Laparoscopic Exposure Research Articles

KeyLoop retractor for global gasless laparoscopy: evaluation of safety and feasibility in a porcine model

BackgroundMany surgeons in low- and middle-income countries have described performing surgery using gasless (lift) laparoscopy due to inaccessibility of carbon dioxide and reliable electricity, but the safety and feasibility of the technique has not been well documented. We describe preclinical testing of the in vivo safety and utility of KeyLoop, a laparoscopic retractor system to enable gasless laparoscopy.MethodsExperienced laparoscopic surgeons completed a series of four laparoscopic tasks in a porcine model: laparoscopic exposure, small bowel resection, intracorporeal suturing with knot tying, and cholecystectomy. For each participating surgeon, the four tasks were completed in a practice animal using KeyLoop. Surgeons then completed these tasks using standard-of-care (SOC) gas laparoscopy and KeyLoop in block randomized order to minimize learning curve effect. Vital signs, task completion time, blood loss and surgical complications were compared between SOC and KeyLoop using paired nonparametric tests. Surgeons completed a survey on use of KeyLoop compared to gas laparoscopy. Abdominal wall tissue was evaluated for injury by a blinded pathologist.ResultsFive surgeons performed 60 tasks in 15 pigs. There were no significant differences in times to complete the tasks between KeyLoop and SOC. For all tasks, there was a learning curve with task completion times related to learning the porcine model. There were no significant differences in blood loss, vital signs or surgical complications between KeyLoop and SOC. Eleven surgeons from the United States and Singapore felt that KeyLoop could be used to safely perform several common surgical procedures. No abdominal wall tissue injury was observed for either KeyLoop or SOC.ConclusionsProcedure times, blood loss, abdominal wall tissue injury and surgical complications were similar between KeyLoop and SOC gas laparoscopy for basic surgical procedures. This data supports KeyLoop as a useful tool to increase access to laparoscopy in low- and middle-income countries.

A Vagino-Laparoscopic Strategy for Hysterectomy of Large Uteri to Ease Surgical Challenges.

To develop a vagino-laparoscopic strategy for hysterectomy (VLH) to treat uteri with large fibroids at ≥ 16 weeks of gestation to ease surgical challenges. This was an observational study conducted in our private general hospital on 64 consecutive cases involving uteri with large and benign fibroids at ≥ 16 weeks of gestation. We excluded cases with an associated ventro-fixed uterus and large cervical fibroids. The VLH strategy involves vaginal separation of the uterosacral with the uterine arteries followed by laparoscopic separation of the remaining upper pedicles. The uterus was then removed vaginally. The largest uteri receiving treatment was at 26 weeks of gestation and the mean uterus weight was 869.60 ± 275.10 g (range: 500-1900 g). The VLH strategy was successful in 63 (98.43%) cases irrespective of the configuration of the uterus. One case (1.56%) required mini-laparotomy conversion due to the need for adhesiolysis; this case exhibited extensive adhesion of the rectum to the posterior wall of the uterus due to a history of previous myomectomy of the posterior wall. There were no conversions due to failed laparoscopic exposure of the adnexal or uterine vascular pedicles, or due to uncontrolled intraoperative bleeding. There were no cases of urinary tract injury or other major complications. The vaginal detachment of uterosacral ligaments before the laparoscopic phase of the VLH strategy increased upwards mobility and dislodged the cervico-isthmic level of large uteri from the narrow lower aspect of the pelvis to the upper wider part of the pelvis; this eased the surgical challenges associated with such cases and avoided complications during laparoscopy. We developed a vagino-laparoscopic strategy for hysterectomy that can ease the technical challenges associated with the majority of large uteri.

Exposure of the Middle Rectal Artery and Lateral Ligament of the Rectum Following the Gate Approach during Total Mesorectal Excision.

Controversial surgical anatomical landmarks in the deep pelvis can be visualized and identified using current technologies. Performing the gate approach technique during deep lateral dissection for total mesorectal excision facilitates visualization of the pelvic neurovascular structures following simple dissection steps to preserve the pelvic autonomic nerves and avoid accidental vascular injuries. Here, we discuss laparoscopic exposure of an infrequent disposition of the middle rectal artery anterior to the lateral ligament of the rectum while performing the gate approach.

