Patient In Lithotomy Position Research Articles

Robotic Resection of a Sciatic Notch Lipoma Using the DaVinci Surgical System: 2-Dimensional Operative Video.

Sciatic notch lipomas are rare benign fatty tumors that can cause significant morbidity due to compression of the sciatic nerve. Surgical excision is the gold standard treatment, but traditional open techniques are associated with significant risks and prolonged recovery times. Robotic surgery provides opportunity to improve on traditional laparoscopic techniques by allowing better visualization of and access to regions of complex anatomy, including the pelvis. The potential benefits of robotic resection include reduced blood loss, minimized tissue trauma, and shorter hospital stays. Building on robotic techniques previously described by our group, we present a video of a robotic resection of a sciatic notch lipoma using the DaVinci Surgical System.1,2 The patient consented to the procedure. The procedure begins with the patient in lithotomy position, followed by the establishment of the robotic trocar sites in the peritoneum, including the endoscope, Da Vinci, and assistant ports. The advanced visualization and precise maneuverability allow for careful dissection and identification of vital structures, including the L5 and S1 nerve roots, with minimal tissue manipulation. Subtotal resection of the lipoma was achieved resulting in decompression of the sciatic nerve with preservation of the surrounding structures. This video highlights the technical aspects of the procedure, emphasizing the advantages of robotic assistance, such as enhanced dexterity, precision, and visualization. This new technique offers a promising alternative to open surgery for the management of sciatic notch lipomas, potentially improving patient outcomes and overall surgical experience.

EVALUATION OF CHANGE IN BLOOD PRESSURE IN REPOSITIONING FROM LITHOTOMY TO SUPINE POSITION IN PATIENTS UNDERGOING SURGERIES UNDER SUB-ARACHNOID BLOCK- AN OBSERVATIONAL STUDY

Objective: Spinal anaesthesia is associated with variety of hemodynamic alterations, because of sympathetic blockade. Hemodynamics are also affected by a variety of surgical techniques. The lithotomy posture and the effects of autotransfusion increases the Systolic Arterial Pressure in the sub-extremities. Study was designed to evaluate the changes in blood pressure in repositioning from lithotomy position to supine position in patients undergoing surgeries under sub-arachnoid block. This Methods: observational study was performed in 41 patients who underwent for elective/ emergency surgeries under subarachnoid block requiring lithotomy position. Demographic information such as age, height, weight, BMI, ASA grade, height of sensory block, quality of motor block and hemodynamics such as Heart Rate (HR), Pulse Oximetry (SpO2), non invasive Blood Pressure (NIBP) during lithotomy position and repositioning to supine position were also recorded. In this study there is no signi Results: cant difference was observed in patients in repositioning from lithotomy position to supine position following sub-arachnoid block. There is slightly increased in Systolic blood pressure in patients in lithotomy position compared to supine position. This study was performe Conclusion: d on 41 patients who underwent surgeries under subarachnoid block requiring lithotomy position and this study concluded that there is no difference was observed in patients in repositioning from lithotomy position to supine position. The purpose of the study is to take necessary precautions will be taken to prevent blood pressure changes intraoperatively. Spinal anaesthesia is most commonly used neuro-axial anaesthesia technique, where the local anaesthesia is directly injected into the intrathecal space (sub-arachnoid block). The uid that surrounds the brain and spinal cord is called cerebro-spinal uid, is present in the sub-arachnoid region (1). Spinal Anaesthesia is usually given in patients in lateral position or sitting position, Trendelenburg position will produce higher level of block as compared to supine position (2). The spinal anaesthesia was rst performed in 1885 by Dr. James Corning of New York City. He used cocaine and the patient was a dog. However, August Bier performed the rst sub-arachnoid block surgery in Germany in 1898. Sub-arachnoid block is the type of regional anaesthetic that was most frequently used for obstetrics and caesarean sections after the 1950s (3). Spinal anaesthesia is used in patients undergoing procedures: femur, ankle orthopaedic hip, tibia and knee surgery, including haemorrhoidectomy and leg vascular surgery, Endovascular aortic aneurysm repair, joint replacement, arthroplasty, Hernia (inguinal or epigastric), Combined general anaesthesia and cystectomy, nephrectomy, transurethral resection of bladder tumours, Transurethral excision of the prostate and Caesarean sections, various hysterectomy methods, cases of urology. By using spinal anaesthesia, a patient can avoid the hazards of a difcult airway, consciousness, and aspiration that come with general anaesthesia in pregnant patients. By using spinal anaesthesia, a patient can avoid the hazards of a difcult airway, consciousness, and aspiration that come with general anaesthesia in pregnant patients. (4) . Hypotension is the most common complication of spinal anaesthesia, which is linked to a variety of haemodynamic abnormalities. The sympathetic blockade, which causes venous and arterial dilatation, are the primary mechanism (5). Total peripheral resistance reduces as a result of arterial dilatation, and cardiac output and venous return both decrease, which can result in severe hypotension (6). Hypotension do occur in almost all patients and signicant hypotension (systolic BP)

