Open Abdominal Approach Research Articles

Approach to radical hysterectomy for cervical cancer after the LACC trial and associated complications: a NSQIP study

BackgroundThe Laparoscopic Approach to Cervical Cancer (LACC) study results revolutionized our understanding of the best surgical management for this disease. Following its publication, guidelines state that the standard and recommended approach for radical hysterectomy is with an open abdominal approach. Nevertheless, the impact of the LACC trial on real-world changes in the surgical approach to radical hysterectomy remains elusive. ObjectiveWe aimed to study the trends and routes of radical hysterectomies and to evaluate post-operative complication rates before and after the LACC trial (2018). Study DesignThe National Surgical Quality Improvement Program registry was used to examine radical hysterectomies performed for cervical cancer between 2012-2022. We excluded vaginal radical hysterectomies and simple hysterectomies. The primary outcome measures were the trends in route of surgery [minimally invasive surgery (MIS) vs. laparotomy] and surgical complications rate, stratified by periods before and after the publication of the LACC trial in 2018 (2012-2017 vs. 2019-2022). The secondary outcome measure was major complications associated specifically with the different routes of surgery. ResultsOf the 3,611 patients included, 2,080 (57.6%) underwent laparotomy and 1,531 (42.4%) underwent MIS radical hysterectomy. There was a significant increase in the MIS approach from 2012 to 2017 (45.6% MIS in 2012 to 75.3% MIS in 2017, p<.001), and a significant decrease in MIS from 2018 to 2022 (50.4% MIS in 2018 to 11.4% MIS in 2022, p<.001).The rate of minor complications was lower in the period before the LACC trial [317 (16.9%) vs. 288 (21.3%), p=.002]. Major complications rate was similar before and after the LACC trial [139 (7.4%) vs. 78 (5.8%), p=.26]. The rates of blood transfusions and superficial surgical site infections were lower in the period before the LACC trial [137 (7.3%) vs. 133 (9.8%), p=.012 and 20 (1.1%) vs. 53 (3.9%), p<.001, respectively]. In a comparison of MIS vs. laparotomy radical hysterectomy during the entire study period, patients in the MIS group had lower rates of minor complications [190 (12.4%) vs. 472 (22.7%), p<.001] and the rate of major complications was similar in both groups [100 (6.5%) in the MIS group vs. 139 (6.7%) in the laparotomy group, p=.89]. In a specific complications analysis, the rates of blood transfusion and superficial surgical site infections were lower in the MIS groups (2.4% vs. 12.7%, and 0.6% vs. 3.4%, p<.001 for both comparisons) and the rate of deep incisional surgical site infections was lower in the MIS group (0.2% vs. 0.7%, p=.048). In a multiple logistic regression analysis, the route of radical hysterectomy was not independently associated with occurrence of major complications [aOR 95% CI 1.02 (0.63-1.65)]. ConclusionWhile the proportion of MIS radical hysterectomy decreased abruptly following the LACC trial, there was no change in the rate of major post-operative complications. In addition, hysterectomy route was not associated with major post-operative complications.

Early bladder dysfunction after vesicovaginal fistula repair: A prospective comparative analysis of transvaginal, open, and laparoscopic abdominal approaches.

We aim to compare the clinical and urodynamic profile oflower urinary tract symptoms (LUTS) in patients undergoing laparoscopic, open transabdominal, and laparoscopic transabdominal vesicovaginal fistulae (VVF) repair at 3 months of repair, that is, in early postoperative period. Fifty-one consecutive patients with endoscopically confirmed VVF were enrolled in our study over 2 years. Malignant fistulae, radiation-induced, and complex fistulae were excluded after cross-sectional imaging. All patients underwent a postoperative assessment for the success of the repair. Then at 3 months, they completed theAmerican Urological Association Symptom Score questionnaire and underwent a dual channel pressure-flow urodynamic study. The results of transvaginal, laparoscopic, and open transabdominal repairs were compared. All patients belonged to the Indian Caucasian race. The mean age was 35.43 ± 6.63 years. Thirty-two patients had supratrigonal and 19 had trigonal fistulae. Laparoscopic transabdominal repair was done in 15 patients, open transabdominal repair in 22 patients, and transvaginal repair in 14 patients. Forty-six patients reported some LUTS at a median follow-up of 5.83 ± 2.37 months postoperatively. Only 18 (35.2%) of these patients had moderate to severe symptoms The postoperative bladder dysfunction rates in open transabdominal, transvaginal and laparoscopic transabdominal groups were 36.4%, 28.6%, and 20%, respectively. Twenty-seven patients (52.9%) had some urodynamic abnormality, that is, small capacity (5), high voiding pressures (14), genuine stress incontinence (3), and poor compliance (3). Bladder capacity was a significant predictor of bladder dysfunction in our patients. In our study, all three surgical approaches were associated with bladder dysfunction, however, it was the least in the laparoscopic transabdominal approach. Postoperative bladder capacity is a significant predictor of bladder dysfunction.

Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis.

Previous reviews on hysterectomy versus uterine-sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned. To provide up-to-date evidence by examining only studies investigating techniques currently in use for POP repair. MEDLINE and Embase databases were searched from inception to January 2023. We included randomized and non-randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded. A random effect meta-analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI). Thirty-eight studies were included. Hysterectomy and uterine-sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74-1.17), intraoperative major (OR 1.34; 95% CI 0.79-2.26) and minor (OR 1.38; 95% CI 0.79-2.4) complications, postoperative major (OR 1.42; 95% CI 0.85-2.37) and minor (OR 1.18; 95% CI 0.9-1.53) complications, and objective (OR 1.38; 95% CI 0.92-2.07) or subjective (OR 1.23; 95% CI 0.8-1.88) success. Uterine preservation was associated with a shorter operative time (-22.7 min; 95% CI -16.92 to -28.51 min), shorter hospital stay (-0.35 days, 95% CI -0.04 to -0.65 days), and less blood loss (-61.7 mL; 95% CI -31.3 to -92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups. No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors.

Preventing Pneumonia in High-risk Patients After Esophageal Cancer Surgery: Mini-tracheostomy and Tazobactam/Piperacillin.

We evaluated the usefulness of prophylactic mini-tracheostomy (PMT) and perioperative administration of tazobactam/piperacillin (TAZ/PIPC) in high-risk patients after esophagectomy. We retrospectively studied 89 consecutive high-risk patients who underwent esophagectomy for esophageal cancer between January 2013 and December 2021. We defined patients with two or more of the following factors as high risk: age ≥70 years, performance status ≥1, respiratory dysfunction, liver dysfunction, cardiac dysfunction, renal dysfunction, diabetes mellitus, albumin <3.5 g/dl, and Brinkman index >600. Standard management was administered to the first 50 patients (standard group). PMT and TAZ/PIPC were administered to the next 39 patients (combination group). Patient characteristics and short-term outcomes were compared before and after propensity-score matching. Before propensity-score matching, 24-hour urine creatinine clearance, retrosternal route, 3-field lymph node dissection, and open abdominal approach were more common, postoperative pneumonia (13% vs. 36%, p=0.045) and complications of grade ≥3b (2.6% vs. 22%, p=0.01) were less frequent, and the postoperative hospital stay was shorter (median: 23 vs. 28 days, p=0.022) in the combination group than in the standard group. In propensity-score matching, patient characteristics, except for 24-h creatinine clearance and reconstructive route, were matched for 23 paired patients. Postoperative pneumonia (8.7% vs. 39%, p=0.035) and complications of grade ≥3b (0% vs. 26%, p=0.022) were less frequent and postoperative hospital stay was shorter (median: 22 vs. 25 days, p=0.021) in the combination group than in the standard group. PMT with TAZ/PIPC can potentially prevent postoperative pneumonia in high-risk patients after esophagectomy.

Safe thoracoscopic repair of recurrent congenital diaphragmatic hernia after initial open abdominal repair.

