Laparoscopic Creation Research Articles

Laparoscopic Creation of Neovagina by Vecchietti's Technique

Laparoscopic Creation of Neovagina by Vecchietti's Technique

Comment to “Laparoscopic radical cystectomy with extracorporeal creation of a ‘y’ shaped orthotopic ileal neobladder using non-reabsorbable mechanical suture (Fontana)”

Increasing evidence in published reports has suggested that titanium staples may be well tolerated inside the urinary tract. Recently, the Italian Group from Piedmont described an “easy, fast, and reliable” technique of a Y-shaped ileal neobladder that was created during open surgery with nonabsorbable mechanical staples. They observed an acceptable 6% rate of stone formation at a median follow-up of 20 months (range 8 to 47). We describe our initial experience with laparoscopic Y-shaped orthotopic ileal neobladder constructed entirely intracorporeally using titanium staples exclusively in an attempt to mitigate the time-consuming and skill-intensive task of freehand suturing required during laparoscopic creation of continent reservoirs.

Avoiding Colectomy during Surgical Management of FulminantClostridium difficileColitis

Clostridium difficile is the most common cause of nosocomial diarrhea in adults. Over the last decade, there has been a substantial increase in the disease-associated morbidity and mortality rate from this infection accompanied by identification of new hypervirulent strains. Fulminant colitis, a severe and complicated form of the disease that frequently necessitates surgical intervention, occurs in 3-8% of patients infected with C. difficile. The postoperative mortality rate for fulminant colitis continues to be dire, ranging from 34-57%. Review of the literature to offer insight into the dilemma associated with the surgical management of fulminant C. difficile colitis and provide alternatives to total abdominal colectomy for treatment. Several recent studies have elucidated factors that contribute to the unacceptably high postoperative mortality rate: Surgical intervention too late in the course of the disease, lack of clearly defined guidelines for patient selection, and difficulty in predicting the clinical course of the disease. Perforation, need for vasopressor support, and end-organ damage all affect the postoperative mortality rate negatively. A high clinical suspicion and careful patient selection for colectomy is imperative to improve postoperative survival. An alternative surgical strategy for fulminant C. difficile colitis is laparoscopic creation of an ileostomy with total colonic washout.

Should Progressive Perineal Dilation be Considered First Line Therapy for Vaginal Agenesis?

In women with vaginal agenesis progressive perineal dilation provides a minimally invasive method to create a functional vagina without the attendant risks or complications of traditional surgical options. We report our 12-year experience with this technique. Patients with vaginal agenesis treated at our institution were analyzed retrospectively and followed prospectively using case report forms and semistructured interviews. Patients diagnosed with vaginal agenesis were counseled on vaginal reconstruction options. Those electing progressive perineal dilation were instructed on the proper use of vaginal dilators by one of us (MRL) and advised to dilate 2 or 3 times daily for 20 minutes. All patients received physician, nursing and social work education and counseling. Parameters reviewed included primary diagnosis, start and end of vaginal dilation, dilation frequency, dilator size, sexual activity and whether the patient experienced pain or bleeding with dilation or sexual activity. Functional success was defined as the ability to achieve sexual intercourse, vaginal acceptance of the largest dilator without discomfort or a vaginal length of 7 cm. Univariate and multivariate analysis was performed to identify factors associated with successful neovaginal creation. From 1996 to 2008 we enrolled 69 females with vaginal agenesis in a progressive perineal dilation program. The primary diagnosis was Mayer-Rokitansky-Küster-Hauser syndrome in 64 patients. Mean age at the start of vaginal dilation was 17.5 years (range 14 to 35) Mean followup was 19 months (range 0 to 100). Four patients (5.7%) were lost to followup. In 7 of the remaining 65 patients (12%) treatment failed due to noncompliance and 50 (88%) achieved functional success at a median of 18.7 months. Patients who dilated frequently (once daily or greater) achieved a functional neovagina at a mean +/- SD of 4.3 +/- 2.4 months. Functional success correlated positively with frequent (once daily or greater) dilation and the initiation of sexual activity. Complications were minor. Three patients reported infrequent pain and 2 reported a single episode of bleeding with dilation. A total of 18 sexually active patients reported satisfactory intercourse without dyspareunia. Progressive perineal dilation for neovaginal creation is a valuable, minimally invasive therapy to create a functional vagina with a high success rate and a much lower complication rate than that in published surgical series. Given these findings, progressive perineal dilation should be offered as first line therapy in adolescents with a congenitally absent vagina.

