Hand Port Research Articles

A Novel Technique for Hand-Assisted Laparoscopy in Difficult Nephrectomies-Is One Hand Better Than Two? A Single-Centre, Single-Surgeon Series.

Laparoscopic radical nephrectomy is the standard of care for T1 renal tumors and nowadays being used for T2 or higher tumors, resulting in higher the conversion rates. To bridge this gap, the hand-assisted laparoscopy (HAL) method was introduced. Even now, in the robotic era, this HAL approach continues to find importance in urology, especially in the most challenging cases, albeit, with a relatively low usage rate due to the cost involved and availability of hand port devices. Here, we report a case series using a novel modification of the HAL nephrectomy (HALN) technique when open conversion is needed. From a prospective database, we retrospectively analyzed the data of Six patients who underwent HALN at the All India Institute of Medical Sciences between January 2019 and December 2022. Indications for surgery included both malignant and benign renal disease. Four surgeries were performed on the right side while two were performed on the left. Five patients underwent a HALN for renal cell carcinoma (RCC) and 1 for a benign non-functioning kidney. In our series, all the cases with RCC had were T2a or higher. Our case series shows that HALN is technically safe, effective, and a great adjunct to conventional laparoscopy. The ingenious use of a surgical glove as a hand port is an easy-to-make-and- use device in such challenging surgeries.

Port Site Recurrence After Laparoscopic Nephrectomy for Renal Cell Carcinoma --Report of Two Cases and Literature review-

A male in his 60s underwent a right transperitoneal laparoscopic partial nephrectomy procedure for a right renal tumor. Rupture of a renal cyst located close to the tumor occurred intraoperatively. The histopathological diagnosis was clear cell renal cell carcinoma (CCRCC), pT1aN0M0, G2, v0, with negative resection margins. At 84 months after surgery, computed tomography (CT) revealed a 10 mm mass in the rectus abdominis muscle at the camera port site used for the partial nephrectomy. An open lumpectomy was then performed and the histopathological diagnosis was CCRCC. One year later, a 40 mm sized mass was detected in the mesentery of the small intestine by CT, which was removed laparoscopically with part of the mesentery and diagnosed as CCRCC. Since that surgery, the patient has been free from recurrence for 8 years. A male in his 60s underwent a left retroperitoneal laparoscopic nephrectomy procedure for a left renal tumor. The histopathological diagnosis was CCRCC, pT1aN0M0, G1, v0, with negative resection margins. At 31 months after surgery, CT revealed a 32 mm mass in the retroperitoneal cavity at the right hand port site used for the laparoscopic nephrectomy. The mass was removed with part of the twelfth rib and erector spinae muscles in a lump, and the histopathological diagnosis was CCRCC. Since that surgery, the patient has been free from recurrence for 19 months. For the treatment of solitary port site recurrence of renal cell carcinoma after a laparoscopic radical/partial nephrectomy, we recommend surgical resection for a good prognosis.

Laparoscopic Living Donor Nephrectomy: A Single Center Comparison of Three Different Techniques.

In this study, we compare three different surgical approaches at a single institution. Pure laparoscopic donor nephrectomy with Pfannenstiel incision (PLDN) was compared with hand-assisted laparoscopic donor nephrectomy via midline hand port (HALDNM) and hand-assisted laparoscopic donor nephrectomy via left iliac hand port (HALDNL). This study included all laparoscopic left donor nephrectomies performed at our institution between January 1, 2020 and December 31, 2021. Donor characteristics including age, sex, body mass index, number of renal arteries, duration of surgical procedure, warm ischemia time (WIT), and length of hospital stay were compared. Cosmetic scores were calculated by totaling the length of all incisions placed. Postoperative complications within 90 days were compared. During the study period 71 laparoscopic donor nephrectomies were performed of which 26 were HALDNM, 24 were HALDNL, and 21 were PLDN. Donor characteristics were similar in all three groups. Total operative time was significantly lower in HALDNM (181 minutes) than PLDN (233 minutes) and HALDNL (242 minutes) (p < 0.001). The WIT was comparable in all three groups: HALDNL (7.2 minutes), PLDN (4.1 minutes), and HALDM (4.9 minutes) (p = 0.913). Median cosmetic score was significantly better in the PLDN group (8.2 cm) when compared to HALDNM (11.1 cm) and HALDNL (9.9 cm) (p < 0.001). Our results show that all three technical modifications of laparoscopic donor nephrectomy are safe and feasible with good postoperative outcomes. HALDNM has the added benefit of decreased operative time while PLDN has a cosmetic advantage.

