Major Laparoscopic Procedures Research Articles

EP109 Assesment of factors contributing to delay of emergency laparotomies and potential solutions to optimize patient flow at a high volume centre. A Quality Improvement Project

Abstract Aim To identify factors resulting in delay of emergency laparotomies and offer potential solutions. Methods This was a retrospective study spanning 7 months including all laparotomies and major laparoscopic procedures excluding appendicectomies and cholecystectomeis. Data from the trust IT system was used to populate the various times of each procedure. Results 265 patients were studied in total including 76 category 1 laparotomies. Transport time defined as the duration between completion of the briefing to patient arrival at the operating theatre was found to be inaccurately documented in 66 cases. Median time was 20 min with 15 patients needing more than 45 min for transport. Median anaesthetic time defined as time from patient arrival to initiation of surgery was 50 min. Median procedure duration was 113 min. Median post operative time defined as the duration between surgery completion and exiting the operating theatre was 17 min. Median post op recovery time was 137 min with 15 patients requiring more than 12 hours in recovery. Post changes of informal education the median transport time reduced to 17 min. Conclusions Factors that can be optimized to reduce delays are ensuring ward prepardeness before transferring to theatres, appropriate documentation of transport times so staff are aware they maybe audited and satisfactory communication between teams (including site/bed managers) to ensure adequate prepardeness and a smooth flow of patients to the ward and prevent a hold up in recovery.

324 The Learning Curves of Major Laparoscopic and Robotic Procedures in Urology: A Systematic Review

Abstract Aim Urology has been at the forefront of adopting laparoscopic and robot-assisted techniques to improve patient outcomes. Defining the learning curves for these procedures enables assessment of trainee performances relative to expected progress and has important implications in research. This systematic review aimed to examine the literature relating to the learning curves of major urological robotic and laparoscopic procedures. Method In accordance with PRISMA guidelines, a systematic literature search strategy was employed across PubMed, EMBASE, and the Cochrane Library from inception to December 2021 for eligible studies alongside a search of the grey literature. Two independent reviewers completed the article screening and data extraction stages, using the Newcastle-Ottawa Scale (NOS) to then undertake quality assessment of the included articles. The review was reported in accordance with AMSTAR guidelines. Results Of 3702 records identified, 97 eligible studies were included for narrative synthesis. 39 studies evaluated robot-assisted laparoscopic prostatectomy (RALP) with the learning curve identified as 10-250 cases for operative time and 250-300 for potency. The shortest learning curve was reported for hand-assisted laparoscopic nephrectomy, involving 4-10 cases. There was considerable variation in the study designs, outcome measures and prior experience of surgeons, with all studies scoring either 5 or 6 on the NOS. Conclusions Standardised reporting of outcomes and performance measures is required to reduce heterogeneity and enable the undertaking of a meta-analysis. Future studies should use multiple surgeons and large sample sizes of cases to identify the currently undefined learning curves for laparoscopic radical cystectomy and for robotic and laparoscopic retroperitoneal lymph node dissection.

ThTP5.8 Single centre, single surgeons’ experience of laparoscopic emergency surgery from a tertiary care NHS hospital: delay in surgery is associated with higher mortality and morbidity

Abstract Aims The objective of this article is to present a single centre experience of laparoscopic emergency surgery reporting outcomes influenced by delay in surgery. Methods A retrospective review of case notes to evaluate postoperative outcomes in patients undergoing laparoscopic emergency gastrointestinal surgery. Results There were 172 major laparoscopic emergency procedures over a span of 5 years. Forty-one colorectal resections were performed within 48 hours of admission (group A) compared to 50 resections (group B) after 48 hours. Mean hospital stay was shorter in group A (10.57 versus 19.97) days. No mortality reported in the group A whereas 4 patients died (8%) in group B. Lower morbidity percentage was also observed in group A (14.6 % versus 22 %). Twenty small bowel resections were performed within 48 hours of admission (group C) compared to 6 resections (group D) after 48 hours. Mean hospital stay was shorter in group C (8.6 versus 29.5) days. 3 patients died (15%) in group C whereas no mortality reported in the group D. Lower morbidity was also observed in group C (14.6 % versus 22 %). Laparoscopic adhesiolysis was performed in 28 patients and significant reduced hospitalization (3.6 versus 12.5 days) and reduced morbidity (0 versus 0) was noted in patients undergoing surgery within 48 hours of the admission. Laparoscopic hernia repair was performed in 20 patients and significant reduced hospitalization (4.5 versus 8.2 days) and reduced morbidity (13.7% versus 20%) was noted among patients who underwent surgery within 48 hours of admission. Conclusion Early laparoscopic surgery in acutely ill surgical patients is associated with better surgical outcomes

