Laparoscopic Scissors Research Articles

Alternative sites for laparoscopic cholecystectomy, in thin and obese patients from the point of view of changes in the abdominal dimensions

Background: Laparoscopic cholecystectomy is the standard operation for treatment of gallstone disease, which is difficult in obese patients, but narrow abdomen and thin patients are also a challenge, resulting in complications which mainly affect patients at the extreme ends of the weight spectrum. This represents a major source of morbidity and mortality from laparoscopic procedures; the majority (80%) of these complications is due to placement of the primary trocar,Searching for techniques to prevent involuntary injuries must be put as the priority, to ensure the optimal retraction, allows enough space available for manipulation of the active jaws of the laparoscopic graspers or scissors. Aim: To define alternative sites for laparoscopic cholecystectomy, in thin and obese patients from the point of view of alteration in the abdominal dimensions, which may reduces laparoscopic, related injury. Methods: In Al Sulaimaniyah Teaching Hospital and Hatwan Private Hospitral , from (July 15th 2004-July14th 2009) 1076 patients underwent laparoscopic cholecystectomy by same team and 35% of them by the same surgeon. Standard 4 ports were used, with first entry port in the periumblical region. Sixty patients were selected, because of their extreme weight and the patients were classified accordingly in to two groups:Group A:had downward displacement of umbilicus (43-60 cm width & 30-45cm height of the abdomen).Group B; had narrow abdominal dimensions (28-38 cm width & 14-27cm height of the abdomen).Results: Different alternative sites for trocar insertion were selected in order to overcome abdominal thickness and discrepancy between length of the hand instruments and distance of the port to the gall bladderConclusions: We recommend using this principle in the patients with extreme weight and narrow abdomen when XU is less than 15 cm or (more than 25cm), to decrease challenges of sequel of laparoscopic cholecystectomy in these groups of patients.

The transrectal single port laparoscopic radical prostatectomy in a cadaver model.

To explore the feasibility of laparoscopic trans-rectal Natural Orifice Transluminal Endoscopic Surgery (NOTES) radical prostatectomy in a cadaveric model and to define anatomical landmarks of this surgical route. After the ethical clearance, the study was conducted in Turkish Council of Forensic Medicine. With the cadaver in an exaggerated lithotomy position, a full thickness incision was made on the anterior wall of the rectum. The anteriorly visible Denonvilliers' fascia was incised sharply, exposing the posterior surface of the prostate. A single-port device (GelPOINT(®)Path) was inserted transanally passing the incision on the anterior wall of the rectum, into the bluntly created space between rectum and prostate. Three, 10 mm ports were placed through the GelPOINT(®)Path, at 3, 6, and 9 o'clock positions. A 5 mm, 0° degree lens was introduced at 6 o'clock position; followed by laparoscopic scissors and laparoscopic grasper. Prostatic and periprostatic anatomy was defined as encountered during each step of the procedure. Exposure of the posterior surface of the prostate and seminal vesicles was easily achieved. No additional openings of the rectal wall were made. Surgical specimen was extracted keeping its integrity. Transrectal radical prostatectomy is technically feasible in the cadaver model, being facilitated by previous experience with perineal surgery. Anatomical observations during the present experimental study suggest that the transrectal NOTES route provides good exposure of the operative field and easy access to the posterior surface of prostate, Future experimental endeavors should focus on reproducibility of this approach and feasibility of lymph node dissection using trans-rectal route.

Transvaginal natural orifice transluminal endoscopic surgery (NOTES)–assisted laparoscopic partial nephrectomy

