Extraperitoneal Group Research Articles

Primary Ventral Hernia Repair and the Risk of Postoperative Small Bowel Obstruction: Intra Versus Extraperitoneal Mesh.

The aim of this study was to compare the likelihood of bowel obstruction according to the placement of the mesh (either intraperitoneal or extraperitoneal) in ventral hernia repairs. Patients were divided into two groups, an intraperitoneal (IP) group (mesh placed by laparoscopy or with an open approach) and an extraperitoneal (EP) group, all operated on in the Digestive Surgery Department at the Dijon University Hospital. The primary outcome was the occurrence of an episode of bowel obstruction requiring hospitalization and confirmed by abdominal CT scan. Between March 2008 and July 2021, 318 patients were included, with 99 patients in the EP group (71 meshes placed preperitoneally and 28 placed retromuscularly) and 219 patients in the IP group (175 patients operated on laparoscopically versus 44 patients by direct approach). Three patients presented an episode of acute intestinal obstruction, with no difference between the two groups (p = 0.245), although all bowel obstructions occurred in the IP group and with the laparoscopic approach (1.7% of patients operated on by laparoscopy). The occlusive events occurred at 1 month, 2 years, and 3 years. There was no difference in terms of recurrence or postoperative chronic pain. There were more seroma and mesh infections in the EP group (p < 0.05). Two patients operated on by laparoscopy had undetected bowel injuries, prompting emergent surgery for peritonitis. No statistically significant difference was found in terms of bowel obstruction between the intraperitoneal and the extraperitoneal position, but all cases of obstruction happened in the intraperitoneal mesh group. Visceral lesions remain a major complication of the laparoscopic approach that should not be neglected.

The same parastomal hernia repairs rate in the different approaches to colostomy.

This study aimed to compare the parastomal hernia repairs rate in the different approaches to colostomy and investigate the risk factors for parastomal hernia formation in patients with permanent colostomies. Consecutive rectal cancer patients who underwent abdominoperineal resection from June 2014 to July 2020 in West China Hospital were divided into two groups according to their surgical approach for permanent colostomies. The impact of different approaches to colostomy on parastomal hernia repairs was determined by comparing a group of patients receiving an extraperitoneal route to colostomy with a group receiving transperitoneal. Potential variables were evaluated first with univariate and then multivariate analyses to identify the risk factors for the formation of parastomal hernia. Two hundred two subjects in the transperitoneal group and 103 in the extraperitoneal group attended the follow-up visit with a median follow-up period of 33 (25th-75th percentiles, 17-46) months. Clinically and radiologically detectable parastomal hernias were present in 76 of 202 (37.6%) and 14 of 103 (13.6%) subjects in the transperitoneal and extraperitoneal groups during the follow-up period (p＜0.01). Besides, 10 of 76 (13.1%) subjects in the transperitoneal group and 2 of 14 (14.3%) subjects in the extraperitoneal group underwent a parastomal hernia operation during the follow-up (p = 0.82). In addition, the transperitoneal approach of colostomy (p = 0.002), older age (p＜0.001), and higher body mass index (p = 0.013) were identified as independent risk factors for the occurrence of parastomal hernia. Extraperitoneal colostomy decreased the detectable parastomal hernias but did not reduce the surgical repair rate of parastomal hernias.

PD54-08 SINGLE-PORT EXTRAPERITONEAL VS TRANSPERITONEAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: A MULTI-INSTITUTIONAL MATCHED-PAIR COMPARISON OF OUTCOMES