First experiences with a diode laser in major gynecological laparoscopic procedures show lack of benefit and impaired feasibility

PurposeThe aim of this study is to evaluate feasibility and potential benefit of a diode laser in major laparoscopic procedures in gynecology.MethodsBetween 2018 and 2020, a total of 42 cases were enrolled in this study comparing standard electrosurgery with diode laser-supported therapy in laparoscopic supracervical hysterectomy (LASH), total laparoscopic hysterectomy (TLH), or laparoscopic myoma enucleation (LME). Dual wavelength 45 W diode laser light was used to cut and coagulate during laparoscopy in the prospective interventional arm consisting of 11 cases, while 31 matching patients who received conventional treatment with monopolar/bipolar current for the same interventions were retrospectively identified in our laparoscopy database. Recruitment in the prospective interventional laser diode arm was terminated after only 11 patients (instead of planned 50) due to intense hemorrhage and massive smoke development.ResultsA total of 42 cases were analyzed (11 LME, 19 LASH, and 12 TLH). Strong smoke development was evident in all 11 cases in the diode laser arm. It was necessary to convert to bipolar or monopolar current in all hysterectomies (n = 9) with initial diode laser implementation due to increased bleeding and smoke development. Conventional current sources had to be used in LMEs (n = 2) due to excessive bleeding and poor visibility during enucleation of the fibroid. A significant difference (p < 0.0001) was observed regarding smoke development when comparing the laser arm with the control arm.ConclusionWe found a 45-W diode laser to be inferior to electrosurgical techniques for major laparoscopic gynecologic surgeries regarding bleeding control and smoke development.

The Interest of Enhanced Recovery After Surgery in a New Bariatric Center.

Background: With the creation of a new bariatric center in Abu Dhabi, United Arab Emirates (UAE) and the organization of this bariatric department according to the international guidelines, a new activity of bariatric surgery started in January 2015. The surgeon had 20 years of experience in this field and he had performed over 5000 major laparoscopic bariatric procedures before starting this new bariatric program. The concept of enhanced recovery after bariatric surgery (ERABS) was applied from the beginning of the program. We decided to analyze the first 2 years of ERAS activity after having split them in two different periods: the 1st year of activity included restrictive procedures and the 2nd year associated malabsorptive surgeries. Materials and Methods: The results of the use of a fast-track program could be measured by different parameters like operative time, length of hospital stay, rate of complications, and rate of readmission and reoperation. Results: Between January and December 2015, 116 patients underwent a bariatric procedure. The mean age was 34.6 years (16-61) and average body mass index (BMI) was 41.7 kg/sqm (32-72.2). Sixty percent of patients were women and 37% of patients had at least one comorbidity (diabetes type 2, high blood pressure, hyperlipidemia, or sleep apnea). Ninety-four percent of the procedures were laparoscopic sleeve gastrectomy (LSG), 2.6% were laparoscopic Roux-en-Y gastric bypass, and 3.4% band removal. The mean operative time was 20 minutes for an LSG (14-45 minutes) and the average hospital stay was 1.2 days (standard deviation [SD]: 0.9-3.3). The rate of complications was 1.7% with 1 postoperative hematoma drained by CT scan on day 14 after the surgery and 1 relative stenosis endoscopically dilated on postoperative day 45. No reoperation was done. No leak was observed. At 1 year, the mean excess weight loss (EWL) was 64% (47-124) in 89 patients with a 76% rate of follow-up. For the 2nd year of activity in 2016, 142 patients went in the program. The mean age was 32.7 years (17-64) and average BMI was 42.3 kg/sqm (31-68). Seventy-two percent were women and 41% of the patients had one comorbidity or more. The majority of surgeries performed were LSG for 83.1% of the patients. RYGB was realized in 4.2% of cases, resleeve gastrectomy in 4.2%, and band removal in 1.4%. Some malabsorptive surgeries were performed as well, such as one anastomosis gastric bypass for 3 patients (4.2%), and single anastomosis duodeno-ilelal in 2 cases (2.8%). The average hospital stay was 1.5 days (SD: 0.9-3.5). No complication was observed. No reoperation was done. Two patients (1.4%) came back to the hospital on postoperative day 2 and 8 after a LSG for one or several episodes of vomiting without further complication. At 1 year, the mean EWL was 68% (49-154) in 98 patients with a 69% rate of follow-up. Conclusions: This new program of bariatric surgery in two steps using fast-track protocols, respecting international guidelines and with an experienced surgeon showed on its 1st year of implementation a 1.7% rate of readmission on 116 patients without reoperation or major complication and a hospital stay of 1.2 days. For the 2nd year of implementation with the inclusion of malabsorptive procedures only 2 patients (1.4%) were readmitted for a short episode of vomiting and the hospital stay was 1.5 days.