Incisional Hernia Development after Live Donor Nephrectomy: Impact of Surgical Technique.

Characteristics of incisional hernia (IH) formation after live donor nephrectomy (LDN) are not well-defined. The goal of this study was to describe the incidence of IH within 3 years after LDN and identify risk factors contributing to their formation. We performed a single-center, retrospective review of all LDN between February 2013 and October 2018. Patients with and without IH were compared based on donor and operative variables. Data were analyzed using chi-square tests with column proportions. Multivariable logistic regression with backward elimination was used to evaluate the likelihood of IH on the basis of potential risk factors. Three hundred one individuals underwent live donor nephrectomy. Twenty-eight patients (9.3%) developed an IH, with a median time to development of 7 months (range: 2-24 months). Obesity (body mass index ≥30), periumbilical hand port, and vertical infraumbilical hand port were associated with increased risk of IH development on univariate analysis. On multivariate analysis, obesity and periumbilical hand port location were persistent risk factors for IH. The incidence of IH after LDN is prevalent and associated with obesity and operative technique. Placing the hand port infraumbilical with a transverse fascial incision may reduce the risk of IH after LDN.

The Role of Preoperative Platelet-to-Lymphocyte Ratio as a Predictor for Incisional Hernias after Hand-Assisted Laparoscopic Liver Surgery for Metastatic Colorectal Cancer.

(1) Background: Hand-assisted laparoscopic surgery for liver resection is a globally established technique. In this study, we report on the incidence and risk factors for postoperative incisional hernia (IH) after hand-assisted laparoscopic surgery for colorectal liver metastasis. (2) Methods: This was retrospective analysis of 89 consecutive hand-assisted laparoscopic surgery for colorectal liver metastasis. (3) Results: Participants were 39 females and 50 males. Median age was 65 years, and in 63%, the BMI was ≥25. Postoperative complications were encountered in 18% of the patients. Seven patients (7.8%) had postoperative incisional hernia in the hand port site. There was significantly higher incidence of incisional hernia in overweight patients (BMI ≥ 25) (p = 0.04), and in cases with simultaneous liver and colon resection (p = 0.02). In univariant and multivariant analyses, simultaneous liver and colon resection (p = 0.004 and 0.03, respectively), and platelet-to-lymphocyte ratio ≤ 200 (p = 0.03, 0.04, respectively) were both independent risk factors for developing postoperative incisional hernia. (4) Conclusions: Both simultaneous liver and colon resection, and platelet-to-lymphocyte ratio ≤ 200 are independent risk factors for postoperative incisional hernia after hand-assisted laparoscopic surgery for colorectal liver metastasis.

Laparoscopic major (&gt; 2 segments) hepatectomy in Greece

Despite gaining traction around the world, laparoscopic approach to major hepatectomy, defined as resection of at least two neighboring hepatic segments, has not been fully adopted in Greece. We sought to describe our growing experience. Data on six patients who underwent major hepatic resection in the last year in two major urban hospitals. The predominant indication for hepatectomy in these patients were metastatic disease to the liver. Three patients had colorectal metastases, one patient had metastatic melanoma, and two patients had benign pathology. There were two males and four females, with an average age of 59 (range: 52-71 years). Four patients had a solitary lesion and two had two lesions. Four patients had received pre-hepatectomy disease-specific chemotherapy or immunotherapy. The median size of the lesion was 5 cm (range: 3.5-12 cm). Two patients underwent a right hepatic lobectomy, one a left hepatic lobectomy together with a right colectomy, and three patients underwent right anterior sectorectomy. All operations were done purely laparoscopic except one, where a hand port was employed due to the size of the lesion. Median operative time was 190 minutes and median stay at the hospital was 2 nights. No patient required intensive care unit monitoring. There was no 30-day mortality. Major laparoscopic hepatic resection can be accomplished safely in well selected patients in the current Greek health system. Patients who have a laparoscopic hepatectomy benefit from a short hospital stay, without jeopardizing the safety of the operation.