The optimal surgical approach for recurrent congenital diaphragmatic hernia (CDH) remains controversial. We compared the surgical outcomes of a thoracoscopic approach versus an open abdominal approach for recurrent CDH after initial abdominal open repair. The subjects of this comparative study were patients who underwent open abdominal or thoracoscopic surgery for recurrent CDH following an initial open abdominal repair. Among 166 patients with Bochdalek-type CDH, 15 underwent reoperation for recurrent CDH following an open abdominal repair. Seven patients underwent open abdominal surgery (group O) and eight underwent thoracoscopic surgery (group T). The operative duration was similar for the two groups, with less blood loss (17.2ml/kg vs. 1ml/kg, P = 0.001) and fewer intraoperative complications in the T group (n = 6 vs. n = 0 cases, P = 0.001). There was no significant difference in the number of postoperative complications (n = 1 vs. n = 1, P = 1.0) or in the number of patients with a second CDH recurrence (n = 2 vs. n = 1, P = 0.569) between the two groups. Thoracoscopic surgery is preferable to the open surgical approach for recurrent CDH following an initial abdominal open repair.

Outcomes of laparoscopic and open ventriculoperitoneal shunt placement

ObjectiveVentriculoperitoneal (VP) shunt placement requires a concurrent abdominal procedure. For peritoneal access laparoscopic or open approach may be utilized. Our aim was to compare patient/procedure characteristics and outcomes by peritoneal approach for VP shunts in children. MethodsNSQIP-Pediatric procedure targeted cerebral spinal fluid shunt Participant Use Data Files from 2016 to 2020 were queried. Patients were grouped into laparoscopic vs open abdominal approach. Patient demographics, procedure characteristics and 30-day outcomes were compared. Results7742 NSQIP-Pediatric patients underwent VP shunt placement. Patients undergoing laparoscopic approach were older and required less preoperative support. Mean operative time was longer with laparoscopy (mean(SD): 74.2(48.1) vs. 64.6(39) minutes, p ​< ​0.0001) but had shorter hospital LOS. There was no difference in SSI, readmissions, or reoperation rates. ConclusionPatients undergoing laparoscopy for distal VP shunts are older with less support needs preoperatively. While laparoscopic approach had a shorter hospital LOS, there was no demonstratable difference in SSI, readmissions or reoperations between approaches. Further studies are needed to assess long-term outcomes.

Practice patterns and complications of hysterectomy for invasive cervical cancer after the Laparoscopic Approach to Cervical Cancer trial

After the publication of the Laparoscopic Approach to Cervical Cancer trial, the standard surgical approach for early-stage cervical cancer is open radical hysterectomy. Only limited data were available regarding whether the change to open abdominal hysterectomy observed after the Laparoscopic Approach to Cervical Cancer trial led to an increase in postoperative complication rates as a consequence of the decrease in the use of the minimally invasive approach. This study aimed to analyze whether there was a correlation between the publication of the Laparoscopic Approach to Cervical Cancer trial and an increase in the 30-day complications associated with surgical treatment of invasive cervical cancer. Data from the American College of Surgeons National Surgical Quality Improvement Program were used to compare the results in the pre-Laparoscopic Approach to Cervical Cancer period (January 2016 to December 2017) vs the results in the post-Laparoscopic Approach to Cervical Cancer period (January 2019 to December 2020). The rates of each surgical approach (open abdominal or minimally invasive) hysterectomy for invasive cervical cancer during the 2 periods were assessed. Subsequently, 30-day major complication, minor complication, unplanned hospital readmission, and intra- or postoperative transfusion rates before and after the publication of the Laparoscopic Approach to Cervical Cancer trial were compared. Overall, 3024 patients undergoing either open abdominal hysterectomy or minimally invasive hysterectomy for invasive cervical cancer were included in the study. Of the patients, 1515 (50.1%) were treated in the pre-Laparoscopic Approach to Cervical Cancer period, and 1509 (49.9%) were treated in the post-Laparoscopic Approach to Cervical Cancer period. The rate of minimally invasive approaches decreased significantly from 75.6% (1145/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 41.1% (620/1509) in the post-Laparoscopic Approach to Cervical Cancer period, whereas the rate of open abdominal approach increased from 24.4% (370/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 58.9% (889/1509) in the post-Laparoscopic Approach to Cervical Cancer period (P<.001). The overall 30-day major complications remained stable between the pre-Laparoscopic Approach to Cervical Cancer period (85/1515 [5.6%]) and the post-Laparoscopic Approach to Cervical Cancer period (74/1509 [4.9%]) (adjusted odds ratio, 0.85; 95% confidence interval, 0.61-1.17). The overall 30-day minor complications were similar in the pre-Laparoscopic Approach to Cervical Cancer period (103/1515 [6.8%]) vs the post-Laparoscopic Approach to Cervical Cancer period (120/1509 [8.0%]) (adjusted odds ratio, 1.17; 95% confidence interval, 0.89-1.55). The unplanned hospital readmission rate remained stable during the pre-Laparoscopic Approach to Cervical Cancer period (7.9% per 30 person-days) and during the post-Laparoscopic Approach to Cervical Cancer period (6.3% per 30 person-days) (adjusted hazard ratio, 0.78; 95% confidence interval, 0.58-1.04)]. The intra- and postoperative transfusion rates increased significantly from 3.8% (58/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 6.7% (101/1509) in the post-Laparoscopic Approach to Cervical Cancer period (adjusted odds ratio, 1.79; 95% confidence interval, 1.27-2.53). This study observed a significant shift in the surgical approach for invasive cervical cancer after the publication of the Laparoscopic Approach to Cervical Cancer trial, with a reduction in the minimally invasive abdominal approach and an increase in the open abdominal approach. The change in surgical approach was not associated with an increase in the rate of 30-day major or minor complications and unplanned hospital readmission, although it was associated with an increase in the transfusion rate.