Laparoscopic Marsupialization Before Inguinal Repair of Large Abdominoscrotal Hydroceles in Infants: Observation of Natural History and Description of Technique

To develop a surgical procedure that would minimize the difficult proximal spermatic cord dissection during excision of the abdominal component of abdominoscrotal hydroceles (ASHs). Because the abdominal component is derived from the peritoneum, we postulated that complete removal of all tissue is unnecessary and laparoscopic creation of a wide peritoneal window is sufficient for treatment before inguinal repair of the scrotal component. We describe a series of 4 patients who underwent laparoscopic marsupialization of the abdominal component of an ASH before inguinal repair. In addition, we describe the natural history of a patient who had had initial normal evaluation of bilateral scrotal hydroceles on ultrasonography and subsequently developed the abdominal portion during the first year after birth. Four patients underwent successful laparoscopic marsupialization of the abdominal component before inguinal repair of the ASH. No postoperative complications occurred, and no patient required repeat operation. Laparoscopic marsupialization of the abdominal portion of an ASH is a practical surgical alternative that may reduce the morbidity of extensive dissection.

A Simple and Effective Traction Device for Laparoscopic Formation of a Neovagina Using The Vecchietti Technique

We sought to present a simple new traction device that was used with success in 4 cases of laparoscopic creation of a neovagina using a modified Vecchietti technique. Four patients were treated with laparoscopic creation of a neovagina. All women had Rokitansky-Küster-Hauser syndrome and no more than a 1-cm vestibule dimple. A 3-cm diameter and 10-cm long plastic tube (mold) was used for traction. We developed 2 independent wood traction devices. They were based on tuning pegs of a guitar. The 1-cm demarcation in the external face of the mold allowed easy observation of the effects of traction. The patients were hospitalized from 7 to 10 days and the postoperative courses were uneventful. One patient was lost after 3 months of follow-up. After a year, the other 3 patients were having intercourse and were satisfied with the results. The laparoscopic technique has several advantages: it does not need grafts, it does not need a dissection of the space between the bladder and the rectum, it uses the mucous membrane of the vestibular area, the time of hospitalization is relatively short, and it possesses good long-term results.

Long-Term Outcome After Laparoscopic Creation of a Neovagina in Patients With Mayer-Rokitansky-Küster-Hauser Syndrome by a Modified Vecchietti Procedure

Long-Term Outcome After Laparoscopic Creation of a Neovagina in Patients With Mayer-Rokitansky-Küster-Hauser Syndrome by a Modified Vecchietti Procedure

Bronchoesophageal fistula in a patient with non-Hodgkin’s lymphoma

Bronchoesophageal fistula secondary to lymphoma is a very rare condition, usually associated with chemo-radiotherapy. We report a case of a patient with a non-Hodgkin's lymphoma (NHL) who, after chemotherapy, developed an oesophago-tracheal fistula. Initially it was treated conservatively but due to the lack of response, a stent was inserted. After nearly one year without success, surgery was considered. Right thoracotomy oesophagectomy and closure of the tracheal defect with an intercostal muscle flap and pericardial patch was performed. This was followed by laparoscopic creation of a gastric tube, which was successfully anastomosed to the cervical oesophagus through a cervicotomy. Unlike oesophageal cancer, NHL can have a good prognosis, so curative treatment of the fistula can be considered. Conservative treatment must always be the first option, leaving stenting or surgery for when the problem persists.

Total Laparoscopic Creation of a Novel Stapled Orthotopic Neobladder in the Porcine Model

