Intraperitoneal Organ Injury Research Articles

Experiences with an Extraperitoneal Transvesicoscopic Repair of a Vesicovaginal Fistula.

Purpose A vesicovaginal fistula (VVF) is a debilitating condition for women in terms of both its personal and social impacts. A reported transperitoneal laparoscopic approach to treatment has some limitations such as risk of intra-peritoneal organ injury and unnecessary bladder dissection. We here report on our experiences with an extraperitoneal transvesicoscopic approach to a VVF repair, which overcomes these drawbacks. Materials and Methods Seven VVF patients were treated using the transvesicoscopic approach. Under general anesthesia, patients were placed in the dorsal lithotomy position. The VVF orifice was obstructed via the vaginal canal using a Foley catheter. The bladder was then filled with normal saline under cystoscopic inspection, and a 5 mm trocar was inserted into it at the suprapubic area. The bladder wall was next fixed to the anterior abdominal wall. Thereafter, two 3 mm ports were punctured at the interspinous skin crease allowing the fistula margin to be cut and sutured in layers. Results Six of the study subjects in whom we attempted a transvesicoscopic repair of VVF had undergone a hysterectomy due to myoma and one had an intraabdominal abscess removal with Behcet's disease. One myoma patient who had a preexisting vesicoperitoneal fistula was converted to an open transabdominal VVF repair. The mean age of the 6 remaining patients was 46.0 ± 7.2 years (range, 35-57). The mean operation time was 273 ± 40.6 minutes (range, 223-323). There was no instances of significant pain or other immediate complications. Five patients showed no recurrence of the fistula during the follow-up period (8.7±5.1 months). Conclusion A transvesicoscopic approach is an effective modality for the repair of a VVF that is more minimally invasive and has a lower morbidity than a transabdominal procedure.

Invited Commentary: Key Concepts of CT for Penetrating Abdominopelvic Injuries.

Invited Commentary: Key Concepts of CT for Penetrating Abdominopelvic Injuries.

Retroperitoneal robot-assisted laparoscopic partial nephrectomy for posterior located renal tumours: Technique and early term outcomes.

Traditionally, the trans-peritoneal approach is preferred for robot-assisted partial nephrectomy (RPN). However, retroperitoneal RPN (RP-RPN) has recently become widespread because of the advantages of easier access to the hilum, ease dissection of posterior tumours, and lower probability of intra-peritoneal organ injury. We aimed to present our initial experience of the RP-RPN series in posteriorly located renal tumours. Twenty-one patients were included in the study, who underwent RP-RPN by a single surgeon between July 2019 and January 2020. RP-RPN was carried out only in posteriorly located renal tumours with ischemic (on-clamp) or zero ischemic (off-clamp) techniques. Patients with solitary kidney and a history of previous retroperitoneal surgery in the lumbodorsal region were excluded from the study. All cases completed without any operative complication and conversion to open or radical nephrectomy. Seven cases were completed as zero ischemic and 14 cases as ischemic technique. The mean operation time was 157.86±64.24minutes and estimated blood loss was 173.81±136.84mL. The mean warm ischemia time was 15.81±12.42minutes. Positive surgical margin observed in 4.8% of the patients. The mean length of stay was 3.33±0.79days. The mean estimated glomerular filtration rate (eGFR) change in the 3rd postoperative month was -3.71±8.57ml/min/1.73m2 (4.6%). Mean follow-up period was 10.29±4.86months. New-onset stage 3-4 chronic kidney disease (eGFR<60m/min/1.73m2 ) was not observed during the follow-up period. RP-RPN is a safe and feasible approach with acceptable oncological and functional results. We think that RP-RPN can be applied as an alternative to the trans-peritoneal approach for selected cases, especially in renal tumours with the posterior location.

A rare complication of inguinal hernia: Small bowel perforation due to falling down while walking

Small bowel perforation can occur either spontaneously or due to traumatic causes. Non-traumatic spontaneous small bowel perforation can be caused by various reasons including infectious, inflammatory, congenital, metabolic, vascular or neoplastic origins. Small bowel injury due to blunt trauma is a rare phenomenon compared to other intraperitoneal organ injuries, and frequently appears in high-energy trauma. Yet, even low-energy trauma can cause small bowel perforation in the presence of an inguinal hernia. Several cases of small bowel perforation after abdominal trauma or direct trauma to the hernia site are previously reported, however perforation of the small bowels following a low-energy trauma, such as a fall while marching, is a rare condition. A 65-year-old male admitted to the ER following a sudden onset of severe abdominal pain after 4hours following a fall while marching. Physical examination revealed a reduced right indirect inguinal hernia. There was diffuse tenderness and defense in the abdomen. The patient was operated due to the acute abdomen after 6hours following a falling down, and primary repair was performed. The patient was discharged on the fifth postoperative day. With this case report, it is aimed to increase the awareness of the surgeons regarding this rare complication.