V02-10 ROBOTIC ASSISTED LAPAROSCOPIC EXCISION OF A FIBROEPITHELIAL POLYP OF THE URETER

You have accessJournal of UrologyMisc. Benign Disease & Transplant & Renovascular (V02)1 Sep 2021V02-10 ROBOTIC ASSISTED LAPAROSCOPIC EXCISION OF A FIBROEPITHELIAL POLYP OF THE URETER Zain Hyder, and Nathaniel Polnaszek Zain HyderZain Hyder More articles by this author , and Nathaniel PolnaszekNathaniel Polnaszek More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001979.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fibroepithelial polyps of the urinary tract are rare tumors and are considered to be benign. We aim to present an exceedingly rare case of a large fibroepithelial polyp and describe its management. METHODS: The patient was a 32-year-old healthy female who presented with gross hematuria. Workup including CT IVP (computed tomography and intravenous pyelogram) demonstrated a large left mid ureteral mass. The patient underwent diagnostic ureteroscopy with biopsy of the mass followed by robotic excision of the mass and reconstruction of the ureter. RESULTS: The total operative time for the case was 185 minutes. In this time, diagnostic ureteroscopy was performed defining the large intramural mass with multiple sites of attachment. Frozen sections of the mass were obtained and demonstrated benign pathology. Robotic assisted laparoscopic exposure of the ureter was performed. A longitudinal ureterotomy was made and the mass was delivered out of the ureter. The mass measuring 7.1cm was entirely excised. The remaining ureter was tailored and reconstructed around an indwelling ureteral stent. The patient was discharged on post-operative day 1. A five month follow up with an Xray IVP showed a patent ureter without hydronephrosis. CONCLUSIONS: Fibroepithelial polyps are rare benign tumors. We demonstrated with an interesting case that robotic management of even very large masses is feasible with favorable post-operative outcomes. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e136-e136 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zain Hyder More articles by this author Nathaniel Polnaszek More articles by this author Expand All Advertisement Loading ...

Splenectomy

Laparoscopic splenectomy has become an established standard of care in the management of surgical diseases of the spleen, except in the hemodynamically unstable trauma patient requiring splenectomy. Although adoption of minimally invasive splenectomy has led to a gradual decrease in the indications for open splenectomy, both procedures are still essential components of spleen surgery. This review describes the indications and contraindications for procedure, preoperative preparation and consent, operative anatomy and technique, and long-term follow-up. Tables review the clinical indications for splenectomy, classification of splenectomy, a comparison of laparoscopic versus open postsplenectomy outcomes, indications and contraindications for partial splenectomy, and reported incidences of postoperative outcomes and complications after splenectomy. Figures depict splenomegaly, the American Society of Hematology 2011 evidence-based practice guidelines for management of primary idiopathic thrombocytopenic purpura in children and adults, a splenic mass, a splenic cyst, massive splenomegaly, laparoscopic splenectomy, the 2014 Centers for Disease Control and Prevention recommendations for adult and pediatric splenectomy vaccination, splenic artery embolization, various laparoscopic approaches to splenectomy, splenic vascularization, division of splenic artery branches, suspensory ligaments of the spleen, laparoscopic exposure and transection of splenic hilum, retrieval bags and related procedures, open splenectomy, stapling, and laparoscopic partial splenectomy. Videos demonstrate purely laparoscopic splenectomy and hand-assisted laparoscopic splenectomy. This review contains 26 figures, 5 tables, 2 videos, and 111 references.

Interdisciplinary Laparoscopic Implantation of Neuromodulation Leads to the Sacral Plexus for Therapy of Chronic Pelvic Pain and Neurogenic Bladder Dysfunctions