Surgical approach for complete resection of giant retroperitoneal liposarcoma with diaphragmatic hernia via ninth rib thoracotomy.

Resection of a giant retroperitoneal liposarcoma is difficult and technically demanding, especially for large retroperitoneal tumors accompanied by a diaphragmatic hernia. Technically, the open abdominal approach can be time-consuming and difficult to perform, with possible intraoperative complications and other factors bringing psychological and physical difficulties to the patient. This study reports a safe and feasible approach for the complete resection of a large retroperitoneal tumor complicated by a diaphragmatic hernia. A 58-year-old male patient with persistent upper abdominal pain and distension was treated at a local hospital on 4 July 2022. Computed tomography showed a mixed-density mass on the right retroperitoneum, and liposarcoma was considered. On 6 July 2022, the patient was transferred to our hospital for further treatment. Computed tomography showed a mass with low-density fatty shadow in the right adrenal region. The boundary with the right adrenal gland was unclear. The mass was 102mm × 74mm, and the right lobe of the liver was compressed. Insufficiency of the right middle lobe of the liver was seen due to a right diaphragmatic hernia and left mediastinal deviation. We considered the traditional approach for tumor resection via laparotomy, but we opted to perform a comprehensive evaluation first. The tumor was close to the back of the right kidney and liver, causing the diaphragm to rise because of its proximity to these organs. Exposing the tumor through laparotomy would be difficult, making it challenging to remove. The patient had a diaphragmatic hernia and moderate pulmonary dysfunction; therefore, we decided to enter the abdomen through a thoracotomy of the ninth rib. Using our technique, the tumor was easily visualized and completely removed in approximately 30min. The intraoperative blood loss was 100ml, and no postoperative bleeding, pneumothorax, intestinal fistula, infection, or other complications occurred. The transthoracic approach may be a safer and more feasible resection method than the traditional open approach for patients with giant retroperitoneal liposarcoma with a diaphragmatic hernia.

Diaphragmatic plication: current evidence and techniques in the management of the elevated hemidiaphragm

