Laparoscopic Clips Research Articles

Laparoscopic clips can be a safe buttressing method for the sleeve gastrectomy operations: An experimental study on resected sleeve gastrectomy specimens

Background/Aim: Laparoscopic sleeve gastrectomy has been accepted in obesity surgery, as it provides rapid weight loss and has low mortality rates. However, because of the long staple line, leakage is a significant problem for these patients. Buttressing methods can be used to reduce the leakage. The aim of this study was to evaluate the efficacy of clips for buttressing the staple line on resected sleeve gastrectomy patients.Methods: The study included 20 patients aged 18–60 years who underwent laparoscopic sleeve gastrectomy surgery in our clinic. Any patients with connective tissue disease or with the removed stomach tissue not intact were excluded from the study. The age, gender, height, weight, and additional disease data were recorded. A manual manometer and inflation mechanism was created, and when the pressure suddenly dropped and a bubble was observed from the staple line, this value was recorded as the leakage pressure. By measuring the leakage pressure in the staple line by inflating the resected and removed stomach, leakage pressure and leakage location were recorded as no-clip leakage pressure. Then, the observed area of leakage was buttressed with laparoscopic clips, and the leakage pressure was measured once more by inflating the stomach; this value was recorded as the clipped leakage pressure. Results: The first pressure value observed had a mean of 43.8mmHg (range, 35–55 mmHg); after application of the clips, the mean was 43.8 mmHg (range (40–50 mmHg) (P = 0.20). The leakage was located in the upper section in 14 (70%) cases, in the mid-section in 5 (25%) cases, and in the lower section in 1 (5%) case. Micro-leakage was observed in 15 (75%) cases, 1-mm leakage in 1 (5%) case, 2-mm leakage in 2 (10%) cases, and 3-mm leakage in 2 (10%) cases. Conclusion: Leakage is the most significant complication following sleeve gastrectomy surgery. The use of laparoscopic clips was described as a buttressing method, but no positive effect of metal clips on leakage pressure was observed in our study. Clarification of the effect of the buttressing with metallic clips is required using in vivo and ex vivo experiments.

Uterine Artery Clipping at the Level of the Ureteric Tunnel for Reduction of Blood Flow

Study Objective Though cervical myomas comprise only 5% of total uterine myomas, they present unique surgical challenge due to proximity to the uterine vessels and ureters. We aim to highlight an approach to robotic-assisted hysterectomy with a large cervical fibroid, with minimal blood loss and clear visualization of the displaced anatomy. Design Video Case Presentation. Setting A robotic-assisted hysterectomy (RAH) was performed under general anesthesia in dorsal lithotomy position at a university-affiliated hospital. Patients or Participants 41-year-old G0 with abnormal uterine bleeding in the setting of 5 × 4 × 5 cm subserosal fibroid of the left posterior cervix. The patient was pretreated with leuprolide acetate injections then letrozole to reduce the fibroid volume, however, no change in size was observed. The patient desired definitive management of the fibroid. Interventions Once in the operating room, a uterine manipulator could not be placed due to displacement of the cervix by the fibroid. Careful retroperitoneal dissection was performed to identify the uterine artery coursing over the ureter at the ureteric tunnel of Wertheim. Laparoscopic clips were applied to the uterine artery to decrease blood supply to the fibroid. After completion of the hysterectomy, the fibroid capsule was entered and myomectomy was completed, resulting in separation of the fibroid from the vagina. Measurements and Main Results Estimated blood loss was 50 cc. Final specimen were uterus, fallopian tubes, and cervix weighing 54 g and cervical fibroid weighing 99 g. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. Conclusion This case demonstrates the use of minimally-invasive surgical approach to safely complete a hysterectomy in the context of a large, cervical myoma. Our video demonstrates improved hemostasis and visualization of the ureters throughout the case due to placement of vessel clips at the level of the ureteric tunnel. Though cervical myomas comprise only 5% of total uterine myomas, they present unique surgical challenge due to proximity to the uterine vessels and ureters. We aim to highlight an approach to robotic-assisted hysterectomy with a large cervical fibroid, with minimal blood loss and clear visualization of the displaced anatomy. Video Case Presentation. A robotic-assisted hysterectomy (RAH) was performed under general anesthesia in dorsal lithotomy position at a university-affiliated hospital. 41-year-old G0 with abnormal uterine bleeding in the setting of 5 × 4 × 5 cm subserosal fibroid of the left posterior cervix. The patient was pretreated with leuprolide acetate injections then letrozole to reduce the fibroid volume, however, no change in size was observed. The patient desired definitive management of the fibroid. Once in the operating room, a uterine manipulator could not be placed due to displacement of the cervix by the fibroid. Careful retroperitoneal dissection was performed to identify the uterine artery coursing over the ureter at the ureteric tunnel of Wertheim. Laparoscopic clips were applied to the uterine artery to decrease blood supply to the fibroid. After completion of the hysterectomy, the fibroid capsule was entered and myomectomy was completed, resulting in separation of the fibroid from the vagina. Estimated blood loss was 50 cc. Final specimen were uterus, fallopian tubes, and cervix weighing 54 g and cervical fibroid weighing 99 g. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. This case demonstrates the use of minimally-invasive surgical approach to safely complete a hysterectomy in the context of a large, cervical myoma. Our video demonstrates improved hemostasis and visualization of the ureters throughout the case due to placement of vessel clips at the level of the ureteric tunnel.

