Extension Of Incision Research Articles

Laparoscopy-assisted surgery for neonatal intestinal atresia: Single-center experience*

Neonatal intestinal atresia surgery requires careful assessment of bowel patency, resection of the affected bowel and a diligent anastomosis. Traditional anastomosis with sutures via a laparoscopic approach would lengthen the surgical time. Various minimally invasive techniques have been reported for neonatal surgery. Our technique offers improved benefits of laparoscopy while observing good principles of surgery. Using a three-port approach to aid careful laparoscopic inspection of the bowel, we performed laparoscopy-assisted neonatal intestinal atresia repair in three term neonates with no cardiorespiratory compromise. Anastomosis was manually performed after exteriorzation of the bowel via the umbilical port site without any extension of the original port-site incision. There were no complications or conversions to open approach. Our technique is an improvement over previously reported limited/umbilical laparotomy approaches and blends the benefits of laparoscopy and open surgery most effectively. Careful bowel inspection and assessment of patency could be safely and systematically performed laparoscopically with limited exteriorization of the bowel for rapid hand-sewn anastomosis and without compromising bowel viability. A multicenter randomized trial will be useful to compare the open laparotomy approach with our technique.

Da Vinci robotic single‐incision cholecystectomy and hepatectomy using single‐channel GelPort access

Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliary surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery using the GelPort laparoscopic system in a preliminary animal study. We performed eight robotic single-incision laparoscopic surgery (SILS) procedures, including four cholecystectomies and four lateral segmentectomy of the liver, in a porcine study using the da Vinci S-HD Surgical System. A single-channel GelPort access was placed through a 2.5-cm single incision for robotic access. A 12-mm camera port, two 8-mm ports for the robotic arms and one 5-mm port for the patient-side assistant were inserted. A Mini Loop Retractor was applied to retract the fundus of the gallbladder. The EndoWrist dissector and grasping forceps was introduced to fine-dissect Calot's triangle. The instruments were crossed to avoid "sword fighting" and clashing of instruments in the abdomen. The cystic duct was divided after double ligation and the gallbladder was removed. Hepatic transection was performed with bipolar Harmonic shears and LigaSure for vascular pedicles. All robotic SILS procedures were completed (8/8, 100%). The cholecystectomies and hepatectomies were safely performed in average operating times of 70min (±15) and 60min (±20), respectively, with minimal blood loss. There were no conversions, re-interventions or extension of the skin incision. Robotic hepatobiliary SILS is technically feasible and safe using GelPort as a single-incision access platform. Robotic SILS is becoming established and is enormously advantageous to the patient.

Selective arterial embolisation: Life-saving intervention in the management of retroperitoneal haematoma in obstetrics

A 21-year-old primigravida underwent caesarean section at term for failure-to-progress beyond 9 cm. The uterus was exteriorised and a right-sided lateral extension of the uterine incision was repai...

Impact of prior abdominal surgery on curative resection of colon cancer via minilaparotomy

To evaluate the impact of prior abdominal surgery on curative resection of colon cancer via a minilaparotomy approach. Feasibility, safety, and oncological outcomes were evaluated retrospectively in 263 patients scheduled to undergo curative resection of colon cancer via a minilaparotomy approach, defined as a skin incision of ≤ 7 cm, between September 2000 and March 2009. Abdominal adhesions were found in 59 (77.6%) of 76 patients who had undergone prior abdominal surgery (PAS group) and in 4 (2.1%) of 187 patients who had not (control group). The success rate of the minilaparotomy approach was 92.1% in the PAS group and 97.3% in the control group (P = 0.08). The incidence of extending the minilaparotomy wound for adhesiolysis was significantly higher in the PAS group than in the control group (6.6% vs 0.5%; P < 0.01). The two groups did not differ significantly in terms of the types of surgery, pathological stage, body mass index, operative time, blood loss, incidence of postoperative complications, length of postoperative hospital stay, and disease-free survival. These results suggest that prior abdominal surgery might require an extension of the minilaparotomy incision but that it does not seem to contraindicate a minilaparotomy approach for curative colectomy.

