Laparoscopic Closure Research Articles

Study of Risk Factors Leading to Conversion of Laparoscopic Simple Closure to Open Surgery in Perforated Peptic Ulcer

Study of Risk Factors Leading to Conversion of Laparoscopic Simple Closure to Open Surgery in Perforated Peptic Ulcer

Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil.

the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil. retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period. the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Needle consideration in umbilical two-port laparoscopic percutaneous extraperitoneal closure for patent processus vaginalis of children: hook-needle or forcep-needle

BackgroundAlthough umbilical two-port laparoscopic percutaneous extraperitoneal closure for the treatment of processus vaginalis patency of children has been verified to be safe and effective, the improvements of technical skills and instruments have been always on their ways. Recently, forcep-needle has begun to be used. In this study, we compared forcep-needle with hook-needle in this minimal invasive procedure for children suffered from hernia or hydrocele, with the aim to evaluate the instrumental convenience of the two needles.MethodsFrom July 2021 to May 2022, we begun to use hook-needle or forcep-needle in umbilical two-port laparoscopic percutaneous extraperitoneal closure for children suffered from hernia or hydrocele. The hook-needle group included nineteen children and the forcep-needle group included twenty-four ones. The data of the patients age, sex, side, operation time, postoperative hospital-stay, follow-up time, postoperative complications were evaluated. Common silk thread was used to encircle the internal ring preperitoneally.ResultsThere were no statistical differences between the two groups for the following items: age, sex, side, operation time, postoperative hospital-stay and postoperative complications (P > 0.05). The follow-up time of the hook-needle group was longer than that of the forcep-one (P = 0.0020). No open transfer happened for all the patients. One hydrocele boy in the hook-needle group reoccurred 1 month postoperatively due to the peritoneal broken. The single pole retreating of the hook-needle accompanied with chaotic movements, while for that of the forcep-needle, the double-arm retreating movements were more orderly. The outer surface of the forcep-needle was smooth without restrain, as for the hook-needle, an inlaid barb held the danger of brokening the peritoneum.ConclusionIn our preliminary experience of umbilical two-port laparoscopic percutaneous extraperitoneal closure using a hook-needle or a forcep-needle, in view of the instrumental convenience and safety, the double-arm and smooth outer surface designs of the forcep-needle contained more spatial orientation perceptions and safety.

Impact of the Recorded Audio and Video Feedback on Simulated Surgical Performance: A Randomized Controlled Trial.

Simulation and coaching have become increasingly important in laparoscopic skills acquisition.This study was designed to evaluate if access to the recorded audio and video feedback after a single proctored session improves the acquisition of laparoscopic suturing skills in obstetrics and gynecology (OB/GYN) residents. Twenty OB/GYN residents received a single face-to-face coaching session on a laparoscopic vaginal cuff closure model. The session was recorded and residents were randomized to access either the video-only or the audio and video recording of the proctored session. The primary outcome measure was comparison of Global Operative Assessment of Laparoscopic Skills plus Vaginal Cuff Metrics (GOALS+) scores of the vaginal cuff closure prior to and following the proctored session. Only 30% of residents accessed the recorded sessions with junior residents most likely to access the recording.Baseline GOALS+ scores were significantly higher in senior residents (mean 21.7, SD 3.9) as compared to junior residents (mean 14.7, SD 3.2) (p<.001). While all learners' GOALS+ scores significantly improved after proctoring the intervention (p<.001), the senior residents continued to have significantly higher GOALS+ scores at the final assessment (mean 28.3, SD 4.2, p=.01) when compared to their junior residents (mean 24.0, SD 3.1). Due to the low uptake of the review of recorded proctored sessions among OB/GYN residents across skill and year levels, we were unable to assess the effect of recorded audio and video feedback on resident performance. However, the intervention of a single proctored session of simulated laparoscopic vaginal cuff closure significantly improved resident performance as assessed with GOALS+ scores.

