Laparoscopic Creation Research Articles

Laparoscopic Creation of a Neovagina in Women with MRKH Syndrome -A New Look to an Old Problem

Laparoscopic Creation of a Neovagina in Women with MRKH Syndrome -A New Look to an Old Problem

Abdominal lymphocele following multi-level anterior lumbar interbody fusion (ALIF) managed with a laparoscopic peritoneal window: case report and review of the literature

PurposeLymphocele formation following anterior lumbar interbody fusion (ALIF) is not common, but it can pose diagnostic and treatment challenges. The purpose of this case is to report for the first time the treatment of a postoperative lymphocele following a multi-level ALIF using a peritoneal window made through a minimally invasive laparoscopic approach.MethodsCase report.ResultsA 74-year-old male with a history of prostatectomy and pelvic radiation underwent a staged L3–S1 ALIF (left paramedian approach) and T10-pelvis posterior instrumented with L1–5 decompression/posterior column osteotomies for degenerative scoliosis and neurogenic claudication. Three weeks after surgery, swelling of the left abdomen and entire left leg was reported. Computed tomography of the abdomen/pelvis demonstrated a large (19.2 × 12.0 × 15.4 cm) retroperitoneal fluid collection with compression of the left ureter and left common iliac vein. Fluid analysis (80% lymphocytes) was consistent with a lymphocele. Percutaneous drainage for 4 days was ineffective at clearing the lymphocele. For more definitive management, the patient underwent an uncomplicated laparoscopic creation of a peritoneal window to allow passive drainage of lymphatic fluid into the abdomen. Three years after surgery, he had no back or leg pain, had achieved spinal union, and had no abdominal swelling or left leg swelling. Advanced imaging also confirmed resolution of the lymphocele.ConclusionsIn this case report, creation of a peritoneal window minimally invasively via a laparoscope allowing passive drainage of lymphatic fluid into the abdomen was safe and effective for management of an abdominal lymphocele following a multi-level ALIF.

Laparoscopic creation of a retrosternal route for gastric conduit reconstruction.

Retrosternal reconstruction is associated with a lower risk of mediastinitis, gastro-tracheal fistula, and hiatal hernia. Historically, traumatic manual creation of the retrosternal tunnel has been performed using one's fist. We report a novel and atraumatic laparoscopic procedure to create the retrosternal route. We have laparoscopically created the retrosternal route in 25 thoracoscopic, mediastinoscopic, or robot-assisted minimally invasive esophagectomies since August 2019. Specifically, a peritoneal incision is started at the dorsal side of the xiphoid process. Through a 12-mm port inserted slightly to the right of and superior to the umbilical camera port, we dissect loose connective tissues from the caudal to the cranial side using behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route was calculated. Then, the cumulative sum (CUSUM) method and the simple moving average of five cases were used to evaluate the learning curve of this novel procedure. Operative outcomes were analyzed according to the learning curve results and also compared with 25 cases of postmediastinal reconstruction counterparts. Twenty-five patients were divided into the early group (six patients) and late group (19 patients) based on the peak of the CUSUM chart. The time required for route creation was 28.5min (median) in the early and 15min in the late group, indicating a significant difference (P = 0.038). The overall incidence of pleural injury was 20% (5 of 25 patients), with no significant difference between the groups. There was no significant difference in the incidence of perioperative complications. Also, there were no significant differences in perioperative complications or gastric conduit functions 1year after surgery between the retrosternal and the postmediastinal reconstruction. Laparoscopic creation of a retrosternal route for gastric conduit reconstruction is safe and feasible and has a short learning curve.