The aim of this study was to report on the use of laparoscopic implantation of leads on the branches of the sacral plexus for neuromodulation in the treatment of chronic pelvic pain (CPP) in a multidisciplinary setting with the help of electrophysiological neuromonitoring. Between 2012 and 2019, six female patients complaining of chronic pain and bladder and bowel dysfunctions underwent laparoscopic exposure and nerve identification with the help of electrophysiological neuromonitoring. A lead was placed laparoscopically in direct contact with the affected nerve. Pain intensity (numerous ranking scale [NRS]), generic health status (EQ-5D-5L), Becks Depressions Inventory (BDI-V), Pain Catastrophizing Scale (PCS), and Client Satisfaction Questionnaire (CSQ-8) were assessed pre-/postoperatively as well as three and six months after surgery. Statistical analysis was performed using Mann-Whitney U and Wilcoxon rank-sum test. The median age was 36.5 years. NRS improved from a median of 9.5 preoperatively to 3.0 (p < 0.001) at six-month follow-up. Median EQ-5D-5L index value before treatment was 0.18, indicating a notably lowered quality of life and increased up to 0.83 after six months (p < 0.001). Preoperative median BDI-V scores indicated a major depressive mood and improved from a median of 46.0 to 12.0 after six months (p = 0.007). Preoperative PCS was elevated with a median score of 41.0 and decreased to 4.0 after six months (p < 0.001). CSQ showed that patients were satisfied with the treatment. This unique method is an alternative and effective treatment option for CPP even years after primary endometriosis surgery.

A novel exposure maneuver in laparoscopic right hepatectomy.

Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver. Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon. The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases. The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.

Application of laparoscopic hepatic portal exposure in children with type III biliary atresia

Objective To explore the clinical value of portal exposure in laparoscopic treatment of children with type III biliary atresia(BA). Methods From June 2013 to October 2017, 30 infants with type III BA who treated with laparoscopic portoenterostomy in Huai′an Women and Children′s Hospital were selected.A percutaneous suture was used to snare the round ligament and retract the liver, other percutaneous stay sutures were then introduced and fundus and neck of gallbladder were sutured to elevate the liver to expose the portal hepatis.The fibro cord and hepatic vessels were mobilized, and then two rubber bands were put around the left and right portal veins and hepatic arteries.The portal hepatis was exposed by laterally stretching the two elastic rubber bands.The fibro cord was removed and then laparoscopic portoenterostomy was accomplished.In 20 cases, the liver was enlarged, part of hepatic lobus quadratus was removed laparoscopiclly for exposure of the portal hepatis. Results There were 30 cases in this group, 2 cases were converted to open surgery by a micro transverse incision.There was no surgical death.Time of laparoscopic procedure varied from 210 to 280 min.All cases survived the surgery without any intraoperative complications.Blood loss during operation was minimal, without necessity for blood transfusion.One case died of respiratory failure one week after surgery.Two cases were lost follow-up.Twenty-five cases were followed up for 3~51 months(mean 22.4 months). Three cases died because of repeated cholangitis and liver failure at 10, 16, 35 months postoperatively.Nineteen patients′ total bilirubin had dropped to normal, three others′ bilirubin levels dropped significantly after surgery. Conclusion The technique of laparoscopic hepatic porta exposure can help to complete hepatic portoenterostomy successfully, reduce the conversion rate of laparoscopic surgery, and improve the surgical effect. Key words: Laparoscopy; Biliary atresia; Anastomosis, surgical; Child; Porta

Safe management of laparoscopic endoscopic cooperative surgery for superficial non-ampullary duodenal epithelial tumors

Background and study aims Endoscopic submucosal dissection (ESD) for duodenal tumors results in a high delayed perforation rate due to the thinness of the duodenal wall. In most cases with perforation after duodenal ESD, additional surgery is needed due to severe peritonitis. A newly developed procedure, laparoscopic endoscopic cooperative surgery for duodenal tumors (D-LECS), may help to avoid perforation after ESD. In our institution, patients with superficial non-ampullary duodenal epithelial tumors (SNADET) smaller than 50 mm which could not have en-bloc resection by endoscopic mucosal resection were treated with D-LECS. After a laparoscopic exposure of anterior duodenal wall of second portion, ESD was performed. Laparoscopic suturing from the serosal side of ESD site was performed for reinforcement. There were neither postoperative leakage nor other complications. Therefore, D-LECS can be performed safely and prevent perforation after ESD for SNADET. D-LECS could be selected as a treatment for SNADET which can be cured by ESD.