Objective To describe the initial clinical experience of transvaginal NOTES–assisted laparoscopy for partial nephrectomy, and evaluate its feasibility and efficacy. Methods Between Aug. 2013 and Aug. 2014, 6 females underwent transvaginal NOTES–assisted laparoscopic partial nephrectomy. All patients were married and delivered. The median age was 37 (30 to 48) yrs. The median tumour size was 3.5 (2.5 to 6.5) cm. Under general anesthesia, the patient was placed in the lithotomy position with the affected side elevated by 60°. Two trocars were placed at the medial margin on both sides of umbilicus. A trocar was placed through the vagina into the abdominal cavity under the direct vision from a flexible–tip 5.4 mm 0° laparoscope. The patients underwent surgeries with main renal artery clamping, segmental renal artery clamping and renal artery unclamping, respectively. The mass was excised using the laparoscopic scissors maintaining a 0.5 cm margin. The inner layer was sutured for closing the collecting system and the second layer was sutured for closing the renal parenchyma with the Quill self–retaining suture. Specimen was placed inside a homemade bag and removed through the posterior vaginal fornix incision. Results Five procedures were completed successfully. One patient with a right upper–pole tumor was converted to radical nephrectomy for continuous bleeding after removing the bulldog clip. All the procedures were finished without conversion to conventional laparoscopy and with no additional trocar. The warm ischaemia time (WIT) was 20, 25 and 28 min for the three patients who underwent surgeries with main renal artery clamping, respectively. The WIT was 35 and 40 min for the two patients who underwent surgeries with segmental renal artery clamping, respectively. One patient underwent surgeries with renal artery unclamping. The median operating time was 130 (110 to 190) min. The estimated blood loss was 150 (100 to 400) ml. One patient who was subjected to postoperative bleeding recovered with conservative treatment. There were no other complications. Pathology indicated that all the tumors were clear cell renal cell carcinoma and all surgical margins were negative. During the follow–up of 3–14 mon, there was no recurrence. The median PSAQ score was 42 (39 to 48). All the patients completed the FSFI questionnaire. The median FSFI score was 27.7 (26.2 to 30.4). Conclusions Transvaginal NOTES–assisted laparoscopic partial nephrectomy is safe and feasible for small renal tumors with less pain, quick recovery and excellent cosmetic results. It does not cause negative effect on the female sexual function. Key words: Natural orifice transluminal endoscopic surgery; Transvaginal surgery; Partial nephrectomy

Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis?

To determine the efficacy and safety benefits of performing intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) to treat symptomatic cholelithiasis. Patients admitted to the Minimally Invasive Surgery Center of Tianjin Nankai Hospital between January 2012 and January 2014 for management of symptomatic cholelithiasis were recruited for this prospective randomized trial. Study enrollment was offered to patients with clinical presentation of biliary colic symptoms, radiological findings suggestive of gallstones, and normal serum biochemistry results. Study participants were randomized to receive either routine LC treatment or LC+IOC treatment. The routine LC procedure was carried out using the standard four-port technique; the LC+IOC procedure was carried out with the addition of meglumine diatrizoate (1:1 dilution with normal saline) injection via a catheter introduced through a small incision in the cystic duct made by laparoscopic scissors. Operative data and postoperative outcomes, including operative time, retained common bile duct (CBD) stones, CBD injury, other complications and length of hospital stay, were recorded for comparative analysis. Inter-group differences were statistically assessed by the χ2 test (categorical variables) and Fisher's exact test (binary variables), with the threshold for statistical significance set at P<0.05. A total of 371 patients were enrolled in the trial (late-adolescent to adult, age range: 16-70 years), with 185 assigned to the routine LC group and 186 to the LC+IOC group. The two treatment groups were similar in age, sex, body mass index, duration of symptomology, number and size of gallstones, and clinical symptoms. The two treatment groups also showed no significant differences in the rates of successful LC (98.38% vs 97.85%), CBD stone retainment (0.54% vs 0.00%), CBD injury (0.54% vs 0.53%) and other complications (2.16% vs 2.15%), as well as in duration of hospital stay (5.10±1.41 d vs 4.99±1.53 d). However, the LC+IOC treatment group showed significantly longer mean operative time (routine LC group: 43.00±4.15 min vs 52.86±4.47 min, P<0.01). There were no cases of fatal complications in either group. At the one-year follow-up assessment, one patient in the routine LC group reported experiencing diarrhea for three months after the LC and one patient in the LC+IOC group reported on-going intermittent epigastric discomfort, but radiological examination provided no abnormal findings. IOC addition to the routine LC treatment of symptomatic cholelithiasis does not improve rates of CBD stone retainment or bile duct injury but lengthens operative time.

Laparoscopic right-sided colonic resection with transluminal colonoscopic specimen extraction.

