Endo-GIA Stapler Research Articles

MP57-15 EN BLOC LIGATION OF RENAL VESSELS DURING LAPAROSCOPIC NEPHRECTOMY AND NEPHROURETERECTOMY

You have accessJournal of UrologyKidney Cancer: Surgical Therapy II1 Apr 2015MP57-15 EN BLOC LIGATION OF RENAL VESSELS DURING LAPAROSCOPIC NEPHRECTOMY AND NEPHROURETERECTOMY Mariam Hult, Mikkel Fode, Claus Dahl, and Nessn Azawi Mariam HultMariam Hult More articles by this author , Mikkel FodeMikkel Fode More articles by this author , Claus DahlClaus Dahl More articles by this author , and Nessn AzawiNessn Azawi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2003AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Conventionally individual ligation of the renal artery and vein with clips is performed during laparoscopic nephrectomy (LN). Concomitant ligation of the vessels (en bloc ligation) is not standard procedure, due to an expected risk of stapler dysfunction and arteriovenous fistulas (AVF). However, recent studies suggest that en bloc ligation may be a safe procedure offering a reduction in surgical time. The objective of this study was to compare en bloc ligation, using EndoGIA stapler 45/2.5 mm (Covidien Inc, Mansfield, MA), with conventional individual ligation, during LN and laparoscopic nephroureterectomy (LNU), regarding surgical time, blood transfusions and development of AVF. METHODS A retrospective chart review of all patients, undergoing LN or LNU at the Department of Urology, Roskilde Hospital, between January 2010 and April 2014, with a follow-up of minimum 6 months, was performed. Demographic data, indication for surgery, method of ligation, blood transfusions and development of CT-verified AVF were collected. Wilcoxon rank sum test, chi square test and Fisher's exact test were used for univariate analyses. Multivariate analyses were performed with linear and logistic regression. RESULTS 228 patients underwent LN and 56 patients underwent LNU. In the LN group, 77 patients (34%) underwent en bloc ligation. The surgical time was significantly reduced in the en bloc group, with a median of 90 minutes (range 30-180) compared to 110 minutes (range 40-240) in the conventional ligation group (p=0.0001). The difference remained significant after controlling for age, gender, indication for surgery, blood transfusions and robotic surgery (-26 min [95% CI; -17 to -36 min], p<0.0001). Three en bloc patients and one conventional ligation patient received blood transfusions. The difference neither reached statistical significance in the univariate analysis (p=0.11) nor after controlling for age, gender, indication for surgery and robotic surgery (p=0.068). In the LNU group, 7 patients (13%) underwent en bloc ligation. There was no significant difference between conventional ligation and en bloc ligation in surgical time on either univariate (p=0.8) or multivariate (p=0.07) analyses. None of the patients needed blood transfusions. With a mean follow-up of 13 months (range 6-50), no AVF were found in any of the 284 patients. CONCLUSIONS En bloc ligation appears to be safe and can reduce the surgical time during LN without increased risk of blood transfusions, or development of AVF. Further studies are needed to assess possible advantages using the method during LNU. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e695 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mariam Hult More articles by this author Mikkel Fode More articles by this author Claus Dahl More articles by this author Nessn Azawi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Endo-GIA stapler vs.suture for spontaneous pneumothorax under video-assisted single port thoracoscope

Objective To analyze and discuss the clinical effect of the application of Endo-GIA stapler vs.suture in the treatment of spontaneous pneumothorax under video-assisted single port thoracoscope (VATS). Methods From March 2009 to March 2012, 92 cases of spontaneous pneumothorax were treated with VATS in our hospital.They were randomly divided into two groups with 48 cases in cutting seam group treated by Endo-GIA stapler in resection of pulmonary bullae, and rest 44 cases in suture group treated by silk in suture and ligation of pulmonary bullae.The clinical effect of these two methods were compared. Results There was no death,conversion to open chest surgery and severe complications after operation in 92 cases of these two groups.Recurrent pneumothorax happened in 5 cases.There were no significant difference in indicators such as tube indwelling time, cicatrisation of observation port and length of hospital stay between two groups[(2. 0±0. 4)d vs.(2. 0±0. 5)d,(5. 2±1. 9)d vs.(5. 8±2. 0)d,P> 0. 05].Bleeding volume in suture group was greater than that in cutting seam group.Operation time in suture was also longer than in cutting seam group.The operation cost in suture group was significantly less than in cutting seam group[(61± 6)ml vs.(90±9)ml,(43±7)min vs.(50±5)min, P< 0. 05] Conclusion These two operation methods were safe and effective.Endo-GIA stapler was applicable to a wide base, clusters of pulmonary bullae or multiple pulmonary bulla patients while suture method was suitable for single and narrow base pulmonary bulla patients. Key words: Pneumothorax,spontaneous; Linear stapler; Video-assisted single port thoracoscope