383 LAPAROSCOPIC CREATION OF RETROSTERNAL ROUTE FOR GASTRIC CONDUIT RECONSTRUCTION; SAFE AND FEASIBLE PROCEDURE

Abstract Reconstruction routes after esophagectomy include posterior mediastinal, retrosternal, and subcutaneous route. We have performed posterior mediastinal reconstruction, but this route has higher risks of gastro-tracheal fistula and hiatal hernia. To avoid these complications, now we take the retrosternal route as our first choice by creating the route laparoscopically before pulling-up gastric conduit. We report the successful and safe procedure. Methods We performed laparoscopic creation of retrosternal route in 13 thoracoscopic/robot-assisted minimally invasive esophagectomies since August 2019. In practice, a peritoneal incision at the dorsal side of the xiphoid process is started. Then, via 12 mm port on the surgeon's right hand inserted slightly to the right and cranial side of the umbilical camera port, we dissect loose connective tissues from the caudal side to the cranial side behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route and pleural injury rate during the procedure was examined. Results Thirteen cases were divided into two groups as early period group (seven cases) and later period group (six cases) respectively. The time required for route creation was 31.3 minutes(average) in the early period group, and 16.7 minutes in the later period group. There is tendency towards faster in later period group than in earlier one. The overall pleural injury rate was 15% (2 of 13 cases). Although it was difficult to determine the amount of bleeding, it was visually observed that the bleeding during the route creation was lower in the later period group than in the early period group. Conclusion The entire laparoscopic procedure to create retrosternal route makes it easier to observe and preserve the pleura and internal thoracic vessels compared to blind blunt dissection. As a conclusion, laparoscopic creation of retrosternal route for gastric conduit reconstruction is safe and feasible with good learning curve. Video https://www.dropbox.com/sh/p0wc3x46n33jp23/AADwiWHYIEUNUX6qZsERVIOga?dl=0.

Three Original Methods of Laparoscopic Colpopoiesis from the Pelvic Peritoneum. Tactics Selection and Results of Treatment

Study Objective To compare results of 3 original techniques of laparoscopically assisted colpopoiesis from pelvic peritoneum. Design Level II-1, Canadian Taskforce. Setting Department of Operative Gynecology, National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Healthcare of Russia Patients or Participants We recruited 203 patients with utero-vaginal aplasia, gonadal dysgenesis, testicular feminization, congenital adrenogenital disorders, male-to-female transgenders. Interventions Adamyan's technique of laparoscopically assisted colpopoiesis from pelvic peritoneum has been used for more than 30 years. Since 2012, we have used three original methods of laparoscopic neovagina creation from pelvic peritoneum: laparoscopic-perineal technique, total laparoscopic technique and combined laparoscopic-perineal technique with ligatures used for bringing down the peritoneum. Measurements and Main Results Total of 71 patients underwent colpopoesis using a laparoscopic-perineal technique: in 94 cases - total laparoscopic technique of colpopoiesis and in 38 - laparoscopic-perineal technique with ligatures were used. 27 patients had history of unsuccessful attempts for surgical neovagina creation. There were no significant differences between three types of colpopoesis in blood loss, duration of surgery, length of postoperative hospital stay and in use of pain relievers postoperatively. From the standpoint of complications, 1 case of bladder injury, 1 case of rectal injury in patients with previous fibrosis were diagnosed and eliminated during surgery followed by asymptomatic recovery. Postoperative neovaginal stricture was seen in 5 cases and dyspareunia was seen in 11 cases, which improved with vaginal maintenance dilation within 1 month. Conclusion Laparoscopy Involving neovagina creation is an effective and safe operation even in patients with unsuccessful previous neovagina attempts and radiation induced fibrosis.which provides sufficient length of neovagina of 10-12 сm, functional aspects such as lubrication, epithelialization, extensibility and sensibility. However, such interventions especially in complex cases should be provided in the specialized medical centers.

Laparoscopic tubularized continent gastrostomy: an alternative to tube gastrostomies.

Gastrostomy tubes, placed either endoscopically or laparoscopically, are the most widely used method to deliver enteral feeding to patients unable to be fed by mouth. Tube gastrostomy is quick and low cost and allows the health care professionals for a convenient route to deliver enteral nutrition to their patients. Nevertheless, bearing an indwelling gastric tube could not be as convenient for patients. Complications, such as bowel perforation, tube dislodgement, peristomal infection or bleeding occur in up to 17% of patients, and some other drawbacks of gastric tubes, such as peristomal pain, are often understated. We present our technique for laparoscopic creation of a tubularized continent gastrostomy, originally conceived for the emergency treatment of patients with a dislodged percutaneous endoscopic gastrostomy, to provide them with a reliable new route for gastric feeding. After healing, this gastrostomy does not need an indwelling tube to stay patent, requires only a light gauze dressing and can be used by intermittent catheterization at conventional feeding times during the day. Laparoscopic tubularized continent gastrostomy can be offered to patients as a reliable alternative to tube gastrostomy.