Laparoscopic Sentinel Lymph Node Mapping with Indocyanine Green Using the iSpies Platform: Initial Experience Argentina

Study ObjectiveTo demonstrate the initial experience in Argentina using the iSpies indocyanine green (ICG) platform in sentinel lymph node mapping in patients with early-stage cervical cancer. DesignStep-by-step demonstration of the technique using a video and pictures (educative video) (Canadian Task Force classification III). SettingLaparoscopic and robotic sentinel lymph node mapping using ICG has been shown to be safe and feasible; however, in developing countries, the opportunities to use fluorescent imaging through a minimally invasive approach are very limited, given the cost restrictions of acquiring the near-infrared technology and the fluorescent dyes. InterventionA 47-year-old woman presented with a stage IB1 squamous cervical cancer. Physical examination revealed a 1.5-cm tumor without evidence of parametrial involvement. Magnetic resonance imaging did not show any evidence of metastatic disease. The patient underwent laparoscopic radical hysterectomy with sentinel lymph node mapping. On laparoscopic exposure of the pelvic spaces, a cervical injection of ICG (1 mL superficial and deep) was administered using a spinal needle at the 3 o'clock and 9 o'clock positions. Sentinel lymph node mapping was then performed using the ICG (Pulsion Medical Systems, Feldkirchen, Germany) and an iSpies near-infrared camera (Karl Storz Endoskope, Tuttlingen, Germany). Bilateral sentinel lymph nodes were detected on the left external iliac artery and in the right obturator space. Both were confirmed ex vivo. The total operative time was 170 minutes. No intraoperative or postoperative complications were reported, and the patient was discharged at 48 hours after surgery. Estimated blood loss was minimal. Sentinel lymph node mapping alone is not the standard of care in our institution, and thus bilateral lymphadenectomy was performed. Ultrastaging is routinely performed when a sentinel lymph node is evaluated. Final pathology revealed a tumor confined to the cervix, with tumor-free margins, and a total of 10 lymph nodes that were negative for any evidence of disease. Disadvantages of this technology compared with the Pinpoint ICG system (Novadaq Technologies; Bonita Springs, FL) is the lack of simultaneous white vision and fluorescence ICG detection, and the to manually change normal vision to infrared vision. An advantage of the Storz iSpies system is its availability in our country, considering that the technology developed by Novadaq is not yet approved in Argentina. ConclusionAlthough ICG sentinel lymph node mapping is becoming a standard of care [1,2], a lack of ICG dye or laparoscopic near-infrared technologies could be a deterrent to its use in developing countries. A focus on expanding this technology in countries with limited resources would allow patients the opportunity to avoid the morbidity associated with full lymphadenectomy.

The correlation between fundamental characteristics and first-time performance in laparoscopic tasks

BackgroundThe ability of characteristics to predict first time performance in laparoscopic tasks is not well described. Videogame experience predicts positive performance in laparoscopic experiences but its mechanism and confounding-association with aptitude remains to be elucidated. This study sought to evaluate for innate predictors of laparoscopic performance in surgically naive individuals with minimal videogame exposure. MethodsParticipants with no prior laparoscopic exposure and minimal videogaming experience were recruited consecutively from preclinical years at a medical university. Participants completed four visuospatial, one psychomotor aptitude test and an electronic survey, followed by four laparoscopic tasks on a validated Virtual Reality simulator (LAP Mentor™). ResultsTwenty eligible individuals participated with a mean age of 20.8 (±3.8) years. Significant intra-aptitude performance correlations were present amongst 75% of the visuospatial tests. These visuospatial aptitudes correlated significantly with multiple laparoscopic task metrics: number of movements of a dominant instrument (rs ≥ −0.46), accuracy rate of clip placement (rs ≥ 0.50) and time taken (rs ≥ −0.47) (p < 0.05). Musical Instrument experience predicted higher average speed of instruments (rs ≥ 0.47) (p < 0.05). Participant's revised competitive index level predicted lower proficiency in laparoscopic metrics including: pathlength, economy and number of movements of dominant instrument (rs ≥ 0.46) (p < 0.05). ConclusionMultiple visuospatial aptitudes and innate competitive level influenced baseline laparoscopic performances across several tasks in surgically naïve individuals.