Complicated Duodenal Ulcer Postcolecystectomy in a Third Level Hospital in Mexico

Introduction: The migration of laparoscopic staple with complications such as duodenal ulcer is a rare postcolecystectomy complication. Complication that can occur at any time, but usually 2 years post cholecystectomy. In this report, a case of complicated duodenal ulcer that occurred 1 year after laparoscopic cholecystectomy is reviewed. Case Presentation: 42-year-old male, with bleeding from non-variceal upper gastrointestinal tract and severe epigastric pain. Surgical history of laparoscopic cholecystectomy CT scan: Plastron complex in vascular bed topography. The patient is scheduled for emergency surgery, laparotomy is performed with the following Findings: lax adhesions of the colon and liver, and omentum to the liver, firm adhesion of the first duodenal portion to the liver bed, with a 3 * 3 cm hematoma in said area that when opening its capsule, mucous duodenal evidence in said region with laparoscopic clips included in the tissue. Procedure performed Billroth II Histopathological report: duodenal ulcer, negative for neoplasia, viable surgical resection edges. follow-up without complications. Discussion: Cholelithiasis is common and laparoscopic cholecystectomy is the treatment of choice. Being one of the most performed surgeries since its introduction, surgical hemostatic clips have been widely used and are generally considered safe. Despite the increasing number of annual cholecystectomies performed, postcolecystectomy clip migration (PCCM) remains rare. Apart from migration to the biliary tree, is the cause of other complications such as duodenal ulcer or clip embolism. Conclusion: Complications such as duodenal ulcer of clips should always be present in patients with abdominal pathology and a history of recent cholecystectomy.

Autonomous Tissue Retraction in Robotic Assisted Minimally Invasive Surgery – A Feasibility Study

In this letter, we describe a novel framework for planning and executing semi-autonomous tissue retraction in minimally invasive robotic surgery. The approach is aimed at removing tissue flaps or connective tissue from the surgical area autonomously, thus exposing the underlying anatomical structures. First, a deep neural network is used to analyse the endoscopic image and detect candidate tissue flaps obstructing the surgical field. A procedural algorithm for planning and executing the retraction gesture is then developed from extended discussions with clinicians. Experimental validation, carried out on a DaVinci Research Kit, shows an average 25% increase of the visible background after retraction. Another significant contribution of this letter is a dataset containing 1,080 labelled surgical stereo images and the associated depth maps, representing tissue flaps in different scenarios. The work described in this letter is a fundamental step towards the autonomous execution of tissue retraction, and the first example of simultaneous use of deep learning and procedural algorithms. The same framework could be applied to a wide range of autonomous tasks, such as debridement and placement of laparoscopic clips.