An unusual appearance of giant Meckel’s diverticulum

Meckel's diverticulum (MD) results from incomplete involution of the proximal portion of the vitelline duct. Although MD is the most commonly diagnosed congenital gastrointestinal anomaly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagnosis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD (B5 cm) are relatively rare and associated with more severe forms of the complications. Herein, we report a 43-year-old male patient presented at the Emergency Department with a complaint of abdominal pain, associated with fever (38,5C), nausea and anorexia. The clinical examination revealed pain in the right lower quadrant, as well as abdominal guarding and rebound tenderness. The leucocyte count was elevated at 18 × 109/L. Plain abdominal xray depicted multiple air-fluid levels. An abdominal and pelvic CT scan revealed a fluid-filled structure in the pelvis adjacent to the distal small bowel. The surgical method of exploration can be either by laparoscopy or through an open incision. Exploratory laparotomy was performed and revealed oedema throughout the entire small bowel, dilation of small bowel segments, and a giant Meckel's diverticulum (10 cm long) with mushroom appearance on the antimesenteric border of the small bowel at 70 cm proximal to the ileocaecal valve . Resection of the small bowel was performed with a linear stapler and an ileoileal anastomosis was generated using a 80 mm endo-GIA stapler. Patient was discharged on post-operative day 4 without any complications. Histopathologic examination indicated Meckel's diverticulitis without gastric or pancreatic metaplasia. Pan African Medical Journal 2015; 21

Use of Stapling Devices for Safe Cholecystectomy in Acute Cholecystitis

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January 2008 to June 2012, 1441 patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.

Comparative Analysis of Pedicular Vascular Control Techniques during Laparoscopic Nephrectomy: En Bloc Stapling or Separate Ligation?

Objective: To compare the safety and efficacy of en bloc stapling and separate ligation techniques for renal vascular control during laparoscopic nephrectomy. Patients and Methods: Clinical data were collected from 60 patients who underwent laparoscopic nephrectomies using en bloc stapling (n = 27, group 1) or the separate ligation method (n = 33, group 2). Comparative analysis was carried out between the two groups, examining operative times, blood loss, intra- and postoperative complications and hospital stay. Results: Compared with the separate ligation method, the en bloc hilar control technique was associated with a shorter total operating time (98 vs. 121 min, p = 0.029). However, both groups were similar in terms of estimated blood loss, hemoglobin drop, changes in creatinine level and postoperative hospital stay. The total complication rates in group 1 and 2 were 3.7 and 15.1%, respectively, with a statistically significant difference. There were no complications related to the use of the endo-GIA stapler and no patients required conversion to open surgery in group 1. In group 2, 2 patients required conversion to open surgery, including 1 due to renal vein bleeding secondary to inaccurate vascular control and the other due to bleeding from the vena cava during dissection. In addition, 1 patient had a superficial bowel injury that was repaired laparoscopically and another had a superficial liver tear that was managed without conversion or transfusion. Conclusion: En bloc ligation of the renal hilum is an easy and reliable technique that allows safe and fast control of the renal pedicle.

Giant Meckel’s diverticulum: An exceptional cause of intestinal obstruction

Meckel's diverticulum (MD) results from incomplete involution of the proximal portion of the vitelline (also known as the omphalomesenteric) duct during weeks 5-7 of foetal development. Although MD is the most commonly diagnosed congenital gastrointestinal anomaly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagnosis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD (≥ 5 cm) are relatively rare and associated with more severe forms of the complications, especially for obstruction. Herein, we report a case of giant MD with secondary small bowel obstruction in an adult male that was successfully managed by surgical resection and anastomosis created with endoscopic stapler device (80 mm, endo-GIA stapler). Patient was discharged on post-operative day 6 without any complications. Histopathologic examination indicated Meckel's diverticulitis without gastric or pancreatic metaplasia.