Laparoscopic urinary diversion remains difficult and time consuming even when performed by experienced laparoscopists. Here we describe a novel procedure that quickly creates an ileal orthotopic neobladder with an afferent tubular segment using a laparoscopic stapling device. Laparoscopic cystectomy and stapled ileal neobladder were performed in five domestic juvenile pigs. Following cystectomy, 30 to 40 cm of terminal ileum was harvested, and ileal continuity restored. The harvested ileum was made into a J configuration, and three to seven laparoscopic staple firings were used to create a spherical pouch with an afferent limb modeled after the Studer-type neobladder. An aperture was created in the dependent portion of the neobladder, and urethral anastomosis was performed using six interrupted absorbable sutures. Ureterointestinal anastomosis was performed using a Wallace technique. Postoperative cystography and intravenous pyelography were performed. A 1-month survival study was completed in one pig. All five procedures were completed successfully without conversion to open surgery. The majority of the steps of the procedures were performed by second- and third-year urology residents (PGY 3-4). Neobladder stapling, ureterointestinal anastomosis, and the first three urethral sutures were performed by an endourology fellow. Average time for neobladder creation and entire procedure was 78 and 355 minutes, respectively. Postoperative cystography revealed spherical orthotopic neobladder with minimal or no leakage in all animals. Average neobladder capacity was 100 mL, and no obstruction was visualized on intravenous pyelography immediately after the procedures. One pig successfully survived the 1-month study period. There was excellent neobladder storage, no clinically apparent renal obstruction, and no postoperative complications. Total laparoscopic urinary diversion and specifically orthotopic neobladder remains one of the frontiers of minimally invasive urologic surgery. Our technique for stapled ileal neobladder provides substantial advantages in terms of the operative time required for orthotopic neobladder reconstruction. This may offer an avenue to foster the development of more feasible techniques for laparoscopic urinary tract reconstructive surgery.

Long-term outcome after laparoscopic creation of a neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome by a modified Vecchietti procedure

Several conservative and surgical methods have been proposed for patients with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. The technique described by Vecchietti is a combination of both dilatation and surgery. We describe a minimally invasive modification of this approach including dissection of the vesico-rectal septum and present long-term patient outcome. Eight patients who underwent surgery at our department between 1996 and 2005 for MRKH syndrome were included in the present analysis. Post-operative follow-up and a semi-structured telephone interview were performed to obtain information on neovaginal functionality, immediate and long-term post-operative outcome, sexual function and physiological and psychological well-being evaluated on a 10-point scale and by the Sintonen 15D questionnaire. After a median post-operative (median operation time: 88 min, range: 63–116 min) follow-up period of 40.3 months (range: 18–84 months) without major complications and a median post-operative stay of 13.8 days (range: 6–15 days), a functional neovagina was created in seven of eight patients. Median vaginal length at the time of discharge from the hospital ranged between 7 and 10 cm (median: 9.6 cm) and reached 11.5 cm (range: 5–15 cm) at the time of evaluation. Except for one patient who neither had regular sexual intercourse nor used the vaginal dilator, sexual intercourse was quoted as satisfactory in six cases (one patient still used the dilator only). Patients reported an improvement of quality of life (mean: 8.1, range: 5–10) and self-confidence (8.1, range: 5–10) and general well-being evaluated by the Sintonen 15D questionnaire (average score of 1.8, SD = 0.06). The laparoscopic-assisted Vecchietti procedure with dissection of the vesico-rectal septum is a safe and effective method for creation of a neovagina in MRKH patients.

Minimally invasive transhiatal and transthoracic esophagectomy

Standard esophagectomy requires either a laparotomy with transhiatal removal of the esophagus or a combination of laparotomy and thoracotomy. Currently, it still is associated with a high rate of morbidity and mortality. Complications leading to greater morbidity and mortality are rarely seen after minimally invasive surgery. The authors present their experience with 25 minimally invasive esophageal resections. Between August 1st, 2003 and November 30th, 2005, the authors performed 25 minimally invasive esophageal resections for 4 woman and 21 men. Data were acquired prospectively. In this series, a laparoscopic transhiatal approach was performed in 9 cases, a combined laparoscopic-thoracoscopic procedure in 12 cases, and laparoscopic creation of a gastric tube combined with thoracotomy in 4 cases. No conversion became necessary. The mean operation time was 165 min (range, 150-180 min) for the laparoscopic transhiatal approach and 300 min (range, 240-360 min) for both combination approaches. Using the combined laparoscopic-thoracoscopic procedure, 23 lymph nodes (range, 19-26 lymph nodes) were removed, and using the laparoscopic transhiatal approach, 14 lymph nodes (range, 12-17 lymph nodes) were removed. The median stay in the intensive care unit was 1.5 days (range, 1-22 days), and the overall postoperative stay was 10 days (range, 7-153 days). Two intraoperative complications and two cervical anastomotic leakages were observed. The 30-day mortality rate was 0%. The findings demonstrate that laparoscopic transhiatal and combined laparoscopic/thoracoscopic esophagectomy are feasible and can be performed with low rates of morbidity and mortality. Due to an equal extent of lymph node dissection, there should be no difference in long-term survival between minimally invasive surgery and open surgery.