PS01.133: ISCHEMIC CONDITIONING OF THE STOMACH PRIOR TO ESOPHAGECTOMY: TIMING AND TECHNIQUE MATTER

Abstract Description This video highlights one method of gastric ischemic conditioning prior to esophagectomy. Multiple reports of ischemic conditioning have not shown benefit, but these studies generally had a short time of ischemia (7–14 days), and did not have a consistent method of conditioning that includes both short gastric and left gastric vessels. Animal data shows that 30 days is likely the minimum timing needed for development of collateral blood flow through the body of the stomach. We have treated 13 patients with between 35 and 180 days of ischemic conditioning prior to esophagectomy, and none of these patients developed a leak, with only one requiring dilation of a benign anastomotic stricture. In these patients, 5 patients underwent a concominant feeding jejunostomy. In our experience, ligation of the arterial and venous blood supply is important, as is ligation of both short gastric and left gastric vessels. If the left gastric vessels cannot be seen, lesser curvature perforating vessels high on the proximal stomach may be ligated as well. We prefer to use the laparoscopic clips to ligate these vessels, while some groups use energy devices to divide the short gastric vessels and clips to occlude the left gastric vessels. This keeps the subsequent adhesive disease to a minimum, which is likely the major barrier to longer conditioning time. Indeed, the ideal timing of the ischemic conditioning procedure is prior to starting chemo-radio-therapy, giving 100 days or more of conditioning time. The video outlines a laparoscopic procedure that we feel is optimum for ischemic conditioning of the stomach. We believe this method has cracked the code of a very morbid procedure and made it into a slightly morbid procedure, which can still have complications, but the anastomotic complications are much less severe with improved perfusion to the gastric conduit. Leaks are less frequent and less severe, and symptomatic strictures are fewer in number. Future work in this area should focus on ischemic conditioning timing, as well as cancer-specific outcomes related to the conditioning procedure. Disclosure All authors have declared no conflicts of interest.

Erratum to: The effect of a performance-based intra-procedural checklist on a simulated emergency laparoscopic task in novice surgeons.

Surgical checklists are in use as means to reduce errors. Checklists are infrequently applied during emergency situations in surgery. We aimed to study the effect of a simple self-administered performance-based checklist on the laparoscopic task when applied during an emergency-simulated scenario. The aviation checklist for unexpected situations is commonly used for simulated training of pilots to handle emergency during flights. This checklist was adopted for use as a standardised-performance-based checklist during emergency surgical tasks. Thirty consented laparoscopic novices were exposed unexpectedly to a bleeding vessel in a laparoscopic virtual reality simulator as an emergency scenario. The task consisted of using laparoscopic clips to achieve haemostasis. Subjects were randomly allocated into two equal groups; those using the checklist that was applied once every 20 s (checklist group) and those without (control group). The checklist group performed significantly better in 5 out of 7 technical factors when compared to the control group: right instrument path length (m), median (IQR) 1.44 [1.22] versus 2.06 [1.70] (p = 0.029), right instrument angular path (degree) 312.10 (269.44 versus 541.80 [455.16] (p = 0.014), left instrument path length (m) 1.20 [0.60] versus 2.08 [2.02] (p = 0.004), and left instrument angular path (degree) 277.62 [132.11] versus 385.88 [428.42] (p = 0.017). The checklist group committed significantly fewer number of errors in the application of haemostatic clips, 3 versus 28 (p = 0.006). Although statistically not significant, total blood loss (lit) decreased in the checklist group from 0.83 [1.23] to 0.78 [0.28] (p = 0.724) and total time (sec) from 186.51 [145.69] to 125.14 [101.46] (p = 0.165). The performance-based intra-procedural checklist significantly enhanced the surgical task performance of novices in an emergency-simulated scenario.

The effect of a performance-based intra-procedural checklist on a simulated emergency laparoscopic task in novice surgeons.