Laparoscopic vs. open pancreaticoduodenectomy: a single centre's initial experience with introduction of a novel surgical approach

Presenter: Evelyn Waugh MD | London Health Sciences Centre Background: The open method has been the standard approach to pancreaticoduodenectomy (PD and is associated with significant morbidity. Laparoscopic PD is posited to reduce postoperative length of stay (LOS) and perioperative complications while maintaining comparable oncological outcomes to open PD. While literature demonstrates a trend toward a benefit of laparoscopic PD, this technique remains in its early years and more evidence must be accumulated as the approach becomes more refined. As one of the few centres in Canada routinely performing laparoscopic PD, London Health Sciences Centre (LHSC) is in a unique position to describe the utilization of this novel technique within the Canadian healthcare system. Methods: Data were collected prospectively from patients undergoing laparoscopic PD between 2018 – 2020 for any elective indication. This timeframe encompasses introduction and early utilization of the technique. Data were reported using descriptive statistics. Primary outcomes include POPF rate, LOS, in-hospital complications, 30d morbidity and mortality, 30d readmission and 30d re-operation. Secondary outcomes include R0 resection and time to recurrence. This examines the chronological trend associated with uptake and early utilization of laparoscopic PD including rates of conversion to open and reasons for conversion. These outcomes were compared to NSQIP institutional and collaborative data for all PD cases. Results: 127 patients underwent PD between January 2018 and November 2020. 17 were completed either laparoscopically or laparoscopic-assisted. 41% (n = 7) of laparoscopic cases were converted to open. Two were planned conversions, one had portal venous involvement requiring vascular reconstruction, one required hand port insertion for specimen palpation, one patient had significant adhesions, one had significant tumour bulk impairing adequate visualization and one patient was difficult to ventilate with pneumoperitoneum. All patients undergoing laparoscopic PD had resectable tumours. Mean operative time was 6 hours 28 minutes. 53% (n=9) experienced Clavien-Dindo Grade III or higher post-operative complication. Median length of stay was 10 days. POPF occurred in 17.6% (n = 3) and were all IPGFS-B. 35% (n = 6) required 30d readmission. 17.6% (n = 3) required re-operation due to gastric outlet obstruction, failure of the hepaticojejunostomy causing GDA bleeding secondary to bile erosion and concomitant missed enterotomy, and erroneous cutting and intra-abdominal retraction of an external pancreatic causing abscess formation. There was one 30-day mortality due to out of hospital cardiac arrest with no evidence of intra-abdominal complication on autopsy. R0 resection margins were achieved in all specimens. No patients had early recurrence. Median follow-up was 92 days (range = 15 – 584). Conclusion: This study demonstrates the early experience of our institution with laparoscopic PD. While some cases required conversion to open due to patient factors, conversions that were either planned or due to difficult dissection occurred earlier in adoption of this technique indicating the presence of a technical learning curve. Postoperative morbidity, readmission and reoperation remains higher than NSQIP reported rates which may also be attributable to early introduction of this approach. Oncologic resection was achieved in all cases. Future directions include a propensity-matched comparison to open PD and ongoing analyses as the technique mature.

Robotic hand port assisted resection of liver and peritoneal metastases in patient with high-grade myxoid liposarcoma

Presenter: Karolin Ginting MD | The Jewish Hospital Background: Extremity soft tissue sarcomas, especially with the myxoid subtype, have a propensity to metastasize to extrapulmonary sites. Among these patients, metastasis to the liver is relatively rare and usually presents in a single site. Methods: We presented a 41-year-old severely obese woman (BMI: 40) with a history of high-grade myxoid liposarcoma of the left thigh presents with liver and peritoneal masses found on surveillance CT scan. Core biopsy showed evidence of metastatic poorly differentiated myxoid liposarcoma. After further discussion during interdisciplinary tumor board conference, surgical resection and adjuvant chemotherapy were recommended. Results: Adequate intraoperative examination and mobilization of these masses was expected to be challenging due to patient habitus, prompting a decision to proceed surgery with robotic and hand-port assisted technique. During diagnostic laparoscopy and intraoperative ultrasound study, two small liver masses in segment IVa and the right liver, and a peritoneal nodule were noted. Complete excisions of these masses were done under ultrasonography guidance. The postoperative course was unremarkable, and the patient was discharged home on day five without complication. Final pathology of both the peritoneal nodule and the largest liver mass showed R0 resection of metastatic myxoid liposarcoma and confirm benignancy of the two smaller number masses. Conclusion: Successful resection and outcome were achieved through a multidisciplinary approach including medical oncology, surgical oncology, radiology and pathology. Further research into survival benefits of resection, as well as the use of radiation or chemotherapy as an adjuvant treatment, would be beneficial in enabling physicians to better understand the available choices further patients, and to generate more valuable decision-making discussions.

