Low Lithotomy Position Research Articles

The effects of different positions on lower extremity hemodynamics during robot-assisted laparoscopic radical prostatectomy for prostate cancer

PurposeThis study aimed to investigate the effects of two different positions on lower extremity hemodynamics during robot-assisted laparoscopic radical prostatectomy (RARP) for prostate cancer.MethodsA total of 196 patients who underwent RARP in our hospital from February 2020 to March 2022 were included in this study. Among them, 98 patients who underwent surgery with the Trendelenburg position and split-leg position with calf reverse arch from March 2021 to March 2022 were assigned to the observation group, while 98 patients who underwent surgery with the Trendelenburg position and low lithotomy position from February 2020 to February 2021 were assigned to the control group. Using an ultrasound diagnostic instrument to detect the internal diameter, mean blood flow velocity, and mean blood flow volume of the left deep femoral vein at different times, such as the supine position (T0), after 5 minutes of placing the patient in the leg spilt or low lithotomy position (T1), after 5 minutes of pneumoperitoneum (T2), after 5 minutes of head-down tilt or head-down tilt and calf reverse arch (T3), 1.5 hours after the start of surgery (T4), before the removal of CO2 gas (T5), and before the patient left the operating room (T6). As well as the patency of deep venous blood flow in both lower extremities before leaving the operating room,ResultsAfter establishment of pneumoperitoneum, the internal diameter of the deep femoral vein increased significantly, while the mean blood flow velocity and mean blood flow volume decreased significantly in both groups(T0) (P<0.001). With the prolongation of surgical time, the impact on lower extremity hemodynamics in the observation group was smaller than that in the control group. From T2 to T6, the internal diameter of the femoral vein in the observation group was smaller than that in the control group, while the mean blood flow velocity and mean blood flow volume were increased compared to the control group (P<0.05). Before leaving the operating room, the patency of deep venous blood flow in the observation group was better than that in the control group (P=0.003).ConclusionPlacing patients in the Trendelenburg position and split-leg position with calf reverse arch during RARP for prostate cancer has a smaller impact on lower extremity hemodynamics than the low lithotomy position, and can relatively reduce the risk of postoperative deep vein thrombosis.

Intraoperative Ascites and Pulmonary Edema during Hysteroscopic Myomectomy: A Case Report

Background:: Operative hysteroscopy is a surgical technique for various procedures of the uterus, for example, hysteroscopic myomectomy[1]. This has been an effective alternative [2] to conventional hysterectomy and has produced better surgical outcomes in terms of faster recovery, less post-operative pain and better patient satisfaction. Case Presentation:: A 49-year-old female was presented to the PAC clinic for hysteroscopic myomectomy for her dysfunctional uterine bleeding. There was no medical history of any previous medical or surgical problems. Her physical examination and routine labs did not reveal any abnormalities. She was labeled an ASA class 1 patient. Hysteroscopic myomectomy under spinal anesthesia was approved by the patient. On the day of the surgery, the patient was presented to the preoperative patient holding and was calm and comfortable. Vital parameters recorded were under normal limits. 20 G intravenous cannula was taken on her left dorsum of the wrist, and she was wheeled to the operating room. She was connected to ASA standard monitors, and her blood pressure, pulse rate, and spo2 were recorded. Spinal anesthesia was performed in a sitting position with a 27 G pencil point needle in a single attempt, and the procedure was regular. The level of anesthesia was ascertained to be till T6, and the patient was handed over to the surgical team. Surgery was started in a low lithotomy position. 65 minutes into the surgery, the patient started to complain of intra-abdominal pain, difficulty breathing, and started being restless. Blood pressure was 133/83mmhg, and SpO2 dropped from 98% to 86%. Her pulse rate was 112 beats per minute. Conclusion:: The patient’s abdomen was examined by moving the operative drapes, and gross abdominal distention was noted. Lung auscultation revealed crepitations on the basal lobes. Immediately, distention syndrome was suspected.

Management of Gestational Choriocarcinoma with Combined Robotic Surgery and Suction D&C to Minimize Blood Loss

<h3>Study Objective</h3> Use of combined surgical techniques to minimize blood loss. <h3>Design</h3> video case report of one patient <h3>Setting</h3> OR setting, low lithotomy position. <h3>Patients or Participants</h3> one female patient from clinical practice setting with gestational choriocarcinoma. <h3>Interventions</h3> Combined minimally invasive techniques, in this case robotic surgery and suction D&C. <h3>Measurements and Main Results</h3> With combined surgical techniques the EBL was 350 ml, there were no short- or long-term complications and patient was discharged same day. <h3>Conclusion</h3> Combined minimally invasive techniques can be used to minimize blood loss or other unwanted surgical outcomes.