You have accessJournal of UrologyCME1 May 2022PD54-08 SINGLE-PORT EXTRAPERITONEAL VS TRANSPERITONEAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: A MULTI-INSTITUTIONAL MATCHED-PAIR COMPARISON OF OUTCOMES Mahmoud Abou Zeinab, Ethan Ferguson, Aaron Kaviani, Alp T. Beksac, Marcio Moschovas, Luca Morgantini, Sij Hemal, Susan Talamini, Jean Joseph, Moses Kim, Simone Crivellaro, Vipul Patel, Jeffrey Nix, and Jihad Kaouk Mahmoud Abou ZeinabMahmoud Abou Zeinab More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Aaron KavianiAaron Kaviani More articles by this author , Alp T. BeksacAlp T. Beksac More articles by this author , Marcio MoschovasMarcio Moschovas More articles by this author , Luca MorgantiniLuca Morgantini More articles by this author , Sij HemalSij Hemal More articles by this author , Susan TalaminiSusan Talamini More articles by this author , Jean JosephJean Joseph More articles by this author , Moses KimMoses Kim More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , Vipul PatelVipul Patel More articles by this author , Jeffrey NixJeffrey Nix More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002631.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The introduction of the ‘purpose-built’ Single-port (SP) robot successfully expanded the surgical approaches in the management of localized prostate cancer to include the extraperitoneal, in addition to the standard transperitoneal approach. We sought to perform a multi-institutional study to assess the perioperative, and functional outcomes between SP extraperitoneal (ERP) and SP transperitoneal (TRP) radical prostatectomy. METHODS: From February 2019 to October 2021, a prospective data collection from six different robotic centers was performed. Data of 412 patients who underwent ERP and 241 patients who underwent TRP were analyzed. All procedures were performed by surgeons with extensive robotic experience. A 1:1 matched-pair analysis for the National Comprehensive Cancer Network (NCCN) risk was performed. Baseline characteristics, intraoperative, postoperative and functional outcomes were evaluated. RESULTS: Before matching, there was a significantly higher percentage of NCCN high risk in the ERP group compared to the TRP group. After matching, patients in the ERP had a higher rate of previous abdominal surgery (p <.001). The median operative time was 203 vs 169 minutes, median estimated blood loss was 150 vs 87 cc for ERP and TRP, respectively (p <.001). TRP was more likely to include an additional surgical port (SP+1). 37.6% of the ERP group had more extraprostatic extension on pathology compared to 26.8% in the TRP, with no significant difference in the positive surgical margins (25.3% and 26.8%). The median lymph node yield was higher in the ERP group (6 vs 3 nodes, p=.017). ERP patients were more likely to be discharged the same day after the surgery (7 vs 14 hours, p <.001), and had their median Foley catheter stay for 7 days compared to 5 days In the TRP group (p <.007). There was no difference in the perioperative complications or continence rates after the surgery. Median follow-up was 6 months. CONCLUSIONS: Both SP ERP and TRP are comparable surgical options for the treatment of localized prostate cancer. ERP is more associated with same-day discharge and higher lymph node yield. TRP has a shorter operative time and less estimated blood loss. The two techniques have similar complications, positive surgical margin, and continence rates. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e918 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mahmoud Abou Zeinab More articles by this author Ethan Ferguson More articles by this author Aaron Kaviani More articles by this author Alp T. Beksac More articles by this author Marcio Moschovas More articles by this author Luca Morgantini More articles by this author Sij Hemal More articles by this author Susan Talamini More articles by this author Jean Joseph More articles by this author Moses Kim More articles by this author Simone Crivellaro More articles by this author Vipul Patel More articles by this author Jeffrey Nix More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF DownloadLoading ...

COMPARISON OF EXTRAPERITONEAL AND TRANSPERITONEAL RADICAL CYSTOPROSTATECTOMY IN TERMS OF FIRST 30 DAYS OUTCOMES

Objective: To compare the first 30-day outcomes of Trans-peritoneal and Extra-peritoneal Radical cysto-prostatectomy.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Armed Forces Institute of Urology, Rawalpindi, from Mar 2015 to Mar 2019.Methodology: A total of 100 patients who underwent Radical cystoprostatectomy were observed in two groups either by extra or trans-peritoneal approach. Patients diagnosed with carcinoma urinary bladder (both muscle and non-muscle invasive) vetted through multidisciplinary meeting, with or without neo-adjuvant chemotherapy were included. Patients undergoing salvage cystectomy or any previous open abdomino-pelvic surgery were excluded. The standard techniques were used for both approaches. Variables under study were recorded for first 30-day-followup period.&#x0D; Results: The mean age was 59.9 ± 7.231 years (range=34-80). In extra-peritoneal group the mean duration of surgery was 5.6 ± 1.16 hours comparing to 7.2 ± 1.34 hours in the trans-peritoneal group. Statistically significant trend was also noted in the favour of extra-peritoneal group for stay in Intensive care in post-operative period (3.00 ± 1.19 days/4.77 ± 1.20, p&lt;0.001) as well total stay in the hospital (6.06 ± 2.8 days/ 11.74 ± 4.17, p&lt;0.001). Overall comparison of total number of complications as per Clavien-Dindo system in both groups was insignificant (p=0.136), however a significant trend in favour of extraperitoneal group was noted with respect to major wound dehiscence as well rate of blood transfusion (p&lt;0.001).&#x0D; Conclusion: Extra-peritoneal approach showed a favourable trend in terms of operative time and early recovery after radical cysto-prostatectomy.