Hand-assisted Laparoscopic Left Donor Nephrectomy Without a Hand-assisted Device: Is it Possible?

BackgroundLive donor nephrectomy is an important donor source. Donor nephrectomy can be performed by laparoscopy or hand-assisted laparoscopy. Different types of hand port devices can be used for assistance. In the literature there are few studies about hand-assisted laparoscopy without a hand port. In this study, we aimed to evaluate the impact of not using a hand port for hand-assisted laparoscopic donor nephrectomy for kidney transplantation. MethodsPatients who were operated on for kidney donation between January 2011 and June 2018 evaluated retrospectively. The patients were divided into 2 groups: group A, on whom a hand port was used, and group B, whose surgeries did not involve a hand port. The groups were compared for sex, age, body mass index, amount of intraoperative bleeding, warm ischemia time, duration of surgery, perioperative complications, duration of hospital stay, and postoperative complications. ResultsThere were 159 patients in group A and 146 patients in group B. There was no difference between the groups considering intraoperative bleeding, warm ischemia time, duration of surgery and postoperative early complications (P > .05 for all). ConclusionHand-assisted laparoscopic donor nephrectomy without a hand port can be considered an easy and effective method of laparoscopic nephrectomy.

When Less Is More: Minimally Invasive Surgery Compared with Laparotomy for Interval Debulking After Neoadjuvant Chemotherapy in Women with Advanced Ovarian Cancer

Study ObjectiveTo compare outcomes of advanced ovarian cancer patients who had minimally invasive surgery (MIS) with outcomes of advanced ovarian cancer patients who had laparotomy for interval cytoreduction after neoadjuvant chemotherapy (NACT). DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingOne large teaching hospital with a tertiary referral function for gynecologic oncology and MIS. PatientsAll consecutive patients with stages III to IV epithelial ovarian, tubal, or peritoneal cancer who underwent MIS or laparotomy for interval cytoreduction after at least 1 NACT cycle from 2006 to 2017 at 1 institution. InterventionsPatients underwent either MIS or laparotomy for interval cytoreduction after at least 1 cycle of NACT. Measurements and Main ResultsMedical records were reviewed and data abstracted and analyzed. Survival was estimated by the Kaplan-Meier method, and outcomes were compared with Fisher's exact test, Student's t test, Wilcoxon rank sum test, and the log-rank test. In total, 157 assessable patients underwent interval cytoreductive surgery through MIS (n = 53) or laparotomy (n = 104). MIS was completed without conversion in 44 of 53 patients (83%), of whom 20 required a hand port and/or mini-laparotomy. R-zero and optimal resections were achieved in 60.4% and 96.3% of MIS patients respectively, compared with 42.3% and 82.7% of laparotomy patients (p = .02). MIS patients had lower estimated blood loss (EBL; 156 vs 278 mL, p <.001), fewer intraoperative transfusions (2% vs 17%, p = .006), and shorter hospital stay (3.0 vs 5.7 days, p < .001). Operative time was longer (171 vs 150 minutes, p = .007), but complications, intensive care unit stay, readmission, median progression-free survival (27 vs 29 months, p = .45), and median overall survival (37 vs 35 months, p = .74) were similar. ConclusionMIS is feasible and effective for interval cytoreduction after NACT in advanced ovarian cancer patients. MIS is associated with less EBL, lower transfusion rate, and shorter length of hospital stay with no difference in patient outcomes.

Hilar control during laparoscopic donor nephrectomy: Practice patterns in Canada.