: Diaphragm plication is the preferred surgical intervention for elevation of the hemidiaphragm. This can be a consequence of trauma, damage to the phrenic nerve, or congenital eventration. There are numerous surgical approaches to diaphragmatic plication including open thoracic, open abdominal, minimally invasive transthoracic, minimally invasive transabdominal, and robotic assisted. All approaches are acceptable practices, but there has been a shift to more minimally invasive and video-assisted approaches. In this clinical practice review, we have assessed the current evidence and techniques used for hemidiaphragm elevation. Most evidence assessing the various techniques comes in the form of case studies, case series, and small institutional studies. Video-assisted thoracoscopic surgery is a commonly employed technique associated with positive outcomes as evidenced by improvement of pulmonary function test following the procedure, fewer chest tube days, decrease in self-reported dyspnea, and short hospital stays. Laparoscopic plication is also an acceptable technique. Multiple case studies showed overall positive outcomes with limited morbidity. Robotic assisted approaches were also reviewed. These interventions were shown to improve spirometry values and dyspnea scores. Minimal data exist on open abdominal approaches, and there are not currently enough data to assess their effectiveness. Open thoracic approaches were associated with improvements in spirometry as well as dyspnea scores. All surgical approaches discussed are acceptable strategies for the treatment of the elevated hemidiaphragm. No one intervention appears to be superior, but minimally invasive approaches have become more popular. The success of these procedures is largely believed to be based on surgeon preference and level of expertise.

Open abdominal approach for perineal hernia repair (with video).

A Kommerell diverticulum (KD) may predispose toward aortic aneurysm, dissection, or rupture, although they are primarily asymptomatic. We report a case of an aberrant left subclavian artery arising from a KD in a right-side aortic arch. The lesions were successfully treated by an endovascular approach involving Amplatzer vascular plug embolization of the aberrant left subclavian artery and endovascular repair of the KD.

Complications of Mesh Sacrocolpopexy and Rectopexy: Imaging Review

Sacrocolpopexy and rectopexy are commonly used surgical options for treatment of patients with pelvic organ and rectal prolapse, respectively. These procedures involve surgical fixation of the vaginal vault or the rectum to the sacral promontory with mesh material and can be performed independently of each other or in a combined fashion and by using an open abdominal approach or laparoscopy with or without robotic assistance. Radiologists can be particularly helpful in cases where patients' surgical histories are unclear by identifying normal sacrocolpopexy or rectopexy mesh material and any associated complications. Acute complications such as bleeding or urinary tract injury or stricture are generally evaluated with CT. More chronic complications such as mesh extrusion or exposure with or without fistulization to surrounding structures are generally evaluated with MRI. Other complications can have a variable time of onset after surgery. Patients with suspected bowel obstruction are generally evaluated with CT. Those with suspected infection, abscess formation, and discitis or osteomyelitis may be evaluated with MRI, although CT evaluation may be appropriate in certain scenarios. The authors review the sacrocolpopexy and rectopexy surgical techniques, discuss appropriate imaging protocols for evaluation of patients with suspected complications, and illustrate the normal appearance and common complications of these procedures. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Hysterectomy in benign conditions: a 20-year single-center retrospective on the development of surgical techniques

IntroductionMinimally invasive (MI) surgery has long been established as a standard for hysterectomy in benign conditions. Robotic surgery is generally seen as equivalent to conventional laparoscopy in terms of patient outcome. However, robotics might facilitate an MI approach even in complex patients, rendering laparotomy unnecessary for almost all patients.Materials and methodsWe identified 1939 patients who underwent hysterectomy for benign conditions between 2002 and 2020 at the University Hospital of Essen. Peri- and postoperative data as well as patient characteristics were collected retrospectively.ResultsRobotic surgery, implemented at our institution in 2010, was the most common approach (n = 771; 39.8%). 60.2% of all hysterectomies (1168/1938) were performed using MI techniques. However, there was a significant shift in the methods used for hysterectomy over time. While in 2002 51.4% of all hysterectomies were performed via an open abdominal approach, this percentage dropped to 1.4% in the year 2020. Accordingly, the use of MI approaches increased from 18.9% in 2002 to 98.6% in 2020. The introduction of robotic surgery in 2010 marked a significant shift towards more MI procedures. MI surgery resulted in shorter hospital stay and less postoperative complications compared to laparotomy.On a special note, our cohort includes the largest uterus myomatous uterus in the scientific literature with a specimen weight of 54.8 kg.ConclusionOur data support the hypothesis that the implementation of robotic surgery leads to an improved capability to perform MI surgery and avoid laparotomy in almost all patients. The known benefits of MI surgery could be confirmed.