Robotic Assisted - Laparoscopic Excision of Abdominal Wall Endometriosis

<h3>Study Objective</h3> The objective is to demonstrate a minimally invasive approach to treating abdominal wall endometriosis with robotic assisted – laparoscopic resection and repair. <h3>Design</h3> We present a video presentation documenting resection and repair of an abdominal wall endometrioma via a robotic assisted - laparoscopic approach, rather than the more traditional and often used open approach. <h3>Setting</h3> This surgical case was performed at a tertiary care center by Minimally Invasive Gynecologic Surgery with General Surgery available for assistance to close abdominal wall defect. Patient was positioned in the low lithotomy position. Robotic ports placed in such a manner to allow triangulation to both the abdominal wall lesion and pelvis. <h3>Patients or Participants</h3> 29-year-old who presented with left sided abdominal pain and palpable mass. Patient had undergone extensive evaluation, eventually leading to ultrasound guided biopsy which demonstrated endometrial glandular tissue within lesion <h3>Interventions</h3> Patient underwent robotic assisted - laparoscopic resection of abdominal wall endometrioma and repair of abdominal wall defect, and as well as ablation and resection of multiple additional endometrial implants within the pelvis. <h3>Measurements and Main Results</h3> The patient has experienced relief of her symptoms in the month following her surgical intervention. <h3>Conclusion</h3> Minimally invasive approaches to complete resection of abdominal wall endometriomas should be considered for lesions within the posterior recuts sheath and may afford patients relief of symptoms with the traditional benefits of minimally invasive surgery.

Robotic assisted ileo-vaginoplasty for vaginal atresia

Vaginal agenesis is a rare congenital disorder of female genital tract. Vaginal reconstruction using bowel segment is usually offered last when dilatation and/or prior vaginal reconstruction attempts using graft or flap has failed. Traditionally accomplished using open surgical approach, we describe here our initial experience of robotic-assisted ileo-vaginoplasty. The index patient presents to us with inadequate vaginal depth after failed buccal mucosal graft vaginoplasty. With the patient in low lithotomy position, port placement and docking of the robot was done. Isolation of ileal segment, closure at its proximal end and end-to-end bowel anastomosis was accomplished successfully. However, in view of dense adhesions the subsequent pull-down of the ileal segment into the perineum could not be done safely. The procedure was completed using combined abdomino-perineal open approach. A vaginal stent (in the ileal segment) and a catheter (in the introitus) were placed post-operatively. Post-operative recovery was uneventful. At 2-weeks, 3 months and a subsequent 1 year follow-up Cystoscopy and examination under anesthesia revealed an adequate vaginal depth with patient reporting successful vaginal dilatation. Robotic reconstruction of vagina using bowel segment in select patient, is safe and feasible, but possible with formidable surgical experience.

Management of proximal penile prosthetic cylindrical complications: a novel direct crural approach

IntroductionPatients with proximal penile prosthetic cylindrical complications (PPPCC) can be treated with a direct crural technique without using the original traditional approach. In this article we present our novel direct crural approach for management of patients with PPPCC.Materials and methodsBetween 2014 and 2019, data were retrospectively collected from 13 patients who underwent surgical revision using our novel direct crural approach for PPPCC. The procedure commences with identification of the affected zone. The patient is in a low lithotomy position. A 2-centimeter longitudinal incision is made directly over the affected site. Dissection is carried down through Colles’ fascia, followed by a longitudinal incision through the tunica albuginea at the proximal part of the affected cylinder. Via the incision we can deliver out the cylinder and manage its problem.ResultsMean operative time was 40 min. No intra or post-operative complications were reported. All patients (Mean age = 57) were discharged on the same day. Postoperative follow-up found correction of all existing deformities at month 1, 3 and 6. All patients were satisfied and reported less pain and faster recovery than the first procedure.ConclusionOur technique, which can be used for all types of penile prosthesis, is both feasible and safe. It may simplify PPPCC revision by avoiding adhesions below the original incision, without jeopardizing the already implanted materials or the urethra. It may also improve patients’ safety and satisfaction, by reducing iatrogenic injury and post-operative recovery time.