Laparoscopic 5-mm Trocar Site Herniation and Literature Review

To evaluate the evidence for fascial closure of 5-mm laparoscopic trocar sites. We conducted electronic database searches of PubMed and the Cochrane Library for articles published between November 2008 and December 2010. We used the keywords trocar hernia, trocar-site hernia, laparoscopic hernia, trocar port-site hernia, laparoscopic port-site hernia. Prospective and retrospective case series, randomized trials, literature reviews, and randomized animal studies of trocar hernias on abdominal wall defects from gynecologic, urologic, and general surgery literature were reviewed. The Cochrane Database was reviewed for pertinent studies. Metaanalysis was not possible due to the significant heterogeneity between studies and lack of randomized trials large enough to assess the incidence of this rare complication. Trocar-site hernias are a rare but known complication of laparoscopic surgery. Trocar size ≥10mm is associated with an increased rate of hernia development. Currently, the accepted gynecologic surgical practice is closure of fascial incisions ≥10mm, while incisions <10mm do not require closure. However, large prospective and retrospective case series reports from general surgery and urology literature support nonclosure of blunt or radially dilating trocars in paramedian sites. Expert opinion and small case reports suggest that in cases of prolonged manipulation of 5-mm trocar sites the surgeon should consider fascial closure, because extension of the initial incision may have occurred. There is no evidence to recommend routine closure of 5-mm trocar incisions; the choice should continue to be left to the discretion of the individual surgeon.

Evaluation of Laparoendoscopic Single-site Gynecologic Surgery with a Multitrocar Access System

Laparoendoscopic single-site surgery (LESS) is an ideal approach for gynecologic surgery and yields better cosmetic results. However, a standard umbilical approach with LESS is not appropriate for gynecologic surgery requiring intra-abdominal suturing and dissection requiring traction. Therefore, we have developed a new multitrocar access system for gynecologic LESS. The purpose of this study was to evaluate the efficacy of gynecologic LESS using this access system. This access system consists of one 12-mm trocar, two 5-mm trocars, and a 5-mm flexible laparoscope. Two 5-mm trocars with small port heads were inserted cross-wise on opposite sides of the sleeve of the centrally positioned 12-mm trocar to maintain triangulation. Thirty-eight patients with various gynecologic conditions underwent LESS with this access system. The results of these surgeries were retrospectively compared to those of conventional laparoscopic procedures. Of the 38 LESS procedures performed with this access system, none was up-converted, converted to an open laparotomy, or required blood transfusion. The Salpingo-oophorectomy with LESS had several benefits, such as no extension of the skin incision of the trocar site and no leakage of the contents of the ovarian cyst into the peritoneal cavity, over that with conventional laparoscopy. A comparison of LESS (11 patients) and conventional laparoscopy (16 patients) for total hysterectomy showed no significant difference in total blood loss (234.0 mL vs. 221.6 mL) or the weight of the resected uterus (276.0 g vs. 285.0 g), although the mean total operative time was greater with LESS (199.0 min vs. 168.5 min). Our multitrocar access system is safe and secure, and can be adapted for various gynecologic surgeries involving complicated procedures. LESS with this access system achieves results comparable to those of conventional laparoscopy with 4 ports, although the operative time is longer.

Anterior Approaches in Hip Surgery

The Smith-Petersen anterior approach and the Watson-Jones anterolateral approach are the two most renowned anterior approaches for hip surgery. The anterior approach offers several advantages, including a reduced dislocation risk as compared with that associated with the posterior approach. The post-operative dislocation rate after total hip arthroplasty is known to be 2~3 times lower than that of the posterior approach. However, a more extensive skin incision and poor anatomical visualization are some of the disadvantages of the anterior approach. Nevertheless, since this approach preserves the circulation to the femoral head, the ability to perform the anterior approach is imperative for hip surgeons.