Curage lombo-aortique et cancers gynécologiques pelviens : cœlioscopie rétroperitonéale ou transpéritonéale ?

IntroductionPara-aortic lymphadenectomy plays a fundamental role in the surgical management of pelvic gynecological cancers. Two laparoscopic approaches exist: the transperitoneal (TP) and the extraperitoneal (EP). The aim of this study was to compare these 2 approaches in terms of surgical outcomes, specially the number of removed lymph nodes according to the surgical technique, and morbidity. Materials and methodA single-center retrospective study was carried out at the Lariboisiere University Hospital between January 2011 and March 2020 including all patients who underwent para-aortic lymphadenectomy for the management of a pelvic gynecological cancer (cervix, endometrium, ovary). Univariate and multivariate analysis (logistic regression) were performed to compare the TP and the EP groups. Results143 patients were included: 74 in the TP group and 69 in the RP group. The total duration of surgery was 220.8minutes in the TP group and 166.4minutes in the EP group (P<0.001 in multivariate analysis). No significant difference between groups were found in the average total number of lymph nodes removed but there was a statistically significant difference in the average latero-aortic number of lymph nodes removed: 8.5 lymph nodes in the TP group and 11.3 lymph nodes in the group RP (P<0.001 in multivariate analysis). There was no difference between groups in peri and postoperative morbidity. ConclusionEP para-aortic lymphadenectomy reduces duration of surgery and increases the average latero-aortic number of lymph nodes removed with same morbidity compared to TP para-aortic lymphadenectomy, this confirming its preferred indication in endometrial and in cervical cancers.

Ambulatory robot-assisted laparoscopic radical prostatectomy with extended recovery by total extraperitoneal approach.

To evaluate the feasibility of performing robot-assisted laparoscopic radical prostatectomy in an ambulatory with extended recovery setting by using a total extraperitoneal approach. Patients with low- to intermediate-risk, prostate cancer were prospectively recruited in the ambulatory robot-assisted laparoscopic radical prostatectomy with extended recovery by total extraperitoneal approach group (n=30), and a matched-pair inpatient surgery control group by total extraperitoneal approach (n=20). Objective discharge criteria were based on the postanesthesia discharge scoring system. All patients underwent preoperative counseling on preoperative preparation and postoperative care. There were no statistically significant differences between the ambulatory with extended recovery-total extraperitoneal approach and inpatient-total extraperitoneal approach groups in patient factors (age, body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index), disease factors (prostate-specific antigen, clinical Tstage, biopsy Gleason score, prostate volume) and peri-operative parameters (operative time, blood loss, Trendelenburg angle). All total extraperitoneal robot-assisted laparoscopic radical prostatectomy patients (ambulatory with extended recovery and inpatient surgery groups) met the postanesthesia discharge scoring system discharge criteria ≤23h from admission. The mean hospital stays for ambulatory with extended recovery-total extraperitoneal and inpatient-total extraperitoneal groups were 20.3 and 52.4h, respectively (P<0.001). A total of 29 of 30 patients (97%) in the ambulatory with extended recovery-total extraperitoneal group were discharged ≤23h of admission. This is the first prospective evaluation of robot-assisted laparoscopic radical prostatectomy by the total extraperitoneal approach, showing that the short-stay ambulatory with extended recovery approach is safe, feasible and with a high success rate. Total extraperitoneal surgical approach is a critical factor for the success of the ambulatory with extended recovery protocol.