Laparoscopic Gravid Hysterectomy for Placenta Accreta at 19 Weeks Gestation

Study Objective To determine if laparoscopic approach to gravid hysterectomy for placenta accreta is a safe alternative to traditional open abdominal route. Design Case report. Setting Gynecology operating room. Patients or Participants A 36-year-old G3P2002 at 19w0d with history of 2 prior cesarean sections presented with undesired pregnancy and placenta previa with suspected placenta accreta. She was consented for laparoscopic gravid hysterectomy, with possible conversion to open abdominal approach. Interventions Total laparoscopic hysterectomy, bilateral salpingectomy, vaginal uterine morcellation, and evacuation of intact fetus Measurements and Main Results The patient was taken to the operating room, where double set up was prepared for both laparoscopic and abdominal approach to hysterectomy. Exam under anesthesia revealed a 20-week gravid uterus. She was positioned in low lithotomy position. Five laparoscopic ports were placed. A sacrocolpopexy cup was placed in the vagina to delineate the vaginal fornices; no tip was placed through the cervix due to placenta previa. The operating room table was airplaned side to side to assist uterine manipulation. A bariatric 45 degree laparoscope aided visualization. The hysterectomy was completed in usual fashion with a bipolar sealing device. After the colpotomy was completed, the uterus was placed in a tissue extraction bag. Strings attached to the bag were grasped with a ring forcep placed vaginally, and the bag was delivered through the vagina. The uterus was morcellated in the bag, amniotomy was performed, and the fetus was delivered intact. The vaginal cuff was closed, and cystoscopy performed. Total estimated blood loss was 50 mL. The patient discharged on post-operative day one. Final surgical pathology confirmed placenta accreta. Conclusion Laparoscopic gravid hysterectomy is a safe alternative to abdominal approach in the setting of placenta accreta, with decreased blood loss, shorter length of stay, and faster recovery.

Risk factors of infectious complications after retrograde intrarenal surgery: a retrospective clinical analysis.

ObjectiveStone disease is one of the most common afflictions in modern society. Complications following retrograde intrarenal surgery (RIRS) vary considerably, and small-diameter ureteral access sheaths are reportedly significantly associated with rates of infectious complications following RIRS. This study aimed to explore additional risk factors for infectious complications after RIRS.MethodsThis study retrospectively analyzed 602 patients who underwent RIRS between December 2016 and October 2019 at the First Affiliated Hospital of Fujian Medical University. All flexible ureteroscopic lithotripsy processes were conducted with patients under general anesthesia in the low lithotomy position. Postoperative systemic inflammatory response syndrome (SIRS) was diagnosed; statistical analyses comprised two-way analysis of variance (ANOVA) and one-way multivariate ANOVA.ResultsThe incidence of infectious complications after RIRS was 7.14%. Operative time was an independent risk factor that increased the risk of infection. Stone size >2 cm was observed in 153 (27.37%) patients in the SIRS group and 29 patients (67.44%) in the non-SIRS group.ConclusionsFindings in the literature suggest that early antibiotic treatment and active fluid therapy might lower the rate of infectious complications after RIRS. Our results indicate that extended operative time and increased stone size may be risk factors for infectious complications after RIRS.

External pressure at calf region in low lithotomy position is higher in men and increases proportionately with height, weight, lower leg size, and foot length

ObjectivePatients placed in lithotomy position (LP) with a leg holder during surgical procedures have been at particular risk of developing well leg compartment syndrome (WLCS). A commonly considered contributing factor of WLCS is obesity. LP is mainly divided into the following four types by the degree of hip angulation and height of lower leg placement relative to the heart: low, standard, high, and exaggerated. We have reported that the external pressure at the calf region in standard LP is independent of weight. In the present study, we investigated the relationship between the external pressure in low LP and physical characteristics, such as body, leg, and foot sizes. MethodsFifty-five volunteers, 27 men and 28 women, participated in this study. They were placed in low LP with the boot-support-type leg holder, with the hip joints flexed at 170° from the trunk and abducted at 45°, and with the knee joints flexed at 120°. Peak contact pressure (PCP) at the calf region was measured as representative external pressure by using the pressure distribution measurement system, BIG-MAT®. ResultsThe mean PCPs at the left and right calf regions in men (37.6 and 39.3 mmHg, respectively) were significantly higher than those in women (31.5 and 33.6 mmHg [P = 0.014 and 0.001], respectively). The left PCPs correlated positively with height (P = 0.003), weight (P = 0.001), body mass index (BMI) (P = 0.037), tibial length (TL) (P < 0.001), bimalleolar breadth (BB) (P = 0.046), maximum calf girth (MCG) (P = 0.035), and foot length (FL) (P = 0.001); and the right PCPs correlated positively with height (P < 0.001), weight (P < 0.001), BMI (P = 0.063), TL (P < 0.001), BB (P = 0.001), MCG (P = 0.005), and FL (P = 0.001). ConclusionThe external pressure at the calf region in low LP is higher in men and increases proportionately with height, weight, lower leg size, and FL, which may contribute to the risks of inducing WLCS during surgeries performed in low LP.

