Laparoscopic Needle Research Articles

V2091 THE USE OF THE URETHRA AS A NOTS (NATURAL ORIFICE TRANS-ENDOSCOPIC SURGERY) FOR URETHERAL CLOSURE AND URINARY BLADDER SUTURE IN PATIENT WHO WAS TAKEN TO LAPAROSCOPIC NEPHREOURETERECTOMY

You have accessJournal of UrologySingle Port Surgery1 Apr 2011V2091 THE USE OF THE URETHRA AS A NOTS (NATURAL ORIFICE TRANS-ENDOSCOPIC SURGERY) FOR URETHERAL CLOSURE AND URINARY BLADDER SUTURE IN PATIENT WHO WAS TAKEN TO LAPAROSCOPIC NEPHREOURETERECTOMY Manuel Duque and Natalia Victoria Manuel DuqueManuel Duque Cali, Colombia More articles by this author and Natalia VictoriaNatalia Victoria Cali, Colombia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2388AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There's always been doubts concerning that in the nephroureterectomy procedures by the time of the release of the urether, tumoral cells could fall into the retroperitoneum, therefore causing potentially carcinogenic spreads in that area. NOTES, is a state of the art procedure that could successfully avoid this complication. METHODS Female Patient. 56 years old. The patient complains from blood in her urine. Smoker for 35 years. Female patient with gross haematuria. No symptoms for abdominal pain other than occasional cramping. CAT Scan shows tumoral lesion between the distal portion of the urether and dispaired function. RESULTS The ureteroscopy shows an ureteral tumor. A PDS 3 0 stitch is passed through the nephroscope sheet; the sheet is then removed and a laparoscopic needle handler is placed as well as the nephroscope. The needle is secured, then a stitching point is placed in the uretheral meatus. The needle is then removed. External knot maid in the suture. The uretheral meatus is released. The electroscalpel and the sheet are pushed into the retroperitoneum for latter closure of the urinary bladder defect in a similar way. Urinary catether is placed and then nephroureterectomy is performed. The distal portion of the urether is observed along with the PDS 3 0 stitching points. Total Surgical Time 2 hours and 30 minutes. Total Blood Loss: 100 cc. Inpatient Care: 1 day. Non opioid pain relief medication required. CONCLUSIONS NOTES could be the answer to the concern that's been around the procedure in terms of the risk of tumoral cells in the retroperitoneum. At the present time five procedures have been performed: Two males; three females, so far in a safe way and with no major complications. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e836 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Manuel Duque Cali, Colombia More articles by this author Natalia Victoria Cali, Colombia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Novel 3-D laparoscopic magnetic ultrasound image guidance for lesion targeting

ObjectivesAccurate laparoscopic liver lesion targeting for biopsy or ablation depends on the ability to merge laparoscopic and ultrasound images with proprioceptive instrument positioning, a skill that can be acquired only through extensive experience. The aim of this study was to determine whether using magnetic positional tracking to provide three-dimensional, real-time guidance improves accuracy during laparoscopic needle placement. MethodsMagnetic sensors were embedded into a needle and laparoscopic ultrasound transducer. These sensors interrupted the magnetic fields produced by an electromagnetic field generator, allowing for real-time, 3-D guidance on a stereoscopic monitor. Targets measuring 5mm were embedded 3–5cm deep in agar and placed inside a laparoscopic trainer box. Two novices (a college student and an intern) and two experts (hepatopancreatobiliary surgeons) targeted the lesions out of the ultrasound plane using either traditional or 3-D guidance. ResultsEach subject targeted 22 lesions, 11 with traditional and 11 with the novel guidance (n= 88). Hit rates of 32% (14/44) and 100% (44/44) were observed with the traditional approach and the 3-D magnetic guidance approach, respectively. The novices were essentially unable to hit the targets using the traditional approach, but did not miss using the novel system. The hit rate of experts improved from 59% (13/22) to 100% (22/22) (P < 0.0001). ConclusionsThe novel magnetic 3-D laparoscopic ultrasound guidance results in perfect targeting of 5-mm lesions, even by surgical novices.