To study the transcolonic extraction of the proximally resected colonic specimens by colonoscopic assistance at laparoscopic colonic surgery. The diagnoses of our patients were Crohn's disease, carcinoid of appendix and adenocarcinoma of cecum. We preferred laparoscopic total mesocolic resections. Colon and terminal ileum were divided with endoscopic staplers. A colonoscope was placed per anal and moved proximally in the colon till to reach the colonic closed end under the laparoscopic guidance. The stump of the colon was opened with laparoscopic scissors. A snare of colonoscope was released and the intraperitoneal complete free colonic specimen was grasped. Specimen was moved in to the colon with the help of the laparoscopic graspers and pulled gently through the large bowel and extracted through the anus. The open end of the colon was closed again and the ileal limb and the colon were anastomosed intracorporeally with a 60-mm laparoscopic stapler. The common enterotomy orifice was closed in two layers with a running intracorporeal suture. There were three patients with laparoscopic right-sided colonic resections and their specimens were intended to remove through the remnant colon by colonoscopy but the procedure failed in one patient (adenocarcinoma) due to a bulky mass and the specimen extraction was converted to transvaginal route. All the patients had prior abdominal surgeries and had related adhesions. The operating times were 210, 300 and 500 min. The lengths of the specimens were 13, 17 and 27 cm. In our cases, there were no superficial or deep surgical site infections or any other complications. The patients were discharged uneventfully within 4-5 d and they were asymptomatic after a mean 7.6 mo follow-up (ranged 4-12). As far as we know, there were only 12 cases reported yet on transcolonic extraction of the proximal colonic specimens by colonoscopic assistance after laparoscopic resections. With our cases, success rate of the overall experience in the literature was 80% (12/15) in selected cases. Transcolonic specimen extraction for right-sided colonic resection is feasible in selected patients. Both natural orifice surgery and intracorporeal anastomosis avoids mini-laparotomy for specimen extraction or anastomosis.

A comparison of peritoneal fluid values in mares following bilateral laparoscopic ovariectomy using a vessel sealing and dividing device versus placement of two ligating loops

The objective of this study was to determine the effect of bilateral laparoscopic ovariectomy on peritoneal fluid values in mares and compare how this effect was modified by the method of ovarian vessel hemostasis used. Ten mares undergoing standing bilateral laparoscopic ovariectomy were used in a randomized clinical study. During surgery, blood vessels within the mesovarium were either: (1) sealed and transected with a vessel sealing and dividing device (VSDD), or (2) ligated using two loops placed proximal to each ovary and then the mesovarium transected using laparoscopic scissors. The ovaries were removed through the ipsilateral body wall. Abdominocentesis was performed before surgery and 24 h and 72 h after surgery.Markers of peritoneal inflammation, as measured by total nucleated cell count, total protein (TP) and red blood cell count via abdominocentesis, were consistently increased for all groups compared to pre-operative values. The mean (range) of TP for the VSDD group was 4.14 (3.9–4.5) g/dL, and that for the ligating loop group was 3.18 (2.7–3.5) g/dL. Use of the VSDD resulted in significantly greater TP concentrations in the abdominal fluid at 24 h and 72 h post-operatively when compared to a ligating loop (P < 0.001 and 0.04, respectively).

Simple technique for laparoscopic appendicectomy to ensure safe division of the mesoappendix

Different instruments, such as endoscopic stapler, endoscopic clip, monopolar hook cautery, harmonic scalpel, and vessel sealing instrument, have been described in appendiceal mesentery dissection (1). Cutting the appendiceal mesentery by laparoscopic scissors and suturing take more time and require intracorporeal experience to tie a knot. On the other hand, endoscopic stapler is expensive. Classical bipolar electrosurgical systems and ultrasonic thermal energy are inadequate for the hemostasis of vessels >2 mm in diameter (2). Several shortcomings are associated with the use of conventional monopolar diathermy, such as thermal injury risk, difficulty in hemostasis, smoke production, and the need of use of additional tools, such as bipolar graspers, sutures and clips. Sharp dissection has the advantage of high heat production with thermal spread in surrounding structures and charring. It has some risks of direct coupling to another metal instrument, direct sparking, and the passage of current from recently coagulated, electrically isolated tissue (3). A simple cost-effective technique is described in this article to provide safe division of the mesoappendix that avoids the use of diathermy with its potential hazards. The technique utilizes a small number of clips. It is particularly useful in cases where the cecum is mobile, as it saves the need for an additional port to achieve control at the base of the appendix. TECHNIQUE

Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage

Noncompressible torso hemorrhage is a leading cause of death in trauma, with many patients dying before definitive hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct than can be used to expand the window of salvage in patients with end-stage hemorrhagic shock. The aim of this study was to evaluate the effect of continuous and intermittent REBOA (iREBOA) on mortality using a highly lethal porcine model of noncompressible torso hemorrhage. Male splenectomized pigs (70-90 kg) underwent a laparoscopic liver injury (80% resection of left lobe) followed by a 10-min free-bleed period. Animals were then divided into three groups (n = 8) for a 60-min intervention phase (n = 8): continuous occlusion (cREBOA), iREBOA, or no occlusion (nREBOA). Groups then underwent whole blood resuscitation, damage control surgery, and further critical care. Endpoints were mortality and hemodynamic and circulating measures of shock and resuscitation. Systolic blood pressure (in mmHg) at the end of the free-bleed period for cREBOA, iREBOA, and nREBOA was 31 ± 14, 48 ± 28, and 28 ± 17, respectively (P = 0.125). Following the start of the intervention phase, systolic blood pressure was higher in the iREBOA and cREBOA groups compared with the nREBOA (85 ± 37 and 96 ± 20 vs. 42 ± 4; P < 0.001). Overall mortality for the cREBOA, iREBOA, and nREBOA groups was 25.0%, 37.5%, and 100.0% (P = 0.001). Resuscitative endovascular balloon occlusion of the aorta can temporize exsanguinating hemorrhage and restore life-sustaining perfusion, bridging critical physiology to definitive hemorrhage control. Prospective observational studies of REBOA as a hemorrhage control adjunct should be undertaken in appropriate groups of human trauma patients.

Successful Ovarian Vitrification and Back-Transplantation to Preserve Fertility in a Patient Requiring Chemotherapy for Malignant Lymphoma

For women with hematologic malignancy anticipating chemotherapy or radio therapy but wishing to preserve fertility, it is preferable that recovery from oophorectomy be as rapid as possible. Considering Reduced-Port Surgery (RPS) to be potentially suitable for such patients, we used RPS for a patient with malignant lymphoma scheduled for pre-bone marrow transplantation chemotherapy. The patient was a 28-year-old woman, gravida 0, who had requested fertility preservation. Thus, with ethics committee approval, the left ovary was removed by RPS, and ovarian cortex with primordial ovarian follicles was cryopreserved by vitrification. The cortex was divided into 12 pieces, 1 cm×1 cm×1 mm each, placed in a container, and stored in liquid nitrogen. The patient’s post-bone marrow transplantation course was good. Because she was judged to have lost ovarian function, ovarian back-transplantation was performed by RPS. The cortex of the remaining right ovary was removed with a laparoscopic cold knife and scissors while heparin saline was instilled to maintain blood flow and a 2 cm×1 cm base was created. Two thawed ovarian cortex pieces were laparoscopically sewed to the base with 5-0 absorbable sutures. By postoperative day 173, the ovarian follicle had increased to 10 mm in diameter, and the patient’s estradiol level had risen to 101 pg/ml, suggesting recovery of ovarian function. Our experience in this lymphoma case suggests that ovarian cryopreservation and back-transplantation for fertility preservation can be performed safely by RPS and is a viable option for selected patients anticipating chemotherapy and bone marrow transplantation for hematologic malignancy.

Robotic learning of motion using demonstrations and statistical models for surgical simulation

In robotic-assisted surgical training, the expertise of surgeons in maneuvering surgical instruments may be utilized to provide the motion trajectories for teaching. However, the motion primitives for trajectory planning are not known until the motion trajectory is generalized. We hypothesize that a generic model that encodes surgical skills using demonstrations and statistical models can be used by the surgical training robot to determine the motion primitive base on the motion trajectory. The generic model was developed from twenty-two sets of motion trajectories of soft tissue division with laparoscopic scissors collected from a robotic laparoscopic surgical training system. Adaptive mean shift method with initial bandwidth determined by the plug-in-rule method was used to identify the primitives in the motion trajectories. Gaussian Mixture Model was applied to model the underlying motion structure. Gaussian Mixture Regression was then applied to reconstruct a generic motion trajectory for the task. The generic model and proposed method were investigated in experiments. Motion trajectory of tissue division was model and reconstructed. The motion model which was trained based on primitives determined by adaptive mean shift method produced RMS error of 3.05° and 3.08° with respect to the demonstrated trajectories of left and right instruments, respectively. The RMS error was smaller than that of k-means method and fixed bandwidth mean shift method. The dexterous features in the demonstrations were also preserved. Surgical tasks can be modeled using Gaussian Mixture Model and motion primitives identified by adaptive mean shift method with minimum user intervention. Generic motion trajectory has been successfully reconstructed based on the motion model. Investigation on the effectiveness of this method and generic model for surgical training is ongoing.