MP79-09 TITLE: ROBOT ASSISTED PENILE INVERSION VAGINOPLASTY A DESCRIPTION OF A NOVEL TECHNIQUE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2017MP79-09 TITLE: ROBOT ASSISTED PENILE INVERSION VAGINOPLASTY A DESCRIPTION OF A NOVEL TECHNIQUE Brenton Armstrong, Aaron Weinberg, Kiranpreet Khurana, Jamie Levine, and Lee Zhao Brenton ArmstrongBrenton Armstrong More articles by this author , Aaron WeinbergAaron Weinberg More articles by this author , Kiranpreet KhuranaKiranpreet Khurana More articles by this author , Jamie LevineJamie Levine More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2493AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Gender confirmation surgery represents an essential component in the management of gender identity disorder. The perineal dissection and creation of the neovaginal canal is the most challenging aspect of the penile inversion vaginoplasty (PiV) and poor visualization can lead to surgical complications. An incomplete dissection also results in a foreshortened neovagina, increased risk for vaginal stenosis and need for excessive postoperative dilations. Here we present the results of our first 15 patients performed at our intuition utilizing our robot assisted PiV (RAPiV). METHODS 15 transgender patients who were already living as females presented to our institution from 1/2016 to 10/2016, and underwent our previously defined RAPiV. Briefly, the RAPiv is performed in the low lithotomy position and the penis is degloved through a circumcision incision. An additional perineal incision is made to the bulbar urethra. The dissected penis, urethra, neurovascular bundle, glans and corpora are delivered through the perineal incision (Figure 1a). We spare the dorsal aspect of the tunica of the corpora cavernosa to reduce risk of glans necrosis. Four robotic ports were placed and the abdomen was insufflated (1b) and robot docked. Denonviller's fascia is opened (1c) and the abdominal dissection is continued to the peritoneal one (1d), the neovagina is passed into robotic field (1e) and pexed to the anterior reflection of the posterior peritoneum (1f). The peritoneal reflection is then closed (1g). We then complete the labioplasty and clitoroplasty. RESULTS The average operative time for RAPiV was 5.8 hours (5-7), 8/15 (53%) required mobilization of additional tissue flaps (4/15, 27%) or underwent concomitant abdominoplasty and skin graft harvest (4/15 27%) to supplement penile skin. EBL was 386cc (100-600) and LOS was 3.7 (2-6). Average postoperative vaginal depth was 11.3cm (10.2-12.7). Two patients had complications, 1 dehiscence of labioplasty treated with conservative therapy and 1 had loss of neovagina depth and distal urethral stenosis secondary to wound infection requiring debridement. CONCLUSIONS We have performed 15 cases utilizing our novel method for robot assisted penile inversion vaginoplasty. Under direct visualization the neovaginal canal is created. This technique achieves maximal vaginal length in a reproducible manner. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1075-e1076 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Brenton Armstrong More articles by this author Aaron Weinberg More articles by this author Kiranpreet Khurana More articles by this author Jamie Levine More articles by this author Lee Zhao More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Single-Port Total Laparoscopic Hysterectomy in a Patient With Deep Infiltrating Endometriosis

