Epigastric Vessel Injury Research Articles

Single-incision laparoscopic transabdominal preperitoneal repair in the treatment of adult female patients with inguinal hernia.

Women have a 3% lifetime chance of developing an inguinal hernia, which is not as common in men. Due to its cosmetic benefits, single-incision laparoscopic transabdominal preperitoneal (SIL-TAPP) inguinal hernia repair is becoming increasingly popular in the management of inguinal hernia in women. However, there are no studies comparing the safety and applicability of SIL-TAPP repair with conventional laparoscopic transabdominal preperitoneal (CL-TAPP) inguinal hernia repair for the treatment of inguinal hernia in women. To compare the outcomes of SIL-TAPP and CL-TAPP repair in adult female patients with inguinal hernia and to estimate the safety and applicability of SIL-TAPP repair in adult female inguinal hernia patients. We retrospectively compared the clinical information and follow-up data of female inguinal hernia patients who underwent SIL-TAPP inguinal hernia repair and those who underwent CL-TAPP inguinal hernia repair at the Affiliated Hospital of Nantong University from February 2018 to December 2020 and assessed the long-term and short-term outcomes of both cohorts. This study included 123 patients, with 71 undergoing SIL-TAPP repair and 52 undergoing CL-TAPP repair. The two cohorts of patients and inguinal hernia characteristics were similar, with no statistically meaningful difference. The rate of intraoperative inferior epigastric vessel injury was lower in patients in the SIL-TAPP cohort (0, 0%) than in patients in the CL-TAPP cohort (4, 7.7%) and was significantly different (P < 0.05). In addition, the median [interquartile range (IQR)] total hospitalization costs were significantly lower in patients in the SIL-TAPP cohort [$3287 (3218-3325)] than in patients in the CL-TAPP cohort [$3511 (3491-3599)]. Postoperatively, the occurrence rate of trocar site hernia was lower in the SIL-TAPP cohort (0, 0%) than in the CL-TAPP cohort (4, 7.7%), and the median (IQR) cosmetic score was significantly higher in the SIL-TAPP cohort [10 (10-10)] than in the CL-TAPP cohort [9 (9-10)]. SIL-TAPP repair did not increase the incidence of intraoperative and postoperative complications in female inguinal hernia patients. Moreover, female inguinal hernia patients who underwent SIL-TAPP repair had a lower probability of trocar site hernia and inferior epigastric vessel injury than female inguinal hernia patients who underwent CL-TAPP repair. In addition, female inguinal hernia patients who underwent SIL-TAPP repair reported a more aesthetically pleasing postoperative abdominal incision. Therefore, SIL-TAPP repair is a better option for the treatment of inguinal hernias in women.

Single-incision laparoscopic transabdominal preperitoneal hernioplasty: 1,054 procedures and experience

PurposeAlthough there have been numerous studies on single-incision laparoscopic inguinal hernia repair (SIL-IHR), the short- and long-term outcomes in patients from a large single institution who underwent single-incision laparoscopic transabdominal preperitoneal hernioplasty (SIL-TAPP) have rarely been reported. The purpose of this study is to evaluate the short- and long-term outcomes of SIL-TAPP and its safety and feasibility in patients from a large single institution.MethodsThe details of 1,054 procedures in 966 patients who underwent SIL-TAPP at the Affiliated Hospital of Nantong University from January 2015 to October 2022 were retrospectively analysed. SIL-TAPP was performed completely through the umbilicus using conventional laparoscopic instruments. Short-term and long-term outcomes of SIL-TAPP were collected by outpatient and telephone follow-ups. In addition, we further compared the operation time, length of postoperative hospital stay, and postoperative complications of patients with simple and complicated unilateral inguinal hernias.ResultsA total of 1,054 procedures were performed for 878 unilateral inguinal hernias and 88 bilateral inguinal hernias. In total, there were 803 (76.2%) indirect inguinal hernias, 192 (18.2%) direct inguinal hernias, 51 (4.8%) femoral hernias and 8 (0.8%) combined hernias. The mean operative time was 35.5 ± 17.0 min for unilateral inguinal hernias and 51.9 ± 25.5 min for bilateral inguinal hernias. There was one (0.1%) conversion to two-incision laparoscopic transabdominal preperitoneal hernioplasty. No intraoperative haemorrhages, inferior epigastric vessel injury or nerve damage occurred. Postoperative complications were minor and could be resolved without surgical intervention. The mean length of hospital stay was 1.3 ± 0.8 days. The median follow-up was 44 months, no trocar hernia occurred, and there was one (0.1%) recurrence. The operation time in the complicated inguinal hernia group was significantly higher than that in the simple inguinal hernia group (38.9 ± 22.3 vs. 35.0 ± 15.6, p = 0.025). The length of postoperative hospital stay and complication rate of the complicated inguinal hernia group were slightly higher than those of the simple inguinal hernia group, but the difference was not statistically significant.ConclusionSIL-TAPP is safe and technically feasible, and both short- and long-term outcomes are acceptable.