Laparoscopic creation of a neovagina and recovery of menstrual function in a patient with Rokitansky syndrome: A Case Report

A 16-year-old woman experiencing primary amenorrhoea and cyclic pelvic pain was diagnosed with Rokitansky syndrome, which was characterized by the absence of the uterus and the upper two-thirds of the vagina, normal salpinges and ovaries and a 4 x 3 cm Müllerian remnant containing functioning endometrium located near the left adnexa. With a combined laparoscopic-vaginal operation, the remnant was anastomized with the apex of the retrohymenal fovea. The operation allowed not only the creation of a neovagina but also the recovery of a regular menstrual activity and the theoretical restoration of the reproductive capacity of this patient. An accurate pre- and intra-operative evaluation of patients with Rokitansky syndrome is necessary to identify those who might benefit from this procedure.

Laparoscopic creation of a neovagina with the laparoscopic Vecchietti operation: comparison of two instrument sets

To compare safety and effectiveness of two different instrument sets for the laparoscopic Vecchietti operation for the creation of a neovagina. Descriptive study. Tertiary referral center. Twenty-six women with Rokitansky syndrome. Twelve consecutive patients had surgery with the kit recently developed by Storz (group 1) and 14 consecutive patients had surgery with the original kit of Vecchietti (group 2). Laparoscopic Vecchietti operation and clinical and instrumental follow-up for all patients. All the parameters reflecting safety, effectiveness, and compliance that were systematically measured for all patients. Patients in group 1 had a wider vagina at device removal and experienced less vaginal bleeding than patients in group 2, and the removal of the device was simpler. Patients in group 1 had a shorter vagina at device removal and retained the device and the Foley catheter for a longer period than patients in group 2. Diameter and length of neovagina at 1-month follow-up were comparable in the two groups. The availability of this new instrument set represents a small but significant improvement in the creation of a neovagina by the laparoscopic Vecchietti operation in women with Rokitansky syndrome.

No-Trocar Laparoscopic Stoma Creation

Creation of an intestinal stoma may be necessary in a wide variety of colorectal diseases of both benign and malignant character. Open and laparoscopic techniques can be used for the fecal diversion. We report a case of a patient with a diverticulitis of the sigmoid colon with abscess formation and fistulation to the abdominal wall and vagina. Owing to severe comorbidity, a permanent fecal diversion was prepared. We performed a laparoscopic no-trocar technique. Only 1 incision, at the planned stoma site, was used. The abdominal wall was elevated with gaspers, no pneumoperitoneum or trocars were used. The laparoscope and reuseable laparoscopic graspers were introduced through the stoma site to correctly identify and grasp a loop of the terminal ileum. Finally, the loop ileostomy was placed on a bar. This laparoscopic technique is a valid alternative to standard laparoscopic stoma creation. Different techniques for stoma creation are discussed.

Laparoscopic creation of a neovagina in Mayer-Rokitansky-Küster-Hauser syndrome by modified Vecchietti's procedure

Objective The objective was to apply Vecchietti's principles to laparoscopy for the creation of a neovagina in patients diagnosed with Rokitansky syndrome. Study design The setting was a university tertiary hospital. The design was a descriptive study to describe the outcome in 18 patients diagnosed with Rokitansky syndrome after laparoscopic creation of a neovagina applying Vecchietti's principles and implementing some useful modifications. Results In 17 patients the result was considered successful when a new neovagina measuring at least 10 cm long was obtained. Less satisfactory in the 18th patient was when a shortened neovagina was found at the 2-year follow-up as the patient did not follow the postoperative recommendations. Conclusion Laparoscopic creation of a neovagina is a safe, minimally invasive treatment with good functional and sexual results.

151 INVITED Strategies for bladder preservation

Increasing evidence in published reports has suggested that titanium staples may be well tolerated inside the urinary tract. Recently, the Italian Group from Piedmont described an “easy, fast, and reliable” technique of a Y-shaped ileal neobladder that was created during open surgery with nonabsorbable mechanical staples. They observed an acceptable 6% rate of stone formation at a median follow-up of 20 months (range 8 to 47). We describe our initial experience with laparoscopic Y-shaped orthotopic ileal neobladder constructed entirely intracorporeally using titanium staples exclusively in an attempt to mitigate the time-consuming and skill-intensive task of freehand suturing required during laparoscopic creation of continent reservoirs.