P-047 PERINEAL HERNIA: RECTUS ABDOMINIS MUSCLE FLAP REPAIR

Abstract Aim Perineal hernia (PH) is a rare complication of pelvic surgeries. We present two cases of male patients with symptomatic PH following abdominoperineal resection (APR), repaired with rectus abdominis muscle flap. Cases presentation N1: 66-year male, 1 year after laparoscopic-assisted APR was treated with rectus abdominis muscle flap repair (RAM) by open abdominal approach. In postoperative period, heavy bronchitis leaded to the disruption of the muscle flap and need of reoperation. The patient healed completely two months after the repair. No recurrence of PH within 5 years has been registered. N2: 64-year male, underwent chemoradiotherapy and open APR for rectal carcinoma. 2 years later, CT showed a PH and 2cm wide mass suspicious of cancer recurrence in pelvis. By the open abdominal – perineal approach, the mass of recurrence was excised, and PH was repaired with vertical rectus abdominis muscle flap (VRAM). The postoperative period was uneventful and 1 year after the surgery, the patient is cancer and PH free. Discussion Treatment of more advanced carcinomas or wide use of radiotherapy can lead to an increased number of PH. Abdominal, perineal or combined approaches exists. The pelvic floor reconstruction is mostly realized by mesh implantation or flap repair. In our presented cases, we took advantage of long existing cooperation with plastic surgeon team and chose rectus abdominis muscle flap reconstruction. We proved its feasibility and good effect on PH repair. Conclusion Perineal hernia repair is challenging. No consensus regarding the ideal method exists. Every case must be assessed individually.

498. MINIMALLY INVASIVE ESOPHAGECTOMY FOR PATIENTS WITH ESOPHAGEAL CANCER AND A HISTORY OF LIVER TRANSPLANTATION: A LITERATURE REVIEW AND CASE SERIES

Abstract The survival after liver transplantation is continually improving. With evidence of an increased risk of de-novo malignancies after liver transplantation, it is urgent to improve the treatment of an esophageal cancer in patients with a history of liver transplantation. With this study we wanted to show a case series of totally minimally invasive Esophagectomy for patients with a history of liver transplantation, as well as an literature review. We performed a systematic literature review according to the PRISMA guidance to identify the documented cases of an operative procedure in patients with a history of liver transplantation. Baseline characteristics, tumor stages as well as operative and postoperative management is compared with the case series of 2 cases operated minimally invasive in our center. Seven studies were identified, with a total of 15 patients who underwent esophagectomy after liver transplantation. In 67% of the cases, including our two patients, alcohol associated liver cirrhosis was the indication for the liver transplantation. All reported cases proceed an open surgical approach for the Esophagectomy, except for 1 case with an open abdominal approach and a thoracoscopic chest procedure. The two cases in our center underwent a totally minimally invasive esophagectomy. The mean length of stay in the hospital was 21.5 days, compared to 8 and 14 days in our presented cases. The importance of an optimal treatment of esophageal cancer after liver transplantation is evident. With this case series we showed that it is technically feasible to proceed a total minimally invasive Esophagectomy for patients with a history of liver transplantation in a curative intention. For a successful and radical treatment of malignancies after liver transplantation a multidisciplinary procedure is necessary.

Reassessment of Surgical Procedures for Complex Obstructive Genital Malformations: A Case Series on Different Surgical Approaches.

The objective of this case series was to describe different uterus-preserving surgical approaches and outcomes in patients with complex obstructive Müllerian duct malformation caused by cervical and/or vaginal anomalies. A retrospective analysis was performed including patients undergoing uterovaginal anastomosis (n = 6) or presenting for follow-up (n = 2) at the Department for Gynecology at the University of Tuebingen between 2017 and 2022. Uterovaginal anastomosis was performed with a one-step combined vaginal and laparoscopic approach (method A), a two-step/primary open abdominal approach with primary vaginal reconstruction followed by abdominal uterovaginal anastomosis after vaginal epithelization (method B) or an attempted one-step approach followed by secondary open abdominal uterovaginal anastomosis due to reobstruction (method A/B). Patients presented at a mean age of 15 years. Two patients were treated by method A, four by method B and two by method A/B. Functional anastomosis was established in seven of eight patients, with normal vaginal length in all patients. Concerning uterovaginal anastomosis, the primary open abdominal approach with or without previous vaginal reconstruction seems to have a higher success rate with fewer procedures and should be implemented as standard surgical therapy for complex obstructive genital malformations including the cervix.