Adding Laparoscopic Iliopubic Tract Repair to Transabdominal Preperitoneal Hernioplasty for Treatment of Recurrent Inguinal Hernia After Totally Extraperitoneal Hernioplasty.

Background: In patients with recurrent inguinal hernia (IH) after totally extraperitoneal (TEP) hernioplasty, re-TEP hernioplasty is difficult because of fibrotic adhesions. Re-laparoscopic hernioplasty is possible by changing the approach from extraperitoneal to transabdominal. If iliopubic tract repair (IPTR), mainly used in the past for the open approach, is added as a laparoscopic procedure, re-laparoscopic hernioplasty is possible when treating recurrent IH. We aimed to evaluate the safety and feasibility of alternate transabdominal preperitoneal (TAPP) hernioplasty supplemented by IPTR for treating recurrent IH after TEP hernioplasty. Methods: We retrospectively evaluated 2600 patients with IHs who underwent TAPP hernioplasty from January 2015 to December 2020. Among patients with recurrent IH, those who underwent primary TEP were included in the study. For reoperation, TAPP hernioplasty was performed and IPTR was added. IPTR was performed by suture closure of the internal inguinal ring by the iliopubic tract and medial aponeurotic arch of the transversus abdominis muscle. Results: Of the 35 patients (33 males and 2 females) with recurrent IH after primary TEP hernioplasty, 51% (18/35) of patients had recurrence within 2 years of the first operation. There were 28 recurrent IHs of the same type as the original, and 7 cases of a different type. The mean TAPP operation time was 41 minutes. Chronic inguinodynia and re-recurrence was not observed. One patient had inferior epigastric vessel injury, which was successfully repaired. Conclusion: Adding laparoscopic IPTR to TAPP hernioplasty is safe feasible treatment for recurrent IH after TEP hernioplasty.

An audit of complications of complex operative gynaecological laparoscopy at a tertiary healthcare facility in South Africa

Background. Operative laparoscopic surgery has many advantages over traditional/open laparotomy. However, it is also associated with complications particularly when performed for complex gynaecological procedures. There are very few reports on operative laparoscopic surgery from developing countries. Objective. To evaluate the intra- and postoperative complications associated with laparoscopic surgery performed for complex gynaecological conditions by a single surgeon at a tertiary institution. Method. This was a retrospective chart review of patients who underwent complex laparoscopic surgery between 2004 and 2016. Results. We retrieved 446 patient records. Surgery for extensive endometriosis (29.8%) and laparoscopic-assisted vaginal hysterectomy (29.8%) were the most common procedures. Less than a tenth of patients (4.3%; n=19) had complications, 9 had minor injuries (4 inferior epigastric vessel injury, 1 peritoneal vessel injury, 1 omental vessel injury, 1 surface tissue bleeding and 2 cases of postoperative ileus) and 10 had major injuries (6 intestinal, 2 ureteric and 3 bladder). More than a quarter of complications (26.3%; n=5) occurred at the time of abdominal entry, 63.2% (n=12) occured intraoperatively and 10.5% (n=2) occurred postoperatively. All entry injuries were vascular. Intestinal injury was the most common intraoperative complication. Conclusion. Despite the many advantages of laparoscopic surgery, complications occur particularly in patients with complex gynaecological pathology.