Thorascopic Resection of Esophageal Heterotopic Pancreas

Heterotopic pancreas is normal pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Heterotopic pancreatic tissue is a rare congenital anomaly found usually in the stomach, duodenum, or jejunum and is rarely seen in the esophagus. This is a case of heterotopic pancreas found in the esophagus that was removed thorascopically.

Stapleless Laparoscopic Splenectomy Using Harmonic Scalpel by 2-Step Sealing

Laparoscopic splenectomy (LS) has been accepted as a safe and effective procedure as compared with open splenectomy. Recently, there have been a few reports on the LigaSure vessel sealing system as an alternative hemostasis to clip ligation. Here we report the experience of LS using an alternative energy device, Harmonic Scalpel laparoscopic coagulating shears (LCS). Preliminary experience of LS with LCS for a patient with idiopathic thrombocytopenic purpura (ITP) is reported. Generally, two-step sealing with LCS was used for vessels of the splenic pedicle approximately 5 mm in diameter without using the Endo-GIA stapler. Operative time was 93 minutes, and blood loss was 40 mL. The patient was discharged on the third postoperative day with no intraoperative or postoperative complications. The LS with LCS was performed safely using two-step sealing. Further experience is necessary to verify the safety of this procedure.

A Technique for Laparoendoscopic Resection of Posterior Fundic Gastric GISTs Without Need for a Gastrotomy

The majority of gastrointestinal stromal tumors (GISTs) are located in the stomach. With greater experience in minimally invasive oncologic surgery, gastric GISTs are being increasingly approached laparoscopically. Posterior proximally located endophytic gastric GISTs can be challenging to approach laparoscopically and excise with an adequate margin without an anterior or posterior gastrotomy, or intragastric ports. The gastrocolic and gastrosplenic ligaments are divided up to the gastroesophageal junction. The left lateral segment of the liver is mobilized to allow anterior reflection of the gastric fundus. Intraoperative ultrasound confirms the location and extent of the tumor base. Upper endoscopy is performed to trans-illuminate, confirm tumor location, and search for multifocality. Traction sutures are placed around the tumor to distract endophytic lesions. With organo-axial rotation of the stomach using the stay sutures, an endoGIA stapler approximates the posterior fundic wall under the base of the lesion ensuring an adequate margin and eliminating the risk of gastric spillage. Appropriate stapler placement and margins are assisted real-time endoscopically with picture-in-picture. The stapleline is tested for leaks and inspected for hemostasis laparoendoscopically. Complete resection of GISTs with adequate margins is performed with sound oncologic principles and demonstrated in tumors of varying sizes and locations in the proximal posterior stomach, including near the GE junction. This video demonstrates a simple laparoendoscopic technique to quickly localize even small tumors, visually confirm adequate margins, and excise gastric GISTs without spillage or gastrotomy that are located in a typically difficult area of the stomach to approach laparoscopically.

Pulmonary artery bleeding caused during VATS lobectomy.