The Role of Endovascular Stents in an Experimental Model of Traumatic Arterial Occlusion – the Temporary Endo-Shunt

Background.We aimed to evaluate patency following the deployment of a bare-metal (BMS) or covered stent (CS) across a traumatic occlusive arterial lesion and to estimate the feasibility of urgent stent placement for temporary endovascular shunting.
 Methods. Fifteen sheep (25-45 kg) underwent laparoscopic creation of a left external iliac artery (EIA) thrombosis by means of repeated clamping. Animals were then randomized into one of three groups: no-treatment (control group), a BMS group or CS group. Animals were followed up for 30 days with no anticoagulants or anti-platelet drugs administered postoperatively. Doppler ultrasound, computed tomography angiography (CTA), and digital subtraction angiography (DSA) were used to evaluate EIA patency.
 Results.Stent implantation resulted in the restoration of in-line flow through the EIA in all cases. The peak systolic velocity (PSV) in the injured limb increased from 10 (0–16) to 31 (28–37) cm/sec in the BMS group (p<0.0001) and from 15 (7–18) to 24 (21–29) cm/sec in the CS group (p=0.043) immediately after stent deployment (both p=0.001 compared to the control group). There was no difference in the PSV between the groups at post-injury day 3, and thereafter. Day-14 CTA and day-30 DSA demonstrated only one patent stent in each study group.
 Conclusions.Stent (BMS or CS) implantation restores arterial patency of a traumatic occlusive lesion for a period of less than three days in our ovine model. While acute recanalization of the injury with stent implantation may be used for temporary endovascular shunting, long-term patency remains a problem.

Laparoscopic extraperitoneal sigmoid colostomy using the totally extraperitoneal hernia repair technique after abdominoperineal resection for rectal cancer.

Stoma creation through the extraperitoneal route reportedly reduces the risk of parastomal hernia and stomal prolapse after abdominoperineal resection (APR) for rectal cancer. We describe a new technique for laparoscopic extraperitoneal sigmoid colostomy following APR. After the rectus abdominis muscle is separated, Lap ProtectorTM and EZ AccessTM devices are placed. An extraperitoneal stoma tunnel is created laparoscopically as much as possible. Next, the peritoneum is separated from the inside of the abdominal cavity, and the extraperitoneal tunnel is opened. At the time of writing, we had performed laparoscopic extraperitoneal sigmoid colostomy in eight patients, without any complications or conversion to the conventional procedure. Thus, laparoscopic extraperitoneal sigmoid colostomy is a useful and safe technique for the laparoscopic creation of an extraperitoneal stoma tunnel after APR.

Laparoscopic Versus Open Sigmoid Loop Colostomy: A Comparative Study from a Cohort of 62 Patients Requiring Temporary Faecal Diversion at a Tertiary Care Center in North India.

Background:Over decades, colostomies have been done through open method, but laparoscopic creation of an intestinal stoma is safe, feasible and has distinct advantages over conventional techniques in specific procedures. The aim of this study compares operative and short-term outcomes of laparoscopic and open sigmoid loop colostomy formation for temporary fecal diversion.Subjects and Methods:A single institution, comparative study conducted in the department of surgery for patients who underwent either laparoscopic or open sigmoid loop colostomy. The 2 years’ study was from December 1, 2013, to November 30, 2015. Subjects were prospectively enrolled in the study after informed consent, both genders of >12 years of age. Data analysis was done using Statistical Package for Social Sciences version 21.0. Variables were tested by Kolmogorov–Smirnov test, compared using unpaired t-test/Mann–Whitney Test, Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant.Results:Sixty-two patients were enrolled; laparoscopy group – 29 patients (46.77%) versus open group – 33 patients (53.22%). Laparoscopic group/open surgery group showed less blood loss (20.69 + 17.71 ml / 121.97 + 35.29ml, P-value 0.0005), lower requirement of analgesics (4.28 ± 1.76 days/6.88 ± 2.75 days), shorter hospital stay (8.79 ± 5.57 days and 11.73 ± 6.61 days, P = 0.001), early return of the bowel function and tolerance to diet. Complications and readmission requirement for any complication was lower in the laparoscopic group.Conclusions:Laparoscopic sigmoid loop colostomy is a simple alternative to open sigmoid loop colostomy with respect to postoperative pain, earlier return of bowel function, lower analgesic requirement, and lesser hospital stay.