A Case of Ureteral Malignant Lymphoma Diagnosed by Laparoscopic Needle Biopsy

A pathological diagnosis of a lesion in the ureteral wall is often attended with a difficulty. We report a case of a 54-year-old man who presented a thickening of the ureteral wall and diffuse swelling of paraaortic lymph nodes diagnosed as a non-Hodgkin lymphoma by a laparoscopic needle biopsy. This is a safe and useful technique by which target tissues can be surely obtained.

Psychosocial and marketing challenges for Natural Orifice Transluminal Endoscopic Surgery and Laparoendoscopic Single‐site Surgery

The introduction of laparoscopic techniques in the late 1980s and early 1990s has ushered in a novel era in the surgical treatment of human diseases. Following the first laparoscopic nephrectomy done by Clayman et al . in 1991 [1], the initially noted advantages of minimally invasive urological surgery were later proved [2,3]. This soon led to the transition from novelty to the current concept of established ‘expectations’. Despite the success of conventional laparoscopic urological surgery, incisions ranging from 1 to 3 cm in length and three to five ports in number are still required. Each additional working port increases the inherent risk of bleeding, infection, concordant organ damage, hernia formation and decreased cosmetic outcome.

Injury of the Thoracic Aorta During Laparoscopic Esophagectomy

We report an unusual complication of laparoscopic esophagectomy for carcinoma. During posterior transhiatal dissection, massive bleeding occurred from the left side of the supradiaphragmatic thoracic aorta. A small tear was clearly visible and temporary bleeding control by packing and pressure with a grasper through one of the trocars was effective. A median laparotomy was performed and the aorta was sutured using a standard laparoscopic needle holder. The esophagectomy was successfully completed through a right thoracic approach. Injury to the intrathoracic aorta may occur during transhiatal dissection of the lower mediastinum. Use of a laparoscopic needle holder allowed to repair the supradiaphragmatic aorta through a laparotomy without the need of patient repositioning for a transthoracic approach.

Devices for laparoendoscopic single-site surgery in urology

The quest to make minimally invasive techniques even more ‘minimal’ has generated a drive within the surgical community to explore novel ways of achieving this. This has led to surgeons attempting to either decrease the number of trocars placed through the abdominal wall or eliminate them completely. This led to the evolution of several approaches, including natural orifice translumenal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), single port access surgery and one port umbilical surgery (OPUS) or E-NOTES. The most recent consensus on nomenclature involves the term laparoendoscopic single-site surgery (LESS). The transition from multiple port access surgery to single port access surgery represents a paradigm shift in reconstructive and extirpative surgery and is a testament to the recent advances in surgical technology. Successful LESS involves the use of articulating or bent instrumentation via a single large-caliber trocar or small, adjacent trocars. Advances in technology have led to the development of new laparoscopic access ports (R-Port™ and Quadriport™ by Advanced Surgical Concepts, Wicklow, Ireland; and Uni-X™ Single Port, PNavel Systems, Cleveland, OH, USA) capable of permitting several instruments to be inserted through multiple channels incorporated in, and as part of, a larger single port. The development of articulating and bent instrumentation permits triangulation intracorporeally despite the close proximity of several instruments via a single port. Currently, commercially available instruments can be broadly divided into articulating laparoscopic graspers and shears (Real Hand™, Novare Surgical Systems, Cupertino, CA, USA; and Autonomy Laparo-angle™, Cambridge Endo, Framingham, MA, USA), endoshears (Cambridge Endo), and laparoscopic needle drivers (Cambridge Endo). Despite the preliminary optimistic results in the outcomes of LESS, an experienced laparoscopic skill set is essential for the safe and effective completion of surgery.