Multimodal Analgesic Therapy With Gabapentin and Its Association With Postoperative Respiratory Depression.

Gabapentinoids are widely used in perioperative multimodal analgesic regimens. The primary aim of this study was to determine whether gabapentin was associated with respiratory depression during phase-I postanesthesia recovery after major laparoscopic procedures. We retrospectively reviewed the electronic health records of 8567 patients who underwent major laparoscopic procedures (lasting ≥90 minutes) from January 1, 2010, to July 31, 2014. We assessed potential associations among patient and perioperative variables and episodes of respiratory depression during phase-I recovery. Multivariable and propensity score-matched analyses were performed to assess potential associations between preoperative gabapentin use and postoperative respiratory depression. The incidence of respiratory depression was 153 (95% confidence interval [CI], 146-161) episodes per 1000 cases. Multivariable analysis showed that gabapentin was associated with respiratory depression (odds ratio [OR], 1.47 [95% CI, 1.22-1.76]; P < .001). These results were confirmed by propensity score-matched analysis among a subset of patients who did not have analgesia supplemented by intrathecal opioids (OR, 1.26 [95% CI, 1.02-1.58]; P = .04). Older patients and those who received more intraoperative opioids had increased risk of respiratory depression. Those who had an episode of respiratory depression had a longer phase-I recovery (P < .001) and an increased rate of admission to a higher level of care (P = .03). The use of gabapentin is associated with increased rates of respiratory depression among patients undergoing laparoscopic surgery. When gabapentinoids are included in multimodal analgesic regimens, intraoperative opioids must be reduced, and increased vigilance for respiratory depression may be warranted, especially in elderly patients.

Laparoscopic repair of parastomal hernia.

Parastomal hernia is one of the most common long-term complications after abdominal ostomy. Surgical treatment for parastomal hernia is the only cure but a fairly difficult field because of the problems of infection, effects, complications and recurrence. Laparoscopic repair operations are good choices for Parastomal hernia because of their mini-invasive nature and confirmed effects. There are several major laparoscopic procedures for parastomal hernioplasty. The indications, technical details and complications of them will be introduced and discussed in this article.

A5147 - The Interest Of Enhanced Recovery After Surgery (ERAS) During The First Year Of Activity In A New Bariatric Center

The implementation of a new bariatric program encounters one major limitation the application of standard protocols for enhanced recovery after surgery (ERAS). From its creation (January 2015), the new bariatric department - the American Surgecenter of Abu Dhabi (ASC) - started his activity based on the IFSO/ASMBS Guidelines with a multidisciplinary team, and a surgeon expertise of ≥ 20 years experience in this field and ≥ 3000 major laparoscopic bariatric procedures performed in France.This new bariatric program applied a fast track protocol on per operative time and on post operative rehabilitation.

An Update on Bariatric Surgery.