Pelvic organ prolapse recurrence after pregnancy following uterine-sparing prolapse repair: a systematic review and meta-analysis.

We sought to determine rates of pelvic organ prolapse (POP) recurrence following pregnancy and delivery in reproductive-age women with prior hysteropexy. Scopus, MEDLine, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to May 2020 for combinations of any of the keywords: "pregnancy", "delivery", "fertility", or "cesarean" with a comprehensive list of uterine-sparing surgical procedures for POP repair. Using approach, 1,817 articles were identified describing surgical, uterine-sparing POP repair techniques and subsequent pregnancy and deliveryoutcomes in reproductive-age women. RESULTS: Twenty-seven studies describing 218 pregnancies, including 215 deliveries and 3 abortions, were summarized using narrative review and descriptive statistics. Successful pregnancies were reported following a diverse range of uterine-sparing prolapse repairs, both native tissue and mesh-augmented, that utilized vaginal, open abdominal, and laparoscopic approaches. We observed shifts from native tissue repairs to mesh-augmented laparoscopic repairs over time. POP recurrence occurred in 12% of subjects overall, 15% after vaginal and 10% after abdominal prolapse repairs. While meta-analysis identified higher recurrence rates after vaginal delivery (15%) than cesarean section (10%), due to small study numbers, multiple confounders, and heterogeneity between studies, no significant differences in recurrence rates could be identified between vaginal and abdominal surgical approaches, utilization of mesh augmentation, or mode of delivery. Although literature on pregnancy following uterine-sparing POP repair is limited, available data suggest that prolapse recurrence after pregnancy and delivery remains similar to that after prolapse repair without subsequent pregnancies with few documented perinatal complications. PROSPERO, CRD42021247722.

Pre-operative surgical planning for minimally-invasive sacral colpopexy: integrating patient choice into surgical approach

Pelvic organ prolapse (POP) occurs when organs in the female pelvis herniate into the vaginal canal. Moderate to severe cases of POP can cause sexual, urinary, and defecatory dysfunction and often require surgical intervention. Sacral colpopexy (SCP) is a safe, durable procedure widely used to treat apical POP. It is typically performed in a minimally-invasive manner via laparoscopic or robot-assisted surgery, but can be converted to an open abdominal approach intraoperatively if unforeseen challenges arise. There is ample literature describing patient risk factors for intraoperative conversion, but little to describe patient preference in surgical approach. The purpose of this study was to examine factors that may influence a patient’s decision to choose to undergo laparotomy vs. opting for a native-tissue vaginal repair. 128 patients between the ages of 32-82 who underwent SCP to treat apical POP were included in the study. Each patient participated in a pre-operative conversation with the operating surgeon during which the patient indicated their preference of surgical approach if intraoperative conversion was deemed necessary. Each patient chose one of two options: to convert the procedure to an open SCP or to convert the procedure to a different, less durable vaginal repair. The data of interest, including demographic information, medical history, and POP severity were collected pre-operatively and were entered into a secure database. Of the 128 patients who underwent SCP, 74% (n=95) elected to undergo laparotomy if intraoperative conversion were to become necessary and 26% (n=33) opted for a native-tissue vaginal repair. The average age of patients who chose laparotomy was 60 years old, which was significantly younger than patients who chose vaginal repair (m=64y, p=0.03). Patients who chose laparotomy were also significantly more likely to have a higher BMI than their counterparts who chose vaginal repair (p=0.03). There was no statistically significant association between groups regarding race, education, marital status, severity of POP, or symptomatology. When given the opportunity to indicate their preference, most patients chose to undergo a more invasive surgery with higher rates of complication to receive SCP, which likely reflects the prolapse patient’s desire for the most durable and effective procedure for treating POP. The group opting for native-tissue vaginal repair was significantly older, which is likely due to a greater risk of complication and longer recovery with open abdominal surgery. Patients with a higher BMI were more likely to choose laparotomy, which could reflect the increased risk of POP recurrence with high BMI, especially after vaginal repair. More research is needed to further examine what influences patient preference of surgical approach in elective surgery.