Surgical checklists are in use as means to reduce errors. Checklists are infrequently applied during emergency situations in surgery. We aimed to study the effect of a simple self-administered performance-based checklist on the laparoscopic task when applied during an emergency-simulated scenario. The aviation checklist for unexpected situations is commonly used for simulated training of pilots to handle emergency during flights. This checklist was adopted for use as a standardised-performance-based checklist during emergency surgical tasks. Thirty consented laparoscopic novices were exposed unexpectedly to a bleeding vessel in a laparoscopic virtual reality simulator as an emergency scenario. The task consisted of using laparoscopic clips to achieve haemostasis. Subjects were randomly allocated into two equal groups; those using the checklist that was applied once every 20s (checklist group) and those without (control group). The checklist group performed significantly better in 5 out of 7 technical factors when compared to the control group: right instrument path length (m), median (IQR) 1.44 [1.22] versus 2.06 [1.70] (p=0.029), right instrument angular path (degree) 312.10 (269.44 versus 541.80 [455.16] (p=0.014), left instrument path length (m) 1.20 [0.60] versus 2.08 [2.02] (p=0.004), and left instrument angular path (degree) 277.62 [132.11] versus 385.88 [428.42] (p=0.017). The checklist group committed significantly fewer number of errors in the application of haemostatic clips, 3 versus 28 (p=0.006). Although statistically not significant, total blood loss (lit) decreased in the checklist group from 0.83 [1.23] to 0.78 [0.28] (p=0.724) and total time (sec) from 186.51 [145.69] to 125.14 [101.46] (p=0.165). The performance-based intra-procedural checklist significantly enhanced the surgical task performance of novices in an emergency-simulated scenario.

Post-laparoscopic cholecystectomy Mirizzi syndrome induced by polymeric surgical clips: a case report and review of the literature.

BackgroundLaparoscopic cholecystectomy is the gold standard treatment of gallbladder disease. Post-cholecystectomy syndrome is a severe postoperative complication which can be caused by multiple mechanisms and can present with multiple disorders. The wide use of laparoscopy induces the need to understand more clearly the presentation and pathophysiology of this syndrome. Post-cholecystectomy Mirizzi syndrome is one form of this syndrome and, according to literature, this is the first report that clearly describes it.Case presentationWe describe the case of a 62-year-old Greek woman who underwent laparoscopic cholecystectomy because of gallstone disease. A few days after surgery, post-cholecystectomy syndrome gradually developed with mild bilirubin increase in association with epigastric pain, nausea, and vomiting. After performing ultrasound, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography, we conducted a second laparoscopic surgery to manage the obstruction, which was converted to open surgery because of the remaining inflammation from the post-endoscopic retrograde cholangiopancreatography acute pancreatitis. Four polymeric laparoscopic clips were removed because they were identified as the cause of her post-cholecystectomy syndrome. She had a quick recovery without further complications.ConclusionsPostoperative Mirizzi syndrome induced by the migration of polymer laparoscopic clips is a rare (only one case referring to polymeric clips has been published in the literature) but a well-identified complication of laparoscopic cholecystectomy which can confuse the diagnostic and therapeutic field requiring simultaneous immediate management.

Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model.

Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation. Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer. Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76). Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.

Transvaginal NOTES-assisted laparoscopic nephrectomy: a survival study in a sheep model

This study aims to evaluate the feasibility and usefulness of an ovine model in order to perform natural orifice translumenal endoscopic surgery (NOTES) approach and laparoscopic nephrectomy for research and training purposes. Ten healthy female sheep were used to perform transvaginal NOTES-assisted right laparoscopic nephrectomy using a flexible 12-mm gastroscope through a vaginal access and two additional 5- and 10-mm trocars placed in the abdomen. The renal artery, the renal vein, and the ureter were dissected, and ligation was accomplished by using laparoscopic clips. The right kidney was retrieved transvaginally after enlarging the vaginal trocar incision. All data related with the surgical procedure, perioperative, and postoperative outcomes were recorded. The animals were monitored after surgery for a 30-day period with daily clinical follow-up. We established a useful animal model of transvaginal NOTES-assisted laparoscopic nephrectomy, performing the transvaginal approach and the abdomen exploration with no complications in any animals. The renal artery, the renal vein, and the ureter were identified, clipped, and transected combining the 5-mm laparoscopic access and the endoscopic vision in the whole group. Mean operative time was 86 ± 14.49 min, estimated blood loss was less than 20 ml in all cases, and there was no bleeding or laceration of adjacent organs. The animals recovered successfully in all cases postoperatively. After 1 month, exploratory laparotomy did not show alterations in abdominal cavity, and the vaginotomy incision healed completely in every animal. This experiment shows that transvaginal NOTES-assisted laparoscopic nephrectomy in ovine model is feasible and reproducible while offering an innovative possibility to help surgeons with this recent technology in the treatment of renal cancer. Well-managed experimental studies need to be carried out to determine the safety and efficacy of NOTES in the treatment of renal cancer.