Obesity is a serious problem facing patients and healthcare providers around the globe. Bariatric surgery has been an increasingly popular choice in the management of obesity, and the last five years have seen an enormous amount of research on the various procedures. Recently bariatric surgery has been recognized as an important modifier of the metabolic and hormonal states associated with obesity's comorbidities. Consequently, research regarding the effect of bariatric procedures on type 2 diabetes mellitus, dyslipidemia, and the inflammatory state has become more plentiful. As bariatric surgery has matured, a growing body of evidence and experience has accrued. A change in the relative popularity of the four major laparoscopic bariatric procedures; sleeve gastrectomy, roux-en-Y gastric bypass, adjustable gastric band, and biliopancreatic diversion with duodenal switch has taken place. This has been driven by technical factors, as well as the individual procedures' efficacy in weight-loss and improvement in comorbidities. Weight recidivism is an increasingly recognized problem as patients are followed for longer periods following their bariatric operations. This important and costly problem has roots in both technical and patient related factors.

Laparoscopic right colectomy with transvaginal extraction in a patient with prior pancreaticoduodenectomy

Previous complicated abdominal surgeries such as pancreaticoduodenectomy with large abdominal incisions may keep the surgeons away from major laparoscopic procedures. To the best of our knowledge, there is no published study that shows the feasibility of major laparoscopic surgery in a patient with previous pancreaticoduodenectomy. A 68-year-old female (BMI 27 kg/m2, ASA II), was admitted for anemia. Her medical history included an open pancreaticoduodenectomy four years ago for chronic pancreatitis. She had an abdominal Mercedes incision. Computed tomography and colonoscopy showed a 5-cm cecal mass with a histological diagnosis of adenocarcinoma. We performed a totally laparoscopic right hemicolectomy and intracorporeal ileotransverse anastomosis. The specimen was extracted through the vagina. The operating time was 500 minutes and the blood loss was 400 ml. The patient was uneventfully discharged on postoperative day four. Laparoscopic colon surgery can be feasible and safe despite previous extensive abdominal surgeries such as pancreaticoduodenectomy. Moreover, laparoscopic surgery in these cases can also be completed with intracorporeal anastomosis and specimen extraction through a natural orifice.

Techniques for laparoscopic repair of major intraoperative vascular injury: case reports and review of literature

Laparoscopic surgery has become increasing popular, and its use has been proven safe. However, major vascular injuries during laparoscopic procedures can have devastating effects, and there is a paucity of information regarding their intraoperative management. Here we report our experience with laparoscopic vascular injury repair and analyze the available literature on this topic. Two cases of iliac vessel injury during laparoscopic colectomy were reviewed from a single surgeon's experience with of over 1,000 major laparoscopic procedures. The details of injury, techniques used, and outcomes were analyzed. A review of the literature was also conducted via PubMed. An injury to the left common iliac artery in a 75-year-old man and an injury to the left external iliac vein in a 39-year-old man during laparoscopic sigmoid colectomy are described, with successful laparoscopic vascular repair in both. Estimated blood loss was 300 and 250 ml, respectively. Patients were discharged home on postoperative days 4 and 3 without complications. A review of the literature yielded descriptions of a total of 704 major vascular injuries, with 6 case reports of vascular injuries involving the iliac vessels and inferior vena cava with successful laparoscopic repair. Laparoscopic repair of major vasculature is feasible if sound techniques are followed. We describe a stepwise technique for dealing with intraoperative laparoscopic vascular injury.

Use of a Disposable Acupressure Device as Part of a Multimodal Antiemetic Strategy for Reducing Postoperative Nausea and Vomiting