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients: Experience at a tertiary care center.

Emergent exploratory laparotomy is recommended for hemodynamically unstable blunt trauma patients suspected of having hemoperitoneum. However, given the unreliability of ultrasonography and rapid scan speed of computed tomography (CT), CT might help clinicians provide accurate information even in hemodynamically unstable trauma patients. This observational study aimed to describe the bleeding site and hospital course of severe blunt trauma patients with hemoperitoneum diagnosed by CT scan.We enrolled all consecutive adult blunt trauma patients (≥18 years old) who underwent whole-body CT before operation between February 2012 and October 2016. Patients with hemoperitoneum on CT images were included and categorized into hemodynamically stable and unstable (persistent hypotension despite fluid resuscitation) groups.Among 1723 severe blunt trauma patients, 136 patients with hemoperitoneum were included. Of these, 98 (72.1%) patients had documented intraperitoneal injury, and the liver (60.2%) was most frequently damaged site, followed by spleen (23.5%) and mesentery (23.5%). The rate of intraperitoneal organ injury did not differ between hemodynamically stable (n = 107) and unstable (n = 29) groups (69.2% vs 82.8%, P = .15), while the documented active internal bleeding was high in the unstable group (29.9% vs 69.0%, P < .001). In the unstable group, 14 (48.3%) patients underwent emergent operation, while 3 patients underwent embolization, and the others were treated in a conservative manner.Even in hemodynamically unstable hemoperitoneum patients, 17.2% had no documented intraperitoneal injury and over half of the patients were treated without emergent operation.

Initial experiences of laparoscopic intravesical detrusorraphy using the Politano–Leadbetter technique

Minimally invasive laparoscopic surgical procedures are increasingly being used for the management of vesicoureteral reflux. We present our experience of the laparoscopic Politano-Leadbetter technique performed under pneumovesicum conditions, which allows an orthotopic ureteral location after vesicoureteral reflux correction. Our procedure recreates the new ureteric orifice in a normal anatomical position with potential less morbidity and better cosmesis. Our series comprises ten cases. The three 5 mm ports were introduced through bladder wall under cystoscopic vision. A 5-0 monofilament traction suture was used and dissection was carried out. After the ureteral mobilization, the location of the new hiatus was selected in a straight line superior to the original orifice. Dissection of the submucosal tunnel was started from the new hiatus and advanced to the original hiatus and the ureter was gently drawn passed through the tunnel. The ureter was rolled up and muscle fibers were incised until ureter could freely move from the base of the new hiatus. Finally, after spatulation of the terminal part of the ureter, ureterovesical anastomosis was performed with intracorporeal suturing using 5-0 monofilament sutures. The average operative time was 125 min, with an average of 93 min for unilateral and 133 min for bilateral reimplantation. Blood loss was minimal and drains were used selectively. Removal of urethral catheter was decided empirically after hematuria stopped. Mean catheterization time was 5.1 days. The mean postoperative hospital stay was 6.2 days. This study had limitations: the small number of cases, follow-up period is relatively short and data on the pre-operative bladder capacity, catheter-related morbidity, pain control and cosmesis are lacking. But most cases showed positive clinical results including acceptable operating time and good resolution rate with minimal complication. Our Politano-Leadbetter transvesicoscopic ureteric reimplantation is safe and useful in the resolution of VUR, even though the laparoscopic ureteric reimplantation is technically demanding even for experienced pediatric surgeons. Considering the main advantages of endoscopic surgery, our new vesicoscopic technique could be an optional treatment to the open reimplantation and has merits because whole the procedure are performed within the bladder, so there is no risk of intraperitoneal organ injury. Though the role of this new technique in the treatment of VUR remains to be determined, the technique could be an optional treatment to replace other surgical methods as a less invasive and effective therapeutic method.