Tying laparoscopic intracorporeal knots with one instrument: "Dowais tie"

In laparoscopic surgery, intracorporeal suturing is one of the most important and difficult techniques.Laparoscopic intracorporeal knot tying in minimally invasive surgery is an advanced skill. Mastering this skill is a difficult process with a long learning curve. Intracorporeal suturing is essential in advanced laparoscopy and is a rate-limiting step in many procedures. The technique we wish to describe makes the art of knot-tying simple and straightforward by the use of a single laparoscopic needle holder. This technique, which we called Dowais tie, is useful for totally trans-umbilical laparoscopic surgery. This simple and useful technique of intracorporeal knot tying is demonstrated in this report

The Efficacy of Viewing an Educational Video as a Method for the Acquisition of Basic Laparoscopic Suturing Skills

Study Objective To estimate the efficacy of viewing an educational video in the acquisition of laparoscopic suturing skills. Design A prospective observational study (Canadian Task Force classification II-2). Setting Tertiary care academic medical institution. Subjects Twelve candidates interviewing for the female pelvic medicine and reconstructive surgery fellowship position at our institution. Interventions Candidates were evaluated in the laparoscopy laboratory before and after watching a 6-minute educational video on the basic principles of laparoscopic suturing. Each candidate evaluation included the following tasks: (1) introduction of a needle through a trocar (timed in seconds); (2) load and position a needle for suturing with a laparoscopic needle holder (evaluated by number of movements); (3) running continuous suture with 2 passes (timed in seconds); (4) intracorporeal knot tying with 2 throws (timed in seconds); and (5) extracorporeal knot tying with 2 knots (timed in seconds). Measurements and Main Results Wilcoxon signed rank test was used for the statistical comparison of the candidates’ performance before and after viewing the video. After viewing the teaching video, the total median time to perform all timed tasks improved by 20% (115.5 seconds, p = .009). Significant improvement occurred in the median time of introducing the needle through a trocar, continuous suturing, and extracorporeal knot tying (p = .02, p = .01, and p = .003, respectively). Conclusion The use of an educational video appears to be an effective method for the acquisition of basic laparoscopic suturing skills.

Design and Characterization of a Novel Hybrid Actuator Using Shape Memory Alloy and DC Micromotor for Minimally Invasive Surgery Applications

The end-effectors in the state-of-the-art robotic tools for minimally invasive surgery (MIS) are actuated by actuator packs located outside the patient's body, with the power transmitted from the actuator pack to the end-effector by means of sliding link or tendon-driven mechanisms. This method of power transmission limits the number of degrees-of-freedom (DOFs) in these systems, as the design of a spherical wrist gets complicated. The design of the spherical wrists can be simplified, and the number of DOFs increased, if local actuation is used for the end-effector. However, there are no suitable actuation systems available in the literature. In this paper, a novel design idea for developing a millimeter-scale actuator is presented for locally actuating the end-effector (5-mm-diameter laparoscopic needle driver) for a robot performing MIS. This actuator is designed by combining a dc micromotor and a shape memory alloy actuator in series. The designed actuator is 5.14 mm in diameter (including casing) and 40 mm in length, and is used to actuate a 20-mm-long needle driver assembly, while generating a force of 24 N, resulting in a gripping force of 8 N. The total stroke length of the actuator is 1 mm, which results in a 45 opening of the needle driver jaw with a gap of 8 mm in between the jaws.

Laparoscopic Surgical Manipulations Affect the Mechanical Properties and the Microstructure of Polymeric Sutures