TorCH manoeuver: Toronto caudate process hepatotomy for laparoscopic exposure and division of the right portal vein branch

Although formal laparoscopic hepatic lobectomies are performed routinely, concerns including the risk of major intra-operative haemorrhage remain regarding such an approach.1,2 Control of the inflow vasculature prior to parenchymal transection reduces intra-operative blood loss during major hepatectomy3, and extra-hepatic dissection, ligation and division of the right hepatic artery and right portal vein (RPV) is effective in reducing intra-parenchymal haemorrhage. Laparoscopic exposure and stapled division of the RPV is limited owing to the weight of the liver and the RPV anatomical position. Excessive tension or torque on the vein while positioning the stapler can result in catastrophic consequences. A major impediment to smooth introduction of the stapler is the caudate process posterior to the RPV. This report and accompanying video describe the author's approach to address these issues. Specific gallbladder retraction and division of the caudate process after hepatic mobilization is crucial (Fig. 1). The approach is summarized as a checklist in Fig. 2. This method (TorCH manoeuver) is readily teachable and can be included in curricula for continuing medical education or for fellows and established surgeons learning laparoscopic techniques. Figure 1 Completed TorCH manoeuver with a stapler around the right portal vein. Illustrated by: Laura Maaske Figure 2 Checklist summarizing the steps of the TorCH manoeuver

LAPAROSCOPIC DESCRIPTIONS OF COURSE, RELATION AND VARIATIONS OF CYSTIC ARTERY IN HEPATOBILIARY TRIANGLE3

Objective: To know in detail the level of origin, course and relation of the cystic artery and to assess frequency of the anatomical variations of cystic artery in hepatobiliary triangle observed during laparoscopic exposure for the guidance of laparoscopic surgeons.&#x0D; Study Design: It was a descriptive cross-sectional study in 6oo patients.&#x0D; Place and Duration of Study: This research work was undertaken in five teaching hospitals with adequate facilities and skillfull surgical team, from 8th Jan 2011-15th Jan 2014.&#x0D; Methadology: Surgical management of Six hundred patients with laparoscopic cholecystectomy was done from 8th April 2012 to 9th April 2014 prospectively. The Stryker, American laparoscope of 30° was employed in this study. We selected patients on the basis of non-probabilty convenient sampling technique. The DVD recorder was used to display course and relations of cystic artery and its variations on endoscopic visualization. using Medical grade video monitor was practiced to display and document anatomical variations. Photographs of each observed anatomical variation was taken.&#x0D; Results: Our experience with 600 laparoscopic cholecystectomies has revealed that anatomic variations of the cystic artery occur frequently. Overall results demonstrated 24% variations in the origin, course, relation of cystic artery in hepatobiliary triangle.In 76% of patients we demonstrared usual anatomy of cystic artery.&#x0D; Conclusion: Laparoscopic surgeons must know origin, course, relation of cystic artery and its variations to avoid vascular injuries, which can cause serious hemorrhage during laparoscopic cholecystectomy and to prevent postoperative complications. These injuries can result into significant morbidity and even mortality.

Manual Laparoscopic Skills Development Using a Low-Cost Trainer Box in Tanzania

To explore the feasibility and effectiveness of guided practice using a low-cost laparoscopic trainer on the development of laparoscopic skills by surgeons in a resource-poor setting. This was a prospective trial involving a pretest/posttest single-sample design. Study participants completed a background survey and pretest on the 5 McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks using a simulator developed and validated by researchers from the University of California, San Francisco. On completion of a 3-month guided practice course, participants were again tested on the MISTELS tasks and completed an exit survey. The Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. Fourteen Tanzanian surgery residents and specialists completed the study. Most of the subjects were surgical residents (64.3%). Only 2 participants (14.2%) had previous laparoscopic training, and baseline laparoscopic surgical experience was limited to intraoperative observation only. Study subjects practiced the MISTELS tasks for an average of 8.67 hours (range: 4.75-15.25) over the 3-month course. On the posttest, participants improved significantly in performance of each of the MISTELS tasks (p < 0.001). Total scores on the tasks increased from 24 ± 44 on the pretest to 384 ± 49 on the posttest (p < 0.001). All study participants were satisfied with the course, found the training personally valuable, and felt that their laparoscopic skills had improved on completion of the training. We have demonstrated the feasibility and effectiveness of training with a low-cost laparoscopic trainer box in Tanzania. Study participants achieved impressive posttest scores on the 5 MISTELS tasks with minimal baseline laparoscopic exposure. We feel that guided training by an expert was key in ensuring correct technique during practice sessions.