In recent years, the method of vascular control during laparoscopic donor nephrectomy (LDN) has come under scrutiny due to catastrophic consequences of a device failure. This study sought to examine the surgical preferences of Canadian donor surgeons with regards to vascular control and their perception on the safety of these modalities. We also surveyed the experience with device malfunction and their subsequent management during LDN. An online survey was sent out to donor surgeons registered with the Canadian Society of Transplantation. Surveys were anonymous and voluntary. Descriptive statistics were used to analyze the collected responses. Recollection of the sequelae and outcomes from device malfunction were also queried. Twenty-eight of 37 surgeons (76% response rate) responded to the survey. At least one surgeon from every institution in Canada performing LDN responded to the survey. Laparoscopic stapler is the most commonly used device for securing the renal artery (61%) and renal vein (67%). Overall, surgeons felt the stapler was the safest method of securing the renal artery. Stapler misfire and clip slippage were reported by eight (28.5%) and 12 (43%) surgeons, respectively. Most cases were salvageable: laparoscopically (30%), open conversion (30%), and by hand port (5%). Slippage of a plastic locking clip resulted in one emergent laparotomy on POD#1 and one stapler misfire was converted to open resulting in donor death. Although rare, hemorrhagic complications can occur from device malfunction resulting in poor outcomes for healthy volunteers undergoing LDN. Surgeons need to remain vigilant when selecting the appropriate modality for vascular control.

Hand Assisted Laparoscopic Surgery: An Updated Overview

Introduction: Hand assisted laparoscopic surgery is an updated highly advanced version of laparoscopic technique. Such technique bridges the gap between traditional surgery and total laparoscopic surgery. Introduction of the hand intracorporeally enhanced the degree of freedom, hence, a remarkable degree of precision and safety in task performance.Clinical and experimental studies confirmed safe use of the hand with insufflation pressure enhancing dexterity as well as a steep learning curve. Therefore, the author made an overview analysis to the factors related to safety; efficiency; dexterity; instrumentation and cost-effectiveness for the use of hand assisted laparoscopic surgery; with an emphasis on live donor nephrectomy. Results and discussion: Prospective studies made by Kolvenbach on the use of hand assisted laparoscopic surgery in aortic aneurysm repair proved high degree of safety and efficiency as well as cost effectiveness. Several studies highlighted a multitude of factors significantly contributing into a high degree of precision and task performance; which reflected on uneventful enhanced recovery programme.The introduction of either hand intracorporeally enhanced the limited degree of freedom for the current laparoscopic tools. There are various hand port devices of which the pros and cons for each port will be discussed in detail. The author’s experimental studies confirmed that optimum safe insufflation pressure would be 10 mm Hg with no leak from the hand port and optimum dexterity and task performance. Conclusion: Hand assisted laparoscopic surgery is a safe and efficient technique. It significantly enhances concept of Enhanced Recovery programme. Raising public awareness can provide a high impact in enhancing live donor nephrectomy; hence reducing the inexorable renal transplant waiting list for patients with end stage renal disease. Such patients are at progressive rise of mortality risk with prolonged waiting list.

Hand‐assisted laparoscopic colorectal surgery with double‐glove technique

AimThe hand‐assisted laparoscopic colorectal surgery (HALS) preserves the advantages of the minimally‐invasive approach. However, its application has faced resistance due to the need of hand port devices and its increased costs. The aim of the present study was to assess the feasibility of an original technique using a double glove to keep pneumoperitoneum.Patients and methodsAll patients operated with the HALS approach between 2004 and 2011 were analysed. Intraoperative and postoperative variables were also analysed. All procedures were performed with a double‐glove technique to preserve the pneumoperitoneum.ResultsThere were 217 patients included in the present study (52 per cent males, mean age of 71 years and mean body mass index of 26.5 kg/m2). The median operating time was 150 min. The mean port number used was three, with a mean wound size of 5.25 cm. The conversion rate was 6 per cent, and the morbidity rate was 8.7 per cent with no postoperative deaths. The median hospital stay was 3 days. Mean harvested nodes were 16 (95 per cent confidence interval: 15–17). The readmission and reoperation rates were 2.3 per cent and 0.9 per cent, respectively.ConclusionThe double‐glove hand‐assisted laparoscopic technique represents a feasible option with good postoperative outcomes. Additionally, it represents a good cost‐effective alternative.

Combining all forces: abdominoperineal resection in an obese male.

