UrologyRobotics - Renal1 Apr 2016V9-06 TECHNICAL INNOVATIONS TO ROBOTIC LEVEL II AND III THROMBECTOMY: STEP BY STEP Andre Luis de Castro Abreu, Sameer Chopra, Chandan Kundavaram, Daniel Shin, Charles Metcalfe, Nariman Ahmadi, Andre Berger, Giuseppe Simone, Osamu Ukimura, Michelle Gallucci, Monish Aron, Mihir Desai, Rene Sotelo, and Inderbir Gill Andre Luis de Castro AbreuAndre Luis de Castro Abreu More articles by this author , Sameer ChopraSameer Chopra More articles by this author , Chandan KundavaramChandan Kundavaram More articles by this author , Daniel ShinDaniel Shin More articles by this author , Charles MetcalfeCharles Metcalfe More articles by this author , Nariman AhmadiNariman Ahmadi More articles by this author , Andre BergerAndre Berger More articles by this author , Giuseppe SimoneGiuseppe Simone More articles by this author , Osamu UkimuraOsamu Ukimura More articles by this author , Michelle GallucciMichelle Gallucci More articles by this author , Monish AronMonish Aron More articles by this author , Mihir DesaiMihir Desai More articles by this author , Rene SoteloRene Sotelo More articles by this author , and Inderbir GillInderbir Gill More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1197AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In this video, we demonstrate technical innovations to facilitate robotic Level II and III IVC thrombectomy. METHODS Following IVC dissection and ligation of the right renal artery, rommel tourniquets (RT) are placed in the infrarenal IVC (IIVC), left renal vein (LRV), and suprarenal IVC (SIVC). The IIVC and LRV RTs are cinched down. A cavotomy over a purse-string suture is performed just distal to the right renal vein, cephalad to the IIVC RT. A 9Fr Fogarty catheter over a soft-tip glide-wire is advanced into the IVC to an infra-hepatic location, proximal to the thrombus. The catheter balloon is inflated to occlude the IVC and retracted. The right renal vein is stapled. Cavotomy is performed and the thrombus is delivered into an Endocatch bag. The SIVC RT is now cinched down at the level of the right adrenal vein without liver mobilization. The right renal vein ostium and the staple-line are resected. Cavoscopy is performed to ensure no IVC wall invasion by the thrombus. Following IVC reconstruction and release of all RTs, Doppler and ICG confirm IVC flow. Resection of IVC and repair with bovine pericardium is performed if there was any IVC invasion requiring excision of cava. RESULTS We successfully performed robotic IVC balloon thrombectomy and bovine path in 3 and 1 patient, respectively. The table provides peri-operative findings. All margins were negative and to date no patient has developed metastasis. CONCLUSIONS The use of a Fogarty balloon for proximal IVC occlusion during robotic IVC thrombectomy for level II and III thrombi is feasible and safe; it facilitates proximal IVC control without the need for short-hepatic vein control, retro-hepatic dissection or liver mobilization. Robotic implantation of a bovine pericardial patch following IVC wall resection is feasible and safe. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e861 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Andre Luis de Castro Abreu More articles by this author Sameer Chopra More articles by this author Chandan Kundavaram More articles by this author Daniel Shin More articles by this author Charles Metcalfe More articles by this author Nariman Ahmadi More articles by this author Andre Berger More articles by this author Giuseppe Simone More articles by this author Osamu Ukimura More articles by this author Michelle Gallucci More articles by this author Monish Aron More articles by this author Mihir Desai More articles by this author Rene Sotelo More articles by this author Inderbir Gill More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot-Assisted Resection of a Large Posterior Mediastinal Mass