A prospective randomized comparison of short-term outcome of laparoscopic, totally extra-peritoneal and trans-abdominal pre-peritoneal repairs for inguinal hernia

Background: Laparoscopic repair of inguinal hernia is steadily gaining popularity among general surgeons. Laparoscopically the preperitoneal space can be approached in two different ways, as a result of which two techniques of laparoscopic repair have emerged. We performed this study to compare the two techniques in a randomized setting in order to ascertain, if possible, which of these techniques is preferable when there is a choice. Methods: This randomized, comparative study was conducted at Shri Mahant Indiresh hospital, Dehradun over a period of three years. Patients with unilateral, uncomplicated, inguinal hernia were randomized into two groups for undergoing surgery using either of these techniques. Patients’ demography and both intraoperative and postoperative variables were compared between the two groups.Results: Mean duration of surgery and mean pain scores in early postoperative period were found to be higher for transabdominal preperitoneal (TAPP) group as compared to totally extraperitoneal (TEP) group. Intraoperative and postoperative complications as well as hospital stay were not significantly different between the two groups.Conclusions: In this study TEP has been found to have an edge over TAPP in some respect but as per the available evidence both techniques are safe and choice of procedure may be tailored according to individual cases.

Surgical complications comparing extraperitoneal vs transperitoneal laparoscopic aortic staging in early stage ovarian and endometrial cancer

ObjectiveTo determine whether the extraperitoneal approach for paraaortic staging lymphadenectomy results in a lower rate of surgical complications compared to the transperitoneal approach, without compromising oncological outcomes. MethodsProspective randomized multicenter study of patients with early endometrial or ovarian cancer undergoing paraaortic lymphadenectomy in 2010–2019. Patients were randomized to minimally invasive surgery (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy. ResultsThere were 103 patients in the extraperitoneal group and 100 in the transperitoneal group. Differences in the composite outcome (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195) were not found. Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7–17] vs, 14 [10–19]: P = 0.026). Older age and greater body mass index (BMI) or waist-to-hip ratio (WHR) increased the risk for surgical complications independently of the laparoscopic approach. ConclusionsThe extraperitoneal approach did not show differences regarding surgical and oncological parameters compared with the transperitoneal approach, although the number of aortic nodes retrieved was higher. The decision to use one or another laparoscopic route is a matter of the surgeon preference.Trial registration ClinicalTrials.gov.identifier: NCT02676726

Técnica extraperitoneal comparada con IPOM plus: Análisis de costos evitados para optimizar el manejo de la hernia ventral por laparoscopia

Introducción. Analizamos los costos en el reparo extraperitoneal de la hernia ventral por laparoscopia, desde la perspectiva del sistema general de salud de Colombia, con el fin de mostrar los beneficios de dicho abordaje y su impacto económico, al compararlo con la técnica más implementada, el IPOM plus. Métodos. Se realizó un análisis económico de costo-beneficio, desde la perspectiva del Sistema General de Seguridad Social en Salud (SGSSS) de Colombia, comparando los costos del reparo de hernia ventral con la técnica extraperitoneal, TAPP o TEP, versus el IPOM plus. Se tomaron como costos de referencia lo establecido en el manual tarifario de Instituto de Seguros Sociales. Los datos fueron analizados con Stata V.15 Resultados. Se recolectó y analizo información de 109 procedimientos; 59 del grupo extraperitoneal TAPP/TEP y 50 del grupo IPOM plus, realizados durante los años 2015 a 2018, por el grupo de pared abdominal de Clínica Colsanitas, identificando un ahorro del 69,8 % o resultados de costo-beneficio a favor del grupo extraperitoneal. Discusión. El abordaje extraperitoneal en el reparo de hernia ventral se consideró una estrategia de alto costo-beneficio para el sistema de salud, validado por la experiencia del grupo de pared abdominal de Clínica Colsanitas, al compararla con el abordaje habitual. Teniendo en cuenta que los insumos utilizados para la disección no cambian, la prótesis utilizada para cada una de las técnicas representa un costo importante a considerar, tanto para el sistema como para las instituciones de salud

Laparoscopic inguinal hernia repair after prostatectomy: Evaluating safety, efficacy, and efficiency

BackgroundFor many surgeons, a prior prostatectomy is considered a contraindication to laparoscopic totally extraperitoneal hernia repair. This study aims to evaluate the safety, efficacy, and efficiency of totally extraperitoneal in these patients. MethodsThis is a review of a prospectively collected hernia database evaluating patients who underwent totally extraperitoneal repair between October 2009 and March 2018. Patients with prior prostatectomy were matched to controls without prior prostatectomy. Secondary analysis compared the case group to patients who underwent open hernia repair. ResultsIn the study, 1,751 patients underwent laparoscopic totally extraperitoneal repair. Thirty patients with a prior prostatectomy were matched to 90 controls. Operative duration was greater in the prostatectomy group (56 vs 36 minutes, P < .0001) and more peritoneal tears occurred (40% vs 12%, P = .002). Duration of stay, return to activity, complications, and rates of recurrence and chronic pain were equivalent. When compared with prior prostatectomy patients who underwent open hernia repair, the laparoscopic totally extraperitoneal group had equivalent rates of complications and outcomes with a faster return to activities of daily living (3 vs 7 days P = .007). ConclusionDespite a more difficult dissection, laparoscopic totally extraperitoneal repair in patients with prior prostatectomy is safe, efficacious, and efficient. In addition, totally extraperitoneal offers similar outcomes to open repair with a quicker recovery in this patient population.