There is still controversy regarding the optimal strategy for managing postoperative nausea and vomiting (PONV) in high-risk surgical populations. Although acustimulation at the P6 acupoint has been demonstrated to be effective in preventing PONV, the effect of this nonpharmacologic therapy on the patient's recovery with respect to resumption of normal activities of daily living has not been previously assessed when it is used as part of a multimodal antiemetic regimen. Therefore, we designed this randomized, sham-controlled, and double-blind study to assess the efficacy of a disposable acupressure device (Pressure Right®; Pressure Point Inc., Grand Rapids, MI) on the incidence of emetic episodes and quality of recovery when used in combination with ondansetron and dexamethasone for antiemetic prophylaxis. One hundred ASA physical status I and II patients undergoing major laparoscopic procedures were randomly assigned to either a control group (n = 50) receiving a "sham" acustimulation device or an acupressure group (n = 50) receiving a disposable Pressure Right device placed bilaterally at the P6 point 30 to 60 minutes before induction of anesthesia. All patients received a standardized general anesthetic. A combination of ondansetron, 4 mg IV, and dexamethasone, 4 mg IV, was administered during surgery for antiemetic prophylaxis in both study groups. The incidence of nausea and vomiting and the need for "rescue" antiemetic therapy were assessed at specific time intervals for up to 72 hours after surgery. The recovery profiles and quality of recovery questionnaires were evaluated at 48 hours and 72 hours after surgery. Patient satisfaction with the management of their PONV was assessed at the end of the 72-hour study period. The 2 study groups did not differ in their demographic characteristics or risk factors for PONV. The incidence of vomiting at 24 hours was significantly decreased in the acupressure group (10% vs 26%, P = 0.04, 95% confidence interval for absolute risk reduction 1%-31%). The overall incidence of vomiting from 0 to 72 hours after surgery was also significantly decreased from 30% to 12% in the acupressure group (P = 0.03, 95% confidence interval 2%-33%). Furthermore, adjunctive use of the acupressure device seemed to enhance patient satisfaction with their PONV management and quality of recovery at 48 hours after surgery. However, the recovery times to hospital discharge, resumption of normal physical activities, and return to work did not differ significantly between the 2 study groups. Use of the Pressure Right acupressure device in combination with antiemetic drugs provided a reduction in the incidence of vomiting from 0 to 72 hours after surgery with an associated improvement in patient satisfaction with their PONV management. However, recovery and outcome variables failed to demonstrate any improvement with the addition of the acupressure device.

Intestinal effects of thoracic epidural anesthesia

Thoracic epidural anesthesia (TEA) is most frequently used after major surgery. However, despite ongoing research, the influence of TEA on the intestinal perioperative pathophysiology is not fully understood. According to recent results, the splanchnic sympathetic activity is reduced during TEA both in animal models and in clinical TEA. The splanchnic sympathetic activity during high TEA is still unknown. Intestinal perfusion effects of TEA are still unclear as the technique and extent of TEA, hemodynamic alteration and size of measurement result in--seemingly--conflicting reports. Postoperative ileus after laparotomy is ameliorated by TEA. Recent findings suggest beneficial effects also after major laparoscopic procedures. Finally, the impact of TEA on the intestinal pathophysiology in critical illness is an area of growing clinical and scientific interest, although this knowledge is just at its beginning. Further research concerning the use of TEA in major laparoscopic procedures and its potential to improve or endanger anastomotic healing is warranted. The experimental studies of TEA in critical illness should be expanded.

Advances in Minimally Invasive Surgery

Advances in Minimally Invasive Surgery

Transdermal Scopolamine: An Alternative to Ondansetron and Droperidol for the Prevention of Postoperative and Postdischarge Emetic Symptoms

Given the controversy regarding the use of droperidol and the high cost of the 5-HT3 antagonists, a cost-effective alternative for routine use as a prophylactic antiemetic would be desirable. We designed two parallel, randomized, double-blind sham and placebo-controlled studies to compare the early and late antiemetic efficacy and adverse event profile of transdermal scopolamine (TDS) 1.5 mg, to ondansetron 4 mg IV, and droperidol 1.25 mg IV for antiemetic prophylaxis as part of a multimodal regimen in "at risk" surgical populations. A total of 150 patients undergoing major laparoscopic (n = 80) or plastic (n = 70) surgery procedures received either an active TDS patch (containing scopolamine 1.5 mg) or a similar appearing sham patch 60 min before entering the operating room. All patients received a standardized general anesthetic technique. A second study medication was administered in a 2-mL numbered syringe containing either saline (for the two active TDS groups), droperidol, 1.25 mg, or ondansetron, 4 mg (for the sham patch groups), and was administered IV near the end of the procedure. The occurrence of postoperative nausea and vomiting/retching, need for rescue antiemetics, and the complete response rates (i.e., absence of protracted nausea or repeated episodes of emesis requiring antiemetic rescue medication) was reported. In addition, complaints of visual disturbances, dry mouth, drowsiness, and restlessness were noted up to 72 h after surgery. There were no significant differences in any of the emetic outcomes or need for rescue antiemetics among the TDS, droperidol, and ondansetron groups in the first 72 h after surgery. The complete response rates varied from 41% to 51%, and did not significantly differ among the treatment groups. The overall incidence of dry mouth was significantly more frequent in the TDS groups than in the droperidol and ondansetron groups (21% vs 3%). Premedication with TDS was as effective as droperidol (1.25 mg) or ondansetron (4 mg) in preventing nausea and vomiting in the early and late postoperative periods. However, the use of a TDS patch is more likely to produce a dry mouth.