Double Trouble: Tips for Colpotomy and Vaginal Cuff Closure with Uterine Bicollis and Longitudinal Vaginal Septum

<h3>Study Objective</h3> To describe the laparoscopic technique for colpotomy, approach for laparoscopic excision of longitudinal vaginal septum, laparoscopic cuff closure with and without intact vaginal septum and considerations for uterine manipulation in patients with uterine bicollis and longitudinal vaginal septum. <h3>Design</h3> Two case reports. <h3>Setting</h3> Two laparoscopic cases at a single tertiary care center in the United States. <h3>Patients or Participants</h3> Two patients undergoing total laparoscopic hysterectomy (TLH) with uterine bicollis and longitudinal vaginal septa, one with a bicornuate uterus and one with uterine didelphys. <h3>Interventions</h3> The first patient with bicornuate uterus underwent TLH using a manipulator with small colpotomizer cup to accommodate the small caliber of the hemivagina and cervices. Colpotomy was performed by placing the manipulator first in the right cervix, then the left. Her vaginal septum left in situ as it was not bothersome. The septum was successfully integrated into the vaginal cuff. The second patient with uterine didelphys underwent TLH using a manipulator without a cup. The colpotomy was completed in a similar manner. Her septum was excised laparoscopically as it caused dyspareunia. The vaginal defect was repaired laparoscopically and cuff closed in the usual fashion. <h3>Measurements and Main Results</h3> Options for manipulation include a small manipulator cup, a manipulator without cup, vaginal devices such as sponge stick, vaginal/rectal probe or Briesky-Navratil retractor. Vaginal septa can be successfully incorporated into the vaginal cuff from a laparoscopic closure or excised laparoscopically. <h3>Conclusion</h3> Alternative means for uterine manipulation are often necessary in patients with uterine bicollis and longitudinal vaginal septa. Longitudinal vaginal septa can be successfully incorporated into the vaginal cuff for laparoscopic closure or excised and repaired laparoscopically.

Left in the Dark: Laparoscopic Cuff Closure for Left-Handed Learners

<h3>Study Objective</h3> This video seeks to educate both learners and educators on techniques for left-handed laparoscopic vaginal cuff closure through three different port configurations. It also aims to highlight disparities between right and left-handed trainees in surgical training and mentorship. <h3>Design</h3> Narrated surgical video. <h3>Setting</h3> Two teaching hospitals (academic and community based). <h3>Patients or Participants</h3> Three patients undergoing total laparoscopic hysterectomy for various indications. <h3>Interventions</h3> Left-handed laparoscopic vaginal cuff closure through three different port configurations. <h3>Measurements and Main Results</h3> We illustrate several key points for educators and left-handed learners including: -Port placement options for the left-handed surgeon -Advantages and disadvantages of various port configurations -Recommended direction of suturing based on port placement -Techniques for assisting a left-handed surgeon -Direct comparison between right and left-handed suturing, demonstrating that they are mirror images of one another <h3>Conclusion</h3> Left-handed laparoscopic vaginal cuff closure can be effectively accomplished through any port configuration. Educators and left-handed learners should be familiar with port placement options, techniques for assisting a left-handed surgeon, and direction of suturing for left-handed cuff closure to optimize surgical education and minimize patient time under anesthesia.

7643 Use of Augmented Reality Training to Improve Laparoscopic Vaginal Vault Closure Metrics

<h3>Study Objective</h3> To assess the impact of Augmented Reality Training on improving Laparoscopic Vaginal Vault Closure using objective performance metrics. <h3>Design</h3> Utilising the LapAR by Inovus Medical Ltd (UK), we asked Obstetrics and Gynecology trainees to perform several Augmented Reality simulated vaginal-vault closures interspersed with LapPass (UK equivalent of FLS) tasks. Objective metrics measured includes: time to completion, distance travelled, smoothness, acceleration, handedness and time in view. Comparison was made with a benchmark score set by an experienced MIGS surgeon. Subjective performance feedback was also provided by experienced MIGS surgeons using the OSATS framework. <h3>Setting</h3> Within an NHS (National Health Service) University Teaching hospital in South London. <h3>Patients or Participants</h3> Obstetrics and Gynecology junior trainees (SHO's and registrars) - US equivalent of residents and fellows. <h3>Interventions</h3> During the course, benchmarks of both LapPass tasks and Vaginal Vault closures were set by each trainee in addition to an experienced MIGS surgeon. Trainees were then asked to perform a series of tasks including further Vaginal Vault closures and LapPass tasks. Following this period of intervention, trainees were set one final benchmark to compare to their original. <h3>Measurements and Main Results</h3> We found that the performance metrics improved when comparing initial & final benchmarks. In addition, the final benchmark metrics of the trainees were compared in a standardisation exercise to the benchmark set by the experienced MIGS surgeon. Of note, time to completion and distance travelled were both markedly reduced following the intervention period. OSAT based review of performance demonstrated a marked improvement in surgical skill. <h3>Conclusion</h3> Augmented Reality task training using a high-fidelity Laparoscopic box trainer such as the LapAR improves objective and subjective performance in vaginal vault closure. It can be inferred that this technique improves the surgical learning curve whilst safely taking it away from the live patient.