Introduction: Ganglioneuromas are rare, typically benign, tumors that arise from tissues that have a neural crest cell origin. They typically occur in patients ranging in age from 10 to 40 years and are classically found in the adrenal glands. Ganglioneuromas are frequently asymptomatic and discovered incidentally while another condition is being investigated. The video demonstrates a difficult dissection that offers technical advantages over traditional thoracoscopy instruments by the articulating instruments of the robot with run time of 4 minutes 31 seconds. Background: An 18-year-old woman who was being followed for scoliosis was found to have a large left chest mass on a chest x-ray. A chest CT scan revealed a 10×7.5×6.5-cm mass in the left upper chest, consistent with a bronchogenic cyst. She had no reports of fever, shortness of breath, or chest pain, although she did endorse frequent feelings of left chest/shoulder tightness. In an attempt to avoid a large thoracotomy or sternotomy, we proceeded with a robot-assisted resection of the large mass. Methods: The patient was laid supine with the left chest slightly elevated and her left arm extended above her head. She was intubated with a Carlens tube for single lung ventilation. With the left lung deflated, an 8-mm robotic trocar was placed in the left midaxillary line (sixth intercostal space), an 8-mm robotic trocar was placed in left anterior axillary line (fifth intercostal space), and an 8-mm trocar was placed posterior to scapula (fourth intercostal space). An additional 5-mm step trocar was placed as an assistant port, lower left midchest in the posterior axillary line. Using hook cautery and graspers with bipolar cautery, the tumor was dissected free from the surrounding tissues and the blood vessels cauterized. The mass seemed to arise from the left sympathetic ganglia chain, which had to be sacrificed for tumor removal. The tumor extended into the apex of the left chest and into the lower part of the left neck just behind the head of the clavicle. The tumor was resected free and placed into an endocatch bag, where it was cut to facilitate its removal. The anterior axillary line trocar was removed and widened to ∼5 cm to allow specimen removal. A 28F chest tube was used because the larger tube was less likely to clog, and the chest hole was already large enough to accommodate it. The operative time was 5.5 hours, with 5 to 10 minutes of setup for the robot. Final pathology revealed a ganglioneuroma. Results: She was admitted to the step down unit postoperatively with patient-controlled anesthesia pain control. She was transitioned to oral pain medicine with a general diet on postoperative day 1. Her chest tube was removed and she was discharged on postoperative day 2. She was seen in clinic the following month with some left arm numbness and slight symptoms of Horner's syndrome (left eye ptosis and miosis when tired). Twelve months later, she reports being asymptomatic from her Horner's syndrome. Conclusions: Robot-assisted thoracic surgery provides great 3D visualization and articulating instruments that can be used to dissect large intrathoracic tumors and possibly avoid a large thoracotomy or sternotomy. No competing financial interests exist. Runtime of video: 4 mins 31 secs This work was presented as a poster at the 2014 IPEG conference in Scotland.

The Use of Robotic Surgery Allows for Improved Dexterity and Visualization During Thoracoscopic Thymectomy

Introduction: Myasthenia gravis (MG) is an autoimmune neuromuscular disease, the effects of which can be improved or alleviated by thymectomy in young patients. However, median sternotomies or thoracotomies have a high degree of morbidity, especially when already weakened from their MG. A thoracoscopic approach allows for a minimally invasive approach, but it can be technically challenging to completely remove all the thymic tissues in the contralateral chest and lower neck, especially in smaller children who typically have larger glands. The video demonstrates the robot-assisted approach for dissection of the thymus gland. Background: This patient is a 3-year-old boy who had been suffering from generalized MG. Due to disease progression that was only partially controlled by medications, his neurologist referred him for thymectomy. After a lengthy conversation with his parents, the decision was made to proceed with a robot-assisted left thoracoscopic thymectomy. Methods: The patient was placed in the supine position on the operating room table. Through a transverse incision in the left axilla, a 5-mm XCEL trocar was placed in the fourth interspace, and pneumothorax was created with a pressure of 4 mm Hg. One additional 5-mm robotic trocar was placed in the left midclavicular line in the sixth interspace, and an additional 8-mm trocar was placed in the sixth interspace in the anterior axillary line. The XCEL trocar was replaced with a 5-mm robotic trocar. At this point, the robot was docked, and the 8-mm camera and 30-degree scope was placed in the central trocar. Hook cautery and a Maryland grasper were used to dissect the gland off of the heart. The left lateral aspect of the thymus was lateral to the left phrenic nerve, which was identified and preserved. Dissection was continued in a caudad direction to free up the entire left lobe of the gland and carried over toward the right chest. A small hole that had been made in the right pleura was widened to prevent a tension pneumothorax from developing. At this point, the dissection was carried around the right lobe of the thymus with care taken to preserve the right phrenic nerve. Dissection was continued to free the gland from the heart as well as both superior horns that extended well into the lower neck. Once the organ was dissected free, it was placed into a 10-mm Endocatch bag that had been placed through the slightly widened 8-mm trocar defect. The lungs were fully inflated before the fascia being closed at all port sites without placing a chest tube. No pneumothorax was seen on the postoperative chest X-ray. Results: The patient tolerated the procedure well without any postoperative complications, had minimal blood loss, and was discharged home the following day. Conclusion: The use of robotic assistance in thoracoscopic thymectomies with its articulating instruments and 3D visualization has allowed this approach to be offered to younger and smaller patients despite having a larger thymus. This approach allows these patients to benefit from an earlier thymectomy while avoiding the morbidity from a sternotomy or large thoracotomy. The authors have no relevant financial disclosures. Runtime of video: 4 mins 13 secs