673 - To Demonstrate Method of Laparoscopic Creation of Neo Vagina by Peritoneal Pull Through Technique in Case of MRKH

Objective: To demonstrate a method of laparoscopic creation of neo vagina by peritoneal pull through technique in case of MRKH.

PS02.019: THORACOSCOPIC INTRATHORACIC ESOPHAGO-GASTRIC ANASTOMOSIS WITH PATIENT IN PRONE POSITION

Abstract Description After laparoscopic gastric conduit creation the patient is placed in prone position, with single-lumen endotracheal intubation. A right pneumothorax at 8 mmHg is created with a port at the apex of the scapula; two operative trocars are inserted in the right 5th and 9th intercostal spaces. The esophageal dissection in performed with an en bloc linfadenectomy. The distal part of the esophagus is tied up with a loop; the esophagus in then divided with an electrocautery scissor. A manual purse-string is made in the proximal esophageal stump with a Prolene 2/0. The envil of a circular stapler is put inside the chest through a port or during the laparoscopic procedure opening the right pleura; so it is introduced in the esophageal stump and the purse-string is closed. The incision of the lower port is enlarged and a laparoscopic wound retractor device is inserted. The specimen and the gastric conduit are retrieved; the stapler is introduced trough the laparoscopic wound retractor tip and through a small gastrostomy in the gastric tube; the puncturing shaft is pulled out through the greater gastric curve. We ensure the gastric conduit to the stapler with a second envil; it is introduced in the chest. After opening the stapler and loosing the second envil we perfomed the esophago-gastric anastomosis. A linear stapler is used to remove the excess of the stomach with the gastrostomy. Some interrupted stitches fixed the anastomosis to the mediastinal pleura. Two right chest tubes are inserted. Disclosure All authors have declared no conflicts of interest.

Magnetic resonance imaging of vaginal support structure before and after Vecchietti procedure in women with Mayer-Rokitansky-Küster-Hauser syndrome.

It is unclear how pelvic floor supporting structures might be affected by the absence of the vagina. It was the aim of this prospective study to analyze the magnetic resonance imaging morphology of pelvic support prior and after a Vecchietti procedure in women suffering Mullerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome). 26 women with a diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome associated vaginal agenesis were recruited prospectively prior to the laparoscopic creation of a neovagina according to the Vecchietti procedure. The primary outcome measure was the magnetic resonance imaging morphology of supporting structures. Secondary outcome measures were anatomical and functional vaginal length. Follow up was conducted six months after surgery. Twenty-six women were analyzed. Mean age was 19.8 ± 4.4 years (±SD) and mean body mass index was 23.7 ± 4.3 kg/m2 (±SD). All were Caucasian. Supporting structures consistent with cardinal and uterosacral ligaments were visible on magnetic resonance imaging in all cases (100%). There were no levator ani defects. The vaginal apex could be visualized postoperatively in 12 women (46.2%) reaching up to Level I. The vagina was visible in both Level II and III with normal relations to the pelvic walls in all cases. On gynecological examination, vaginal length was 8.8 ± 2.1 cm (mean ± SD) anatomically and 10.2 ± 2.2 cm (mean ± SD) functionally. The preoperative presence of pelvic support structures into which the vagina is lengthened by the surgery likely explains the uncommon occurrence of vaginal prolapse in women who had the Vecchietti procedure.