Laparoscopic Redo Vaginoplasty with Uterine Buds: A Case Report

Study Objective To show that laparoscopic approach is beneficial for previously operated and failed modified Davydov vaginoplasty. Design A case report. Setting laparoscopy surgery with patient in lithotomy position under anaesthesia. Patients or Participants 20 years female diagnosed as a case of MRKH syndrome with single right sided kidney previously operated by modified Davydov surgery 6 months ago. Interventions Laparoscopic redo vaginoplasty by using uterine buds. Measurements and Main Results In modern era, endoscopy has replaced abdominal and vaginal approach of vaginoplasty. There is hardly any case report of Redo vaginoplasty done by vaginal or laparoscopic approach. Laparoscopic redo vaginoplasty by using uterine buds is done for the first time as per our knowledge and no such case has been reported in literature. The patient presented with complaints of shortening of vagina even with gradual vaginal dilatation. On per speculum examination, the vaginal length had shortened to about 2cm and width around 1.5cm. Patient was planned for redo vaginoplasty by laparoscopic approach. Intraoperatively, the lateral peritoneal flap on left side was tried but because of extensive fibrosis and shrinkage of peritoneum from previous surgery we proceeded with mobilization of Right sided uterine buds as a flap and used for creation of anterior vaginal wall. The vaginal vault was opened after difficult separation of bladder and rectum. The right uterine bud was mobilized into vaginal opening to form anterior vaginal wall and rectum pulled down to create posterior vaginal wall. Purse string suture was taken to create vaginal apex to create a vaginal length of approximately 8-10 cm. Vaginal mold placed and gradual dilatation done. At 1-year follow-up, patient had good anatomical and functional vagina of length 7-8cm. Conclusion Laparoscopic redo vaginoplasty using uterine buds can give successful outcome for failed vaginoplasty with added benefits of laparoscopic routes. To show that laparoscopic approach is beneficial for previously operated and failed modified Davydov vaginoplasty. A case report. laparoscopy surgery with patient in lithotomy position under anaesthesia. 20 years female diagnosed as a case of MRKH syndrome with single right sided kidney previously operated by modified Davydov surgery 6 months ago. Laparoscopic redo vaginoplasty by using uterine buds. In modern era, endoscopy has replaced abdominal and vaginal approach of vaginoplasty. There is hardly any case report of Redo vaginoplasty done by vaginal or laparoscopic approach. Laparoscopic redo vaginoplasty by using uterine buds is done for the first time as per our knowledge and no such case has been reported in literature. The patient presented with complaints of shortening of vagina even with gradual vaginal dilatation. On per speculum examination, the vaginal length had shortened to about 2cm and width around 1.5cm. Patient was planned for redo vaginoplasty by laparoscopic approach. Intraoperatively, the lateral peritoneal flap on left side was tried but because of extensive fibrosis and shrinkage of peritoneum from previous surgery we proceeded with mobilization of Right sided uterine buds as a flap and used for creation of anterior vaginal wall. The vaginal vault was opened after difficult separation of bladder and rectum. The right uterine bud was mobilized into vaginal opening to form anterior vaginal wall and rectum pulled down to create posterior vaginal wall. Purse string suture was taken to create vaginal apex to create a vaginal length of approximately 8-10 cm. Vaginal mold placed and gradual dilatation done. At 1-year follow-up, patient had good anatomical and functional vagina of length 7-8cm. Laparoscopic redo vaginoplasty using uterine buds can give successful outcome for failed vaginoplasty with added benefits of laparoscopic routes.