Dural Opening/Removal for Combined Petrosal Approach: Technical Note

Detailed descriptions of stepwise dural opening/removal for combined petrosal approach are presented. Following maximum bone work, the first dural incision was made along the undersurface of the temporal lobe parallel to the superior petrosal sinus. Posterior extension of the dural incision was made in a curved fashion, keeping away from the transverse-sigmoid junction and taking care to preserve the vein of Labbé. A second incision was made perpendicular to the first incision. After sectioning the superior petrosal sinus around the porus trigeminus, the incision was extended toward the posterior fossa dura in the middle fossa region. The tentorium was incised toward the incisura at a point just posterior to the entrance of the trochlear nerve. A third incision was made longitudinally between the superior petrosal sinus and the jugular bulb. A final incision was initiated perpendicular to the third incision in the presigmoid region and extended parallel to the superior petrosal sinus connecting the second incision. The dural complex consisting of the temporal lobe dura, the posterior fossa dura, and the freed tentorium could then be removed. In addition to extensive bone resection, our strategic cranial base dural opening/removal can yield true advantages for the combined petrosal approach.

Comment on ‘Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: conventional method versus reverse breech extraction’

Maternal and fetal morbidity of two different methods of delivering the baby during cesarean section performed in advanced labor when the fetal head is deeply engaged was assessed retrospectively, i.e. delivering as 'cephalic' with or without assistance to push up the fetal head from the vagina (head first or push method) and 'reverse breech extraction' (feet first or pull method). Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at > or =7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during 'cephalic' delivery as compared to 'reverse breech extraction' (22.8% versus 2.2%; p=0.001). Use of 'reverse breech extraction' is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity.

A Simplified Lateral Canthopexy Technique

Sir: Lateral canthopexy has become a routine part of cosmetic lower blepharoplasty to prevent lower lid malposition, especially in those patients with laxity of the lower lid and negative vector anatomy.1 All canthopexy techniques involve securing the lateral retinaculum to the periosteum of the superolateral orbital rim with a suture. However, the surgical approach to identify the lateral retinaculum varies, with some techniques requiring more surgical expertise than others. Perhaps the most challenging technique is that of Jelks et al.,2 who dissect the lateral retinaculum from above through an upper blepharoplasty incision. Dissection of the lateral retinaculum through the lateral extension of a lower blepharoplasty incision is advocated by others.3,4 In this article, we describe a technical modification of the Hamra5 transcanthal canthopexy that involves percutaneous placement of the canthopexy suture through the confluence of the superior and inferior gray lines at the lateral canthal angle. An upper blepharoplasty is completed, but the lateral extent of the incision is not closed or, in the case in which upper blepharoplasty is not performed, a small incision is made in the upper eyelid crease laterally. An 18-gauge needle (Fig. 1) is used to create a puncture wound at the confluence of the superior and inferior gray lines at the lateral commissure of the eye. One arm of a double-armed 5-0 Prolene suture (Ethicon, Inc., Somerville, N.J.) is placed through the puncture wound, capturing the lateral retinaculum, and directed into the upper blepharoplasty incision, below the orbicularis oculi muscle. The second arm is subsequently placed through the same puncture wound but on a slightly different path into the upper lid incision. These two sutures are secured to the periosteum on the undersurface of the superolateral orbital rim at a level just above the pupil or superior limbus, thus tightening the tarsoligamentous sling. The suture is tied and tension of the lower lid is checked. (SeeVideo, Supplemental Digital Content 1, which demonstrates the lateral canthopexy technique, https://links.lww.com/PRS/A164.)Fig. 1.: Needle placement.Video.: Supplemental Digital Content 1 demonstrates the lateral canthopexy technique, https://links.lww.com/PRS/A164.The lateral canthopexy described here is a modification of the Hamra transcanthal canthopexy. In our modification, a needle is used to access the lateral retinaculum and direct canthopexy suture placement. It is a minimally invasive technique that is simple to perform, especially in the hands of a novice blepharoplasty surgeon. An advantage of this technique is absolute assurance of capturing the lateral canthal tendon. Extensive dissection to identify the tendon is not required, which limits operative time and postoperative edema. Furthermore, recreation of the lateral retinaculum and canthal angle as in canthoplasty (cantholysis) techniques is obviated. With this minimally invasive technique, results have been excellent, with few complications. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Mort Rizvi, M.D. Michael Lypka, M.D., D.M.D. Mark Gaon, M.D. Bradley Eisemann, B.A. Michael Eisemann, M.D. Department of Plastic and Reconstructive Surgery Methodist Hospital and Weill Cornell Medical College Houston, Texas Michael Lypka, M.D., D.M.D. 1 Hermann Museum Circle Drive, Suite 3070 Houston, Texas 77004