腹腔鏡下姑息的人工肛門造設術の有用性に関する検討

目的：腹腔鏡下姑息的人工肛門造設術の有用性について検討する．対象と方法：2010年1月から2015年2月までの期間，当院において腹腔鏡下姑息的人工肛門造設術を施行した13例を対象に，患者背景，手術成績，術後成績について検討した．結果：原疾患は，大腸癌11例，胃癌腹膜播種1例，虚血性腸炎1例，その他1例．腹腔鏡完遂率53.8％（7例/13例）．開腹移行例は，特殊例2例を除くとすべて腹膜播種症例であった．SSIをきたしたのは開腹移行例（3例/6例50％）のみであった．SSI以外の合併症は，減圧不良，誤嚥性肺炎，内ヘルニアがそれぞれ1例であった．大腸閉塞スコア（CROSS）に則ると，術前後でScoreは明らかに改善していた．結論：腹腔鏡下姑息的人工肛門造設術は比較的安全に施行できており，有用であると考えられた．ただ，腹膜播種症例に対しては，慎重に行う必要があると考えられた．

Endoscopic retrograde cholangiopancreatography through laparoscopically created gastrotomy for the management of biliary complications of Roux-en-Y gastric bypass

Objective The aim of this study was to evaluate the feasibility, safety, and surgical outcome of laparoscopically assisted endoscopic retrograde cholangiopancreatography (ERCP) through gastrotomy in patients who had undergone Roux-en-Y gastric bypass as a bariatric procedure and indicated for ERCP. Patients and methods The study included 12 patients who had undergone Roux-en-Y gastric bypass surgery in the past 1–4 years and developed biliary obstruction since 23.3±7 days (range: 13–36 days). The operative procedure involves laparoscopic creation of gastrotomy; a sterile ERCP scope was inserted through a 12-mm port site and passed manually under laparoscopic visualization through the gastrotomy orifice, and then sphincterotomy (papillotomy) and cannulation were performed. Preprocedural and postprocedural dye injection was performed to ensure the patency of biliary passages. The gastrotomy site was closed in two layers. Results Laparoscopic exploration was performed successfully in all patients, with successful adhesiolysis in three patients. In all patients, laparoscopic creation of gastrotomy in the gastric remnant was uneventful and successful, but gastrotomy site bleeding occurred in two cases and was controlled. Sphincterotomy was successful in all patients, but cannulation and injection of dye for intraoperative choledochography were performed successfully in 10 (83.3%) patients. Two patients required sphincter stenting. The mean operative time was 66.9±10.5 min (range: 55–90 min); the mean time until first ambulation and oral intake was 1.6 and 11.5 h, respectively, and the mean duration of postoperative hospital stay was 32.9 h. Eight minor postoperative complications were encountered. Conclusion Laparoscopic transgastrotomy ERCP is feasible and safe for the diagnosis and treatment of biliary complications secondary to bariatric surgery, with minimal treatable complications.

Spleen and splenic vessel preserving distal pancreatectomy for bifocal PNET in a young patient with MEN1

MEN1 patients requiring resection of neuroendocrine tumors (pNET) are frequently young, active patients in whom a minimal access approach minimizes perioperative morbidity and splenic preservation decreases the risk of post-splenectomy sepsis. Laparoscopic spleen preserving distal pancreatectomy can be performed with removal (Warshaw's technique) or preservation of the splenic vessels, the later having a higher rate of successful splenic preservation. This is an active, 16-year-old Jehovah's Witness with trifocal nonfunctioning neuroendocrine tumor in the proximal body and tail of the pancreas as part of MEN1 syndrome. A spleen preserving distal pancreatectomy was performed with the final pathology showing three pNET with low mitotic count and three lymph nodes free of cancer (final stage pT2pN0). This video demonstrates patient and trocar positioning as well as operative tactics for a laparoscopic distal pancreatectomy with preservation of splenic vessels. Intraoperative ultrasound is crucial in assessing pNETs' relation to critical vessels, pancreatic duct, and to exclude synchronous lesions. The video focuses on safe laparoscopic creation of the retropancreatic tunnel and dissecting the pancreas off the splenic vessels using novel energy devises to control direct splenic venous branches into the pancreas. Improvements in laparoscopic techniques and technology have enabled surgeons to preserve the major splenic vessels to avoid splenic infarcts, abscesses and re-operations, and minimize the risk of left-sided portal hypertension. Splenic preservation is particularly important in young MEN1 patients undergoing laparoscopic pancreatectomy for pNET due to the increased risk of overwhelming post-splenectomy sepsis.