In the last years a new clinical method to carry out surgical operations has been introduced. It consists in minimally invasive vascular surgery (also called laparoscopy). In one hand, during laparoscopy procedures, sutures cannot be handled with fingers, and the use of stainless-steel needle holders is required. In the other hand, companies that fabricate sutures clearly mention that metal-made devices should be avoided when manipulating the monofilaments. Therefore, the manipulation of the suture monofilaments (made of polymers) by laparoscopic needle holders (made of metals) is controversial. Literature in this field is limited and incomplete. Therefore, the aim of this study was to investigate the mechanical and microstructural effects of the manipulations with laparoscopic needle holder on polymeric suture monofilament. Surgipro© (polypropylene), Teflene© (polyvinylidene fluoride) and Gore-Tex© (polytetrafluoroethylene) monofilament suture were pinched with a standard clinical protocol by a surgeon. Scanning electron microscopy, micro-mechanical testing, differential scanning calorimetry, x-ray diffraction, small angle x-ray scattering and Fourier transform infrared spectroscopy were then performed. Results showed that the ultimate tensile strength of Teflene and Gore-Tex sutures does not change after pinching whereas it decreases significantly for Surgipro sutures. This is attributed to stress concentration and to the compressive strength applied on the monofilament, which are closely related to the permanent deformation of the suture after pinching. Teflene and Gore-Tex monofilament sutures showed to be not affected even after severe pinching with laparoscopic needle holders. Therefore, our results clearly showed that the use of Surgipro II sutures in laparoscopic interventions should be avoided.

Experimental results and early clinical experience with an easy method for intracorporeal knot tying using a novel laparoscopic needleholder

Intracorporeal suturing and knot tying are among the most difficult procedures in laparoscopic operations. An easy and inexpensive method for intracorporeal instrumental ligation with a modified laparoscopic needle driver is presented. The needle driver developed in this study has a novel mechanism that can fix the suturing thread in a hook at the distal site of the holder's jaw hinge. This hook projects out from the rod only when the jaw of the holder is open. After the needle is removed from the tissue using the grasper, the needle driver is placed under the grasper, which the surgeon manipulates by the left hand. Then the thread is hooked on the needle driver by withdrawal of the driver with the jaw opening. The tip of the needle driver is moved over the shaft of the grasper by keeping the thread on the hook. The thread is entwined during a series of crossing movements of the rods of the forceps. The short tail of the suture material is gripped and tied up as a first throw of ligation. The side edge of the jaw, used for thread cutting, is sharpened by grinding. When the angle of the forceps is set at 90 degrees in the box trainer, no difference in terms of ligation time and degree of error is observed between the hook and conventional C-loop methods. In the case of the 30 degree forceps angle, the novel method is superior to the conventional method. The novel needle driver provides an easy and inexpensive method for performing an intracorporeal ligation, particularly in a case involving a sharp axis angle of the forceps. More clinical experience is necessary for evaluation of this method, but it has potential advantages in laparoscopic operations.

Survey of Residency Training in Laparoscopic and Robotic Surgery

We determined the current status of residency training in laparoscopic and robotic surgery in the United States and Canada. A total of 1,188 surveys were sent via the Internet to all 1,056 current urology residents and 132 program directors with an Internet address registered with the American Urological Association. Responses were received from 372 residents (35%) and 56 program directors (42%). Of respondents 47% reported greater than 100 laparoscopic procedures performed yearly by 1 (36%) or more (51%) faculty members. Robotic procedures were performed at 54% of the institutions, mainly consisting of prostatectomy and pyeloplasty. At all institutions laparoscopic radical nephrectomy was performed and those at 69% of the institutions believed that it is the gold standard for renal tumors today. Urologists were involved in 87% of adrenal surgeries and 54% of respondents believed that is the gold standard approach. However, only 35% of respondents had participated in laparoscopic adrenalectomy. Of respondents 36%, 42% and 17% reported that laparoscopic donor nephrectomy was performed by only urologists, only a nonurology transplant team and shared equally, respectively. Of respondents 41% planned on performing laparoscopic donor nephrectomy in the next year. Laparoscopic needle ablation renal surgery was done in 51% of the programs and percutaneous needle ablation was done in 63%. None of the respondents (0%) believed that it is the gold standard but 51% believed that ablative procedures look promising for renal tumors. Of respondents 39% had participated in robotic radical prostatectomy and 53% thought that it looked promising but was not the gold standard. Of respondents 31% believed that they will be performing robotic surgery after residency, 30% were unsure and 29% will not be using the robot. Overall 38% of residents thought that their laparoscopic experience was at least average or acceptable. A large number of laparoscopic urological procedures are being performed at training institutions with robotic procedures being performed at 54% of respondent facilities. Residents are participating in most cases but only 38% consider their laparoscopic experience to be satisfactory. A need still exists for increased laparoscopic training for residents, which can be accomplished by expanding training facilities and increasing the number of faculty members performing laparoscopic procedures.