Vaginal Application of the Endo Catch Bag

Vaginal Application of the Endo Catch Bag

The Sydney Contained in Bag Morcellation Technique

Study ObjectiveTo demonstrate a modification of the Shibley single-port technique suitable for morcellation of large myomatous uteri after total laparoscopic hysterectomy in a contained environment within the abdominal cavity [1]. DesignStep-by-step explanation of the technique using descriptive text and an educational video. SettingIn light of recent concern about the use of power morcellators and increasing the risk of disseminating occult leiomyosarcomatous myoma fragments throughout the abdominal cavity, we propose this new technique for management of morcellation of large myomatous uteri after total laparoscopic hysterectomy, to contain the morcellation process and minimize the risk. This technique, which we have coined “Sydney Contained in Bag Morcellation” involves introduction of a sterile plastic bag (Dual Drawstring Bag, 460 × 460 mm; Southern Cross Hospital Supplies, Northmead, NSW, Australia) before introducing an optical port and the power morcellator. Before insertion this bag is modified in several ways to facilitate bag opening and specimen retrieval. The dual drawstring is removed and replaced with a 150-cm length of PDS I (polydioxanone) suture material as the new drawstring, with its exit at the mouth of the bag in the 6 o'clock position. Five stay sutures are placed around the bag mouth, corresponding to the 12, 1, 5, 7, and 11 o'clock positions. This assists with opening the mouth of the bag intraabdominally and enables orientation to be maintained. The bag is then inserted in a McCartney tube (Gates Healthcare, Cheshire, UK). Corresponding slits are made in the tip of the tube to enable the end of the stay sutures to be securely held in place during tube insertion. These ends are then retrieved using atraumatic graspers and exteriorized and clipped alongside their corresponding port sites. After hysterectomy the uterus is placed in the bag, and the stay sutures maintain the mouth opening. The bag is closed and its mouth exteriorized onto the abdominal wall at the site of the umbilical trocar. The 12-mm umbilical trocar is then replaced within the bag, and pseudopneumoperitoneum is created. Once established, an optical trocar is introduced via one of the lower quadrant port sites using a balloon tip trocar (Kii; Applied Medical, Rancho Santa Margarita, CA). The insufflation tubing is attached to this trocar, and the umbilical trocar is replaced with the morcellator device. Morcellation is performed under direct vision in a contained environment. Once complete, all fragments are removed, and the bag is washed out. The original pneumoperitoneum is re-established. The bag is then removed during aspiration to encourage negative pressure relative to the re-established pneumoperitoneum, minimizing aerosolized fragment leakage. InterventionContained in bag morcellation of a large myomatous uterus during total laparoscopic hysterectomy. This technique has been specifically developed to address the concerns of morcellating large myomatous uteri after hysterectomy. In the case of supracervical hysterectomy or myomectomy, in which there would be no vaginal conduit to exploit, we use an endocatch bag, inserted in the usual manner, with reintroduction of the umbilical trocar within the mouth of the bag to enable creation of pseudopneumoperitoneum. Again, an optical trocar would be introduced in a lower lateral port, and morcellation would be performed under direct vision. An article describing this technique has recently been published [2]. ConclusionThe Sydney Contained in bag Morcellation technique offers a possible solution to the risk of dissemination of benign morcellated and potentially leiomyosarcomatous myoma fragments. Certain aspects of the procedure are key to its success. The stay sutures are essential to facilitate orientation and opening of the bag mouth. The McCartney tube enables easier insertion of the flaccid bag into the vagina, and the suture-retaining slits enable the mouth of the bag to be opened quickly and easily. We have used this technique in 5 cases with uteri ranging in weight from 350 to 978 g. Recently, similar techniques have been described for use in single-port surgery and conventional laparoscopy [1,2]. Our technique is suitable for use with large uteri after total laparoscopic hysterectomy because the large capacity of the bag enables containment of uteri that would exceed the capacity of manually deployed specimen retrieval bags. This technique offers an alternative to vaginal morcellation, with the advantage of improved vision during morcellation and the ability to morcellate large uteri using a familiar instrument and view.