Management of Vaginal Vault Dehiscence after Laparoscopic Hysterectomy

<h3>Study Objective</h3> To review the epidemiology, diagnosis and management of vaginal vault dehiscence, and to illustrate a 5-step surgical approach to laparoscopic vault repair. <h3>Design</h3> Surgical footage was obtained from an emergency case after appropriate consent from the patient. <h3>Setting</h3> A tertiary care centre. <h3>Patients or Participants</h3> A 34-year-old female who presented 8 weeks after a total laparoscopic hysterectomy with a complete vault dehiscence. <h3>Interventions</h3> Vaginal vault dehiscence complicates 0.64% to 1.35% of laparoscopic hysterectomies, and can be categorized as complete cuff dehiscence, partial cuff dehiscence or partial thickness. Protective factors include the use of barbed sutures as compared to non-barbed sutures and laparoscopic closure as compared as compared to vaginal closure. Smoking and low BMI have been associated with an increased risk of dehiscence. <h3>Measurements and Main Results</h3> The surgical approach to a laparoscopic repair of cuff dehiscence can be standardized in 5 reproducible steps: abdominal survey, bladder and/or rectal dissection, vault debridement, vault closure and cystoscopy. <h3>Conclusion</h3> Vaginal vault dehiscence being uncommon, residents may graduate without being exposed to a case. This video represents an educational tool that covers the clinical and surgical approaches to the reproducible management of vaginal vault dehiscence.

7578 Hysterectomy with or without Oophorectomy for Transgender Male Patients: Preoperative and Intraoperative Considerations

<h3>Study Objective</h3> To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender male patients. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Approximately 0.3% of hysterectomies performed annually in the U.S. are for transgender male patients, most commonly to alleviate gender dysphoria. A hysterectomy with or without oophorectomy can be offered to patients who have met criteria outlined by the World Professional Association for Transgender Health (WPATH) guidelines. <h3>Patients or Participants</h3> Transgender male patients seeking hysterectomy with or without oophorectomy. <h3>Interventions</h3> Important perioperative counseling points for transgender male patients include: •Establishing terminology to minimize gender dysphoria •Discussing options for fertility preservation •Discussing the importance of continuing testosterone therapy post-oophorectomy to reduce the loss of bone density •Reviewing intraoperative and postoperative expectations Important intraoperative considerations for the performance of safe and effective hysterectomy with or without oophorectomy for transgender male patients include: •Maintaining a margin of at least 2 cm between the surgical instrument and the ovary during coagulation and transection of the infundibulopelvic ligament to prevent ovarian remnant syndrome •Performance of a two-layer vaginal cuff closure to reduce the risk of vaginal cuff complications <h3>Measurements and Main Results</h3> The patients recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, it is essential to minimize the patient's experience of gender dysphoria by providing gender-affirming care before, during and after surgery. In particular, the surgeon should take care to perform oophorectomy with an adequate margin to minimize the risk of ovarian remnant syndrome and use a two-layer laparoscopic vaginal cuff closure to decrease the risk of vaginal cuff complications.