Right-sided Congenital Diaphragmatic Hernia (Morgagni Hernia)- A Rare Clinical Manifestation in an Adult

Congenital Diaphragmatic Hernia (CDH), usually presents in the childhood period. It presents as an idiopathic human malformation. It is a condition where the organs of the abdomen enter the thorax due to a defect in the diaphragm, that is, herniation from the pleuroperitoneal fistula. Morgagni hernias are commonly incidentally diagnosed on a chest radiograph or a patient may have cardiorespiratory or abdominal symptoms. Repair of hernia without the use of mesh is advised in asymptomatic cases also due to feared complications like strangulation and incarceration. The treatment of Morgagni Hernia is primary surgical repair which can be done either transthoracically or transabdominally. It is advised that surgical repair should be done even in asymptomatic cases. This report is about a 66-year-old female patient with a right-sided Morgagni hernia, who presented with abdominal pain and vomiting. Since the patient was symptomatic, surgical approach was preferred and she underwent laparoscopic abdominal surgery which was converted to open abdominal approach. Postoperatively, the patient recovered from her symptoms and had no complications.

Differences in Outcome Between Open vs Laparoscopic Insertion of Ventriculoperitoneal Shunts.

Abdominal access during ventriculoperitoneal (VP) shunt insertion has historically been obtained by neurosurgeons via an open abdominal approach. With recent advances in laparoscopy, neurosurgeons frequently consult general surgery for aid during the procedure. The goal of this study is to identify if laparoscopic assistance improves the overall outcomes of the procedure. This retrospective study included all patients who underwent open or laparoscopic VP shunt placement between September 2012 and August 2020 at our tertiary referral hospital. Patient demographics, comorbidities, prior history of abdominal surgery, open vs. laparoscopic insertion, operation time, and complications within 30days were obtained. Neurosurgery placed 107 shunts using an open abdominal technique and general surgery placed 78 using laparoscopy. The average OR time in minutes was 75.5minutes for the open cohort and 61.8 for the laparoscopic cohort (p = 0.006). In patients without a history of abdominal surgery, the average OR time in minutes was 79.4 in the open cohort and 57.1 in the laparoscopic cohort (p = 0.015). The postoperative shunt infection rate was 10.2% in the open group and 3.8% in the laparoscopic group (p = 0.077). Laparoscopic placement of VP shunts is a reasonable alternative to open placement and results in shorter OR times. There is also a trend toward few infections in the laparoscopic placement. There appears to be an advantage with a team approach and laparoscopic placement of the peritoneal portion of the shunt.

Racial Disparities in Outcomes of Women Undergoing Myomectomy.

To assess the association of racial and socioeconomic factors with outcomes of abdominal myomectomies. All women undergoing abdominal myomectomy in California from 2005 to 2012 were identified from the OSHPD (Office of Statewide Health Planning and Development) using appropriate International Classification of Diseases and Current Procedural Terminology codes. Demographics, comorbidities, surgical approaches, and complications occurring within 30 days of the procedure were identified. Multivariate associations were assessed with mixed effects logistic regression models. The cohort of 35,151 women was racially and ethnically diverse (White, 38.8%; Black, 19.9%; Hispanic, 20.3%; and Asian, 15.3%). Among all procedures, 33,906 were performed through an open abdominal approach, and 1,245 were performed using a minimally invasive approach. Proportionally, Black patients were more likely than White patients to have open procedures, and open approaches were associated with higher complication rates. Overall, 2,622 (7.5%) women suffered at least one complication. Although severe complications did not vary by race or ethnicity, Black (9.0%), Hispanic (7.9%), and Asian (7.5%) patients were more likely to suffer complications of any severity compared with White patients (6.7%, P<.001). As compared with patients with private insurance (6.4%), those with indigent payer status (Medicaid [12.1%] and self-pay [11.1%]) had higher complication rates (P<.001). Controlling for all factors, Black and Asian patients were more likely to suffer complications compared with White patients. The overall complication rate after abdominal myomectomy was 7.5%. Comorbidities, an open approach, and indigent payer status were associated with increased complication risk. Controlling for all factors, Black and Asian patients still had increased risks of complications.