VATS lobectomy is a very successful procedure with proven benefits over open lobectomy, including reduced hospital stay, reduced tube drainage and better compliance with post operative chemotherapy (1-4). But there is a learning curve with this operation as with all complex procedures and thus surgeons must be aware of the particular complications that may face them, and the novel methods that are required to try to overcome them (5-7). In the case presented in this video, we were performing a left upper lobectomy for a proven T1bN0M0 adenocarcinoma (Video 1). The patient was 73 years old and had COPD with an FEV1 of 40%. He had undergone all routine preoperative tests including a CT Head and a mediastinoscopy to exclude N2 disease. Video 1 Pulmonary artery bleeding during VATS lobectomy The video clip commences after the posterior oblique fissure has been opened up, the pulmonary artery has been dissected out and its sheath opened up and we had already dissected out and divided the lingular artery and the posterior segmental artery. The artery that we were now isolating was an anteroapical truncal artery, as in this particular patient there was not further artery after the apical segmental artery to the left upper lobe, and this artery was therefore supplying both segments. In the video you will see that we had successfully gone round the artery with a 30 cm Roberts artery forcep. We then attempted to introduce the endo GIA stapler with a white 2.5 mm insert in order to divide this vessel. However you may also see that the angle of the stapler is not correct and it is pushing into the crux of the apicoanterior segmental artery and the main pulmonary artery. While attempting to pass the stapler round this vessel a sudden gush or dark blood is seen as the pulmonary artery is breached. The first step is to introduce a swab mounted on a rampleys forceps. This is our first move for any significant bleeding and such a ‘swab-on-a-stick’ should always be available in case of significant bleeding. It should be remembered that the pressure in the pulmonary artery is often 1/3rd or less of systemic pressure and therefore pressure via the anterior working port will most often control the bleeding. We pressed on this area for 10 minutes and during that time we first cleared the area of blood and secondly as the bleeding was now controlled, we performed some further dissection in order to gain us better access to the area of the tear. This is an important point in trying to obtain control. When you have temporary control of the bleeding point, you have time to inform your staff about the event, obtain additional instruments if required, make sure that you are ready to perform a thoracotomy, ensure that blood is available, and that any additional instruments such as artery forceps are available. We then removed the swab and as quite often occurs in these cases, the bleeding had actually stopped. This again allowed us to further mobilize around this vessel, in the hope that we might again be able to pass the stapler and obtain haemostasis endoscopically. Unfortunately it can be seen that on investigation by the sucker, the PA started to bleed again. While using the suction to investigate this area, a rampleys forcep was placed on the left upper lobe so that bleeding could be quickly covered and pressed on, which was the case. After this bled for a second time, the decision was made to perform a thoracotomy, but in a balanced and timely manner. On examination there was a large tear 50% of the diameter of the segmental vessel right at the crux with the main PA. We used a side biting clamp to resect the pulmonary artery branch, we then completed the lobectomy, and finally we placed a small bovine pericardial patch over the defect and sutured this in place with 5.0 prolene. We also covered this with coseal and the patient made an uncomplicated recovery.

A Two-Step Control of Secondary Splenic Pedicles Using Ligasure during Laparoscopic Splenectomy

Objective: We modified the LigaSure vessel sealing into a two-step technique without using Endo-GIA stapler for the secondary splenic pedicle control in laparoscopic splenectomy (LS). This study evaluated the efficacy and safety outcomes of this technique.Methods: Patients (n = 105) scheduled for elective LS were consecutively and prospectively enrolled, including 24 males and 81 females, with a mean age of 43.6 (range 11-75) years. Following the mobilization of the spleen, the splenic inflow was interrupted by applying a Hem-o-lock clip. LigaSure was used to seal and transect the secondary splenic pedicles adjacent to the pancreatic tail and subsequently in proximity to the spleen.Results: Of 105 patients, 103 patients (98.1%) underwent successful LS, whereas two patients (1.9%) required the conversion to laparotomy. The mean operative time was 100 min, whilst the mean volume of blood loss was 500 mL. No clinically significant morbidities or mortality occurred following LS. An average of 8,000 RMB (range: 6900 to 9000; 1 USD = 6.5 RMB) was saved by using this two-step technique.Conclusion: Secondary splenic pedicles can be successfully controlled in LS by using a two-step technique with the LigaSure vessel sealing system in an economically favorable way.