Laparoscopic creation of neovagina and neocervix, followed by their reconstruction with polytetrafluoroethylene graft/buccal mucosa and pudendal artery perforator flap

Abstract Congenital cervical agenesis of is a rare Mullerian anomaly that may be associated with partial or complete vaginal aplasia and renal anomalies. Symptoms such as amenorrhea and abdominal pain usually develop shortly after menarche, when the absence or obstruction of the cervical canal results in blood accumulation in the uterus and fallopian tubes, and finally in the peritoneal cavity. Physical examination sometimes reveals normally developed external sex organs. Delayed diagnosis and treatment may potentially result in extensive endometriosis, which may potentially cause severe adhesion and damage to reproductivity. Such consequences could complicate further the management of the disease. Traditionally, hysterectomy has been the treatment of choice in these cases because of the high failure rate of canalization procedures and risk of serious ascending infection. With advanced laparoscopic techniques, conservative management seems feasible and has been recommended. We herein present a patient with complete cervical and vaginal agenesis. Creation of a neovagina and uterovaginal anastomosis were performed first under the guidance of laparoscopy ( Figure 1 ). A neocervix was composed of a polytetrafluoroethylene graft and a piece of oral mucosa retrieved from the buccal area. The neovagina was reconstructed with an external pudendal artery perforator flap. A cervical Fr 16 size Foley was left in place as a stent. The patient had uneventful postoperative recovery and fair wound healing at the outpatient follow-up. Congenital agenesis of the uterine cervix and vagina can be differentiated accurately and reconstructed laparoscopically. Using mesh-buccal mucosa composite and pudendal perforator flap is a practical way to reconstruct neocervix and neovagina after their creation.

Follow-Up in Women With Vaginal Agenesis After Laparoscopic Creation of Neovagina

Study ObjectiveTo compare 2 different methods to create a neovagina in patients with Rokitansky syndrome and to describe their functional results during the follow-up. DesignDescriptive study on functional outcome in 32 patients with Rokitansky syndrome (Canadian Task Classification Force II-2). SettingUniversity tertiary Hospital. Design and Patients18 patients (group 1) underwent our original technique. 14 patients (group 2) were operated on with the modified technique. InterventionComparison between 2 different techniques of laparoscopic approach. ResultsBoth groups had excellent surgical outcomes. The modified technique (group 2) obtained an optimal vaginal depth in fewer days than in the first group (p < .001). Consequently, the hospital stay was shorter in the second group (p < .001). Follow-up was 85 months for group 1 and 17.2 months for group 2. Functional outcome was excellent during the follow-up in both groups. ConclusionLaparoscopic creation of a neovagina is a safe, minimally invasive treatment with good functional and sexual results.

P-0236 Indications and Outcomes after Laparoscopic Stoma Creation: The Philippine General Hospital Experience

ABSTRACT Introduction Fecal diversion through an open surgical approach is associated with considerable trauma, stress, and post-operative pain. Laparoscopic stoma creation, on the other hand, has been widely documented to decrease post-operative pain, to reduce adynamic ileus, to hasten post-operative feeding, to improve recovery and to induce earlier commencement of neoadjuvant treatment for patients with locally-advanced rectal cancer. This study aims to describe and evaluate cases of laparoscopic stoma creation in terms of indication, post-operative outcome, length of hospital stay, morbidity and mortality. Methods This is a descriptive, retrospective study. All adult patients admitted by the Division of Colorectal Surgery at the University of the Philippines-Philippine General Hospital (UP-PGH) from January 01, 2007 to December 31, 2011 who underwent laparoscopic stoma creation were included in the study. Results Fifty-one patients underwent laparoscopic stoma creation from 2007 to 2011. Mean operation time was 80 minutes (SD: -20 to 25 minutes). The most common indication was for locally-advanced, obstructing colorectal cancer (88.23%, 45/51). Transverse loop colostomy was the most common type of surgery (65.66%, 34/51). There was only one conversion. Two patients were re-operated on for stoma prolapse, translating to a morbidity rate of 3.92%. No procedure-related mortality was documented. Patients were discharged after two to fifteen days post-operatively (mean 5.54 days). Conclusion Laparoscopic stoma creation is a safe and short surgical procedure with low morbidity and mortality rates.