Fetus delivery time in extraperitoneal versus transperitoneal cesarean section: a randomized trial

Objective: We compared the extraperitoneal cesarean section to transperitoneal cesarean on fetal delivery time.Material and methods: This randomized study included 210 pregnant women undergoing cesarean section for elective reasons, repeat cesarean (< four), or dystocia. Patients who required an urgent cesarean section, who were at high risk for obstetric or maternal bleeding, who had a uterine or adnexal mass, or who requested tubal ligation were excluded from the study. The primary outcome of the study was the skin incision-to-delivery time. The sample size was set to detect of 1-minute difference in fetal delivery time between groups (two-tailed hypothesis, α = 0.05, β = 0.10). Secondary outcome measures were total operation time, intraoperative nausea, gag reflex, vomiting, pain and anxiety for those receiving regional anesthesia, postoperative pain, change in hemoglobin, postoperative analgesic requirements, nausea, vomiting and shoulder pain, urogenital distress, time until gas passage, and neonatal outcome.Results: No significant difference occurred between the two groups for skin incision-to- delivery time (extraperitoneal cesarean 3.9 minutes [2.1–7.3] versus transperitoneal cesarean 4.2 minutes [1.9–8.2], p = .065). Significant differences regarding intraoperative pain, total operation time, postoperative pain at the surgical site and shoulder pain, analgesic requirements, time until gas passage, and oral tolerability favored the extraperitoneal group. No significant differences between groups occurred regarding other seconder outcome parameters.Conclusions: There is no clinically significant difference between extraperitoneal cesarean section and transperitoneal cesarean on fetal delivery time. Extraperitoneal cesarean reduces postoperative pain, analgesic requirements, and improves oral tolerability.

Relationship between stoma creation route for end colostomy and parastomal hernia development after laparoscopic surgery.

The therapeutic benefits of extraperitoneal colostomy with laparoscopic surgery remain unclear. The aim of this study was to investigate the relationship between the route for stoma creation with laparoscopic surgery and stoma-related complications, especially parastomal hernia (PSH). From January 2007 to March 2015, a total of 59 patients who underwent laparoscopic abdominoperineal resection or Hartmann procedure were investigated. Patient demographic and treatment characteristics, including stoma-related complications, were analyzed retrospectively. Transperitoneal and extraperitoneal colostomy were performed in 29 and 30 patients, respectively. Median follow-up duration was 21months (range: 2-95). Patient demographic and treatment characteristics were comparable between the transperitoneal group (TPG) and the extraperitoneal group (EPG). PSH developed in 12 (41%) patients in TPG, and 4 (13%) patients in EPG (p=0.020). The incidence of other stoma-related complications and non-stoma-related complications did not differ significantly between TPG and EPG. No patient characteristics except for transperitoneal route for stoma creation were associated with PSH development. The extraperitoneal route for stoma creation is associated with a significantly lower incidence of PSH development after laparoscopic surgery. Whenever possible, extraperitoneal colostomy should be recommended, even with laparoscopic surgery.

Less Invasive Endometrial Cancer Surgery with Extraperitoneal Pelvic and Para-aortic Lymphadenectomy via a Small Midline Abdominal Incision and the Retroperitoneal Approach.