Control of laparoscopic instrument motion in an inanimate bench model: Implications for the training and the evaluation of technical skills

Computer-assisted analysis of wrist movement has recently emerged as an objective laparoscopic performance evaluation method. The first purpose of this study was to assess the differences in motion characteristics between the tip of the instrument and the wrist. The second purpose was to describe the control strategies used to move laparoscopic instruments. During a bead transfer task, motions of a laparoscopic needle driver's tip, heel, and the participants’ wrist were monitored. Results showed that large amplitude movements were best described by movements of the wrist, and small amplitude movements were evidenced by motions of the instrument tip. Thus, for describing expertise, and for evaluation and feedback, motion of the tip of the laparoscopic instrument should be quantified, in addition to motion of the wrist. The motions of the instrument were controlled by utilizing the flexibility of the skin of the laparoscopic trainer in addition to using the fulcrum, and sliding through the trocar. In order to increase fidelity, virtual reality trainers should simulate the flexibility of the real structures around the insertion of the instrument.

51 Laparoscopic suturing: effect of instrument handling on suture strength

Introduction: The limited operative field of laparoscopic surgery necessitates repeated instrument handling of suture material, which is discouraged in conventional open surgery. The quantitative effect of instrument handling on suture material has not previously been investigated. The aim of this study was to assess the effect of instrument trauma on various suture materials by laparoscopic needle holders and forceps.Materials and Methods: Three sutures of various gauge and material, 2‐0 and 3‐0 Polyglactin 910 and 2‐0 Poliglecaprone 25, commonly used in laparoscopic urological reconstruction, were tested. Controlled damage was performed by grasping the suture without tension between the jaws of either a toothed laparoscopic grasping forceps or a laparoscopic needle holder. Physical testing was performed using an Instron 5564 computer controlled tensile testing, which measured suture extension and tensile strength. Samples were examined using scanning electron microscopy.Results: There was no difference in mean percentage extension or tensile strength when comparing suture types damaged with laparoscopic graspers and controls regardless of their gauge or material. Following controlled damage with laparoscopic needle holders, % extension of damaged sutures was significantly lower compared with undamaged sutures. Tensile strength was significantly lower for 3‐0 Vicryl and 3‐0 Monocryl after damage with laparoscopic needle holders compared with undamaged sutures, but not 2‐0 Vicryl.Conclusion: The handling of suture material with laparoscopic instruments, especially needle holders, results in surface damage to the suture, which impacts on the suture mechanics. Limiting surface damage to suture material requires careful technique, avoiding shear force, minimising handling of the suture, and using shorter suture lengths.