Suturing for post cholecystectomy bile leaks: a safe and efficient technique

Figure 3 When the suturing is finished, a Lapra-Ty® clip is once again applied, eliminating the need for tying an intracorporeal knot. Figure 2 When the suture is passed, the use of pre-applied Lapra-Ty® clip eliminates the need for a knot. Figure 1 A Lapra-Ty® clip is applied to the suture length before inserting into the abdominal cavity. BACKGROUND Bile leak after laparoscopic cholecystectomy occurs in around 0.3–2.7% of patients.1 Re-laparoscopy is a useful diagnostic and therapeutic tool to facilitate identification of the site and nature of the leak, peritoneal lavage and repair. However, after identification of the site of leakage, if control cannot be obtained by application of laparoscopic clips, then laparoscopic suturing of the offending duct (either accessory duct of Luschka or cystic duct stump) is necessary and can be technically challenging, both due to a difficult angle to tie the laparoscopic knot and the ease with which sutures cut through the liver substance. TECHNIQUE We describe a simplified and efficient method for laparoscopic suturing and knot tying in this situation, using Lapra-Ty® absorbable suture clips (Ethicon Endo-Surgery, Caguas, Puerto Rico). A standard port length of 3/0 Prolene is used and a Lapra-Ty® clip is applied extracorporeally to the end of the suture, which is then introduced into the peritoneal cavity. The offending duct is sutured in a standard fashion and a second Lapra-Ty® clip is applied at the end of the suture as an alternative to intracorporeal knot tying. Figures 1–3 show a stylised version of the technique. DISCUSSION This method eliminates the need for intracorporeal knot tying, especially in areas of difficult access, and more importantly permits surgeons to apply the correct tension on tissues to secure control without the suture cutting through the gallbladder bed. The Lapra Ty® clips substitute for knots and also permit the surgeon to apply additional tension if required.2 The clip is composed of absorbable polydioxanone. It maintains tensile strength for 14 days and is completely absorbed by 90 days.2

Robotic assisted laparoscopic treatment of gonadal vein syndrome in a boy

Gonadal vein syndrome, with ureteral obstruction and compression by an overlying testicular vein is a controversial and rare diagnosis. Open, laparoscopic, and robot-assisted laparoscopic repairs have been described. We report the first case of robot-assisted gonadal vein ligation for treatment of gonadal vein syndrome in a nine year-old boy. A 9 years-old boy presented with a four to six month history of worsening intermittent flank pain, nausea and vomiting. Ultrasound revealed moderate hydronephrosis. Diuretic renography and intravenous pyelography reproduced his pain and demonstrated left-sided hydronephrosis and obstruction. The patient underwent left robot-assisted surgery via a four port approach. The colon was reflected medially. The gonadal vein was dissected off the underlying ureter and ligated using laparoscopic clips. Segmental vein excision and ureterolysis was performed. Inspection of the renal hilum did not reveal any other crossing vessels. Operative time was 94 minutes. The patient was discharged 36 hours after surgery. His hydronephrosis has resolved completely. He remains pain-free nine months after surgery. Robot-assisted laparoscopic vein excision and ureterolysis is a safe option for the management of ureteral obstruction caused by the gonadal vein.