[Objective] To achieve less invasive lymphadenectomy in endometrial cancer patients, we performed extraperitoneal pelvic and para-aortic lymphadenectomy via a small midline abdominal incision with retroperitoneal approach. The feasibility and safety of this method were investigated.[Methods] Inclusion criteria were 1) endometrioid adenocarcinoma diagnosed by preoperative biopsy, 2) myometrial invasion by magnetic resonance imaging, and 3) no peritoneal dissemination or distant metastasis by computed tomography. Systematic extraperitoneal dissection of pelvic and para-aortic lymph nodes was performed via an approximately 12-cm midline lower abdominal incision, after which hysterectomy and bilateral salpingo-oophorectomy were done (extraperitoneal group). The historical control group was patients who underwent standard transperitoneal lymphadenectomy followed by hysterectomy and bilateral salpingo-oophorectomy. The two groups were compared for demographic characteristics, perioperative factors, and complications.[Results] A total of 62 patients were enrolled. Demographic and clinicopathological factors showed no differences between the extraperitoneal group (n = 34) and the historical control group (n = 28). The median number of pelvic (30 vs. 28) and para-aortic (14 vs. 17) nodes dissected was also similar. However, median intraoperative blood loss was significantly smaller in the extraperitoneal group than the control group (220 vs. 573 g). Median operating time (265 vs. 323.5 min), median laparotomy time (60 vs. 295 min), and median initial flatus time (8 vs. 32 hours) were all significantly shorter in the extraperitoneal group, while complications and severe postoperative pain were significantly less frequent.[Conclusions] Our new technique was feasible, safe, and less invasive than standard laparotomy. It is an alternative to laparoscope-assisted or robotic procedures.

Comparison Between Transperitoneal and Extraperitoneal Laparoscopic Paraaortic Lymphadenectomy in Gynecologic Malignancies

Study ObjectiveTwo validated laparoscopic approaches for para-aortic lymphadenectomy (PAL) exist: the transperitoneal and the extraperitoneal. The aim of this study was to compare the surgical outcomes of both approaches. DesignA retrospective review of all patients who underwent laparoscopic PAL for a gynecologic malignancy between January 2008 and October 2013. SettingUniversity Hospital. PatientsTwo patients groups were compared: transperitoneal (n = 51) and extraperitoneal (n = 21). InterventionsParaaortic lymphadenectomy. Measurements and Main ResultsThe χ2 test, Fisher's exact test, or Student's t-test were used for univariate analysis and a stepwise logistic regression for multivariate analysis. The threshold of statistical significance was set at 0.05. All patient characteristics were similar between the 2 groups (p > .05 for all variables). There was only 1 (1.3%) conversion to laparotomy encountered in the transperitoneal PAL group and 3 conversions from extraperitoneal to transperitoneal PAL (14.2%). In 1 case of extraperitoneal PAL, the procedure was abandoned because of inadequate equipment (body mass index 48 kg/m2). The mean duration of surgery was longer in the transperitoneal group: 200 min (35–360) versus 125.6 min (45–180) in the extraperitoneal group (p = .001). The mean number of harvested lymph nodes was higher in the transperitoneal group: 17 (4–37) versus 13 (3–25) in the extraperitoneal group (p = .029). There was no difference in postoperative course and complications between both groups in multivariate analysis. ConclusionsIn nonobese patients, the extraperitoneal PAL is associated with shorter surgical duration, whereas the transperitoneal approach was associated with a higher number of harvested lymph nodes. As a result of improved ergonomy, the transperitoneal approach enables laparoscopic management of operative complications.

A study of laparoscopic extraperitoneal sigmoid colostomy after abdomino-perineal resection for rectal cancer.

Objective: To established a procedure for laparoscopic extraperitoneal ostomy after abdomino-perineal resection (APR) and study safety aspects and complications.Method: From July 2011 to July 2012, 36 patients with low rectal cancer undergoing APR were included in the study and divided into extraperitoneal ostomy group (n = 18) and intraperitoneal ostomy group (n = 18). Short- and long-term complications were compared between the two groups. All patients were followed up and the median duration was 17 months (range: 12–24).Results: The rates of short-term complication related to colostomies were comparable between the two groups, except the rate for stoma edema was higher in the extraperitoneal group (33.3% vs 0%; P = 0.008). In the intraperitoneal ostomy group, two patients developed stoma prolapse, one had stoma stenosis, and two had parastomal hernia. In contrast, no long-term complications related to colostomies occurred in the extraperitoneal ostomy group. The rate of long-term complication was lower in the extraperitoneal ostomy group (0% vs 22.2%; P = 0.036).Conclusion: The laparoscopic extraperitoneal ostomy is a relatively simple and safe procedure, with fewer long-term complications related to colostomy. However the follow-up period was not too long and needs to be extended.