Study ObjectiveTo present the feasibility of single-port laparoscopic surgery at patients with deep infiltrating endometriosis. DesignStep by step explanation of the surgery using videos (Canadian Task Force classification III-c). SettingSingle-port laparoscopic surgery is an emerging technique and an option for improving the benefits of laparoscopic surgery. The goals of single-port laparoscopic surgery is to further enhance the cosmetic benefits of minimally invasive surgery and minimize the potential risk and morbidity associated with multiport surgery [1,2]. This procedure is not without challenges, however, such as instrument crowding and clashing, ergonomic difficulties, loss of instrument triangulation, and the need for advanced laparoscopic skills [1,2]. Despite these challenges, technical advances in optics and instrumentation have led to the widespread use of single-port laparoscopic surgery to treat such gynecologic disorders as endometriosis, uterine myomas, and cancers [2,3]. InterventionsA 42-year-old woman was admitted to our clinic with a complaint of chronic pelvic pain dysmenorrhea and deep dyspareunia. Her medical history revealed a cesarean section delivery and a diagnosis of endometriosis. Despite treatment of her endometriosis with dienogest, there has been no decline at her complaints. Ultrasound examination performed at admission revealed a 6 × 6 cm right adnexal mass compatible with endometrioma, with a normal left ovary and uterus. Rectovaginal examination detected no endometriotic nodules. Although all treatment options were explained and discussed and laparoscopic excision of right ovarian endometrioma was recommended, the patient strongly desired removal of the uterus and the ovaries to avoid recurrence of endometriosis and related complaints. Thus, laparoscopic hysterectomy and bilateral salpingo-oophorectomy were planned. Under general anesthesia and endotracheal intubation, the patient was placed in low lithotomy position with the arms tucked. An orogastric tube and a Foley catheter were placed. Abdominal access was performed following an open Hasson technique with a 2.0- to 2.5-cm vertical umbilical incision and a 4-channel (with two 10-mm and two 5-mm channels) access port was placed into the peritoneal cavity. On pelvic examination, a 6 × 6-cm right ovarian endometrioma adherent to the pelvic sidewall was detected, along with severe adhesions on the left side between the left adnex and the pelvic sidewall. The uterus was normal. The adhesion on the left side was released using a Harmonic scalpel (Ethicon Endosurgery, Cinncinnati, OH). The pelvic sidewall peritoneum was opened, and the ureters were identified and isolated at the pelvic brim and followed toward the true pelvis. The internal iliac artery, uterine and obliterated umbilical artery, and infundibulopelvic ligament were dissected and identified. The paravesical, pararectal, and rectouterine spaces were opened. Deep infiltrating endometriosis implants on the right side located in the uterosacral ligment and pararectal space were dissected and excised. After restoration of pelvic anatomy, hysterectomy and bilateral salpingo-oophorectomy were performed. The vaginal cuff was closed with intracorporeal knots. The patient was discharged on postoperative day 1, and reported no problems at follow-up. ConclusionSingle-port laparoscopic hysterectomy appears to be a safe and feasible option in patients with deep infiltrating endometriosis, especially when performed by well-experienced surgeons.

The clinical application of suctioning flexible ureteroscopy with automatically controlling renal pelvic pressure

Objective To evaluate the safety and efficacy of suctioning flexible ureteroscopy with automatic control of renal pelvic pressure. Methods A total of consecutive 87 patients, including 54 male cases and 33 female cases, with upper urinary tract calculi were enrolled in this study from November 2014 to August 2015. The average size of stone was (15.9±4.2)mm. The average age was (48.2±13.1 )years old. All patients were performed suctioning flexible ureteroscopic lithotripsy under general anesthesia in low lithotomy position. They were treated by suctioning flexible ureteroscopy with automatic control of renal pelvic pressure (RPP) by a patented intelligent system including an irrigation and suctioning platform and a ureteral access sheath (F12/14) with a pressure-sensitive tip. There are two connecting channels on the back end of the UAS, which are connected to the vacuum device with suctioning effect and pressure monitoring feedback device, respectively. On the platform, control value was set at -15--5 mmHg(1 mmHg=0.133 kPa), RPP warning value was set at 20 mmHg, and RPP limit value was set at 30 mmHg. Infusion flow rate was set at 50-150 ml/min .Intraoperatively, Holmium laser was used to powderize the stone at 0.6-0.8J/pulse with a frequency of 20-30 Hz (fiber diameter 200μm). Statistical analysis was performed regarding RPP, operative time, stone-free rates, and complications. Results 76 of 87 patients only accepted one surgery to remove the stone. There were 7 cases who failed the first surgery due to difficulty in placing the ureteral access sheath but flexible ureteroscopy were successfully performed in these patients after indwelling a D-J stent for 2 weeks. Four cases were converted to percutaneous nephrolithotomy due to significant ureteral stenosis. For the 83 patients who underwent successful flexible ureterosocopy the actual RPP was controlled under 20 mmHg with clear operative visualization. The average operative time was (24.8±14.7) min. The stone-free rates at day 1 and day 30 were 86.7%(72/83) and 95.2%(79/83), respectively. Complication occurred in 16 cases. The ClavienⅠcomplications were noted in 14 cases, including pain in 6 cases , fever in 5 cases, nausea/vomiting in 2 cases and tachycardia 1 case. While ClavienⅡhypertension complications were noted in 2 cases. Conclusions Suctioning flexible ureteroscopy with automatically controlling RPP is technically feasible, safe, and efficacious for treating upper urinary tract calculi with the advantages of breaking stones at high efficacy and low complication rates. Key words: Upper urinary tract calculi; Renal pelvic pressure; Pressure feedback; Equipment