Magnetic retraction for NOTES transvaginal cholecystectomy

Natural orifice translumenal endoscopic surgery (NOTES) has the potential to decrease the burden of an operation on a patient. Limitations of the endoscopic platform require innovative solutions to provide retraction and create an operation comparable with the gold standard, laparoscopic cholecystectomy. Four patients underwent transvaginal cholecystectomy. All procedures were performed under laparoscopic vision to ensure safety. The endoscope and a long articulating RealHand instrument were placed via a 15-mm vaginal trocar. A magnetic retraction system was used to retract the gallbladder safely. Laparoscopic clips were used to ligate the cystic duct and artery. All four gallbladders were successfully removed. No complications occurred. The mean operating time was 102 min. All four procedures were completed without complications. The four patients all were discharged shortly after surgery and reported normal sexual activity without pain. Transvaginal cholecystectomy can be completed safely using current technology. Further studies are needed to determine the safety of the procedure and to determine whether it confers any benefits other than cosmesis.

NOTES: transvaginal cholecystectomy with assisting articulating instruments

Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques. A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min. The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics. The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach.

Transvaginal Endoscopic Cholecystectomy in Human Beings: Preliminary Results

The exciting concept of performing surgery in the peritoneal cavity without abdominal incisions by means of flexible endoscopes introduced through natural orifices-natural orifice transluminal endoscopic surgery (NOTES) has been widely investigated in recent years in experimental settings. However, experience with this procedure in human beings is still lacking. In this paper, we report the preliminary results of a small consecutive series of transvaginal endoscopic cholecystectomies. A standard double-channel gastroscope introduced into the abdominal cavity through a posterior colpotomy was used to perform the cholecystectomy. The introduction of a 5-mm trocar in the left-upper abdominal quadrant was mandatory to create and monitor the pneumoperitoneum and allow the application of the standard laparoscopic clips. This port was also used to introduce a grasper that assisted in the exposure of the gallbladder. The gallbladder was removed through the vagina and was protected in a plastic bag. Since July 2007, 3 patients were successfully operated on by this approach, including 1 morbidly obese woman with a body mass index (BMI) of 45. The mean operative time was 136 minutes (range, 110-190). No postoperative complications occurred, and the patients did not complain of pain at both access sites. At the 1-month follow-up, none of the patients complained of dyspareunia. The transvaginal cholecystectomy is feasible, safe, and reproducible in women within a wide range of BMI. NOTES might dramatically change the way surgery will be conceived and performed in the future, as it holds the potential to abolish the historic association of surgery with pain and scars.

What We Learned From the Experience of Laparoscopic Splenectomy in Patients With Idiopathic Thrombocytopenic Purpura (ITP)???Single Surgeon Experiences

From October 1994 to December 2004, 50 cases of laparoscopic splenectomy (LS) have been carried out by a single surgeon for treating patients with idiopathic thrombocytopenic purpura (ITP). This study was performed to analyze a single surgeon's experiences of LS in ITP and discuss lesions that we have learned and the technical changes based on perioperative outcomes of LS. It seems that strict right lateral decubitus is definitively the position of choice because it ensures good exposure of splenic vascular structure in hilum. We also found that a flexible scope or 45-degree angled telescope, not to mention a 30-degree one, allowed for optimal vision, and made laparoscopic procedures easy and secure. We could control the vascular structure safely by just applying 5-mm laparoscopic clips without using harmonic scalpel or endo-GIA. When delivering spleen, it maybe easy and safe way to remove the plastic pouch with spleen fragmented through the umbilical port after changing the patient's position to supine again.

Bipolar electrocoagulation for clipless division of left renal vein branches during laparoscopic living donor nephrectomy

We present our experience of using the bipolar electrocautery for division of the left renal vein branches in laparoscopic right living donor nephrectomy. This has been performed in 160 cases with no complications related to the technique. The absence of laparoscopic clips allows easier and safer placement of the endostaple.

Use of an endoscopic suturing device for laparoscopic resection of the apex of the bladder and umbilical structures in normal neonatal calves.