In patients with rectal cancer, pelvic dissection is challenging. A complete total mesorectal excision (TME) is particularly difficult in a narrow and long pelvis often encountered in males. This difficulty is compounded in the obese. In addition to the open approach being morbid, laparoscopy has often proven difficult secondary to rigid instruments along with a steep learning curve. Robot assistance offers an advantage, however limitations are observed in abdominal colon dissection outside of the pelvis. As these individual modalities have their disadvantages, they each can contribute unique aspects in a combined or a hybrid approach to rectal tumors. Therefore, a multi-modal, combined approach, involving hand assist, laparoscopic, and robotic assistance, to a 5-cm tumor at the anal verge was applied to an abdominoperineal resection in an obese, male patient. An obese 58-year-old male, BMI of 36 kg/m2, with a 5-cm anal canal squamous cell carcinoma which recurred after Nigro protocol treatment, underwent a multi-modal abdominoperineal resection. The approach to recurrent anal cancer is as that for rectal cancer. Hence, a hand port was placed to assist in colon mobilization, visceral mesenteric dissection, and to facilitate the laparoscopic division of the inferior mesenteric artery (IMA) at its origin. The robot was used for deep pelvic dissection and TME. The levators were divided in the perineal phase. A complete mesorectal excision was achieved and a cylindrical specimen was extracted. An abdominoperineal resection with a multi-modal approach (hand assist, laparoscopic, and robotic) is safe and effective in resection of low rectal cancers especially in the narrow, obese, and male pelvis.

Left Lateral Sectionectomy Performed Under Minimal Open Access after the Completion of Hand-Assisted Laparoscopic Mobilization

Purpose: Left lateral sectionectomy is one of the best methods for laparoscopic anatomical liver resection. We have developed a three-port method for anatomical left lateral sectionectomy, in which the sectionectomy is performed via a minimal incision after hand-assisted laparoscopic mobilization. Methods: Access for the open laparotomy was obtained by making an 8 cm incision for a hand port. The other ports were used as the camera port and working port. Liver immobilization was completed under pneumoperitoneum. Fingertip tape ligation is a very simple method for encircling the hepatoduodenal ligament and does not require any special equipment. The standard open technique was then employed for liver dissection through the minilaparotomy. We compared the clinical and operative variables of the patients that underwent the open procedure (n = 6) with those of the patients that underwent the laparoscopic procedure (n = 5) at our institute between January 2005 through June 2008. Results: We developed a three-port method for left lateral sectionectomy. No technical difficulties or major complications occurred. The laparoscopy group exhibited significantly less intraoperative bleeding and a significantly shorter period of hospitalization than the open procedure group. Conclusion: The three-port method is suitable for hand-assisted left lateral sectionectomy and is easily repeatable by all liver surgeons, as it does not require any special skills.

Laparoscopic sigmoid colectomy: Are all laparoscopic techniques created equal?

Laparoscopic colectomy has been associated with improved postoperative pain control, earlier return to work, and shorter hospital stays compared to open colectomy. However, there are varied technical approaches to laparoscopic resections. We therefore sought to determine whether the straight laparoscopic approach was associated with shorter length of stay compared to hand-assisted and laparoscopic-assisted techniques for sigmoid colectomies. A retrospective review of laparoscopic sigmoid colectomies performed by five colorectal surgeons from 2010 to 2014 was performed. Approaches were defined as: (1) straight laparoscopic if colon mobilization, inferior mesenteric artery transection and intra-corporeal anastomosis were performed laparoscopically, (2) hand assisted if a hand port was utilized to assist with mobilization and vessel transection, and (3) laparoscopic assisted if only the colon mobilization was performed intra-corporeally. Poisson regression was performed to determine the impact of surgical technique on LOS while controlling for differences in patient factors. A total of 191 patients were identified with 71 straight laparoscopic, 57 hand-assisted, and 63 laparoscopic-assisted cases. Substantial variability in choice of surgical technique was seen across surgeons. Patient populations were similar, with the exception of hand-assisted procedures being more often used in obese patients. Unadjusted average postoperative days to discharge were 3.6days for straight laparoscopic and 4.1 and 4.0days for hand-assisted and laparoscopic-assisted approaches, respectively. While controlling for factors associated with longer hospital stay, the straight laparoscopic approach was associated with a 14% shorter stay compared to laparoscopic-assisted colectomy and a 15% shorter stay compared to hand-assisted colectomy. The straight laparoscopic approach was also associated with earlier return of bowel function compared to other approaches. The straight laparoscopic approach to sigmoid colectomy is associated with substantially shorter postoperative stay and earlier return of bowel function when compared to hand-assisted and laparoscopic-assisted techniques. When technically feasible, the straight laparoscopic approach is preferred.