LB-S&T-19 RADICAL VIDEOSCOPIC INGUINAL LYMPHADENECTOMIES IN 70 CASES: A STEP-BY-STEP TECHNIQUE AND PRELIMINARY RESULTS

You have accessJournal of UrologyLate-Breaking S&T Poster1 Apr 2016LB-S&T-19 RADICAL VIDEOSCOPIC INGUINAL LYMPHADENECTOMIES IN 70 CASES: A STEP-BY-STEP TECHNIQUE AND PRELIMINARY RESULTS Yunlin Ye and Hui Han Yunlin YeYunlin Ye More articles by this author and Hui HanHui Han More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.03.100AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical inguinal lymphadenectomy is the standard surgical approach for patients at risk for lymph node metastases as recommended in the guidelines. Recent reports have demonstrated that videoscopic inguinal lymphadenectomy (VIL) was associated with decreased morbidity and comparable oncological control in short-term follow-ups. While, most reported VILs have been performed in the femoral triangle, which might result in residual lymph node tissue. So radical VIL was performed in this study to evaluate its modifications and feasibility. METHODS Radical VIL had been performed in 70 cases of 38 patients, with two modifications. First, the scope of the radical inguinal lymphadenectomy was precisely achieved through improved positioning and fine-needle penetration guidance. The patient was placed in a low lithotomy position; the body and thigh were straight, the thigh was at 20-30° of external rotation, and the legs drooped naturally. During the operation, this positioning was critical to expose the entire Daseler’s area, and the boundaries were defined accurately by fine-needle penetration guidance. Second, the clear dissection plane that was created through the 4-cm incision along the inferior boundary ensured en bloc inguinal lymph node dissection, and we were able to identify three useful anatomic markers, i.e., the white, semi-hyaline membrane, under the superficial layer of Camper’s fascia, the fascia lata and SV. RESULTS From August 2014 to October 2015, 70 VILs were performed in 38 patients. The clinical characteristics of the patients are listed in Table 1. According to the Clavien-Dindo classification, 6 lateral complications were observed in the patients who underwent VIL. Complications were detected as illustrated in Table 2, and no grade III or IV complications were detected. CONCLUSIONS Modified radical video-scopic inguinal lymphadenectomy is feasible and practical with results in less morbidity, but the oncological outcomes require further investigation. The dissecting field and the defined plane were critical to these modifications. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e344 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Yunlin Ye More articles by this author Hui Han More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Postoperative pain and neuromuscular complications associated with patient positioning after robotic assisted laparoscopic radical prostatectomy: a retrospective non-placebo and non-randomized study.

To evaluate postoperative pain and neuromuscular complications associated with positioning after robotic assisted laparoscopic radical prostatectomy (RALP). Between September 2010 and June 2014, 534 patients who underwent RALP were evaluated. Patients were positioned in operating theater by operating room staff, and two independent urologists noted postoperative follow-up. Patient's demographic data, postoperative complications associated with positioning, pain score according to visual analogue scale, and hospital stay were recorded. Statistical analyses were performed and p < 0.05 was considered significant. Postoperative pain and neuromuscular complications were observed in 54 (10.1 %) and 27 (5 %) patients, respectively. We found ASA, BMI, and comorbidities were significantly associated with postoperative pain levels in univariate analyses (p = 0.01, p = 0.013, and p = 0.01, respectively). Additionally, ASA, previous operations, and comorbidities were significantly associated with postoperative neuromuscular complications (p = 0.04, p = 0.01, and p = 0.02, respectively). According to statistical analyses, BMI < 30 and presence of an implant were significantly associated with postoperative pain in multivariate logistic regression analyses (p = 0.010 and p = 0.033, respectively). Additionally, having comorbidities was significantly associated with postoperative neuromuscular complications in multivariate analyses (p = 0.04). Patients with previous operations, comorbidities, and high ASA score are at risk of neuromuscular complications during RALP. Lower BMI and having an implant also lead to higher postoperative pain. Operating room staff and anaesthesia team should be very careful with patients undergoing RALP in steep Trendelenburg and low-lithotomy position.