Laparoscopic totally extraperitoneal hernioplasty: Theodor Bilharz Research Institute preliminary experience

Background The two standard methods for inguinal hernioplasty is open and minimal access laparoscopic technique. Most laparoscopic surgeons use a transabdominal preperitoneal approach but totally extraperitoneal (TEP) approach potentially offers several advantages. Objective The aim in this study was to assess the learning curve, cost value, safety, and feasibility of TEP approach. Patients and methods Prospectively collected data on 185 consecutive patients submitted to laparoscopic TEP hernioplasty for inguinal hernia from 2016 to 2018 in Theodor Bilharz Research Institute Hospital. This study involved repair of primary, recurrent inguinal hernia and femoral hernia. The prolene mesh was used for groin hernia repair in all cases with and without fixation. Results All 185 cases started with the laparoscopic TEP technique with only four cases converted to transabdominal preperitoneal technique (2.1%). In 110 (60.7%) cases the mesh was placed without fixation. In 71 cases the mesh was fixed by Tackers or Histoacryl. In unilateral hernia, the mean operating time was 45 min, while in bilateral hernia it was 61 min. Intraoperative complications included three cases of inferior epigastric vessel injury which were managed by metallic clips of 5 mm. The mean pain score was 7.5, while the mean satisfaction score was 5.4. The mean hospital stay was 16.4 h. Regarding postoperative complications, 10 (5.5%) patients developed a postoperative seroma, four (2.1%) patients developed a hematoma, two (1.1%) patients developed a hydrocele, and five (2.7%) patients experienced neuropathic pain. There were three (1.1%) recurrent cases; all these cases were managed by open hernioplasty. Conclusion In this study, the laparoscopic TEP approach is found to be an effective, and safe technique regarding primary, recurrent open inguinal and femoral hernias with good learning curve to laparoscopic surgeon who started with transabdominal preperitoneal technique technique.

A rare cause of acute abdomen – Spontaneous rectus sheath hematoma

Spontaneous rectus sheath hematoma (SRSH) is a rare entity that mimics acute abdomen. Rectus sheath hematoma is the accumulation of blood in rectus sheath due to muscle or epigastric vessel injury. However, SRSH without a trauma or anticoagulation is rare. It frequently mimics acute abdomen and it may lead to misdiagnosis and unnecessary laparotomy. In this article, we described two cases of SRSH with their diagnostic and therapeutic strategy. Both of our patients in report were neither consumed antiplatelet nor coagulopathy. They both had abdominal muscle straining before their symptoms presentation. We hypothesized that the SRSH may be induced by rectus muscle injury secondary to inappropriate straining or posture. To diagnose SRSH, clinical findings are important but radiologic imaging such as computed tomography, can be diagnostic. In expanding SRSH, percutaneous arterial embolization of epigastric artery is useful to secure the bleeding. If embolization is not feasible, surgical exploration hemostasis is curative. In non-expanding SRSH, it can be managed nonoperatively. SRSH is an important initial differential for acute abdomen. Radiologic imaging helps in diagnosis. Stable SRSH can be managed conservatively with good outcome.

Effectiveness of Postgraduate Training for Learning Extraperitoneal Access for Robot-Assisted Radical Prostatectomy