Open Donor Nephrectomy is a Safe Approach for Starting Kidney Transplantation

Aim: Living kidney donation is important due to the shortage of organ donors in Turkey. Classic retroperitoneal open donor nephrectomy is more beneficial as it can prevent intraperitoneal organ injuries and postoperative adhesion formation. Here we have presented our initial experience about donors who were undergone open donor nephrectomy. Material and Methods: We retrospectively analyzed 14 donors who were undergone open nephrectomy between November 2010 and June 2011. We reviewed demographic data, intraoperative and postoperative complications, hospital stay, and serum creatinine levels (discharge time, postoperative maximum level and currently) for these donors. Results: Fourteen donors were operated during this period. The male to female ratio was 8:6 among donors. Mean age was 43.57 (range; 27-68) years. Mean body mass index was 27.71 (range; 21.3-36.1). Five right and nine left kidneys were harvested. There was no intraperitoneal organ injury. All kidney grafts started to function immediately. There was no vascular thrombosis in the transplanted kidneys. There was one major hemorrhagic complication requiring reoperation (7.1%). There were three minor wounds complications (21.4%). None of the donors had incisional hernia. Mean postoperative hospitalization time was 5.85 (range; 4-18) days. Mean flow up period was 125 days (range; 18-210 days). Mean serum creatinine level of discharge time, postoperative maximum level, and currently were; 1.04 mg/dL (range; 0.6-1.7); 1.26 mg/dL (range; 0.8-1.9); 1.08 mg/dL (range; 0.78-1.41) respectively. Conclusions; We did not have any major complication in our initial series for open donor nephrectomy. For those who are starting kidney transplantation, open donor nephrectomy is a safe method. Key words: Nephrectomy; Kidney Transplantation; Living Donor.

Rectal impalement injury through the pelvis, abdomen and thorax

Impalement rectal injuries with intraperitoneal organ injuries are rare. It is even rarer for such injuries to result in pelvic, abdominal and thoracic internal injuries. We present the case of a 39-year-old man who was admitted after an assault where a broken broomstick was inserted forcibly into his rectum. Surgery revealed penetration through the rectum, dome of the bladder, mesentery, liver and right lung. The patient survived following management by a multispecialty surgical team. Our literature review identified four similar cases with one fatality only. Prognosis seems to be good in these types of injuries provided there is an early presentation, the penetrating object is left in situ before the operation and, most importantly, an organised team approach to deal with the various injuries.

腹部臓器損傷におけるDamage Control Surgeryの適応と意義

腹部臓器損傷におけるDamage Control Surgeryの適応と意義

Use of fourth arm in da Vinci robot-assisted extraperitoneal laparoscopic prostatectomy: Novel technique

Introduction The da Vinci robot-assisted laparoscopic radical prostatectomy is a relatively new approach that is revolutionizing the surgical treatment of localized prostate cancer. Since its introduction, several improvements have been made in the robot design model, as well as in the surgical technique for prostatectomy. One of the more recent advances in this technology has been the introduction of a four-arm robot model. This modified system allows the operating surgeon to use the fourth arm for key steps and maneuvers during the operation, thereby decreasing the reliance on advanced assistant laparoscopic skills. In this report, we describe our modifications for the extraperitoneal approach for laparoscopic removal of the prostate using the four-arm da Vinci surgical system. Technical Considerations During a 24-month period, 154 consecutive patients with clinically localized prostate cancer underwent extraperitoneal robot-assisted laparoscopic radical prostatectomy using the four-arm da Vinci robot system. All cases were videotaped and subsequently reviewed. Important factors regarding extraperitoneal access, patient positioning, port placement, and assistant role with or without the fourth arm were defined. Conclusions Our experience has revealed that the extraperitoneal approach allows for a more natural patient position during the operation and avoids intraperitoneal organ injury. The addition of the fourth arm to the da Vinci robot provides the operating surgeon with a great deal of independence, which facilitates all aspects of robot-assisted laparoscopic prostatectomy. It allows the operating surgeon to retract tissue during critical steps in this challenging operation and reduces the reliance on highly trained laparoscopic assistants.

Penetrating Torso Trauma: Triple-Contrast Helical CT in Peritoneal Violation and Organ Injury—A Prospective Study in 200 Patients