Single-Incision Laparoscopic Detorsion and Oophoropexy during Pregnancy

A 32-year-old female, G3P0A2, who was pregnant at gestational age 12 weeks, presented with acute onset left lower abdominal pain. Transabdominal ultrasonography showed left adnexal cystic mass 8.8*5.6cm. Under the impression of left ovarian corpus leutum cyst with torsion, she received emergent single-incision laparoscopic surgery. Under general anesthesia and endotracheal intubation, the patient was placed in the low lithotomy position. Single incision over umbilicus was made.The telescope was introduced through the umbilicus after establishing a pneumoperitoneum of 15 mmHg in pressure with Veress needle.

Side Docking the Robot for Robotic Laparoscopic Radical Prostatectomy

Low lithotomy position with the robot between the legs for docking is a standard position for robotic radical prostatectomy. Its complications include occasional nerve injury and compartment syndrome. In some patients with conditions that limit hip abduction, this position may be infeasible. We report a docking technique that obviates stirrups and simplifies setup without altering surgical technique. A total of 100 consecutive patients underwent robotic radical prostatectomy for localized prostate cancer. Fifty patients (group 1) were in the standard lithotomy position, and the remaining 50 patients (group 2) were in slight trendelenburg position with the robot at the side of the bed - "side-docked." Setup and docking times were recorded and both groups were compared for differences in operative variables. Mean setup time for group 2 was 4.7 minutes shorter than for group 1 (p = 0.02). Docking time and other operative variables were statistically similar and not affected by the adoption of side-docking technique. However, overall surgical time was longer due to modifications in other aspects of the technique during the study period. Side-docking for robotic radical prostatectomy is associated with small but significant improvement in setup time and can be utilized in patients with limited hip abduction.

Surgical Techniques: Low Lithotomy Patient Positioning for Penile Prosthesis Implantation

Figure 1Low lithotomy positioning of the patient with the surgeon in front of the penis provides excellent exposure for all parts of the procedure, especially in obese patients. It allows for very proximal corporotomy placement that minimizes tubing contact with cylinders, as well as a more proximal tubing exit, making tubing less palpable near the upper scrotum and base of penis. To begin, the patient is shaved and then undergoes a 10-minute prep. An extremity drape is utilized. A Foley catheter is placed and the bladder is drained. A scrotal incision is made starting at the penoscrotal junction and dissection is continued through the Dartos until full dissection to both proximal corpora is accomplished.Figure 2Low lithotomy positioning enables excellent exposure of both proximal corpora where the bulbocavernosus muscles are identified. Two stay sutures of 2-0 Vicryl are placed in each corpus just distal to bulbocavernosus muscles. The corporotomy is performed between the stay sutures with the Bovie. Proximal and distal corporal dilation is accomplished with Hegar dilators and both are dilated to size 13. The low lithotomy positioning allows for a more anatomic corporal measurement by placing the sizer proximally in the corpus. In addition, the penis is now placed on stretch and the distance to mid-glans is measured. This is performed with the sizer inside of the proximal corpora but still outside the distal corpus adjacent to the penile shaft giving a more anatomical measurement as opposed to measuring proximal and distal separately, and then adding them together. This also cuts down on measurement error and discrepancy.Figure 3The external ring is easily accessible for perforation of the transversalis. After making sure the bladder is fully drained, the surgeon inserts a finger into the space of Retzius and sweeps out a space adequate to hold the inflated reservoir without back pressure. Subsequently, the cylinders are placed in the corpora and inflated to assure correct sizing and position. By making small proximal corporotomies, prosthesis tubing contact with cylinders inside the corpora is minimized. Next, corporotomy closure can most often be accomplished by tying down the 2-0 Vicryl stay sutures. However, if more suture is needed, there is good exposure reducing the risk of needle damage to the cylinders.Figure 4A Dartos pouch is fashioned in the scrotum and the pump is placed after the surgeon has performed the final checks and is confident the device is functioning normally and all components are in correct position. Upon completion, the device is left partially inflated and a compressive dressing is applied for at least 24 hours to decrease scrotal hematomas and swelling. Placement of the dressing is easily accomplished in this low lithotomy position. Throughout the procedure, the operative field is sprayed with the same antibiotic solution that is used to soak the device.