A Comparison of State and Response Entropy Versus Bispectral Index Values During the Perioperative Period

Cerebral monitoring indices are associated with a large degree of inter-patient variability and electrical signal interference during surgery. We designed this clinical study to test the hypothesis that use of the spectral entropy (Entropy) module is associated with less frequent intraoperative interference with the displayed indices than the bispectral index (BIS) monitor when used during general anesthesia with propofol and desflurane. Thirty consenting patients scheduled for major laparoscopic surgery procedures were enrolled in this prospective study. The elapsed time to obtain a baseline index value was recorded, as well as the simultaneous state entropy (SE), response entropy (RE), and BIS values at specific time intervals during the induction, maintenance, and emergence periods in patients administered a standardized general anesthetic technique. During the maintenance period, the changes in these indices were evaluated after a bolus dose of propofol (20 mg IV) and a 2% increase or decrease in the inspired concentration of desflurane. As expected, the baseline SE values were less than the RE and BIS values (88 +/- 2 versus 96 +/- 3 and 96 +/- 4, respectively). However, the SE and RE values correlated with the BIS value during the induction (r = 0.77 and 0.78, respectively) and emergence (r = 0.86 and 0.91, respectively) periods. The area under the receiver operating characteristic curve for detection of consciousness also indicated a similar performance of the SE (0.93 +/- 0.04) relative to the RE (0.98 +/- 0.04) and BIS (0.97 +/- 0.04). During the maintenance period, the responses to changes in propofol and desflurane concentrations were consistent with all three indices. Finally, the entropy indices were less interfered with by the electrocautery unit during the operation (12% versus 62% for the BIS monitor). Because the average selling prices of the Entropy and BIS disposable electrode strips (14.25 dollars versus 14.95 dollars USD, respectively) are comparable, we conclude that the Entropy module is a cost-equivalent alternative to the BIS monitor.

Efficacy and Safety of Fast-Track Recovery Strategy for Patients Undergoing Laparoscopic Nephrectomy

Factors that adversely affect early recovery after major laparoscopic procedures include ileus, pain, nausea, emesis, and fatigue. The objective of this randomized controlled study was to evaluate the impact of a multimodal fast-track (FT) rehabilitation program on recovery and length of hospital stay after laparoscopic nephrectomy. Thirty patients undergoing laparoscopic nephrectomy received either conventional care (control) or an FT recovery program. All patients received a standardized anesthetic technique and patient- controlled analgesia (morphine) for postoperative pain control. In the FT group, patients received premedication with rofecoxib and ranitidine, local anesthesia was administered at the ports and renal fosa during surgery, and postoperative non-opioid analgesic and gastrokinetic drugs were administered as part of an early enteral nutrition and mobilization program. During the postoperative period, pain and nausea were assessed at specific time intervals. In addition, recovery room and hospital discharge times, the need for rescue analgesics and antiemetics, patient satisfaction with pain management and quality of recovery, and side effects were recorded daily for 3 days after surgery. Patients were discharged home when they met previously defined discharge criteria. The FT group was discharged earlier from the recovery room (74+/-23 v 103+/-47 minutes) and the hospital (41+/-11 v 59+/-11 hours). Pain and nausea scores were consistently lower in the FT group during the first 48 hours after surgery. In addition, the requirement for antiemetic rescue therapy during the first 24 hours was reduced in the FT group (15% v 58%). The FT group also received less morphine during the first 2 postoperative days (14+/-16 v 40+/-24 mg). Finally, patient satisfaction with postoperative pain control was significantly higher in the FT group. A multimodal approach to minimizing postoperative side effects led to a reduced recovery room and hospital stay, as well as better pain control and patient satisfaction after laparoscopic nephrectomy.