Laparoscopic Suturing: Effect of Instrument Handling on Suture Strength

In open surgery, handling of suture at any position other than the end is discouraged because of evidence that handling deforms and weakens the material. The limited operative field of laparoscopic surgery necessitates repeated instrument handling of suture, and the effect of such handling has not been investigated. We assessed the effect of trauma imposed on various suture materials by laparoscopic needle holders and forceps. Also, the ideal suturing technique (interrupted v continuous) according to the physical characteristics of the suture material and the optimal length for laparoscopic sutures were determined. Sutures of 2-0 and 3-0 polyglactin 910 and 2-0 poliglecaprone 25 were tested. Controlled damage was inflicted by grasping the suture for 1 second between the jaws of either toothed laparoscopic grasping forceps or a laparoscopic needle holder at a pressure of 45 MPa. Blind physical testing was then performed using a computer-controlled tensile testing system. The length and proportion of suture extension prior to breaking and the tensile strength were measured. Samples of undamaged and controlled damaged specimens, before and after breakage, were examined by scanning electron microscopy (SEM). The mean percentage extension in the control group was 46.3 mm for 3-0 Monocryl, 26.3 mm for 3-0 Vicryl, and 28.1 mm for 2-0 Vicryl. The mean tensile strengths were 47.9 N, 42.4 N, and 70.4 N for 3-0 Monocryl and 3-0 and 2-0 Vicryl, respectively. The 3-0 Monocryl and 3-0 Vicryl had significantly reduced tensile strength after damage compared with control sutures, whereas 3-0 Vicryl and 2-0 Vicryl had significantly impaired extension. After infliction of controlled damage with laparoscopic needle holders, the percent extension of damaged sutures was significantly less than that of undamaged sutures. Tensile strength was significantly lower for 3-0 Vicryl and 3-0 Monocryl after damage than before. The handling of Monocryl by laparoscopic needle holders and graspers produced punched-out defects and scratch marks, respectively. A number of damaged 2-0 and 3-0 Vicryl samples from the laparoscopic needle holder group showed disruption or unravelling of the braided filaments. We expect that our results underestimate the potential effect on suture strength and extension inflicted by laparoscopic suturing. The exact length of suture material cannot be recommended from the findings. However, interrupted sutures should be preferred, particularly for long suture lines. In addition, the findings support the use of laparoscopic graspers in preference to needle holders. The combination of a grasper in one hand and needle holder in the other is ideal. Finally, urologists initially embarking on laparoscopic reconstruction must take meticulous care in their suturing technique and, in particular, the number of times and force with which the suture is grasped.

Evaluation of a Novel Modified Suture Material Designed to Facilitate Intracorporeal Knot Tying during Laparoscopic Surgery

Laparoscopic intracorporeal knot tying in minimally invasive surgery is an advanced skill. Mastering this skill is an arduous process with a long learning curve. While recent advances in instrumentation have allowed easier suturing and tying, until now, no attempts have been made to modify the suture material in order to facilitate this process. We present an evaluation of a novel modified suture material designed to allow inexperienced surgical residents to tie intracorporeal knots laparoscopically using conventional laparoscopic needle drivers. Surgical residents with no prior experience in laparoscopic surgery were invited to take part in this investigation. Each of the 14 participants was given a 10-minute demonstration of laparoscopic intracorporeal knot tying and then allowed a mentored practice session of 10 minutes. In the first trial, they were then randomized to tie a laparoscopic knot with either a standard or a modified dry suture. Time and accuracy scores were recorded. They then performed the same task with the other type of suture. On the second trial, wet standard and modified sutures were used, and the order of the sutures used in the first trial was reversed. The average time taken to tie an intracorporeal knot laparoscopically was significantly less when the modified suture was used in both dry and wet conditions (162.71 +/- 10.79 seconds v 270.86 +/- 22.76 seconds; P = 0.0039, and 123.29 +/- 4.70 seconds v 247.57 +/- 23.17 seconds; P = 0.0032, respectively). No significant difference in accuracy scores was noted with the two sutures. Our modified suture design allowed inexperienced surgical residents to perform intracorporeal laparoscopic knot tying on average faster than the standard suture did. The concept of modifying suture design to facilitate laparoscopic suturing and knot tying deserves further investigation and development.