To develop a laparoscopic technique using an endoscopic suturing device for the resection of the apex of the bladder and the umbilical structures in large-animal neonates. Study Design-Experimental study. Animals or Sample Population-Seven healthy male Holstein calves. A laparoscopic technique for resection of the apex of the bladder was developed on 2 calf cadavers, then evaluated on 5 anesthetized calves. The calves were positioned in dorsal recumbency, and 4 ventral abdominal portals were used. The umbilical vessels were double-ligated using an endoscopic suturing device and subsequently transected. The apex of the bladder was transected between a row of laparoscopic clips applied near the apex and atraumatic laparoscopic forceps applied distally; then, the edges were apposed using an endoscopic suturing device. The dissected umbilical remnants were removed from the abdomen through a small incision centered at the umbilicus. One month later, the calves were euthanatized and a second-look laparoscopy performed; then, bladders were collected for gross and histologic examination. No major complications occurred during or after surgery. The endoscopic suturing device permitted both effective ligation of the umbilical vessels and closure of the bladder. During second-look laparoscopy, healing of the peritoneal surface of the bladder and umbilical vessels was assessed to be excellent in 4 calves. A focal adhesion of omentum to the bladder suture line was observed in 1 calf. Focal adhesions of the omentum to the umbilical incision site occurred in 2 calves. The bladder mucosa was completely healed at the surgical sites. Resection of the apex of the bladder and umbilical vessels in calves can be accomplished laparoscopically using an endoscopic suturing device.

RETROPERITONEOSCOPY ASSISTED LIVE DONOR NEPHRECTOMY: THE YONSEI EXPERIENCE

Retroperitoneoscopy assisted live donor nephrectomy has become standard based on our experience with 103 consecutive cases operated on between January 1993 and May 2000. We describe the advantages of retroperitoneoscopy assisted compared to laparoscopic live donor nephrectomy. After performing more than 1,200 cases of open live donor nephrectomy (S. C. Y.), we combined our experience with open and laparoscopic surgery to develop a specific technique of minilaparotomy live donor nephrectomy. Operations were performed by 1 senior surgeon and 1 assistant, with the help of specially designed piercing abdominal and peritoneal retractors. A 5 to 7 cm. transverse pararectal skin incision is made at the level of 10th rib and the abdominal muscles are split without division. A 10 mm. port is placed at the lower abdomen to allow for the telescope. The procedure is performed extraperitoneally, combining open and laparoscopic instruments under direct vision. Renal pedicles and ureters are ligated using laparoscopic clips and sutures. The kidney is removed via laparotomy and the wound is closed. Average operating time for the 103 live donor nephrectomies was 130 minutes (range 85 to 210), and there was no case of kidney loss, open surgical conversion or blood transfusion. Mean warm ischemia time was 2.3 +/- 1.2 minutes and average incision length was 6.5 cm. (range 5.1 to 7.0). Postoperative pain was minimal and analgesics were generally not required by postoperative day 2. Patients were fully ambulatory a mean 1.5 days (range 1 to 3.5) postoperatively. Retroperitoneoscopy assisted live donor nephrectomy is not only feasible, but reproducible. Any surgeon with previous experience with conventional open live donor nephrectomy can perform this hybrid, minimally invasive procedure.

How secure are the arteries occluded by a newly developed ultrasonically activated device?

We developed a new ultrasonically activated device (USAD) for endoscopic surgery. The current investigation was conducted to evaluate the security of the arteries occluded and divided by this USAD. The intraperitoneal arteries of anesthetized living pigs were individually occluded by the USAD at power levels of 70% or 100%. The burst pressures of the harvested arteries were measured in vitro. For comparison, arteries occluded by laparoscopic clips or silk ligatures were evaluated in the same manner. The pressures to burst the occluded artery ranged from 353 to 2,148 mmHg with an average of 1,204 mmHg in the USAD group at 70% power level; from 324 to 2,207 mmHg with an average of 1,193 mmHg in the USAD group at 100% power level; from 794 to 1,868 mmHg with an average of 1,421 mmHg in the clip group; and from 618 to 3,207 mmHg with an average of 1,586 mmHg in the silk ligature group. The data suggest the improbability that small- to medium-size arteries appropriately occluded and divided by the USAD can burst when exposed to intravascular pressures commonly found in living animals.