To determine the effectiveness of postgraduate training for learning extraperitoneal robot-assisted radical prostatectomy (EP-RARP) and to identify any unmet training needs. The training resources used were live surgery observations, digital video disc instruction, postgraduate courses, and literature review. Modifications to the transperitoneal (TP) setup in equipment, patient positioning, port placement, and access technique were identified. A surgeon who had previous experience with 898 TP robot-assisted radical prostatectomies (TP-RARPs) performed EP-RARP in 30 patients. We evaluated setup results, emphasizing access-related difficulties, and compared the EP cohort with a nonrandomized, concurrent TP cohort of 62 patients for short-term outcomes. The median setup time for EP was 26 minutes (range 15-65 min) for EP compared with 14 to 17 minutes for the comparable TP setup and dropping the bladder. During EP setup and dissection, peritoneal entry occurred in 37%, incorrect port spacing in 10%, epigastric vessel injury in 10%, and other minor pitfalls in 10%. No significant differences were found between EP and TP in postsetup operative times, hospital stay, complications, surgical margin status with organ-confined disease, or lymph node dissection yield. EP had significantly higher estimated blood loss (300 vs 200 mL, P=0.001) and more symptomatic lymphoceles when extended pelvic lymph node dissection was performed (3/16 vs 0/47, P=0.001). Using postgraduate education resources, an experienced TP-RARP surgeon successfully transitioned to EP-RARP, achieving the major objectives of safety and equivalent outcomes. We identified several minor nuances in the setup that need further refinement in future education models.

Injury of epigastric vessels at laparoscopy: diagnosis and management

The abdominal wall has an abundant vasculature which is particularly susceptible to injury at laparoscopic surgery [1]. The most commonly injured vessels in laparoscopic procedures are the epigastric arteries, both the superficial and deeper vessels [2, 3]. As early as 1823, injury to the epigastric vessels during surgery was recognised [4]. We present two different manifestations of inferior epigastric vessel injury at laparoscopic surgery and how they were managed.

Complications in laparoscopic radical cystectomy: The South American experience with 59 cases

In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality. From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally. Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20%) required blood transfusion. All 7 (12%) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30%) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5%) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7%) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3%) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism. Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.

Feasibility of hand-assisted laparoscopic surgery (HALS) in gynecologic oncology patients

5153 Objective: Although hand-assisted laparoscopic surgery (HALS) has been utilized in multiple surgical procedures, limited data exists on the use of HALS for gynecologic oncology indications. Our goal was to evaluate the indications, potential benefits, and complications of HALS in cases of suspected gynecologic malignancy. Methods: We performed a retrospective chart review of patients who had an HALS procedure performed from 1/03 until 10/04. Data was collected on patient demographics, indications for surgery, operative morbidity, and length of stay. Results: 37 patients who underwent a HALS procedure were identified. The median age was 51 years (range, 19–86) and the mean BMI was 28.7 m2 (range, 17.8–40.7). The indications for surgery included pelvic mass (n=29), prophylactic oophorectomy (n=2), secondary cytoreduction for ovarian cancer (n=2), uterine fibroids (n=2), surgical staging for endometrial cancer (n=1), post-menopausal bleeding (n=1), and vaginal vault prolapse (n=1). The mean estimated size of pelvic mass removed was 11.2 cm (range, 3–30). 6 of 29 (21%) patients with a pelvic mass were diagnosed with an ovarian carcinoma. All patients underwent general endotracheal anesthesia for the following procedures performed: oophorectomy (n=31), lysis of adhesions (n=14), surgical staging (n=9), hysterectomy (n=9), loop colostomy (n=1), and sacrocolpo suspension (n=1). Mean operating time was 90 minutes (range, 46–157) with mean estimated blood loss of 110 cc (range, 10–400). One patient was converted to laparotomy due to a large unresectable mass. One intraoperative complication of epigastric vessel injury due to trocar placement occurred. The average length of post-operative hospital stay was 2.8 days (range, 2–5). 4 of 37 (11%) patients experienced a post-operative complication including ileus (n=2), pre-renal azotemia (n=1), and transfusion of packed red blood cells (n=1). Conclusions: HALS is an innovative surgical technique that allows a number of surgical procedures to be accomplished in gynecologic oncology patients. HALS appears to be safe and feasible based on acceptable operating time, estimated blood loss, conversion rate, complication rate, and length of hospital stay. No significant financial relationships to disclose.

Optical Access Trocar Injuries in Urological Laparoscopic Surgery

Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution. From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed. The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair. Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar.