Objective analysis of surgeons’ ergonomy during laparoendoscopic single-site surgery through the use of surface electromyography and a motion capture data glove

Adding to the ergonomic inconveniences already presented by traditional laparoscopy (LAP), laparoendoscopic single-site (LESS) surgery has been found to entail other more specific problems, including greater reduction in movement freedom, in-line vision with loss of triangulation, and greater proximity of instruments. The objective of this study was to evaluate surgeons' ergonomy during LESS surgery, through the study of muscular activity, wrist angle, and hand movements, and compare it with conventional laparoscopy. The study group was composed by 14 experienced laparoscopic surgeons, all right-handed. Each one performed dissection tasks on a physical simulator through LAP and LESS approaches. For LAP, straight laparoscopic scissors and dissector were used, whilst for LESS articulating tip scissors and dissector were chosen. During both tasks, muscular activity of biceps brachii, triceps brachii, forearm flexors and extensors, and trapezius muscles was registered through surface electromyography. Simultaneously right-hand movements and wrist angles were obtained through a motion capture data glove (CyberGlove(®)), which allowed for the use of a modified RULA test applied to the recorded angles with subsequent establishment of risk levels for the wrist joint. Muscular activity for trapezius (LAP 6.94 ± 4.12 vs. LESS 11.32 ± 4.68; p ≤ 0.05) and forearm extensor muscles (LAP 9.2 ± 2.45 vs. LESS 37.07 ≤ 16.05; p ≤ 0.001) was significantly lower in conventional laparoscopy compared with LESS approach. No statistical significance was obtained between the different sensors, except in 3 of the 11 analyzed CyberGlove(®) sensors. The modified RULA test showed a score of 3 for laparoscopy (unacceptable), whereas for LESS a score of 2 was obtained (acceptable), with statistically significant differences between them (p ≤ 0.05). The LESS approach entails greater level of muscular activity in the trapezius and forearm extensor muscles, but we have found evidences of a better wrist position during LESS compared with traditional laparoscopy.

Incisional hernia repair in horses: A cadaveric study of endoscopic component separation

To report a technique for endoscopic component separation in horses and quantify the amount of body wall advancement obtained. Descriptive study. Fresh cadaveric horses (n = 14). After a preliminary anatomic study, 7 horses had unilateral endoscopic component separation involving transection of the external abdominal oblique fascia lateral to the rectus abdominis muscle. A laparoscope, placed using a balloon dissector, was used to create an intermuscular working space between the external abdominal oblique fascia and internal abdominal oblique muscle. A single instrument portal was created 10-12 cm medial to the laparoscope portal. Laparoscopic scissors were used to transect the external abdominal oblique fascia, lateral to its insertion to the external rectus sheath, from ≈ 20 cm cranial to the costochondral junction to the level of the superficial inguinal ring. Subsequently, a 30 cm ventral median celiotomy was created and the myofascial advancement was quantified at points 10 and 20 cm cranial to the umbilicus. Endoscopic component separation was successfully completed in all horses. Component separation provided a net mean (± SD) abdominal wall advancement of 3.5 ± 1.3 cm and 3.4 ± 0.5 cm, 10 cm, and 20 cm cranial to the umbilicus, respectively. Endoscopic component separation in horses is technically feasible but, as conducted, results in modest abdominal wall advancement.