This Month in JoVE - Assessing Freezing Tolerance in Plants, Patterning 2D Shapes with DNA, Studying Ischemia In Vitro, Studying Social Cognition in Monkeys

Here's a look at what's coming up in the May 2015 issue of JoVE: The Journal of Visualized Experiments. In JoVE Environment, it's the middle of spring in the earth's Northern Hemisphere, so seeds are sprouting and buds are blooming. But for actively growing plants, especially those with no freezing tolerance, a cold snap can be deadly. A hard frost can dramatically alter natural ecosystems and devastate agriculture. Even more concerning, erratic weather patterns related to climate change can cause cold-susceptible plants to bud and bloom too early, then fall victim to a subsequent freeze. To protect plants from freezing, we need a better understanding of the freezing process. Wisniewski et al. describe a protocol to visualize this process using high-resolution infrared thermography (HRIT). Using this technology, scientists can determine how ice forms and propagates, and test various compounds that might alter the freezing process or increase freezing tolerance. In JoVE Chemistry, the principles of self-assembly have been used to engineer a variety of complex structures from biological and non-biological building blocks. This month, Wei et al. present detailed protocols for the self-assembly of single-stranded DNA tiles into complex 2D shapes with the tiles acting as molecular pixels on molecular canvases. These are visualized by atomic force microscopy. The modular nature of this approach allows it to be scalable, and the tiles can self-assemble into tubes and rectangles of varying sizes. This technique is also highly versatile-enabling the construction virtually any 2D shape. In JoVE Clinical & Translational Medicine, ischemic stroke happens when a blockage in an artery restricts blood flow to the brain, depriving it of oxygen and nutrients. When the blood returns, reperfusion can cause further damage by disrupting the blood-brain barrier and triggering inflammation and oxidative stress. There are many in vivo models of ischemia-reperfusion injury, and while all disease models have drawbacks, in vivo models tend to be technically challenging, with limited applicability for mechanistic studies. To help overcome some of these limitations, Alluri et al. present an in vitro model of ischemia-reperfusion, which can be used to study the molecular mechanisms of blood-brain barrier dysfunction and signs of oxidative stress. In JoVE Behavior, Fagot et al. study social cognition in monkeys. In this protocol, monkeys living in social groups have free access to multiple test units. When a monkey enters a testing chamber, and reaches through the hand port, a computer recognizes the monkey through its radio frequency ID (RFID) chip and starts the experiment A touch screen displays the stimulus and a food dispenser delivers the reward. Over several years, this procedure has been shown enhance motivation in the subjects and favor complex learning-particularly the social aspects. You've just had a sneak peek of the May 2015 issue of JoVE. Visit the website to see the full-length articles, plus many more, in JoVE: The Journal of Visualized Experiments.