A Nationwide Analysis of Complications Associated With the Tension-Free Vaginal Tape (TVT) Procedure

This study presents a series of all patients in Finland who underwent the tension-free vaginal tape (TVT) procedure for urinary stress incontinence before the end of 1999. Data regarding numbers of operations and complication rates were collected via questionnaires sent to the 38 hospitals whose staff were trained to perform TVT. The process for teaching this operation was carefully planned. First, urogynecologists from four of the five university hospitals in Finland underwent an extensive training program held at the fifth hospital, where this procedure was developed. Each doctor was approved to perform the procedure only after the main instructor visited his or her facility and observed the local team at work through several TVT operations. The university hospital-based urogynecologist was authorized to train local gynecologists after successfully performing 20 TVT operations with no major problems in 6 months of follow-up. Eventually, a TVT-certified urogynecologist was on the staff at all central and local hospitals in Finland. In all, there were 1455 TVT operations performed in Finland by the end of 1999. The overall rate of complications was 255 per 1000 procedures, including 206 per 1000 in university hospitals, 253 per 1000 in central hospitals, and 283 per 1000 in local hospitals. In the 1455 cases, there were five major complications that required laparotomy (case of arterial bleeding, two undetected bladder perforations, one vesicovaginal fistula, and one case of severe urinary retention) and 362 minor complications that necessitated some form of intervention. Intraoperative blood loss greater than 200 ml was noted in 27 patients (incidence 19/1000). Five cases resolved with minimal vaginal packing. Manual compression, intravenous tranexamic acid, and/or blood transfusion were required in three women. One woman underwent laparotomy for arterial bleeding behind the symphysis with removal of the TVT tape. Bladder perforation occurred in 56 women (38/1000). In 39 cases, the injury was recognized by cystotomy. The TVT needle was removed and reinserted in 36 of these; in 2 others interruption of the operation was required. One perforation was so near the urethral orifice that the TVT tape had to be removed. Nine perforations were noted after the TVT needle had been pulled through the bladder, requiring removal of the tape in two cases and partial removal (behind a midline cut) with reattachment of new tape in seven cases. In six women, the injury to the bladder was not recognized at the time of surgery. The TVT tape had to be partially or wholly removed in all of these patients. Injury of the epigastric vessel injury, which was treated with simple ligation, occurred in one patient. One woman sustained an injury of the obturator nerve that caused her to limp and led to adhesion formation at the Achilles tendon. Surgical evacuation was required for treatment of vagina hematoma in one patient, and the TVT procedure was interrupted in another patient because of a urethral lesion. Postoperatively, 34 women experienced complete urinary retention, with only 1 persisting beyond 3 months (incidence 23/1000). Minor voiding difficulties were reported by 111 patients (incidence 76/1000), 108 of whom resolved spontaneously or with conservative treatment. Two patients were treated by cutting the TVT tape at the midline, and one resolved after 4 months of repeated catheterization.

Endoscopic management of uterine myoma.

This study was undertaken to evaluate the various gynecologic endoscopic surgical techniques including resectoscopic myomectomy, laparoscopic myomectomy, and laparoscopy assisted vaginal hysterectomy (LAVH) used in the treatment of uterine myomas. The medical records of 136 cases of uterine myomas treated using one or more of the gynecologic endoscopic surgical techniques in the Department of Obstetrics and Gynecology at Yonsei University were retrospectively reviewed from March 1997 to September 1998. Of the 136 cases reviewed, there were 40 submucosal myomas and 96 intramural and subserosal myomas. For statistical analysis, Student's t-test was used. Submucosal myomectomy using the resectosope was performed in 35 cases (mean age: 39 +/- 1.5 years), laparoscopic myomecotmy in 35 cases (mean age: 36 +/- 1.9 years), and LAVH in 66 cases (mean age: 42 +/- 1.1 years). In cases of huge myomas, the GnRH agonist was used prior to surgery, and in cases of heavy uterine bleeding, angioblock of the uterine artery was undertaken before the endoscopic procedures. The mean operating time was significantly shorter in resectoscopic myomectomy (41 +/- 12 min), followed by laparoscopic myomectomy (85.0 +/- 10.3 min) and LAVH (123 +/- 5.3 min). The mean hospital stay for resectoscopic myomectomy, laparoscopic myomectomy, and LAVH was 1.9 +/- 0.5, 2.5 +/- 0.5, and 3.4 +/- 0.8 days (p < 0.001), respectively. There were 3 cases of complications including pulmonary edema and uterine perforation in the resectoscopic myomectomy group, and 4 cases of complications including bladder, ureter, and epigastric vessel injury in the LAVH group. In conclusion, the therapeutic effect of various gynecologic endoscopic surgical techniques can be maximized in terms of shorter operation time, shorter hospital stay, faster recovery, and less blood loss by the appropriate management of uterine myoma in well-chosen patients.