561: Major Laparoscopic Urologic Procedures in Infants Weighing Less than 10 Kilograms

561: Major Laparoscopic Urologic Procedures in Infants Weighing Less than 10 Kilograms

Laparoscopic Renal Surgery in Infants 10 kg or Less

Major laparoscopic urologic procedures have been successful in children, but few reports of laparoscopic surgery in infants weighing <10 kg exist. We present our series of laparoscopic renal procedures in such patients. The hospital records of 17 consecutive patients (9 boys, 8 girls) with a median age of 7 months (range 1-25 months) weighing a mean of 8.5 kg (range 4.2-10 kg) who had undergone laparoscopic renal surgery (nephrectomy, partial nephrectomy, nephroureterectomy) between March 1999 and January 2004 were reviewed. Twelve patients underwent laparoscopic nephrectomy, three laparoscopic nephroureterectomy, and two laparoscopic heminephrectomy. Additional procedures were performed concomitantly in three patients. All operations had minimal estimated blood loss. Excluding those patients who underwent additional procedures, the mean operative time was 138 minutes (range 77-229 minutes). The postoperative hospitalization was 23 hours or less in all except two patients, both of whom had undergone additional procedures. The only complication was an intraoperative diaphragmatic injury that was repaired laparoscopically without sequelae. There were no delayed complications, and by 2 weeks postoperatively, all patients were recovered fully. Major laparoscopic urologic procedures can be performed in infants weighing <10 kg with low morbidity and rapid recovery.

Prostatectomía radical laparoscópica. ¿Sólo en Centros de excelencia?

To present and evaluate our experience and initial results in radical laparoscopic prostatectomy which we have been using for two and an half years in our General Hospital (covering a total population of 200.000 inhabitants). Between December 2002 and August 2005, were selected 26 patients for radical laparoscopic prostatectomy (25 transperitoneal and 1 extraperitoneal). Mean age was 62.3 +/- 5.3 years (range 52-69). Mean PSA level was 9.16 +/- 4.20 ng/mL (range 5.26 to 24.3). Pre-operative classification was Tlc in 10 patients (38.4%), T2a in 8 (30.8%) and T2b in 8. Mean Gleason Score was 6 +/- 0.8 (range 4-7). Three patients had undergone preoperatively neo-adjuvant hormonal blockage (11.5%). Simultaneous bilateral inguinal lymphadenectomy was performed in two patients. In no case did we consider a nerve sparing approach. The procedure was accomplished in 20 patients. Mean follow-up was 12.4 +/- 8.6 months (range 3 - 34). There was no perioperative mortality. Conversion to open surgery was required six times in the ten first cases but not thereafter. Mean operating time for the whole series was 303 +/- 95 minutes (range 150-540) but with a distinct difference between the first fourteen and the last six cases: 332 +/- 92.58 versus 236.6 +/- 66.5 (p<0.02). Mean blood loss was 90.25 +/- 46.5 ml. There were early postoperative complications in 4 patients (15.38%). Final pathological staging was: T2a in three patients (15%), T2b (50%) in 10, T3a (15%) in three and T3b (20%) in four. Positive margins were found in three cases (11.5%): T2b, T3a and T3b. Mean hospitalisation time was 4.7 +/- 3.1 days. Provided there was no urinary leakage, the urinary catheter was removed at 12.7 +/- 2.7 days. Full continence at three months was achieved in 17 of the patients (85%) who had undergone the full laparoscopic procedure. Our previous experience in other major laparoscopic procedures has allowed us to perform radical laparoscopic prostatectomy with a fast learning curve even in a setting of a relatively low population. Initial long term results seem similar to those achieved with conventional surgery.