217: pureWRIST: A Revolutionary Needle Driver

To describe and highlight the use and benefit of the pureWRIST articulating needle driver. Both dry laboratory and pig laboratory footage is utilized to demonstrate the use of the needle driver in a number of challenging clinical scenarios. Northeastern suburban teaching hospital and private animal facility. No human patients are included in the video. A 50 lb adolescent female pig was utilized in the training and footage from that session is included. All procedures were simulated in videoscopic “box trainers” or in a live porcine model. The articulating pureWRIST needle driver was compared with a standard laparoscopic needle driver for the placement of difficult sutures. The pureWRIST demonstrated higher versatility and precision than the standard straight needle driver. The pureWRIST articulating needle driver is a unique design which offers some distinct advantages to the advanced laparoscopist, including simplification of needle setting and intracorporeal knot tying, as well as improved precision when attempting to suture tissue from a difficult angle.

Laparoscopic Placement of Oreopoulos–Zellerman Catheters in CAPD Patients

Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease. Various techniques have been described for the insertion of peritoneal dialysis catheters. Lately, with the evolution of laparoscopic surgery, different laparoscopic techniques have also been presented, suggesting the technique is preferable to the open and percutaneous methods. To introduce and evaluate a new laparoscopic technique for insertion of Oreopoulos-Zellerman catheters in CAPD patients. The study was carried out in the First Department of Propaedeutic Surgery, Athens University Medical School, Hippokration Hospital. Between November 2000 and March 2002, the technique was applied in 20 consecutive patients (mean age 62 years, range 54 - 70 years) with end-stage renal disease. During this technique, a 10-mm trocar is placed just below the umbilicus for the optics and a 5-mm trocar is placed in the right lower quadrant. With the help of a 10-mm trocar, a tunnel is formed in the standard paramedian position on the left side, 2 - 3 cm below the plane of the umbilicus, for the insertion of the peritoneal catheter. A laparoscopic needle (GraNee needle; R-Med, Oregon, Ohio, USA) is used for the closure of the 10-mm trocar-induced peritoneal and fascia defect using a purse-string suture. The catheter is advanced into the abdomen under direct vision and guided toward the Douglas pouch. The subcutaneous tunnel and the patency test of the catheter are performed as the last main steps in our procedure. One surgeon undertook all procedures. All procedures were completed laparoscopically. The mean operative time was 30 minutes (range 25 - 40 minutes). There was no intraoperative complication or surgical mortality. One patient developed leakage at the catheter exit site 3 days after surgery; it was corrected under local anesthesia. During a mean follow-up time of 17 months (range 12 - 28 months), 1 patient required catheter removal due to fungal peritonitis. Laparoscopic insertion of the Oreopoulos-Zellerman catheter is a simple, quick, and safe method. We believe future experience will encourage the laparoscopic technique as the method of choice.

Hand-assisted laparoscopic suturing: reconstruction.

Reconstructive techniques performed using open, laparoscopic, or hand-assisted techniques depend on the surgeon's ability to approximate tissues and secure bleeding vessels safely and efficiently. The indications for hand-assisted suturing include hemostasis, diaphragmatic and visceral repair, and reconstruction. The equipment required includes a standard laparoscopic needle driver, sutures with noncutting needles, and the handaccess device. The surgeon should be comfortable with the particular equipment available in his/her operating room. Techniques for suturing during hand-assisted laparoscopic reconstructive surgery are described.

Improvement of the laparoscopic needle holder based on new ergonomic guidelines

The aim of this study is to create new ergonomic guidelines for the design of laparoscopic needle holders. An ergonomic literature study, observations in the operating room, handle-shaft angle measurements, and anthropometric data were used to compile new ergonomic criteria, specified to the function of a laparoscopic needle holder. Based on these guidelines a new needle holder was designed. The prototype and three currently available needle holders were evaluated according to the new guidelines. In addition, a pelvi-trainer test was done to measure the extreme wrist excursions. The ergonomic evaluation of three commonly used handles and the new prototype indicate that the new handle is an ergonomic improvement in the field of laparoscopic needle holders: only the new handle satisfies all criteria. This is validated by the results of the pelvi-trainer test, which showed that the new prototype significantly (p <0.001) reduced the extreme wrist excursions. The new design guidelines for a laparoscopic needle holder result in an ergonomic improvement of the instrument.