V12-10 HAND-ASSISTED LAPAROSCOPIC RIGHT COLON MOBILIZATION FOR CONTINENT CUTANEOUS ILEAL CECOCYSTOPLASTY

You have accessJournal of UrologyReconstruction1 Apr 2015V12-10 HAND-ASSISTED LAPAROSCOPIC RIGHT COLON MOBILIZATION FOR CONTINENT CUTANEOUS ILEAL CECOCYSTOPLASTY Travis Pagliara, Daniel Liberman, and Sean Elliott Travis PagliaraTravis Pagliara More articles by this author , Daniel LibermanDaniel Liberman More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2780AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Continent cutaneous ileal cecocystoplasty (CCIC) offers an effective treatment option for patients with a thick-walled neurogenic bladder. To achieve a tension-free ileo-colic anastomosis, the right colon must be mobilized past the hepatic flexure via an extended laparotomy. We introduce hand-assisted laparoscopic right colon mobilization to allow for a tension-free bowel anastomosis through a Pfannenstiel incision. METHODS A 10cm Pfannenstiel incision is used to begin mobilization of the cecum along the line of Toldt. A gel hand port is inserted and pneumoperitoneum is achieved. A 12mm camera port is inserted through the umbilicus under direct vision. A 5mm midline trocar is placed one handbreadth cephalad to the umbilicus. The right colon is grasped through the hand port and is mobilized past the hepatic flexure, using electro-dissection via the 5 mm port. A Kocher maneuver is continued until the inferior vena cava and duodenum are well exposed. The stapled ileo-colic anastomosis, staple-tapering of ileum, and bladder augmentation are performed in the usual open fashion. The stoma is matured through the umbilical port site. RESULTS The hand-assisted laparoscopic modification of the CCIC has been performed on 20 patients at our institution with an average operative time of 4 hours. One case was aborted before bowel harvest when it was apparent that severe morbid obesity (body mass index of 60) and tight mesentery would preclude a tension-free anastomosis. There have been no bowel injuries or ileo-colic anastomotic leaks. CONCLUSIONS CCIC using a hand-assisted laparoscopic mobilization of the right colon allows for a less invasive and more efficient bladder reconstructive procedure. Future research will explore whether there is a difference in hernia rates, wound complications or length of stay. Multiple Choice Question: Q: How far should the right colon be mobilized to ensure a tension-free ileo-colic anastomosis during continent cutaneous ileal cecocystoplasty A) not at all B) to the ileo-colic artery C) to the hepatic flexure D) past the hepatic flexure until the inferior vena cava E) past the gastrocolic ligament Explanation: To allow for a tension-free ileo-colic anastomosis during bladder augmentation surgery it is important mobilize the right colon past the hepatic flexure until the inferior vena cava. This allows for the bowel anastomosis to be done through a pfannenstiel incision without tension and injury to the mesentery. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e979 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Travis Pagliara More articles by this author Daniel Liberman More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Hand-assisted laparoscopic bladder cuff excision via the same hand port as that used for nephroureterectomy

The aim of this study was to report our technique of hand-assisted laparoscopic bladder cuff excision through the same hand port as that used for nephroureterectomy and evaluate its benefits and short-term oncologic outcomes. We included 67 consecutive patients treated by a single surgeon between June 2011 and November 2014 with hand-assisted laparoscopic bladder cuff excision through the same hand port as that used for nephroureterectomy. We retrospectively analyzed procedure-related clinical data and short-term oncologic outcomes. The mean patient age was 66.2 ± 10.6 years. The mean follow-up period was 17.6 months (range 1-37 months). The mean operation time was 243.5 ± 60.4 min. There were no major accidents or open conversions. Forty-two patients (63 %) underwent immediate mitomycin C instillation without complications. There was one high-grade complication (prolonged lymphatic leakage) that required reoperation and multiple hospitalizations. Thirty patients (45 %) underwent regional lymph node dissection. The pathological stages included CIS in 2 (3 %), Ta/T1 in 32 (48 %), T2 in 6 (9 %), T3 in 27 (40 %), and N+ in 4 (6 %) cases. G1, G2, and G3 were seen in 3 (5 %), 21 (31 %), and 43 (64 %) patients, respectively. Eighteen patients (26 %) underwent postoperative adjuvant chemotherapy. Two patients died during the study period, and nine patients (13 %) had bladder recurrences. HAL bladder cuff excision through the same hand port used for nephroureterectomy is a feasible technique that is both amenable to oncologic principles and can reproduce the open surgical technique.

Micro-laparoscopic Colectomy: Initial Experience

IntroductionSingle-port surgery (SPS) has been growing in acceptance as an alternative to traditional laparoscopic surgery. With SPS, there are technical skills required that are not routine to standard laparoscopy. We explored the feasibility of micro-laparoscopic colectomy (MLC) using 3 mm instruments in patients eligible for standard laparoscopic surgery. MethodsWe performed an IRB approved retrospective review of all segmental colectomy performed by a single surgeon in selected patients using a micro-laparoscopic technique. We utilized two 3-mm trocars and one 12-mm Hasson umbilical incision, which was later widen for specimen extraction. ResultsEighty patients underwent MLC: Twenty-six for diverticulitis, 26 for cancer, 22 for polyps, 3 for Crohn’s disease, and 3 for volvulus. Eight patients were converted into either laparotomy or hand port (10 %) and three patients required the addition of one 5-mm trocar. Mean final extraction incision length was 3.9 cm. In cancer patients, the average lymph node harvest was 26 (range 13–70). The 30-day mortality was zero and the anastomotic leak rate was 1.3 %. ConclusionsMLC is safe and feasible when performing colon resections for benign and oncologic pathology. Extraction incision length is small and offers similar cosmesis to SPS without the steep learning curve needed to learn this technique.