Effect of a Short Preclinical Laparoscopy Course for Interns in Surgery: A Randomized Controlled Trial

Surgical interns are often not well prepared and have high anxiety about the execution of basic technical skills. This study investigates whether a short preclinical course focusing on laparoscopic camera-navigating skills is useful in the preparation for internship. Through randomization, an experimental group who attended a short laparoscopic training session and a control group were created. Students' interest for this training and their confidence for laparoscopic exposure during surgical internship were inquired. During internship, camera-navigating skills were assessed by the operating surgeons (using a validated global rating scale) as well as by the students themselves (using a 10-points Likert scale). All research was performed in the Center for Surgical Technologies, Leuven, Belgium. A total of 205 fifth-year medical students at the University of Leuven, Belgium. Of the control group students, 80% were interested in attending the training session. There was no difference in confidence between experimental and control group. According to the surgeons and students, there was a significant improvement in clinical performance from the first (scores on global rating and Likert scales ±50%) to the last procedure (scores ±70%) for both groups. However, there was no difference in performance between groups. Students are very interested in attending a preclinical laparoscopic training session. However, trained students did not display higher confidence or better clinical performance during internship. Even without previous training, students are fast to acquire the necessary skills during surgical internship.

Does pure robotic partial nephrectomy provide similar perioperative outcomes when compared to the combined laparoscopic-robotic approach?

Laparoscopic and robotic partial nephrectomy have become the preferred option for surgical management of incidentally discovered small renal tumors. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection followed by tumor extirpation and renorrhaphy with robotic assistance provides improved perioperative outcomes compared to a pure robotic approach alone. We performed a comparison of perioperative outcomes between combined laparoscopic-robotic partial nephrectomy-or hybrid procedure-and pure robotic partial nephrectomy (RPN). A multi-center retrospective analysis of patients undergoing RPN and hybrid PN using the da Vinci S system(®) was performed. Patient data were reviewed for demographic and perioperative variables. Statistical analysis was performed using the Welch t test and linear regression, and nonparametric tests with similar significance results. Thirty-one patients underwent RPN while 77 patients underwent hybrid PN between 2007 and 2011. Preoperative variables were comparable in both groups with the exception of lesion size and nephrometry score which were significantly higher in patients undergoing hybrid PN. Length of surgery, estimated blood loss and morphine used were significantly less in the hybrid group, while warm ischemia time was significantly longer. The difference in WIT was accounted for in this data by adjusting for nephrometry score. In our multi-center series, the hybrid approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. We believe this approach is a valid alternative to RPN.

Laparoscopic Management of Sacral Nerve Root Schwannoma With Intractable Vulvococcygodynia: Report of Three Cases and Review of Literature

Herein we report the feasibility of laparoscopic resection of schwannomas of the sacral nerves roots in 3 women with intractable vulvodynia and coccygodynia. Laparoscopic en bloc resection of the sacral schwannomas was performed, with primary control of the tumor blood supply and with exposure and sparing of the sacral nerve roots. In all 3 patients, laparoscopy was successful, with minimal blood loss and without complications. Histologic examination confirmed the diagnosis of schwannoma without malignant transformation in all 3 women. At mean follow-up of 27.66 months, no patient reported recurrence or worsening of symptoms. All patients are able to walk normally without gait aids. Primary control of the tumor blood supply during laparoscopic surgery to resect deep sacral masses reduces considerably the risk of operative hemorrhage. Compared with classic neurosurgical approaches, laparoscopic exposure of the rectum, ureters, and sacral nerve roots renders the procedure safer and easier, with less risk of postoperative functional morbidity.

1399 DOES PURE ROBOTIC PARTIAL NEPHRECTOMY PROVIDE SIMILAR PERIOPERATIVE OUTCOMES WHEN COMPARED TO THE COMBINED LAPAROSCOPIC-ROBOTIC APPROACH?