Laparoscopic Suturing of the Vaginal Cuff: A Surgical Education Module for Obstetrics and Gynecology Residents

<h3>Study Objective</h3> We aim to review the assembly of a laparoscopic box trainer with a validated vaginal cuff model and to highlight principles for efficient two-handed laparoscopic vaginal cuff closure using three unique port configurations (ipsilateral, contralateral, and midline). This video was created as part of a surgical education module for Obstetrics and Gynecology residents. <h3>Design</h3> Surgical education video. <h3>Setting</h3> Laparoscopic box trainer with a validated vaginal cuff model. <h3>Patients or Participants</h3> Education module for Ob/Gyn resident physicians. <h3>Interventions</h3> The validated vaginal cuff model incorporates multiple layers to represent the vaginal epithelium and vaginal wall. We demonstrate laparoscopic suturing using a running technique from ipsilateral, contralateral, and suprapubic port configurations. A braided suture with a knot at the end simulates a unidirectional barbed suture that does not require knot tying. Critical steps needed for proper cuff closure are highlighted. <h3>Measurements and Main Results</h3> In this video, we highlight a reproducible setup of a validated vaginal cuff model within a laparoscopic box trainer. We demonstrate correct needle loading for enhanced accuracy in needle entry and exit. Efficient techniques to achieve adequate exposure, incorporation of vaginal epithelium, appropriate suture tension, and optimized ergonomics are also reviewed. <h3>Conclusion</h3> We present a surgical education video to teach safe and efficient laparoscopic suturing techniques to Ob/Gyn resident physicians using multiple two-handed port configurations. Key surgical principles include proper needle loading, needle entry, exposure, and optimized ergonomics.

8387 Instructional Video on Tandem Vaginal Cuff Closure

<h3>Study Objective</h3> To demonstrate the steps of tandem vaginal cuff closure, outline specific movements of the surgeon and assistant, and provide suggestions for efficient closure. <h3>Design</h3> Instructional Video. <h3>Setting</h3> Operating room of large academic hospital. <h3>Patients or Participants</h3> Single patient undergoing a laparoscopic vaginal cuff closure at the time of hysterectomy. <h3>Interventions</h3> In this technique, two surgeons close the vaginal cuff at the time of hysterectomy through an umbilical port for the 5mm camera and two 5mm lateral ports for instrumentation. This eliminates the need for fascial closure and improves cosmesis. The surgeon stands at the patient's left and holds the needle driver in the right hand. The surgeon positions the needle correctly to facilitate an efficient and effective cuff closure starting from the patient's right and proceeding toward the left. The direction of closure is from posterior to anterior. At least 5mm of vaginal mucosa is incorporated into each bite, and uterosacral and cardinal ligaments are incorporated bilaterally to provide support. A key component is to push the needle through the tissue, with over supination of the surgeon's wrist while lifting the needle cephalad. This over-supination allows better visualization and provides the correct angle for needle reloading. The assistant, standing on the patient's right, provides visualization, places the loop of the barbed suture over the needle, and manipulates the anterior or posterior cuff over the needle. <h3>Measurements and Main Results</h3> Complete and efficient vaginal cuff closure with incorporation of uterosacral and cardinal ligaments for support. <h3>Conclusion</h3> With the use of two skilled surgeons, we demonstrate the efficient movements required to carry out a tandem vaginal cuff closure.

Ring closure outcome for laparoscopic ventral hernia repair (IPOM plus) in medium and large defects. Long-term follow-up.

Despite advances in laparoscopic ventral hernia repair (LVHR) with the Intra-peritoneal onlay mesh technique (IPOM), recurrence continues to be a frequent postoperative complication. The aim of this study is to analyze the long-term recurrence rate in two series, by incorporating in IPOM technique the laparoscopic closure of the defect (IPOM plus). We also want to determine the ring size cut-off point from which the recurrence risk increases in IPOM technique and determine if the cut-off point is modified with IPOM plus technique. A comparative retrospective study was conducted analyzing patients who underwent LVHR. They were divided into 2 groups according to the surgical technique used: IPOM or IPOM plus. We determined in each group the cut-off point where the ring size presents a greater recurrence risk by calculating the better point of sensitivity/specificity relationship of the ROC curve. Between 2007 and 2018, 286 patients underwent LVHR. The ROC curve for IPOM technique has shown a cut-off point of higher recurrence risk for rings larger than 63 cm2. While the ROC curve in IPOM plus group showed an increase in the cut-off point, with a higher recurrence risk in rings > 168cm2. Overall median ring size was 30 cm2 (range 4-225; IQR 16-61). However, when comparing the ring size between techniques we found a relatively larger size in IPOM plus (p: 0.013). The recurrence rate in the IPOM group was 19.51% while in the IPOM plus group was 3.57% (p: 0.005). For standard LVHR with IPOM technique, the greatest recurrence risk occurs in rings larger than 63cm2. The addition of ring closure (IPOM plus) was associated with a recurrence risk reduction, which occurs in rings larger than 168cm2. These findings would allow expanding the indication for LVHR, using the IPOM plus technique.