Ergonomic risk associated with assisting in minimally invasive surgery

Given the physical risks associated with performing laparoscopic surgery, ergonomics to date has focused on the primary minimally invasive surgeon. Similar studies have not extended to other operating room staff. Simulation of the assistant's role as camera holder and retractor during a Nissen fundoplication allowed investigation of the ergonomic risks involved in these tasks. Seven subjects performed camera navigation and retraction tasks using a box trainer on an operating room table that simulated an adult patient in low lithotomy position. Each subject stood on force plates at the simulated patient's left side. A laparoscope was introduced through a port into the training box with four 2-cm circles as rear-panel targets located in relation to the assistant as distal superior, proximal superior, distal inferior, and proximal inferior target effects. The subjects held the camera with their left hand, pointing it at a target. The task was to match the target to a circle overlaid on the monitor. Simultaneously, a grasper in the right hand grasped and pulled a panel-attached band. A minute signal moved the subject to the next target. Each trial had three four-target repetitions (phase effect). The subjects performed two separate trials: one while holding the camera from the top and one while holding it from the bottom (grip effect). A 4 x 3 x 2 (target x phase x grip) repeated-measures design provided statistics. Dividing the left force-plate vertical ground reaction forces (VGRF) by the total VGRF from both plates provided a weight-loading ratio (WLR). The WLR significantly increased (p < 0.005) with proximal targets (2 by 80% and 4 by 79%). The WLR decreased 75%, 74%, and 71% over time. No difference existed between the grip strategies (grip effect, p > 0.5). A high-risk ergonomic situation is created by the assistant's left or caudal leg disproportionately bearing 70-80% of body weight over time. A distance increase between the camera head location and the camera holder increases ergonomic risk. The phase effect was interpreted as a compensatory rebalancing to reduce ergonomic risk. Ergonomic solutions minimizing ergonomic risks associated with laparoscopic assistance should be considered.

Robotic Reconstruction for Recurrent Supratrigonal Vesicovaginal Fistulas

We report our experience with robotic reconstruction for recurrent supratrigonal vesicovaginal fistulas and its outcome. From August 2006 to October 2007 we treated 7 cases of recurrent supratrigonal vesicovaginal fistula. Salient features of our technique are 1) vaginoscopy and cystoscopy with bilateral Double-J stent or ureteral catheter placement and placement of a catheter through the fistula from vagina to bladder, 2) patient positioning in a low lithotomy position with a 60-degree Trendelenburg tilt and a 5-port transperitoneal approach, 3) peritoneoscopy and adhesiolysis with minimal posterior cystotomy encircling the fistulous opening, 4) mobilization of the bladder and vaginal flaps to allow tension-free closure, 5) excision of the fistulous rim, 6) bladder and vaginal edge freshening, 7) bladder and vaginal closure, 8) omental, peritoneal or sigmoid epiploic tissue interposition and 9) insertion of a Foley catheter and drain. Difficulty was primarily noted with regard to the safe establishment of pneumoperitoneum, the need for extensive adhesiolysis, dissection of the fistula from perifistulous fibrosis in close vicinity to the ureteral opening, tension-free closure of the larger defect and occasional absence of omentum for use as interposition tissue. The average size of supratrigonal fistulas was 3.0 cm. Mean operative time was 141 minutes (range 110 to 160). Mean blood loss was 90 cc. No significant intraoperative or postoperative complications were observed. Mean hospital stay was 3 days. The catheter was removed 14 days postoperatively. All patients had a successful outcome. Our experience suggests that robotic repair for recurrent vesicovaginal fistulas is feasible, results in low morbidity and provides outstanding results. It provides an attractive option for vesicovaginal fistula repair by a minimally invasive approach for the surgeon and the patient alike.

COMPARTMENT SYNDROME ASSOCIATED WITH LITHOTOMY POSITION AND INTERMITTENT COMPRESSION STOCKINGS

In Brief Background Compartment syndrome is a condition in which increased tissue pressure within a limited tissue space compromises the circulation and function of the contents of the space. Case A 43-year-old black woman, para 3, had repair of a recurrent vesicovaginal fistula. She was placed in a low lithotomy position with thigh length sequential compression sleeves. The procedure lasted more than 5 hours. On postoperative day 1, she complained of pain in her right leg and foot. Compartment syndrome was diagnosed and emergency fasciotomy was done. Conclusion Gynecologists should be aware of the possibility of compartment syndrome during prolonged procedures with patients in the lithotomy position. Concomitant intermittent compression sleeves might further increase the risk. Early diagnosis and treatment of compression syndrome are essential to minimize long-term neurovascular morbidity. Concomitant intermittent compression sleeves might increase the risk of compartment syndrome further during prolonged procedures with patients in the lithotomy position.