Laparoscopic radical cystectomy with intracorporeally constructed Y-shaped orthotopic ileal neobladder using nonabsorbable titanium staples exclusively

Increasing evidence in published reports has suggested that titanium staples may be well tolerated inside the urinary tract. Recently, the Italian Group from Piedmont described an “easy, fast, and reliable” technique of a Y-shaped ileal neobladder that was created during open surgery with nonabsorbable mechanical staples. They observed an acceptable 6% rate of stone formation at a median follow-up of 20 months (range 8 to 47). We describe our initial experience with laparoscopic Y-shaped orthotopic ileal neobladder constructed entirely intracorporeally using titanium staples exclusively in an attempt to mitigate the time-consuming and skill-intensive task of freehand suturing required during laparoscopic creation of continent reservoirs.

Standard und Risiko von laparoskopischen Anastomosentechniken an Dünn- und Dickdarm

Since the first laparoscopic colectomies in the beginning of the nineties the technique became the standard for special indications today. Common standards in anastomotic-technique developed empirically without studies of high evidence. Studies focussing on special risks of laparoscopic anastomoses are also missing. By assimilation of conventional techniques for anastomoses the results can be carried over to the laparoscopic technique. For anastomotic creation in laparoscopic surgery the anastomoses can be done inside or outside the abdominal cavity. Principles of the technique are similar for open and laparoscopic surgery. Fundamental for any anastomoses are a good blood supply, the reconstruction without tension and a satisfactory wideness. There are special risks and problems in laparoscopic anastomotic creation. For example the overview during creation of anastomoses in obese patients can be insufficient. Standards in reconstruction in laparoscopic surgery are hardly different from conventional surgery. Extraabdominal hand-sewn anastomoses are the standard reconstruction for small bowel resections as well as for right hemicolectomy. In left hemicolectomy and rectal resections transanal stapled anastomoses are the standard procedures. Originalarbeit

Creación de neovagina por laparoscopia en el síndrome de Rokitansky. Análisis de nuestros casos

Objective Vecchieti's principles were applied to laparoscopic construction of a neovagina in patients with Rokitansky syndrome. Patients and method Sixteen patients with a diagnosis of Rokitansky syndrome were treated with a modified Vecchietti method by laparoscopic approach. Results A satisfactory result was defined as a neovagina of at least 8 cm long on the final follow-up visit and was found in 15 patients. The result was much less satisfactory in the 16th patient in whom the vagina was discovered to be shortened from 12 cm to 6 cm at 2 years’ follow up as she had not followed the postoperative treatment. Conclusions Laparoscopic creation of a neovagina is a safe, minimally invasive treatment with few risks and good functional results.

Enhanced renal parenchymal cryoablation with novel 17-gauge cryoprobes

Objectives To evaluate novel, 17-gauge cryoprobes with a modified heat exchange mechanism to evaluate the area of ablation that could be achieved with 17-gauge (1.47-mm) cryoprobes. Methods Eleven pigs were divided into four groups. Each animal underwent laparoscopic creation of three cryolesions with an ellipical iceball-generating 17-gauge cryoprobe (group 1), one that generates a teardrop-shaped iceball (group 2), a template of three standard 17-gauge cryoprobes (group 3), or a single, standard, large-caliber (3.4-mm) cryoprobe (group 4). Each cryolesion was created with a standard double-freeze cycle. Intraoperative ultrasonography was used to measure the maximal iceball dimensions, and the renal temperatures were measured with a thermocouple. The animals were killed after 14 days. The gross lesion size and histopathologic area of necrosis were documented. Results The mean temperature for the surrounding renal parenchyma was not significantly different among the groups. No statistically significant difference was noted in the size of the gross or histopathologic lesions created among the four groups. The gross lesion size correlated statistically significantly with the histologic area of necrosis ( P <0.01). Conclusions Despite the diminutive size of the 17-gauge cryoprobes tested, the probes ablated tissue volumes equivalent to that ablated using the larger, standard 3.4-mm cryoprobe or a configuration of three standard 17-gauge cryoprobes. These novel 17-gauge cryoprobes may facilitate ablation of small and medium-size renal tumors and may have expanded application for percutaneous ablation owing to the decreased risk of hemorrhage.