Abstract 18025: Cryomaze for Sole-Therapy Atrial Fibrillation

Objectives: Surgical AF treatment program was started at our institution in August 2008. We report our initial results using minithoracotomy approach for endocardial cryomaze. Methods: All 30 patients undergoing Cryomaze between 8/08 and 12/10 are included. 1 patient underwent MVR while two others needed sternotomy for incidental aortic aneurysm and coronary artery disease diagnosed during preoperative workup. Surgical technique consisted of femoral cannulation for cardiopulmonary bypass and right mini-thoracotomy with video-assistance. Aortic root vent used in all cases and Chitwood clamp was used in arrested heart cases. On the left side, all pulmonary veins were isolated as an island and another line was made to the mitral annulus (LA isthmus line). On the right side, SVC was connected to IVC and this line was connected to tricuspid annulus (RA isthumus line). Left atrial appendage was oversewn in two layers, except during sternotomy, where it was stapled off with endo-GIA stapler. Beta blockers were used as tolerated and amiodarone was only used if patient developed AF. Postprocedure follow-up included spot EKG at 1, 3, 6 and 12 months and yearly thereafter. Symptomatic patients underwent three week continuous rhythm monitoring. Results: Outcomes are given in table below. 4(13%) patients required permanent pacemakers. There were 6 (20%) complications including catheter ablation for atrial tachycardia, pericardial effusion (no intervention needed), subcutaneous emphysema, lung hernia, femoral lymph leak and reopening of one LAA. There were no mortalities or strokes. Conclusions: Minimally invasive Cryomaze has acceptable morbidity and excellent short-term results in treating AF. Freedom from AF in this series was not influenced by left atrial vs biatrial ablation, beating heart vs arrested heart ablation, primary vs prior failed catheter ablation, or Paroxysmal vs Persistent AF.

The Implementation of Laparoscopy for Acute Caustic Gastrointestinal Injuries Is Limited: Reply

To the Editor, We are grateful for the clinical experience and suggestions provided by Dr. Huscher and colleagues concerning their laparoscopic management of caustic injuries to the upper gastrointestinal tract (UGI). Also, we congratulate them on their brilliant results. Minimally invasive surgery such as video-assisted thoroscopic surgery (VATS) and laparoscopy has been performed regularly in our department for more than 10 years. Total minimally invasive esophagectomy and gastric tube reconstruction for esophageal cancer with assist devices, such as the harmonic scalpel and endo-GIA stapler, have also been performed in a certain number of cases. However, the application of endoscopy in emergency surgery for patients with severe caustic UGI injuries remains a contentious issue. The operative indications in our series are listed in our article. Most of our patients underwent operation because of shock or persistent metabolic acidosis despite intensive resuscitation. As you can imagine, clinical conditions (hypotension, acidosis etc.) became even worse during the operation. The only way to save these patients is to remove the necrotic organs and tissue as soon as possible, i.e. to stop the continuous absorption of toxins, which would otherwise cause sepsis. In most cases, we finished resection within 60–90 min. We then irrigated the entire abdominal cavity, using approximately 10,000 ml of warm saline to clear all intraperitoneal soiling and thus prevent postoperative abdominal abscess. The entire anesthesia time should be as short as possible for these patients. The disadvantages of laparoscopic resection that concern us most are: (1) the instillation of carbon dioxide into the peritoneum, further compromising cardiopulmonary function and causing unpredictable intraoperative tragedy; (2) intraperitoneal spillage of gastrointestinal contents due to necrotic perforation—difficult to completely clean up through the endoscope and potentially very time consuming. The operative time achieved by Dr. Huscher was 218 ± 28 min, but is the time used for peritoneal lavage after resection taken into account? We have to point out that one of the main differences in caustic UGI injuries in Western countries and Taiwan is the caustic agent. In Taiwan, acid is the most commonly ingested agent. Unlike the localized lesions caused by ingestion of solid alkaline pellets, the low pH of acid causes diffuse injuries from the midor even upper esophagus down to the gastric body and antrum. This extent of injury greatly increases operative difficulty. We agree that laparoscopy is of value in the management of a limited number of cases of acute caustic GI injuries, provided the patient’s vital signs are stable and there is no perforation. Also, it is a valuable tool for early diagnosis of some cases with equivocal clinical conditions. For the ‘‘very sick patients,’’ as Dr. Huscher has said, what would be more important, a life-saving operation or minimally invasive surgery in order to reduce surgical trauma? Intestinal continuity was restored in two of Dr. Huscher’s young patients; what about the other 4? We appreciate this opportunity to reply to Dr. Huscher’s comments. Also we acknowledge and thank Jadzia Chou for manuscript revision. S.-H. Chou H.-P. Li Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome

An 81-year-old woman with a previous history of chronic mesenteric ischemia presented with recurrent post-prandial abdominal pain, early satiety, diarrhea, and weight loss. Her past history was significant for documented mesenteric ischemia, requiring multiple attempts of superior mesenteric artery (SMA) angioplasty and stenting 6 years prior to presentation. These procedures provided only short-term relief, and she subsequently underwent definitive supraceliac aorta-to-SMA bypass with a Dacron graft that alleviated her symptoms for several years. Over the past several months, she had experienced recurrent moderate abdominal pain after meals, early satiety, frequent and copious bowel movements, and significant weight loss from 120 to 85 lb. She denied nausea, vomiting, or fear of eating. Her past medical history was significant for atrial fibrillation and renovascular hypertension that was treated with bilateral renal artery stenting. Her surgical history was significant for an open cholecystectomy, appendectomy, hysterectomy, and supraceliac aorta-to-SMA bypass. Physical examination was unremarkable except for a scaphoid abdomen. No abdominal bruits were detected. Laboratory studies showed that her electrolytes were within normal limits and albumin borderline low at 3.4 g/dl. Fecal fat testing, stool cultures, and colonoscopy were negative. An upper gastrointestinal (GI) barium study with small bowel follow through revealed marked dilation of the third portion of the duodenum with a sharp vertical filling defect projected over the expected location of the SMA (Fig. 1). A computed tomography (CT) angiogram of the abdomen confirmed patency of the aorto-SMA graft (Fig. 2). The study similarly revealed marked dilation of the proximal duodenum with narrowing as it passed anterior to the spine and posterior to the chronically occluded SMA and the patent aorto-SMA bypass graft (Fig. 3). Based on these radiographic findings, the patient was diagnosed with SMA syndrome, with the cause likely being a fibrotic reaction from the stented and occluded native SMA and/or the adjacent parallel bypass graft. She was thus offered a surgical bypass via a laparoscopic duodenojejunostomy. Intra-operatively, the third portion of the duodenum was markedly dilated. A side-to-side anastomosis was created between the third portion of the duodenum and a loop of proximal jejunum at an infracolic location with an EndoGIA stapler (Fig. 4). The anastomosis was completed and reinforced with intracorporeal absorbable sutures. Her postoperative course was unremarkable. An upper GI study on post-operative day 4 showed good patency of the anastomosis, decompression of the duodenum and no evidence of extravasation (Fig. 5). She was discharged home on postoperative day 5 tolerating a regular diet. At her 2-week follow up visit, she had a very good appetite and no postprandial epigastric pain, but still had loose bowel movements. This was empirically treated with rifaximin for small presumed bowel bacterial overgrowth without improvement, and eventually was controlled with loperamide. At her 3-month follow up visit, she remains asymptomatic and was starting to gain weight.

Laparoscopic Excision of Type I Choledochal Cyst and Hepaticoduodenostomy in an Adult with Short Bowel Syndrome

Introduction: Although laparoscopic excision of the choledochal cyst is an established treatment option in the pediatric population, only a few cases of laparoscopic excision have been reported in the adult patients. Biliary reconstruction after excision of the choledochal cyst is performed by hepaticojejunostomy in most cases. However, in selected cases, hepaticojejunostomy might not be feasible due to the immobility or inadequacy of the jejunum. The authors present a case of a 62-year-old woman with symptomatic type I choledochal cyst. She had a history of multiple bowel excisions resulting in short bowel syndrome. Laparoscopic excision of choledochal cyst and biliary reconstruction with hepaticoduodenostomy was performed. A video with a run time of 8 minutes 1 second is presented to demonstrate the technique used. Materials and Methods: The patient was placed in the Lloyd-Davies position, with the operating surgeon standing in between the patient's legs. A 12-mm port was inserted with the open technique in the right lumbar region away from the previous scars. Another two 12-mm ports and two 5-mm ports were inserted under direct vision. Adhesions were taken down to facilitate the insertion of these ports. The Calot's triangle was dissected to identify the cystic duct and artery. The cystic duct was ligated and divided. The gallbladder was retracted superiorly to facilitate exposure of the hilar structures. The peritoneum anterior to the choledochal cyst was divided, and the cyst was dissected circumferentially. Distal dissection was performed down to the intrapancreatic part of the distal bile duct before transecting with Endo-GIA staplers. Proximal dissection was continued up to the hilar region, carefully protecting the right hepatic artery and portal vein. The proximal bile duct was then transected just below the confluence. The duodenum was mobilized by an extended Kocher's maneuver to facilitate a tension-free hepaticoduodenostomy. The anastomosis was performed with a single-layer, continuous, intra-corporeal suturing by using polydioxanone 4/0 sutures. The specimen was retrieved with an endopouch. Result: The patient recovered uneventful and was ready for discharge on day 3 after surgery. She remained asymptomatic at 6 months of follow-up. The histopathological examination confirmed the specimen to be a choledochal cyst with no evidence of malignancy. Conclusion: This case illustrates the feasibility laparoscopic excision of choledochal cyst in adults. Hepaticoduodenostomy may be a safe alternative method of biliary reconstruction in selected cases such as this patient with short bowel syndrome. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 8 mins 1 sec