Total Laparoscopic Cervical Encerclage in 16 Weeks Pregnant Uterine Didelphis Uterus Category: Laparoscopy

Study Objective To demonstrate Laparoscopic approach for encerclage in pregnancy in a ℅ uterine didelphys. Design A case report. Setting laparoscopy surgery with patient in lithotomy position under anaesthesia. Patients or Participants A 26-year-old female came G3 A2 with previous 2- 2nd trimester abortions with failed vaginal encerclage and uterine didelphys diagnosed on MRI with 16 weeks pregnancy. Interventions Laparoscopic cerclage was planned using Mersilene tape. Measurements and Main Results Cervical insufficiency (CI) or incompetence is a well-known condition in obstetrics with an incidence of 0.1–1% and is notoriously associated with a high risk of second trimester abortion and/or preterm delivery. The traditional surgical treatment for cervical insufficiency consists of vaginal placement of cervical stitches, known as transvaginal cervical cerclage (TVC). Advances in the field of minimally invasive surgery resulted in development of a new approach to cervical cerclage placement. Laparoscopic cerclage offers the benefit of reduced blood loss, reduced postoperative pain, and fewer adhesions, as well as decreased length of hospital stay and overall faster recovery time. Principles of surgery: 1. Dissection of loose UV fold of peritoneum. 2. Creation of window in the broad ligament on both sides. 3. Passing the needle of mersilene tape from medial to the uterine artery of left side at the level of internal os. 4. Passing the Mersilene tape all around the uterus 5. Passing the needle of mersilene tape from medial to uterine artery on right side. 6. Tightening the mersilene tape at the level of the internal os. Conclusion Similar to the transabdominal approach, laparoscopic cerclage can be placed during pregnancy or as an interval procedure. Success rates for laparoscopic cerclage were reported in the range of 76% to 100%. To demonstrate Laparoscopic approach for encerclage in pregnancy in a ℅ uterine didelphys. A case report. laparoscopy surgery with patient in lithotomy position under anaesthesia. A 26-year-old female came G3 A2 with previous 2- 2nd trimester abortions with failed vaginal encerclage and uterine didelphys diagnosed on MRI with 16 weeks pregnancy. Laparoscopic cerclage was planned using Mersilene tape. Cervical insufficiency (CI) or incompetence is a well-known condition in obstetrics with an incidence of 0.1–1% and is notoriously associated with a high risk of second trimester abortion and/or preterm delivery. The traditional surgical treatment for cervical insufficiency consists of vaginal placement of cervical stitches, known as transvaginal cervical cerclage (TVC). Advances in the field of minimally invasive surgery resulted in development of a new approach to cervical cerclage placement. Laparoscopic cerclage offers the benefit of reduced blood loss, reduced postoperative pain, and fewer adhesions, as well as decreased length of hospital stay and overall faster recovery time. Principles of surgery: 1. Dissection of loose UV fold of peritoneum. 2. Creation of window in the broad ligament on both sides. 3. Passing the needle of mersilene tape from medial to the uterine artery of left side at the level of internal os. 4. Passing the Mersilene tape all around the uterus 5. Passing the needle of mersilene tape from medial to uterine artery on right side. 6. Tightening the mersilene tape at the level of the internal os. Similar to the transabdominal approach, laparoscopic cerclage can be placed during pregnancy or as an interval procedure. Success rates for laparoscopic cerclage were reported in the range of 76% to 100%.

Transcervical Ultrasound-Guided Targeted Radiofrequency Ablation of Localized Adenomyosis

<h3>Study Objective</h3> To review the definition, diagnosis, and procedural management options for adenomyosis with a focus on a novel procedure of transcervical ultrasound guided radiofrequency ablation. This video highlights one of the first successful examples of improved post operative symptoms and uterine volume reduction for a case using transcervical ultrasound-guided radiofrequency ablation. <h3>Design</h3> A 6-minute video reviewing the step-by-step demonstration of a single patient who underwent transcervical ultrasound-guided radiofrequency ablation of adenomyosis with six month post operative outcomes. <h3>Setting</h3> Surgery was performed in an outpatient surgical center with the patient in lithotomy position. <h3>Patients or Participants</h3> 42-year-old nulligravid female with no past medical or surgical history who presented with a chronic history of heavy menstrual bleeding, dysmenorrhea and worsening abdominal bulk symptoms desiring minimally invasive uterine sparing surgery. <h3>Interventions</h3> Transcervical ultrasound-guided targeted radiofrequency ablation of adenomyosis with a total of four ablations performed and combined time of 16 minutes and 30 seconds. <h3>Measurements and Main Results</h3> At six months post operation, the patient reported sustained resolution of dysmenorrhea and lighter menstrual periods. Six month post operative MRI was compared to pre operative MRI and noted a 43.5% decrease in uterine corpus volume and decrease in number of T2 hyperintense cystic foci within the uterus. <h3>Conclusion</h3> This video demonstrates one of the first successful examples of improved post operative symptoms and uterine volume reduction at six months with the transcervical ultrasound guided radiofrequency ablation of adenomyosis. Benefits of the procedure include its incisionless technique, improved intraoperative image monitoring because of the proximity of the ultrasound probe to pathology that can be operated by a single surgeon, fast recovery from surgery, and potentially cost-effective option for uterine sparing surgical management of adenomyosis. Since this is the first known published short term outcome data for this procedure on adenomyosis, more studies need to be conducted to demonstrate persistent safety and efficacy