A comparison of extraperitoneal versus transperitoneal laparoscopic or robotic para-aortic lymphadenectomy for staging of endometrial carcinoma

ObjectiveThe optimal surgical approach for complete lymphadenectomy in patients with endometrial cancer is controversial. The objective of our study was to compare the surgical outcomes of extraperitoneal laparoscopic, transperitoneal laparoscopic, and robotic transperitoneal para-aortic lymphadenectomy in endometrial cancer staging. MethodsA retrospective review was performed on patients who underwent extraperitoneal or transperitoneal para-aortic lymphadenectomy for endometrial cancer staging from January 2007 to November 2012. Three patient groups were compared: extraperitoneal laparoscopic para-aortic lymphadenectomy, robotic hysterectomy and pelvic lymphadenectomy (“extraperitoneal group”; N=34); laparoscopic hysterectomy and transperitoneal pelvic and para-aortic lymphadenectomy (“transperitoneal laparoscopic group”; N=108); and robotic hysterectomy and transperitoneal pelvic and para-aortic lymphadenectomy (“transperitoneal robotic group”; N=52). Fisher's exact test and Kruskal–Wallis test were used for statistical analysis, and statistical significance was defined as P<0.05. ResultsThe median number of para-aortic lymph nodes obtained was higher in the extraperitoneal group than in the transperitoneal laparoscopic and robotic groups (10, 5, and 4.5 nodes, respectively; P<0.001). BMI was higher in the extraperitoneal group (median, 35.1kg/m2) than in the transperitoneal groups but did not differ between the transperitoneal laparoscopic group (median, 28.4kg/m2) and the transperitoneal robotic group (median, 30.2kg/m2). Among patients with a BMI <35kg/m2, the median number of para-aortic nodes harvested was higher in the extraperitoneal group than in the transperitoneal laparoscopic and robotic groups (9, 4, and 5 nodes, respectively; P<0.01). The same pattern was observed among patients with a BMI ≥35kg/m2 (10, 6, and 3 nodes, respectively), but only the extraperitoneal group and the transperitoneal robotic group were significantly different (P=0.001). There was no significant difference in median estimated blood loss between the extraperitoneal group and either the transperitoneal laparoscopic group (100 vs. 112.5mL; P=0.06) or the transperitoneal robotic group (100 vs. 67.5mL; P=0.23). The median operative time was longer in the extraperitoneal group (339.5min; range, 242–453min) than in the transperitoneal laparoscopic group (286min; range, 101–480min) and the transperitoneal robotic group (297.5min, range 182–633min) (P<0.01). ConclusionExtraperitoneal laparoscopic para-aortic lymphadenectomy resulted in a higher number of para-aortic lymph nodes removed than transperitoneal laparoscopic or robotic lymphadenectomy. The extraperitoneal approach should be considered for endometrial cancer staging.

Drainage Placement Through the Extraperitoneal Tunnel Can Prevent Its Postoperative Dislodgement Effectively in Laparoscopic Rectal Surgery

Drainage placement is frequently used in laparoscopic rectal surgery, and dislodgement is common in conventional transperitoneal drainage placement. We proposed that extraperitoneal tunnel for drainage placement is useful to prevent the dislodgement. We conducted an observational case-matched control study. In study group, a total of 40 patients undergoing laparoscopic rectal surgery with drainage through the extraperitoneal tunnel were enrolled. In control group, a total of 35 matched patients with drainage through the transperitoneal route were enrolled. Clinical data, tumor features, and intraoperative and postoperative characteristics were analyzed. Ten patients had drainage dislodgement in the transperitoneal group (28%) and 4 patients in the extraperitoneal group (10%). The P value was 0.039. Postoperative recovery was faster in the extraperitoneal group than in the transperitoneal group, as reflected by a shorter time to diet (P=0.049) and postoperative length of stay (P=0.032). In a multivariate analysis, drain dislodgement had a significant impact on the time to diet (P=0.023) and the postoperative length of stay (P=0.037). Drain placement influenced the time to diet (P=0.055) and the postoperative length of stay (P=0.079). In laparoscopic rectal surgery, drainage placement through the extraperitoneal tunnel can prevent its postoperative dislodgement effectively and is associated with better postoperative recovery.