Single-incision laparoscopic splenectomy with innovative gastric traction suture

Laparoscopic splenectomy is now the gold standard for patients with idiopathic thrombocytopenic purpura (ITP) undergoing splenectomy. There are a few reports in literature on single-incision laparoscopic (SIL) splenectomy. Herein, we describe a patient undergoing SIL splenectomy for ITP without the use of a disposable port device. We report a 20-year-old female patient with steroid-refractory ITP having a platelet count of 14,000/cmm who underwent a SIL splenectomy. Dissection was facilitated by the use of a single articulating grasper and a gastric traction suture and splenic vessels were secured at the hilum with an endo-GIA stapler. She made an uneventful postoperative recovery and was discharged on the second postoperative day. She is doing well with no visible scar at 8-month follow-up.

Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax using a single-incision laparoscopic surgery port: a feasible and safe procedure

Recent authors have pioneered the use of single-incision laparoscopic surgery (SILS) for umbilical cholecystectomy. The SILS approach has the potential of reducing the trauma of the surgical access and postoperative pain. Video-assisted thoracic surgery (VATS) greatly reduces patient postoperative pain compared with traditional thoracotomy incisions. The current trend is to use fewer working ports to reduce even more postoperative pain, chest wall paresthesia, and hospital stay. No reports have described using a SILS port in VATS. From September 2009 to March 2010, 13 patients had surgery for primary spontaneous pneumothorax. The patients underwent single-lung ventilation. A 2.5-cm-long incision was made at the sixth intercostal space in the median axillary line. The pleural space was entered by blunt dissection for placement of a single flexible port. A 5-mm 0° videothoracoscope, a roticulating grasper, and an endoGIA stapler were introduced through port channels. Apical lung blebs were stapled, and pleurodesis by pleural abrasion with Marlex mesh was performed. The study enrolled nine men (69.2%) and four women with a median age of 26.3years. No complications were recorded. The postoperative pain was mild for 10 patients (76.9%) and moderate for 3 patients. Mild chest wall paresthesia (numbness) was observed in three patients (23.07%). The postoperative hospital stay was 2.15days. Although the SILS port is for laparoscopic use, it allowed an adequate lineup of the instruments along the intercostal space and adequate instrument maneuverability for stapling and resecting of apical lung bullae or blebs. The procedure was accomplished successfully for 92.3% of the patients. This is the first report on the use of a SILS port in VATS. Further work and development of a proper thoracic single port are needed to define the uses and advantages of this uniportal technique.

Stapled Renal Vein With In Situ Tumor Thrombus: A Useful Intraoperative Maneuver to Facilitate Radical Nephrectomy and Inferior Vena Cava Thrombectomy

Patients with genitourinary tumors and inferior vena cava thrombus often have large lesions and significant neovascularity. Early division of the renal vein with the in situ thrombus is desirable; however, concerns have been raised regarding tumor spillage and thrombus migration. We describe a novel technique using a stapling device to secure the renal vein during resection of renal tumors associated with an inferior vena cava thrombus. Since 2005, 38 patients have undergone surgery for genitourinary tumors and inferior vena cava tumor thrombus by a single surgeon. We examined the utility of an endovascular stapler (Endo-GIA) to transect the renal vein and the in situ thrombus. The renal vein containing the tumor thrombus was divided with an endovascular stapler in 14 of 38 patients. The outcomes of this technique were assessed. The stapled group included more level III-IV thrombi than the nonstapled group. The tumors removed in the stapled group were larger (median 11.5 versus 9 cm), and the median intraoperative transfusion requirements were greater (9.5 versus 3 U). One patient developed an intraoperative pulmonary embolus, and another experienced hemodynamic changes suggestive of an embolus. Local recurrence developed in 1 and 2 patients in the stapled and conventional groups, respectively, during a median follow-up period of 3 months. The Endo-GIA stapler is a safe and effective instrument for division of the in situ renal vein component of the tumor thrombus, allowing the surgeon to complete the nephrectomy, achieve hemostasis, and, subsequently, concentrate on the vena cava and tumor thrombus aspects of the procedure.