Reconstruction of Esophagojejunostomies Using Endoscopic Linear Staplers in Totally Laparoscopic Total Gastrectomy

Totally laparoscopic total gastrectomy for gastric cancer is not a commonly performed procedure due to the technical difficulty. We devised a technique for intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. In the reconstruction, nearly two thirds of the diameter of the esophagus was transected with an endoscopic linear stapler and the unstapled esophagus was transected with laparoscopic scissors. First suture was created at the end of the stapled line and second suture was created at the esophagostomy. During the reconstruction, assistants retracted the 2 sutures to prevent slippage of the esophageal stump into the thoracic cavity. Finally the remnant entry hole was closed with an endoscopic linear stapler. This reconstruction was successfully performed in all patients; none of the patients required conversion to open surgery. All operations were curative and there were no deaths. This method can be performed easily and safely, and may become a powerful alternative procedure for totally laparoscopic total gastrectomy.

Bio-Inspired Spring-Loaded Biopsy Harvester

Bio-Inspired Spring-Loaded Biopsy Harvester

841 TRANSCOLONIC HYBRID NOTES NEPHRECTOMY: A SURVIVAL STUDY IN PIGS TO MINIMIZE FECAL CONTAMINATION

You have accessJournal of UrologyTechnology & Instruments: Laparoscopy: Malignant & Benign Disease1 Apr 2013841 TRANSCOLONIC HYBRID NOTES NEPHRECTOMY: A SURVIVAL STUDY IN PIGS TO MINIMIZE FECAL CONTAMINATION Richard Knight and Kyle Weld Richard KnightRichard Knight Fort Sam Houston, TX More articles by this author and Kyle WeldKyle Weld Fort Sam Houston, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.408AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To develop a technique for transcolonic extraction of a kidney following laparoscopic nephrectomy while maintaining sterility of the peritoneal cavity and demonstrate survival to 4 weeks in a pig model. METHODS After confirming the presence of bilateral kidneys on ultrasound, a laparoscopic left nephrectomy was performed in five pigs weighing 70-90 kilograms. A single dose of ceftriaxone 1gm was given intravenously prior to the procedure. A tap water enema was performed until all fecal material was removed in the distal 50 cm of the colon as confirmed with colonoscopy. The colon was flushed with 60ml of 10% povidone-iodine. A standard laparoscopic specimen pouch was then stapled to the wall of the colon using a laparoscopic stapler. The pouch was then laparoscopically cut open and through this opening, a colotomy was made with laparoscopic scissors. The kidney was removed through the colotomy, using the pouch as a shield to avoid peritoneal contamination. The colotomy was then closed with a laparoscopic linear stapler. The pouch was then removed through one of the laparoscopic ports. Swabs for culture of the peritoneal cavity were obtained at the beginning and end of the procedure. Necropsy was performed on all animals after a four week survival period. RESULTS All five animals survived the surgery. Sterility of the peritoneal cavity can be maintained using this technique. Our complications consisted of superficial wound infections that were self-contained. Necropsy demonstrated minimal peritoneal adhesions and excellent healing of the colotomy site. CONCLUSIONS 1) Transcolonic extraction of the kidney may be performed using standard commercially available equipment. 2) Further refinements of technique are necessary to reduce the likelihood of peritoneal contamination during transcolonic procedures. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e345 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Richard Knight Fort Sam Houston, TX More articles by this author Kyle Weld Fort Sam Houston, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison of Peritoneal Fluid Values after Laparoscopic Cryptorchidectomy using a Vessel‐Sealing Device (Ligasure™) Versus a Ligating Loop and Removal of the Descended Testis

To determine the effect of unilateral laparoscopic cryptorchidectomy and removal of the descended testis on peritoneal fluid values, and to compare effect between 2 methods for cryptorchid testis vessel hemostasis. Randomized clinical study. Stallions (n = 10) with unilateral abdominal cryptorchid testis. During standing laparoscopic cryptorchidectomy, blood vessels within the mesorchium of the cryptorchid testis were either sealed and transected with the LigaSure Atlas™ or 2 ligating loops were placed proximal to the testis and the tissue transected with laparoscopic scissors. The testis was removed through the body wall. After laparoscopic cryptorchidectomy, stallions were anesthetized and the descended testis was removed using a closed technique leaving the scrotal incision open. Abdominocenteses were performed before surgery, and 24, and 72 hours after surgery. Values for peritoneal total nucleated cell count (TNCC), total protein concentration (TP), and red blood cell count (RBCC) were all elevated at 24 and 72 hours when compared with baseline. Median TNCC for LigaSure™ (59,780 cells/μL) was nearly twice that of the ligating loop (32,880 cells/μL) at 24 hours postoperatively. There was no statistically significant difference in TNCC, TP, or RBCC between groups. TNCC, TP, and RBCC increase appreciably from baseline 24 hours after laparoscopic cryptorchidectomy and closed castration but are markedly reduced by 72 hours.