Effect of laparoscopic pelvic lymph node dissection on the natural history of D1 (T1-3, N1-3, MO) prostate cancer

Reports of abdominal wall tumor implantation after laparoscopic procedures have raised questions regarding the safety of laparoscopic surgery when applied to patients with malignancies. Our objective was to determine if laparoscopic pelvic lymph node dissection (LPLND) had a negative effect on tumor behavior and clinical outcome in men with Stage T1-3, N1-3, M0 (D1) prostate cancer. Fifty-two men were retrospectively identified at four institutions who had pelvic nodes positive for metastatic prostate adenocarcinoma at LPLND and at least 1 year of follow-up. Operative and clinical records were reviewed to determine morbidity, adjuvant treatment, onset of hormone-resistant disease, and survival. During a mean follow-up of 3.1 years, there were no cases of trocar site tumor implantation. There were four perioperative complications, including enterotomy, epigastric vessel injury, abscess, and symptomatic lymphocele formation. There were three deaths from prostate cancer (5.8%) occurring 3 to 4 years after LPLND. For the 45 men treated with early androgen ablation, the 5-year biochemical prostate-specific antigen and clinical progression free rates were 45% and 55%, respectively. Abdominal wall tumor implantation after LPLND for prostate cancer was not demonstrated, even in patients who developed hormone-resistant disease. LPLND in men with Stage D1 disease did not alter short-term disease progression. Longer follow-up in a larger cohort is necessary to determine if LPLND will have an impact on the 5 and 10-year disease progression and survival rates for patients with Stage D1 prostate cancer.

A Review of Results in a Series of 113 Laparoscopic Colposuspensions

The case records of 113 women having laparoscopic retropubic colposuspensions (Burch procedure) performed for the treatment of genuine urinary stress incontinence between December, 1992 and April, 1995 were retrospectively reviewed. The mean age of the group was 49.4 (30-80) years, mean weight 72.1 (44.5-114) kg, and mean parity 2.7 (0-8). All patients had preoperative urodynamic study to confirm genuine stress incontinence (GSI). Sixteen patients (14%) had dual pathology (GSI and detrusor instability). A transperitoneal approach was used in 93 operations and extraperitoneal in 20. The mean operating time was 108 (30-320) minutes and mean hospitalization 3.3 (1-10) days. In 13 women the operation was converted to laparotomy; 10 due to adhesions and diminished bladder mobility, 1 for inferior epigastric vessel injury, 1 for an ovarian tumour discovered incidentally at the procedure and 1 for equipment problems. Operative complications included 10 cystotomies (5 repaired laparoscopically), 2 extraperitoneal cases converted to transperitoneal, 1 inferior epigastric vessel injury, 1 vaginal tear, 1 suture through the bladder and 1 case of possible enterotomy oversewn at laparoscopy. The mean follow-up period was 8.4 (1-28) months. All patients were reviewed postoperatively and then contact was attempted either by telephone or in consultation. There was an overall 87% subjective success rate. Two patients felt sutures tear out at 4 and 6 months and were deemed failures; 4 felt their incontinence was improved but had ongoing stress incontinence of urine; 9 had symptoms of detrusor instability and one developed an enterocele 9 months after surgery.

Management of Epigastric Vessel Injury During Laparoscopy

Injury to the epigastric vessels during trocar placement is a recognized complication of laparoscopic surgery. We present a technique for laparoscopic management of this problem utilizing a Stamey urethropexy needle under direct vision. The relevant anatomy and methods to prevent this complication are discussed.