Polyostotic rib fibrous dysplasia resected by video-assisted thoracoscopic surgery with preservation of the overlying periosteum

Video-assisted thoracoscopic rib resection has rarely been reported, but a relatively simple procedure that uses readily available instruments can prove to be feasible. A conventional approach would involve an incision greater than the length of the mass itself. Such an approach would require significant resection of the chest wall musculature and could lead to significant postoperative morbidity and decrease in quality of life. Multiple rib tumors would require an even more extensive incision and may require multiple incisions to facilitate exposure and removal. We report the removal of 2 expansile bone tumors by video-assisted thoracoscopic surgery while preserving the periosteum to allow for bone formation. To the best of our knowledge, no such attempts

Single‐port transvesical enucleation of the prostate: a clinical report of 34 cases

To present our experience with single-port transvesical enucleation of the prostate (STEP) in 34 patients with large-volume benign prostatic hyperplasia (BPH). We performed STEP in 34 patients with large volume (>60 g) BPH (mean age 69 years, body mass index 26 kg/m(2), and American Society of Anesthesiology class 2). The mean prostate volume estimated by transrectal ultrasonography was 102.5 mL and the mean baseline prostate-specific antigen level was 6.7 ng/mL. A novel single-port device was inserted percutaneously into the bladder through a 2-3 cm incision in the suprapubic skin crease. After establishing pneumovesicum, the prostate adenoma was enucleated transvesically using standard laparoscopic instruments, and the adenoma was extracted in pieces through the port. Digital assistance expedited enucleation of the apical adenoma in 19 (55%) cases. Transvesical enucleation was completed in all 34 cases; the mean operative duration was 116 min, and the estimated blood loss was 460 mL. There was one death from postoperative bleeding from uncontrolled coagulopathy in a Jehovah's Witness who refused a transfusion of blood and blood products. There were three complications during STEP (one death, one bowel injury and one haemorrhage) and five afterwards (four bleeding, one epididymo-orchitis). Open conversion was necessary in two patients for complications, and extension of the skin incision by 1-2 cm was necessary in two to expedite apical digital enucleation. The mean hospital stay was 3 days and mean analogue pain score at discharge was 2. All 33 patients (excluding the patient who died) were voiding spontaneously at a maximum follow-up of 8 months, with a mean American Urologic Association symptom score of 3, a maximum urinary flow rate of 44 mL/s, and a postvoid residual of 30 mL at the latest follow-up. No patient developed urinary incontinence. STEP is an effective treatment option for selected patients with large-volume obstructive BPH. Under pneumovesicum using laparoscopic visualization, the entire adenoma can be effectively enucleated and expeditiously extracted through the novel single port. Comparison of the STEP procedure with other open and transurethral techniques will determine its place in the surgical treatment of large-volume BPH.