Sydney Contained in Bag Morcellation for Laparoscopic Myomectomy

Study ObjectiveTo demonstrate a new technique of contained in bag morcellation of a myoma after laparoscopic myomectomy. DesignStep-by-step explanation of the technique in a narrated video. InterventionContained In Bag Morcellation of myoma after laparoscopic myomectomy. Measurements and Main ResultsRecent controversy regarding the risk of disseminating occult leiomyosarcomatous tissue during morcellation means we need to revise our current approach to tissue extraction at laparoscopic myomectomy and morcellation in general. Herein we present a novel technique, conceived by Dr. Danny Chou, called the Sydney Contained In Bag Morcellation technique for laparoscopic myomectomy. In this technique an EndoCatch bag (EndoCatch II Auto Suture Specimen Retrieval Pouch; Covidien, Mansfield, MA) is introduced in the typical fashion, the myoma is retrieved, and the mouth of the bag is exteriorized onto the abdominal wall. A 12-mm trocar is then introduced within the bag, and pneumoperitoneum is created before introducing an optical balloon tip port (KII Balloon Blunt Tip System; Applied Medical, Rancho Santa Margarita, CA) and the power morcellator device. Morcellation is then performed within the bag, under direct vision.This technique may offer a safer approach to morcellation because the bowel is not within the morcellation field and there is lower risk of disseminating occult leiomyosarcomatous tissue during morcellation. Subsequent to the morcellation process, suctioning of the bag removes any aerosolized particles of myoma, further minimizing the risk of possible dissemination. ConclusionThis technique may enable a minimally invasive approach to myomectomy to continue as a viable option in the era since the warning by the US Food and Drug Administration.

Laparoendoscopic Single-Site Donor Nephrectomy Video

Introduction: Laparoendoscopic single-site (LESS) surgery is a modification of multiport or conventional laparoscopy. Utilizing a single site for access, LESS attempts to minimize the number of scars produced. This may result in improvements in pain, convalescence, and cosmesis. Outcomes, however, must not be compromised using this approach. At our institution, we have performed LESS donor nephrectomy (LESS-DN) and have compared it to conventional laparoscopic donor nephrectomy (LDN) in a prospective, randomized fashion to assure that LESS-DN outcomes are not inferior to LDN. The technique and the outcomes of our trial are outlined in the video. Methods: LESS-DN access is obtained through the extraction pfannenstiel incision. Three ports are placed within this incision and donor nephrectomy is performed with the aid of the EndoEye articulating scope. The colon is reflected after incising the white line of Toldt, and the ureter is identified. Dissection toward the hilum is performed and the renal artery and vein are skeletonized with branching vessels ligated and transected with hemolock clips. The lateral and upper pole renal attachments are freed and the renal artery and vein are staple ligated. The kidney is placed in an endocatch bag and extracted through the pfannenstiel incision. Results: LDN and LESS-DN were performed in 14 and 15 patients, respectively. Patients had similar parameters on study entry and had similar outcomes with LESS-DN patients enjoying less pain on postoperative days 1 and 2. Conclusion: LESS-DN is safe, feasible, and comparable to LDN. LESS-DN may result in improvement in pain and convalescence. Number of scars are decreased with the use of LESS-DN. No competing financial interests exist. Runtime of video: 5 mins 37 secs

Technique to Minimize Spillage during Ovarian Cystectomy of Dermoid Cyst

One of the concerns regarding dermoid cystectomy is to decrease the amount of spillage that may inadvertently occur during the procedure. Here, we show our method of minimizing spillage by placing a 15mm EndoCatch bag through a posterior colpotomy incision. This allows for the cystectomy to occur with any spillage that occurs be contained within the EndoCatch bag. Once dissection is complete, the dermoid cyst can be removed through the posterior colpotomy with repair of the incision either laparoscopically or vaginally.