How Can Laparoscopic Appendectomy Become the First-Line Treatment for Acute Appendicitis in Lower-Income Countries: A 15-Year Experience

Introduction: The barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource cost and availability. The present study evaluates the impact of actions took over 15 years in a single academic center aiming to implement the routine use of laparoscopy for acute appendicitis. Methods: Retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared with 4 major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. Results: We identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p < 0.001). Since 2016 the standard of care in our institution is appendiceal stump closure with polymeric clips, even in complicated acute appendicitis. Conclusion: The development of a feasible, reproducible, and safe technical standardization is one of the cornerstones for a consistent and viable change in the current practice for appendectomies in lower-income countries.

Successful laparoscopic repair for reduction en masse of infantile inguinal hernia: a case report of this rare condition.

BackgroundReduction en masse (REM) is a rare condition following manual inguinal hernia (IH) reduction in which a hernia sac is reduced back into the preperitoneal space with a loop of the bowel incarcerated at the neck of the sac. It resembles successful manual reduction and may thus be overlooked easily. We herein report an infantile case of REM of an IH that was successfully treated laparoscopically.Case presentationA 10-month-old boy with a surgical history of bilateral open IH repair at 4 months old presented with a bulge in his left groin and vomiting. A left incarcerated recurrent IH was suspected, and manual reduction was performed. The hernia was apparently reduced successfully, but abdominal distention and vomiting persisted. He was admitted for further observation due to the symptoms. On day 2 after admission, abdominal X-ray showed extensive small bowel obstruction (SBO). Enhanced computed tomography (CT) revealed protrusion of the small bowel with a closed-loop in the left groin. A closed-loop SBO due to postoperative adhesion or an internal hernia was suspected. To assess the etiology of SBO, emergent laparoscopic exploration with hernia repair was planned. Laparoscopy revealed REM of the left incarcerated IH with a thickened peritoneum at the neck of the sac. Laparoscopic reduction was performed, and the incarcerated small bowel showed no signs of ischemia. The hernia sac was not associated with the previously ligated processes vaginalis, which had been closed by a previous Potts’ procedure. It was located at the inside of the processes vaginalis. The sac was successfully closed by laparoscopic percutaneous extraperitoneal closure procedures, and iliopubic tract repair was also performed via the previous inguinal incision. The postoperative course was uneventful.ConclusionPediatric IH is due to the patent processes vaginalis, and REM is extremely rare. Laparoscopic surgery for REM is a relatively common and useful approach for the diagnosis and treatment of adults. In our infantile case, the laparoscopic approach was similarly effective for both investigating the cause of SBO and performing high ligation of the sac for this rare condition with IH.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40792-022-01535-1.

Comparison of laparoscope-assisted single-needle laparoscopic percutaneous extraperitoneal closure versus open repair for pediatric inguinal hernia