You have accessJournal of UrologyTechnology & Instruments: Robotics - Malignant Disease & Benign Disease II1 Apr 20121399 DOES PURE ROBOTIC PARTIAL NEPHRECTOMY PROVIDE SIMILAR PERIOPERATIVE OUTCOMES WHEN COMPARED TO THE COMBINED LAPAROSCOPIC-ROBOTIC APPROACH? Andrew Harbin, Xi Cheng, Vincent Stanford, Kevin McGeagh, Jonah Murdock, Reza Ghasemian, Gaurav Bandi, and Jonathan Hwang Andrew HarbinAndrew Harbin Washington, DC More articles by this author , Xi ChengXi Cheng Washington, DC More articles by this author , Vincent StanfordVincent Stanford Washington, DC More articles by this author , Kevin McGeaghKevin McGeagh Washington, DC More articles by this author , Jonah MurdockJonah Murdock Washington, DC More articles by this author , Reza GhasemianReza Ghasemian Washington, DC More articles by this author , Gaurav BandiGaurav Bandi Washington, DC More articles by this author , and Jonathan HwangJonathan Hwang Washington, DC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1848AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopic partial nephrectomy (LPN) has become the preferred option for surgical management of incidentally discovered renal masses. Robotic surgery offers the advantages of a laparoscopic access while minimizing the technical difficulty of laparoscopic intracorporeal suturing. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection with a robotic extirpation and renorrhaphy provides improved perioperative outcomes compared to a pure robotic approach. We performed a comparison of perioperative outcomes between combined laparoscopic-robotic partial nephrectomy (LRPN) and pure robotic partial nephrectomy (RPN). METHODS A multi-center retrospective analysis of patients undergoing RPN and LRPN using the Da Vinci S system ® was performed. LRPN consisted of a laparoscopic exposure and hilar dissection, and the robot was docked for extirpation and renorrhaphy. Patient charts were reviewed for perioperative variables. Statistical analysis was performed using R ® statistical program. RESULTS Thirty-one patients underwent RPN while 81 patients underwent LRPN between 2007-2011. Four patients in the LRPN group were excluded due coversion to total nephrectomy. Preoperative variables were similar between each group, with the exception of lesion size and nephrometry score (Table 1). Length of surgery, estimated blood loss and morphine used were significantly less in the LRPN group, while warm ischemia time (WIT) was significantly longer (Table 2). The difference in WIT disappeared after controlling for nephrometry score. There was no significant difference in perioperative creatinine. Table 1. Perioperative Demographic Information Patient Characteristic Lap-Robotic Pure Robotic T-Test Patients 77 81 Age 60 60 Male 39 (48%) 22 (70%) Female 41 (52%) 9 (30%) BMI 30.2 31 Lesion Size 3.5 2.6 *p < 0.05 Nephrometry Score 6.2 4.7 ***p < 0.001 Table 2. Perioperative Outcomes Perioperative Variable Lap-Robotic Pure Robotic T Test Warm Ischemia Time (min) 28 18.5 ***p < 0.001 Length of Surgery (min) 173.8 211.9 ***p < 0.001 Estimated Blood Loss (ml) 139.3 271.9 ***p < 0.001 Length of Stay (days) 2.4 2.6 Mg of IV Morphine 19.7 32.4 *p < 0.05 Preoperative Creatinine 1.1 1.2 Postoperative Creatinine 1.2 1.2 Clear Cell Renal Cell Carcinoma 37 (48%) 12 (39%) Papillary Renal Cell Carcinoma 23 (30%) 9 (29%) Benign Mass 14 (19%) 10 (32%) Other 2 (3%) 0 Minor Complications 5 3 Major Complications 2 1 CONCLUSIONS The combined LRPN approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. This finding may translate into a reduced utilization of hospital resources and cost. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e567-e568 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Harbin Washington, DC More articles by this author Xi Cheng Washington, DC More articles by this author Vincent Stanford Washington, DC More articles by this author Kevin McGeagh Washington, DC More articles by this author Jonah Murdock Washington, DC More articles by this author Reza Ghasemian Washington, DC More articles by this author Gaurav Bandi Washington, DC More articles by this author Jonathan Hwang Washington, DC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical evaluation of a novel bipolar radiofrequency ablation system for renal masses