Aspects in the Interdisciplinary Decision-Making for Surgical Intervention in Ulcerative Colitis and its Complications

Ulcerative colitis (UC) is a chronic inflammation of the large bowel, predominantly affecting young adults of 20 to 30 years of age. Even though the majority of patients with limited and extensive UC can be managed medically, 20 to 30 % will require surgical intervention at some point in their life to gain control of the inflammatory process. The most common reason for urgent and emergency surgery is a lack of response to maximal medical inpatient therapy after five to ten days. Other indications include hemorrhage, free perforation, sepsis, and toxic megacolon. Procedure of choice for the majority of surgeons is open or laparoscopic subtotal colectomy and end ileostomy, with or without exteriorization of the rectal stump. The laparoscopic approach requires more time, but allows for faster return of bowel function and discharge from the hospital. Creation of a definite restoration in form of a J pouch should be delayed for at least three months. Indications for elective surgical intervention include cancer, dysplasia associated lesion or mass, and stricture. Preferably, the J pouch and Brooke ileostomy are performed in two stages, with a takedown of the ileostomy several months later. A single-stage operation is associated with increased anastomotic dehiscence, sepsis, and long-term pouch failure. The laparoscopic creation of a J pouch is largely dependent on the surgeon's experience, but results in a number of advantages, including faster return of bowel function, tolerance of diet, and discharge. Regardless of emergency, urgent, or elective surgical intervention, early involvement of a team of gastroenterologist, surgeon, nutritionist, and stoma nurse is essential in the management of severe UC to maximize a satisfactory patient outcome.

In Vivo Assessment of an Absorbable and Nonabsorbable Knotless Barbed Suture for Laparoscopic Single-Layer Enterotomy Closure: A Clinical and Biomechanical Comparison Against Nonbarbed Suture

Laparoscopic intracorporeal suturing and knot tying is a complex skill that requires repeated deliberate practice to master. A novel self-anchoring barbed suture material that does not require knot tying can eliminate knot failure and reduce operating time. The goal of this study was to compare the in vivo efficacy of two novel knotless barbed sutures (absorbable and nonabsorbable) for use with the Endo Stitch™ device (Covidien), against conventional suture (Endo Stitch device with Polysorb™ suture; Covidien) for laparoscopic closure of viscerotomies in canine stomach, jejunum, and colon. Following Institutional Animal Care and Use Committee approval, 24 dogs underwent laparoscopic creation of 25-mm viscerotomies, three each in the stomach, jejunum, and colon. All viscerotomies were closed with the Endo Stitch device using the absorbable or nonabsorbable barbed suture or conventional suture. Closure time for each viscerotomy was recorded. Animals were survived for 3, 10, or 21 days, at which point the viscerotomies were burst-pressure tested. The closure leak rate in this study with 216 total viscerotomy closures was 0%. There was no statistically significant difference in mean burst pressure between viscerotomies closed with barbed suture versus control suture at any of the survival intervals. Barbed suture with the Endo Stitch device was associated with statistically significantly faster closure times than the control suture with the Endo Stitch device (P<.05), resulting in a reduction in closure time between 35% and 42%. This study reports the first use of barbed suture for the Endo Stitch device in laparoscopic gastrointestinal closure. The barbed suture for the Endo Stitch device is effective for laparoscopic single-layer gastrointestinal closure and is associated with a significantly reduced closure time.