A Novel Approach for Reinforcing the Pancreatic Remnant in Laparoscopic Distal Pancreatectomy

The major postoperative complication after open and laparoscopic distal pancreatectomy is pancreatic fistula. Different operative techniques have been tested to minimize this unpleasant complication. We evaluated a new technique for pancreatic stump reinforcement with synthetic glue after laparoscopic distal pancreatectomy. Ten female domestic pigs were divided into 2 groups; in group A (n=5), the pancreas was transected using an EndoGIA stapler, whereas in group B (n=5), the pancreas was transected using a Ligasure device and the pancreatic stump was reinforced with a hydrogel sealant. The clinical postoperative course was uneventful in all the cases. No differences were observed in pancreatic remnant healing between the groups, and only minor microscopic alterations of the healing process were found in the groups. The technique using Ligasure transection reinforced by the hydrogel sealant seems to be comparable with the standard transection technique using the stapler.

Approaches to Anomalous Vasculature in Laparoscopic Renal Surgery

Introduction: Recognition and safe management of vascular anomalies during laparoscopic renal surgery has become increasingly important as more challenging cases are undertaken via a laparoscopic approach. Recent studies have found comparable results in cases where vascular anomalies were found with low complication rates for laparoscopic donor nephrectomies1 and partial nephrectomies.2 The following video demonstrates the management of anatomic variations of the renal vein and artery, gonadal vein, lumbar vein, and accessory veins during laparoscopic radical nephrectomy, donor nephrectomy, and pyeloplasty. Methods: Digital video captures of laparoscopic renal surgeries were reviewed to find cases of anomalous renal vasculature. Cases were selected for their quality and content, with regard to demonstrating a distinct scenario in which a vascular anomaly is managed. During laparoscopic renal surgery, hilar vessels are managed either with clips or vascular staplers. The endo TA™ (Covidien, Mansfield, MD) is used for donor nephrectomies to increase vascular length, whereas the endo GIA™ (Covidien) or clips are used for radical nephrectomies. Vascular branches and small accessory vessels are managed with bipolar electrocautery. Results: A total of six cases are shown. The first case is a laparoscopic left radical nephrectomy complicated by a circumaortic renal vein. The anterior portion of the vein is taken with an endo GIA stapler to expose the renal artery, which is then controlled and divided. The posterior portion of the vein is divided last. The second case, a laparoscopic donor nephrectomy, demonstrates the use of the endo TA stapler, which adds length to the vessels by providing three rows of staples on the proximal side only, rather than the three rows of staples on both sides when using the endo GIA. The third case is a donor nephrectomy with two renal arteries. These are taken with the TA stapler, but some bleeding is noted in the staple line. This is corrected with clips. The fourth case demonstrates the management of large gonadal and lumbar veins with bipolar cautery during a laparoscopic donor nephrectomy. The fifth case, a laparoscopic pyeloplasty, shows an accessory renal vein and artery crossing the ureteropelvic junction. The vein is freed from the artery and divided using bipolar cautery. Division of the vein creates increased mobility, allowing one to move the artery away from the area of stricture. The last case, a laparoscopic donor nephrectomy, demonstrates a very proximal renal vein bifurcation, which is controlled with a stapler placed proximal to this bifurcation. Conclusion: Vascular anomalies are more frequently encountered in laparoscopic renal surgery. One must recognize these anomalies and often adjust to safely manage these. This requires familiarity with all forms of vascular control, including clips, staplers, and bipolar cautery. The authors of this video do not have any financial disclosures related to the production of this video. Runtime of video: 7 min 48 sec