What's known on the subject? and What does the study add? With the advancement of minimally invasive surgery, the management of small renal masses (SRM) has dramatically changed. Ablative technology such as radiofrequency ablation (RFA) and cryoablation have emerged as viable alternative modalities to extirpative surgery. RFA is one of the most studied and applied energy-based, needle-ablative treatment modalities, with encouraging mid- and long-term oncological outcomes. Monopolar devices have several shortcomings. The electrodes are susceptible to the cooling effect of nearby blood vessels that act as a 'heat sink', limiting the extent of tissue ablation and forming lesions with asymmetric borders and 'skip lesions'. Therefore, it is difficult to monitor and accurately predict the size of ablated lesions. A novel bipolar radiofrequency ablation (BRFA) device has been recently developed to address concerns with monopolar systems (Trod Medical, Paris, France). The BRFA system addresses the limitations of monopolar RFA, in terms of lesion size, targeting, consistency and concerns about cell death in the ablated area. We evaluated the BRFA device in 10 patients undergoing laparoscopic partial or radical nephrectomy. The present study demonstrates the safety and efficacy of a novel BRFA device. A BRFA device can produce a defined reproducible lesion with a precise transition zone to normal tissue. The area of ablated tissue exhibited completely devitalized cells and precise transition zone. With these characteristics, the potential advantages of this new technology during RFA ablation of SRM include less collateral damage and more complete ablation without skip lesions. This has the potential to lower rates of local recurrence and reduce incidence of skin burns. Further follow-up studies are necessary to determine its oncological efficacy. To evaluate a novel bipolar radiofrequency ablation (BRFA) system for the destruction of kidney tumours in patients. Bipolar radiofrequency ablation (BRFA) was used to ablate renal masses in 10 patients undergoing laparoscopic radical or partial nephrectomy. The probe was placed percutaneously and laparoscopically guided into the tumour after routine laparoscopic exposure. The electrical current was continuously adjusted by the generator to overcome disruption from increasing impedance created from desiccated tissue. The specimens were then excised in routine fashion and analysed by a single pathologist. Lesion size and shape, and size of the transition zone to viable tissue were measured via nicotinamide adenine dinucleotide (NADH) staining. Ablation was successful in all 10 tumours. Mean time to set up and place the probe was between 2 and 4 min. Duration of ablation was 200 s. None of the ablated tissue showed signs of viable cells by histological examination and NADH staining. The mean size of the ablation zone was 6.26 cm(3), with regular borders and a tapered cylindrical shape similar to the shape of the outer coil. The width of the transition zone, or area spanning complete tissue ablation to the first viable cells, ranged from 10 to 60 µm. There were no complications noted due to the ablation. A BRFA device can produce a defined reproducible lesion with a precise transition zone to normal tissue. The area of ablated tissue exhibited completely devitalized cells and precise transition zone.

Use of the LION procedure on the sensitive branches of the lumbar plexus for the treatment of intractable postherniorrhaphy neuropathic inguinodynia

To report on the use of the laparoscopic implantation of neuroprosthesis (LION) procedure on the sensitive branches of the lumbar plexus for the treatment of refractory postherniorrhaphy neuropathic inguinodynia. Laparoscopic exposure and implantation of an electrode to the different nerves is undertaken by the transumbilical transperitoneal approach. The genitofemoral nerve is identified on the anterior surface of the psoas major muscle, the ilioinguinal, iliohypogastric, and of the lateral femoral cutaneous nerves on the anterior surface of the quadratus lumborum muscle behind the kidney and colon. A quadripolar electrode is placed laparoscopically in direct contact with the injured nerve(s). All patients included in this series had reported failure of all previous treatments. Twenty-three consecutive patients were included in this series. Success, defined as visual analog scale (VAS) reduction >50%, was obtained in 19 patients. To date (mean follow-up 28.61 months [± 16.2; min. 6 months to max. 68 months]), 11 patients report a reduction of the mean VAS of more than 80% and eight report a reduction of between 50 and 80%; the mean VAS score could be reduced, so far, from 8.1 (± 8.1; range 6-10) preoperatively to 3.1 (± 2.8; range 0-5) postoperatively (P < 0.001). The presented technique of laparoscopic implantation permits a selective implantation and neuromodulation of all sensitive branches of the lumbar plexus. These preliminary results suggest that the technique described is effective, safe, minimally invasive, and must be indicated in patients after failure of all other treatments.