7918 Laparoscopic Repair of Cervico-Vaginal Agenesis in a Previously Failed Attempt of Mcindoe's Vaginoplasty: A Case Report

<h3>Study Objective</h3> A unique Laparoscopic approach for surgical repair of Cervico-vaginal agenesis. <h3>Design</h3> A case report with 6 months follow-up. <h3>Setting</h3> laparoscopy surgery with patient in lithotomy position under anaesthesia. <h3>Patients or Participants</h3> A 23-yrs old female came with primary amenorrhea with lower abdominal pain since 2 years. Her MRI was suggestive of: 1) upper 2/3rd vaginal aplasia with hematoma in the cervical canal 2) b/l hematosalpinx 3) b/l ovarian hemorrhagic cysts. McIndoe's Vaginoplasty was attempted 6months back which had failed. <h3>Interventions</h3> Laparoscopic cervico- vaginal agenesis repair was planned <h3>Measurements and Main Results</h3> The occurrence of cervical agenesis is quite uncommon (1:80 000–1:100 000) and only 39% of these cases simultaneously have vaginal agenesis. Initially, these cases were managed by hysterectomy or abdominal cervicovaginoplasty. Later, a minimally invasive approach came to light with the advent of laparoscopy and surgical expertise. Principles of surgery: 1. Laparoscopic management of Hematosalpinx and hemorrhagic cysts. 2. Dissection of UV fold and pushing the bladder down to expose 3-4 cm length of the vagina. 3. Dissection between cervix and vagina in the right plane. 4. Creating neo-vagina by dissection of the vaginal agenesis. 5. Vertical incision on the cervix and horizontal incision on the vagina Suturing techniques between cervix and vagina and placing a silicon catheter in cervical canal and neo-vagina. <h3>Conclusion</h3> Laparoscopic approach for cervico vaginal agenesis is better than vaginal approach with cutting cervix vertically for patency of cervical canal.

Uterine Artery Occlusion Techniques: Tips and Tricks... and Some Pitfalls

<h3>Study Objective</h3> To demonstrate the benefits and challenges of various uterine artery occlusion techniques available to minimally invasive gynecologic surgeons. <h3>Design</h3> Educational Video Presentation. <h3>Setting</h3> Teaching hospital, Minimally Invasive Gynecology OR Team, patients in lithotomy position with various port configurations. <h3>Patients or Participants</h3> Patients at a Medical Teaching Facility. <h3>Interventions</h3> Uterine Artery Occlusion during Myomectomy and Hysterectomy. <h3>Measurements and Main Results</h3> Various research has shown that uterine artery occlusion is associated with decreased blood loss during laparoscopic and robotic hysterectomy and myomectomy. This video compares the benefits and challenges to each of the follow occlusions techniques: bipolar coagulation, bulldog clamps, polymer clips, laparoscopic clip appliers, and suture ligation. Comparisons are made between these options related to cost, technical difficulty, the extent of dissection needed, risk of thermal spread, port size requirements, and other notable differences. Intraoperative video demonstrates tips and tricks for successful application of each of these occlusion options. In addition, we also include intraoperative video of various pitfalls that surgeons can encounter with suboptimal applications of these various methods, so as to help surgeons prevent running into these foreseeable pitfalls. <h3>Conclusion</h3> Various uterine artery occlusion techniques are available to help reduce blood loss during minimally invasive gynecologic surgery. Knowing the benefits and challenges to each method can assist surgeons in choosing the best technique for each clinical circumstance.