To assess the accuracy of computed tomography (CT) in demonstrating the presence or absence of peritoneal violation and type of intraperitoneal organ injury, if any, in hemodynamically stable patients with penetrating torso trauma but without definite peritoneal signs or radiographic evidence of free intraperitoneal air. During a 29-month period, helical CT with oral, rectal, and intravenous contrast material (triple-contrast) was performed in 200 hemodynamically stable patients, including 169 men (age range, 15-85 years; mean age, 31 years) and 31 women (age range, 17-45 years; mean age, 28 years) with penetrating torso trauma. The study group included 86 patients with gunshot wounds, 111 with stab wounds, and three impaled by sharp objects. CT scans were evaluated prospectively by three trauma radiologists for evidence of peritoneal violation to determine injury to intra- or retroperitoneal solid organs, bowel, mesentery, vascular structures, diaphragm, and urinary tract. Sensitivity, specificity, and accuracy of CT in the diagnosis of peritoneal violation were determined. CT findings aided diagnosis of peritoneal violation in 34% of patients (68 of 200) and were negative for peritoneal violation in 66% of patients (132 of 200). Two patients with negative CT findings failed to improve with observation and underwent therapeutic laparotomy. CT had 97% sensitivity (66 of 68 findings), 98% specificity (130 of 132 findings), and 98% accuracy (196 of 200 findings) for peritoneal violation. CT aided diagnosis of 28 hepatic, 34 bowel or mesenteric, seven splenic, and six renal injuries. Laparotomy based on CT findings in 38 patients was considered therapeutic in 87% (33 of 38) and nontherapeutic in 8% (three of 38) and had negative results in 5% (two of 38). Triple-contrast helical CT accurately demonstrates peritoneal violation and visceral injury in patients with penetrating torso wounds.

Retroperitoneal organ injury caused by anterior penetrating abdominal injury in children.

To describe the retroperitoneal organ injury pattern after anterior penetrating abdominal injury in children. The paediatric surgical department of a university teaching hospital. All children presenting with firearm and stab wounds to the anterior abdomen between January 1983 and April 2001. Forty-nine children (34%) with penetrating anterior abdominal wounds had retroperitoneal organ injury. The most injured organs were the descending colon in 17 patients (35%), ascending colon in eight patients (16%), and kidney in seven (14%). The most commonly associated injured organ was the small bowel. Postoperative septic complications were seen in 10 patients (20%). The most common postoperative complication was wound infection. When we compared patients with intraperitoneal organ injury with patients with retroperitoneal injury, there was no difference in parameters such as age, associated organ injury, morbidity and mortality between both groups. The main causative factor of retroperitoneal injuries was shotgun wounds, whereas it was stabbing in intra-abdominal injuries (P<0.05). The number of injured organs and the hospital stay is significantly greater in retroperitoneal organ injuries, and the trauma scores such as the Injury Severity Score (P<0.001) and the Penetrating Abdominal Trauma Index (P<0.001) were found to be significantly higher. Retroperitoneal organ injury is commonly associated with anterior penetrating abdominal trauma. Even if there is no preoperative sign of retroperitoneal organ injury, an exploratory laparotomy and a meticulous retroperitoneal exploration should also be performed for associated retroperitoneal organ injury.

Management of anorectal injuries in children: an eighteen-year experience.

Anorectal injuries (ARI) are rare in childhood and yet occur due to sexual abuse and firearm injuries in developed countries. The labeling of ARI remains controversial in spite of a number of divergent reports over the past decade. We evaluated the surgical indications for primary repair of ARI without stoma, and also the potential risk factors affecting morbidity and mortality in children with ARI. Between 1983 and 2001, 41 children were diagnosed as ARI in our institution due to blunt or penetrating trauma. There were 17 male and 24 female patients. Causes of anorectal injury were blunt injuries in the majority of cases (56 %). Vagina and extremity fractures were the organs most frequently associated with ARI. There was isolated ARI in 49 % of cases. Intraperitoneal organ injury was found in 3 patients (7 %). The distribution of injury location according to the classification of ARI in our children was as follows: 10 % in G I, 32 % in G II, 51 % in G III, and 10 % in G V. Primary repair without colostomy was performed in 51 % of cases. Primary repair and diversion of faecal stream by loop colostomy was required in 20 (49 %) patients. Postoperative septic complications occurred in 29 % of cases. Some potential risk factors such as trauma mechanism and associated organ injury were not significantly correlated to postoperative septic complications, while other risk factors such as mode of treatment, time of operative intervention and contamination were significantly related to postoperative septic complications (p < 0.05). The sensitivity of trauma scoring systems for the estimation of postoperative complication occurrence was significant for ISS (p < 0.05) and ARI score (p < 0.05). The relative risk of developing a postoperative septic complication was higher than 2 for patients with ARI grade III, ISS > 15, primary repair + colostomy group, and time of operative intervention > 8 hours. A child in the colostomy + primary repair group died on the first postoperative day from rapidly progressing septicaemia and multiple organ failure (2.4 %). The management of ARI can be carried out by primary repair procedure without colostomy in the majority of cases if the needed selectivity is established.

Outcome of Minimally Bleeding Liver and Spleen Injuries

Ultrasound and diagnostic peritoneal lavage can fail to detect intraparenchymal and subcapsular solid intraperitoneal organ injury when such injury