Surficial Geologic Map of the Upper Conejos River Drainage, Southeastern San Juan Mountains, Southern Colorado, USA

Please click here to download the map associated with this article. During the Last Glacial Maximum (LGM), the San Juan Mountains of southern Colorado, USA were covered by one of the largest ice caps in North America. The deposits formed subsequent to LGM retreat provide a record of the interaction between post-LGM climate change and late Quaternary landscape evolution. In order to determine the role of post-LGM climate change in alpine landscape modification, a high resolution surficial geologic map was produced for the four primary tributaries and the main stem of the upper Conejos River watershed in the southeastern San Juan Mountains. Soil development, 14C ages, and stratigraphic relationships provide evidence for three distinct periods of hillslope, alluvial fan and/or stream terrace deposition (∼9.5–13 k.y.a., ∼1.2–2.1 ybp, and modern) in the upper Conejos River watershed. We interpret the first of these periods to be the result of paraglacial hillslope adjustment. The lack of subsequent early to mid-Holocene deposits suggests that an interval of relatively warm climate coincided with landscape stability. We attribute late-Holocene deposition to an interval of cooling that has been documented in nearby proxy records. Modern deposits in the field are limited both in extent and occurrence, and are interpreted to be the result of erosion localized outcrops of soft, volcaniclastic bedrock. In addition to post-LGM depositional units, relatively flat erosional bedrock surfaces that sit 1–100 m above the modern stream, and that are capped with glacial till, are present in all four tributaries of the field area. These are interpreted as former glacial valley bottoms. The modern streams are incised into the floors of these hanging valleys. Headward erosion presumably initiated following deglaciation and is still active today. Modern channel long profiles differ between the four tributaries. We attribute the variability of incision into these hanging valleys to differences in basin size and bedrock erodibility, with more extensive incision occurring in basins characterized by more erodible rocks (poorly welded volcaniclastics) and larger basin size. Overall we see that the post-LGM landscape evolution in this alpine environment is the result of the complex interaction of Holocene climate change acting on basins of varying size and bedrock type.

Mini-lap cholecystectomy: Modifications and innovations in technique

Background As with any technology-driven field, laparoscopic surgery has made tremendous progress in recent years. Since the performance of first laparoscopic cholecystectomy by Prof Dr Med Erich Mühe of Böblingen, Germany 1985, this procedure has overtaken open cholecystectomy as the treatment of choice in cholelithiasis. However due to the cost incurred thereof and surgical training needed, open cholecystectomy is still performed on a very large scale in most parts of the third world countries. We tried to modify the conventional cholecystectomy to a minimal access approach (with minimal required infrastructure) to suit majority of patients with cholelithiasis in lieu of cost and morbidity. Objective To assess the outcome of modified mini-lap cholecystectomy and report our experience with our innovations and modifications of the technique. Patients and methods Between May 2006 and May 2008, two hundred patients with cholelithiasis aged between 15 and 56 years underwent mini-lap cholecystectomy in a prospective study in Government medical college Srinagar. Our surgical approach was carried out using a 3–5 cm oblique incision located two finger breadths below the costal margin; fashioned more laterally with a muscle cutting or splitting technique. The outcome was assessed in terms of intraoperative and postoperative parameters. The median (range) age was 38 (15–56) years and there were 143 females and 57 males in the study. All the procedures were completed successfully without any complications, though one patient needed the extension of incision as in conventional cholecystectomy. Results All the procedures were completed successfully. The mean (range) operative time was 35 (20–110) min and the average blood loss was 30 ml. The mean (range) hospital stay was 2 (1–5) days. All patients returned back to routine work within 9 days of surgery. The mean follow-up was 12 (7–14) months. Conclusions These results confirm that mini-lap cholecystectomy by our modified approach is safe, feasible and has lesser morbidity and postoperative pain as compared to conventional open cholecystectomy. The technique is cost effective, easy to practice and can benefit majority of patients who otherwise cannot afford the laparoscopic surgery. Hence it can serve as an alternative to the gold standard laparoscopic cholecystectomy with almost comparable results.