BackgroundLaparoscopic-assisted repairs for pediatric inguinal hernia have gained gradual acceptance over the past decade. However, consensus about the optimal management is still lacking. The aim of this study is to compare outcomes of a modified laparoscope-assisted single-needle laparoscopic percutaneous extraperitoneal closure (LPEC) versus open repair of pediatric hernias/hydrocele in a single institution.Materials and methodsWe retrospectively reviewed the medical data of children who underwent laparoscope-assisted single-needle LPEC and open repair (OR) for inguinal hernia from 2014 to 2019. Data collection included demographics, laterality of hernia, surgical time and time to follow-up. We also reviewed and analyzed the evidence of recurrence, the incidence of metachronous contralateral inguinal hernia (MCIH), and other complications.ResultsIn our cohort, 961 patients in the OR group and 1098 patients in the LPEC group were analyzed retrospectively. Mean operative time was significantly shorter in the LPEC group (22.3 ± 3.5 min) than in the OR group (27.8 ± 5.9 min) for bilateral hernia repair (p < 0.001). Postoperative recurrence was 1.3% (13/1035) in the OR group and 0.5% (6/1182) in the LPEC group (p = 0.056). Iatrogenic cryptorchidism occurred statistically more frequently in the OR group than in the LPEC group (0.4% vs. 0%, p = 0.013). In addition, the incidence of MCIH was 3.7% (33/887) in the OR group and 0.3% (3/1014) in the LPEC group (p < 0.01).ConclusionComparing to open technique, laparoscope-assisted single-needle LPEC provides a simple and effective option for pediatric inguinal hernia/hydrocele repair with excellent outcomes, a low incidence of recurrence, and reduced MCIH.

A case of bilateral inguinal hernia associated with Marfan syndrome

Marfan syndrome, a connective tissue disease, is associated with a high incidence and recurrence rate of inguinal hernia. We herein report a three-year-old boy with bilateral inguinal hernia associated with Marfan syndrome. While preoperative contrast-enhanced computed tomography (CT) revealed a left indirect inguinal hernia and a right direct inguinal hernia, laparoscopy showed bilateral patent processus vaginalis (PPV) and vulnerability of the abdominal wall at the bilateral medial inguinal fossae. In addition to laparoscopic percutaneous extraperitoneal closure (LPEC), open iliopubic tract repair was also performed. To our knowledge, this is the first report of a therapeutic strategy for pediatric inguinal hernia with Marfan syndrome. • Children with Marfan syndrome may develop direct inguinal hernias. • Computed tomography while awake in the prone position led to the diagnosis. • Combined laparoscopic and open hernia repair were useful.

WE5.3 Emergency laparoscopic “hybrid” IPOM+ repair of incarcerated umbilical hernia in patient with BMI 62 and small bowel obstruction; a case study

Abstract Background Large abdominal incisions in obese patients are associated with considerable rates of systemic and wound complications. Recently published European Hernia Society guidelines recommend laparoscopic intraperitoneal on-lay mesh (IPOM) repair for large hernia defects and patients at higher risk of wound morbidity, ideally with closure of the defect and a 5 cm overlap. Case Presentation: We report on a 69-year-old, morbidly obese (BMI 62), comorbid woman who presented as an emergency with a 5-day history of vomiting and abdominal pain. A pre-operative computed tomography (CT) scan confirmed small bowel obstruction secondary to a ventral abdominal wall hernia. Operative findings confirmed an obstructed paraumbilical hernia containing small bowel and omentum. A laparoscopic “hybrid” IPOM+ repair was performed, with a generous overlap. She recovered uneventfully with no surgical complications. Discussion: Minimally-invasive surgical techniques are preferred for obese patients with evidence suggesting lower perioperative complications and recurrence rates compared with open repair. However, additional challenges must be taken into consideration including; surgeon expertise, timing of operation, surgeon ergonomics, distortion of surface anatomical landmarks, need for higher pneumoperitoneum pressures and the physiological effects of this on the patient. Conclusion With preoperative planning, our case study demonstrates that IPOM ventral hernia repair remains a viable option for severely obese patients even in emergency presentations. The closure of the defect is recommended whenever feasible. Addition of the hybrid approach (excision of the sac with a limited incision after the laparoscopic closure) reduces the risk of postoperative seromas.

Single-port laparoscopic percutaneous extraperitoneal internal ring closure for paediatric inguinal hernia using a needle grasper.