Lysis of Abdominal Wall and Intestinal Adhesions Using Scissors without Electrosurgery before TLH

Adhesiolysis by laparoscopy and laparotomy can be very challenging, time-consuming, and technically difficult. Therefore, we will present a case of menorrhagia and pelvic pain associated with history of right salpingo-oophorectomy for rupture hemorrhagic cyst via vertical laparotomy incision, which demonstrates how laparoscopic scissors without energy can be successful used to approach the intestinal adhesions. This video demonstrates four key points when performing bowel adhesiolysis: safe laparoscopic entry, scissors dissection without electrosurgery, countertraction, and blunt dissection.

Identification of the narrow lumen of the ureter using a Fogarty catheter during laparoscopic pyeloplasty

It is difficult to identify the narrow sites of the ureter from the outside while carrying out laparoscopic pyeloplasty in patients with ureteropelvic junction obstruction. We developed and named a new method, the Fogarty test, to identify the narrow sites of the ureter using a Fogarty catheter. A 4- to 5-Fr Fogarty catheter was inserted through an incision in the pelvis to the proximal ureter, inflated with air and withdrawn gently to determine resistance. The narrow lumen of the ureter was identified under direct vision and spatulated by laparoscopic scissors. This procedure was carried out repeatedly until the ureter was fully spatulated. By using the Fogarty test, we can visualize the narrow position and length of the ureter under direct vision, and confirm whether it is fully spatulated or not. This technique is very simple and easy to carry out. We believe it is useful for sufficient spatulation of intrinsic ureteral stricture, especially in patients where multiple narrow sites exist.

Single-Port Laparoscopic Diverting Sigmoid Colostomy

Single-port laparoscopic surgery has been described for various colorectal conditions. Here, we report the first 4 single-port laparoscopic sigmoid colostomies for fecal diversion. A 1.5-cm-round incision was made on the skin at a previously marked colostomy site. A wound retractor was inserted and an access platform with four 5-mm trocars was attached to the wound retractor. The sigmoid colon was mobilized using electrocautery, laparoscopic scissors, or an advanced bipolar device. A standard Brooke colostomy was created through the initial skin incision. Four elective single-port laparoscopic diverting colostomies were performed. Indications included obstructing colon and rectal cancers and intractable Crohn's proctitis. The average operative time was 73 minutes (range, 53-105), and blood loss was minimal (<50 mL). There were no intraoperative complications. Three of 4 patients received oral analgesia, and one patient received patient-controlled intravenous analgesia postoperatively. The average time to passage of flatus was 1 day. Diet was advanced either on the day of surgery or on postoperative day 1. The length of hospital stay ranged from 0 to 15 days. Single-port laparoscopic sigmoid colostomy is an effective technique that allows full intra-abdominal visualization and colonic mobilization while eliminating the need for additional skin incisions other than the colostomy site itself.

Laparoscopic Gonadectomy for Complete Androgen Insensitivity Syndrome: A Case Report

Objective: Our aim was to present and discuss a case with androgen insensitivity syndrome who underwent laparoscopic gonadectomy. Case: A 21 year-old women admitted to our clinic with the complaint of primary amenorrhea and infertility. She had sufficient breast maturation but have scanty pubic and axillar hair. In gynecologic examination vagina was 5 cm in length and ended blindly. In ultrasonographic examination uterus was absent, there were bilateral masses each 3 cm in diameter located near the internal os of the inguinal canals. Her karyotype was 46 XY. Results: The patient underwent laparoscopy. Pelvic inspection revealed no internal genitalia except bilateral gonads appearing as testis. The pedicle of gonads were coagulated with bipolar diathermy and cut with laparoscopic scissors and removed with endobags. Conclusions: Androgen insensitivity syndrome should be suspected in cases with primary amenorrhea and laparoscopic gonadectomy should be performed after puberty