Effect of expansion technique of uterine incision on maternal blood loss in cesarean section

The purpose of this study was to determine whether the method used to expand the uterine incision (sharp vs. blunt) for cesarean section (CS) affects maternal blood loss. A prospective study conducted on 200 nulliparous who underwent lower segment transverse CS divided into two groups. One hundred women were assigned to have blunt expansion of the uterine incision by fingers of the surgeon, and 100 women to have sharp expansion using bandage scissors. Finally, a comparison of two groups was made regarding blood loss, change in hematocrit, uterine tears and blood transfusion. P < 0.05 was considered significant. Maternal blood loss and postoperative hematocrit drop were significantly higher in sharp group (375 ± 95 cm³ in blunt vs. 443 ± 86 in sharp, P = 0.001 and 2.4 ± 2.6 in blunt vs. 4.1 ± 2.6 in sharp, P = 0.001, respectively). There was no significant difference in the extension of uterine incision. Our findings support that blunt expansion of uterine incision during lower segment cesarean is safer and easier than sharp expansion.

Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: Conventional method versus reverse breech extraction

Maternal and fetal morbidity of two different methods of delivering the baby during cesarean section performed in advanced labor when the fetal head is deeply engaged was assessed retrospectively, i.e. delivering as 'cephalic' with or without assistance to push up the fetal head from the vagina (head first or push method) and 'reverse breech extraction' (feet first or pull method). Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at > or =7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during 'cephalic' delivery as compared to 'reverse breech extraction' (22.8% versus 2.2%; p=0.001). Use of 'reverse breech extraction' is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity.

Laparoscopic Management of Intussusception in Pediatric Patients

Minimally invasive approaches are beginning to be employed in the management of pediatric patients with intussusception who fail radiographic reduction. Successful laparoscopic reduction has been demonstrated, but the utility of laparoscopy, for more complex cases, is less well documented. Therefore, we reviewed our experience with laparoscopy in patients with radiographically irreducible intussusception to document the safety and effectiveness of this approach. We conducted a retrospective review of all of the patients who had a radiographically irreducible intussusception treated via the laparoscopic approach at a single institution from 1998 to 2008. Means are expressed +/- standard deviation. A total of 22 patients were identified, with an average age of 2.9 +/- 3.0 years. Average length of stay was 2.67 +/- 1.5 days (median, 2). Sixteen (73%) of the 22 patients were male. There were 19 ileocecal and 3 small bowel intussusceptions. Twenty patients (91%) were able to be managed entirely laparoscopically or via extension of the umbilical incision, while 2 necessitated conversion, using a right-lower quadrant incision. Nine patients had an extension of the umbilical incision; 7 of these underwent a bowel resection. Ten patients (46%) had a bowel resection, of which 5 were an ileocecectomy and 5 were segmental small bowel resection. There were a total of 9 patients with a pathologic lead point, 5 patients with lymphoid hyperplasia, and 4 with Meckel's diverticula. We conclude that laparoscopy is a reasonable approach to pediatric intussusception, even in the event when bowel resection is necessary.

Use of Hem-o-lok Clips for Vascular Control During Retroperitoneoscopic Nephrectomy in Children

Aim: To evaluate safety and efficacy of 5-mm Hem-o-lok clips in children undergoing retroperitoneoscopic nephrectomy. Material and Methods: Twenty-four retroperitoneoscopic nephrectomies were performed between September 2004 and August 2007. The indications of nephrectomy were ureteropelvic junction obstruction, reflux nephropathy, ectopic ureteral opening with renal dysplasia, and stone disease with pyonephrosis and primary obstructed megaureter with renal dysplasia. Nine cases were on right side and others on left side. Multiple 5- or 10-mm Hem-o-lok clips were used to control renal artery and vein separately in each case. The specimen was mobilized and removed either by extension of a port site incision or by a separate incision at ipsilateral iliac fossa at the lateral border of the rectus muscle. Results: Hem-o-lok clips were deployed on renal pedicle separately in each case. Two clips were deployed on the body side and one on the specimen side. On the left side lumbar, gonadal and adrenal tributaries were also clipped by 5-mm Hem-o-lok clips. No clip dislodgement was observed in any patient. Mean operative time was 111 (80 ± 47) minutes, and mean blood loss was 25 (10 ± 45) mL. Mean hospital stay was 2.4 (1.9-3.1) days. Conclusion: Five- and 10-mm Hem-o-lok clips are safe and effective for renal pedicle control during retroperitoneoscopic nephrectomy in children.

Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil™) after laparoscopic total gastrectomy

Laparoscopic total gastrectomy (LTG) has not become as popular as laparoscopic distal gastrectomy (LDG) because of the more difficult reconstruction technique. Despite various modifications of reconstruction methods after LTG, an optimal procedure has yet to be established. The authors report the newly developed reconstruction technique after LTG: intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien, Mansfield, MA, USA). After full mobilization of the abdominal esophagus, the esophagus is transected with an endoscopic linear stapler. The anvil is then transorally inserted into the esophagus by using the OrVil system. After jejunojejunostomy is performed through a 4-cm midline minilaparotomy, preparing a 50-cm Roux-en-Y jejunal limb, a circular stapler is inserted into the jejunum and introduced into the abdominal cavity. Pneumoperitoneum is established by sealing off the laparotomy wound retractor with a surgical glove attached to the circular stapler. Double-stapling esophagojejunostomy with a circular stapler is performed intracorporeally, and the jejunal stump is closed with an endoscopic linear stapler. Of the 16 patients who underwent this operation, there was no intraoperative complication or conversion to open surgery, and no patient required an extension of the initial incision for anastomosis. Mean operation time and blood loss were 194 min and 272 ml, respectively. One patient developed an intra-abdominal abscess postoperatively. Postoperative fluorography revealed no anastomosis leakage or stenosis in any of the patients. Patients resumed an oral liquid diet on postoperative day 3-5, and the mean postoperative hospital stay was 11 days. We have successfully performed LTG with Roux-en-Y reconstruction using our technique in 16 patients without any anastomosis complications. We believe that our procedure is a secure and reliable reconstruction method after LTG, which is especially useful in obese patients, in whom conventional extracorporeal anastomosis often is difficult.

Blunt Expansion of the Low Transverse Uterine Incision at Cesarean Delivery

The surgical approach to low transverse cesarean delivery has been modified since it was first described in 1926, but the main steps are largely the same. Transversal expansion-the conventional procedure used to extend the surgical incision-involves separation of the surgeon’s index fingers in a transverse direction (medial to lateral and slightly cephalad at the same time). The investigators hypothesized that expansion of uterine incision by separation of the surgeon’s forefingers in a cephalad-caudad direction along the midline might avoid greater lateral extension of the distal incision and could minimize tissue trauma. This prospective randomized study compared cephalad-caudad and transversal expansion in a total of 811 women who were scheduled for low-segment transverse cesarean delivery after 30 weeks’ gestation; 406 women were assigned to the transversal expansion group, and 405 to the cephalad-caudad expansion group. Baseline obstetric and demographic characteristics were similar in the 2 groups. An extension was defined as any lateral or vertical uterine wall defect that required additional surgery to repair. Excessive bleeding during the procedure was defined as estimated blood loss of >1500 mL. The primary outcome measure was the incidence of unintended extension. There was no significant difference between the groups in the estimated blood loss or the need for transfusions. Univariate analysis showed that the occurrence of unintended extension was significantly higher in the transverse group than in the cephalad-caudad group (7.4% vs. 3.7%; P = 0.03). As a result, more women in the transverse group required additional sutures. The incidence of blood loss of >1500 mL was also higher in the transverse group compared with the cephalad-caudad group (2.0% vs. 0.2%; P = 0.04). Multivariate logistic regression analysis showed that transversal expansion was an independent risk factor for unintended expansion and blood loss of >1500 mL. These data show that there is less risk with the cephalad-caudad technique for unintended extension and blood loss of >1500 mL compared with transversal expansion. The investigators conclude from these findings that the cephalad-caudad technique is preferred when lower segment cesarean delivery is performed.