Single-site laparoscopic percutaneous extraperitoneal closure has been widely used for the repair of paediatric inguinal hernia. In this study, we aimed to introduce the usage of a needle grasper in single-port laparoscopic herniorrhaphy in children. In our study, 447 children with inguinal hernia underwent single-port laparoscopic percutaneous extraperitoneal closure between October 2018 and October 2021 in Shenzhen Children' hospital were retrospectively reviewed. Among 447 patients, there were 396 males and 51 females with a mean age of 2.24 ± 0.36years. A contralateral patent processus vaginalis was present in 165 unilateral hernia patients. All patients underwent laparoscopic percutaneous extraperitoneal closure successfully without converting to open operation. The mean operating time in unilateral and bilateral hernia patients were 10.23 ± 2.25 mine and 14.54 ± 2.81 mine respectively. One patient had subcutaneous emphysema, two male patients had inguinal hernia recurrence and none had complications such as hydrocele and testicular atrophy. Additional 0.3cm port was done in 4 cases. The mean follow-up time was 22.36 ± 4.56months. Single-port laparoscopic percutaneous extraperitoneal closure of paediatric inguinal hernia using a needle grasper is a feasible and safe procedure. It has the advantages of fewer skin surgical incisions, short operating time, low complication and low recurrence rate.

Laparoscopic Percutaneous Extraperitoneal Closure for Hydrocele of the Canal of Nuck in Children.

Background: Hydrocele of the canal of Nuck (HCN) is a rare cause of inguinal swelling in women. The optimal surgical procedure for HCN in children remains unclear. To assess the safety and efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) for HCN in a pediatric population, a retrospective study was conducted. In addition, to clarify the pathogenesis of HCN, we assessed the morphological findings of the internal inguinal ring (IIR). Materials and Methods: We retrospectively analyzed 10 consecutive female patients with HCN who underwent LPEC at our hospital between January 2010 and May 2020. Age, operative time, and complications were recorded. Concerning the findings of the IIR, we classified the morphological features as follows: Type 1 (flat), Type 2 (narrow patent processus vaginalis [PPV] with a peritoneal veil), and Type 3 (widely opening PPV). Results: The median age of patients who underwent LPEC was 3 (1-12) years. Although 2 patients showed contralateral inguinal hernia (IH), there were no cases of ipsilateral IH. All patients showed ipsilateral PPV, and the morphological features of the IIR were mostly classified as Type 3 (70%). In total, 6 of 8 HCN cases without preoperatively diagnosed contralateral IH had contralateral PPV (75%), and all were closed by LPEC. All operations were accomplished laparoscopically, and the postoperative course was uncomplicated, with no recurrences observed during the study period. Conclusions: LPEC is a safe and simple surgical approach to repair the HCN in children with minimal complications.

Post-Hysterectomy Rectovaginal Fistula: A Series of Five Cases

Background: Post-hysterectomy recto-vaginal fistula (PH-RVF) is a condition where abnormal communication develops between the healing vaginal vault and the rectum secondary to an iatrogenic surgical insult. The purpose of this study was to evaluate the clinical presentation, work-up, management, and outcomes of patients with PH-RVF. Methods: Patients who underwent repair from January 2006 to December 2020 were analysed. The data was obtained retrospectively from a prospectively maintained database. Results: Five patients formed part of the study. All patients presented with faecal peritonitis required a faecal diversion. The mean distance of the fistula was 9.4 cm from the anal verge. Multi-detector CT with rectal contrast delineated the fistula in all. There were no associated fistulae. Laparoscopic repair was undertaken at a median of 12 weeks after faecal diversion. The average blood loss and mean operative time were 66 mL and 176 minutes, respectively. Tissue interposition was done in three patients. There was no major morbidity. The median hospital stay was five days. Four patients had successful repairs. A recurrence was managed with a laparotomy, fistula takedown, and rectus abdominis interposition. Bowel continuity was restored 10 weeks (mean duration) after definitive repair. At a median follow-up of 114 months, none had vaginal discharge, urinary tract infections, or complaints regarding sexual function. Conclusion: PH-RVF, a particular subset of high recto-vaginal fistula, is a complex fistula. Faecal diversion is required early in the course of management. With adequate planning, laparoscopic primary closure with or without tissue buttress is feasible, safe, and has a favourable long-term outcome.