Surgical Outcome of Extraperitoneal Paraaortic Lymph Node Dissections Compared With Transperitoneal Approach in Gynecologic Cancer Patients

Study ObjectiveTo evaluate the surgical outcome of extraperitoneal paraaortic lymph node dissection compared with the traditional transperitoneal approach. DesignRetrospective review (Canadian Task Force classification III). SettingUniversity hospital. PatientsWomen with gynecologic malignancies admitted to our hospital between 2007 and 2011 who underwent laparoscopic paraaortic lymphadenectomy. InterventionsIndication, diagnosis, and outcome according to type of surgery were evaluated. Measurements and Main ResultsOf 47 patients who underwent laparoscopic paraaortic lymphadenectomy because of gynecologic indications, 28 patients underwent extraperitoneal paraaortic lymph node dissection and 19 underwent the same procedure via the classic transperitoneal technique. The most frequent indication for extraperitoneal lymph node dissection was cervical cancer (71.4%), and for the transperitoneal technique was endometrial cancer (47.4%). The mean (SD) duration of surgery was 211 (38) minutes in the transperitoneal approach group, and 173 (51) minutes in the extraperitoneal lymphadenectomy group (p = .009). No significant differences between groups were found in the number of lymph nodes removed (15 [5.9] nodes in the extraperitoneal group vs 17.4 [8.6] in the transperitoneal group; p = .25). However, a higher rate of positive nodes was observed in the extraperitoneal group than in the transperitoneal group (42.8% vs 36.2%, respectively [p = .001]), and a significantly shorter stay in the intensive care unit in the extraperitoneal group (0.59 [0.5] vs 1.1 [0.5] days, respectively; p = .02). No significant differences in complication rate were found between groups. ConclusionsExtraperitoneal paraaortic lymph node dissection is a minimally invasive procedure that is an excellent and safe approach to the paraaortic area, with a low complication rate, sufficient number of lymph nodes, and short hospital stay. It seems to be a good alternative to the classic transperitoneal approach.

Midline Extraperitoneal Approach for Retroperitoneal Lymph Node Dissection for Testicular Germ Cell Tumor

Retroperitoneal lymph node dissection (RPLND) for the treatment of testicular germ cell tumor is technically difficult and associated with significant morbidity. We postulated that a novel midline extraperitoneal (EP) approach might minimize the morbidity. We describe a midline extraperitoneal approach in detail. The operative time, estimated blood loss, lymph node yield, return of bowel function, length of stay, and postoperative complications were retrospectively reviewed. From April 2010 to May 2011, 12 consecutive patients underwent EP-RPLND at 2 tertiary centers by a single surgeon, including 5 primary and 7 postchemotherapy RPLNDs. The clinical characteristics and outcomes were compared with those from a matched cohort of transperitoneal-RPLND patients. The median follow-up was 173 and 201 days in the EP and transperitoneal groups, respectively. The EP group had a shorter mean operative time of 292 versus 337 minutes (P = .02) and lower estimated blood loss of 305 versus 575 mL (P = .05). More lymph nodes were retrieved in the EP group (44 vs 27 nodes, P = .0006). Finally, an earlier return of bowel function (1.7 vs 2.9 days, P = .0001) and a shorter median length of stay (3.3 vs 5.3 days, P = .0001) was seen in the EP group. EP-RPLND can be performed safely without prolonged operative times or compromised lymph node retrieval, even in the postchemotherapy setting, and is associated with a faster return of bowel function and shortened length of stay.

The clinical analysis of 128 cases of extraperitoneal cesarean section

Objective To explore the advantages of extraperitoneal cesarean section.Methods 128 cases of extrperitoneal cesarean section (extraperitoneal group)and 128 cases of conventioneal intraperitoneal cesarean section (intraperitoneal group)were compared.Results The preoperative blood,the time from a skin incision to the baby delivered,the total operative time and neonatal Apgar scores of two groups were compared,there was no significant difference(P＞0.05).While the exhaust time after the operation,ambulation time,postoperative antibiotic time,postoperative hospital,illness and complications after operation had significant difference(P＜0.05).Conclusions There is no abdominal operations,no bowel adhesion and bowel abstruction,little complications,faster recovery of gastrointestinal function,and the operation method is simple to master,such as recovery of gastrointestinal function.It's suitable for clinical application. Key words: Extraperitoneal cesarean section; Intraperitoneal cesarean section; Bowel adhesion