Vaginal and Laparoscopic Repair of Vesico-Vaginal Fistulae: A Comparison of Techniques

<h3>Study Objective</h3> To compare vaginal and laparoscopic techniques for vesico-vaginal fistula (VVF) repair and suggest which situations may be appropriate for each technique. <h3>Design</h3> Video is used from two operations: a vaginal fistula repair using the Latzko technique and a laparoscopic repair using the O'Conor technique. <h3>Setting</h3> Both operations were performed in a standard gynecologic operating room with the patient in lithotomy position. For the laparoscopic repair, one 5mm umbilical port was used for the laparoscope, and two 5mm lateral ports were placed on each side to allow suturing by both surgeons. <h3>Patients or Participants</h3> One patient with a VVF resulting from a hysterectomy, and one patient with a VVF resulting from a cystotomy during an emergent cesarian delivery. <h3>Interventions</h3> The first patient, who had sufficient descent of the vaginal apex, underwent a Latzko-style vaginal repair. The vaginal epithelium was dissected away from the fistula opening, and the fistula tract was closed with a purse string suture and inverted with an additional suture. The vaginal epithelium was then closed interrupted sutures. The second patient, in whom the fistula was located in an inaccessible location high in the vagina, underwent a laparoscopic repair based on the O'Conor technique. The bladder was dissected away from the upper vagina. The bladder was entered near the site of the fistula and the fistula tract was excised. The bladder was closed in two layers, and the vagina was repaired in a single layer. <h3>Measurements and Main Results</h3> Both patients had resolution of urinary leakage and neither fistula recurred. <h3>Conclusion</h3> Vaginal VVF repairs are appropriate when VVF are accessible through the vagina, and a laparoscopic technique is appropriate for inaccessible VVF.

Current Concepts in Endoscopic Bladder Neck Injection: Combined Antegrade and Retrograde Endoscopic Injection of the Bladder Neck in Children with Neurogenic Bladder.

Introduction: Urinary incontinence is common in patients with neurogenic bladder, and efficient management is an ongoing challenge. Besides open surgical procedures like bladder neck reconstruction, artificial sphincter implantation, or sling procedures, endoscopic bladder neck injections of bulking agents enable minimally invasive access with promising results. Several studies report on the effect of antegrade vs. retrograde endoscopic injection techniques. We report our preliminary experience of combined antegrade and retrograde endoscopic injection of the bladder neck in children with neurogenic bladder, in selected cases combined with intravesical Botox® injection. Methods: With the patient in lithotomy position, antegrade urethrocystoscopy was performed using a 9.5 Fr cystoscope. In parallel, percutaneous suprapubic bladder access introducing a second 9.5 Fr. cystoscope was accomplished. Four quadrant Dx/H injections were performed, with the two surgeons guiding each other by parallel endoscopy to the optimal localization for injection. In selected patients, the procedure was completed with transurethral intravesical Botox® injection. Results: A total of 6 children underwent the combined procedure (2/6 patients including intravesical Botox® injection). The mean follow-up was 15 months (range 3 to 48). 5 Patients experienced a significant improvement of urinary incontinence, however one patient demonstrated complete failure. Conclusions: Even if we present only preliminary results with a limited number of patients, we present a minimally invasive technique with encouraging results. In carefully selected patients, combined antegrade and retrograde endoscopic injection of the bladder neck is a useful tool to treat urinary incontinence.

\u201cNear-TME\u201d: proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis

BackgroundThe aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction.MethodsWe demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain.ResultsThe posterolateral dissection during a near-TME is similar to that of an oncologic TME, whereas the anterolateral is similar to that of a close rectal dissection. The near-TME technique preserves the superior hypogastric plexus, the hypogastric nerves, the nervi erigentes, the inferior hypogastric plexus, the pelvic plexus and the cavernous nerves.ConclusionThe near-TME technique is the standardisation of the technique for proctectomy in male patients with ulcerative colitis. Near-TME requires experience in pelvic surgery and an exhaustive knowledge of the embryological development and of the surgical anatomy of the pelvis.

Vaginal Actinomycosis in a Female without a History of Intrauterine Contraception: A Case Report

<h3>Study Objective</h3> describe a relationship between actinomycosis and persistent foreign bodies in the female genital tract; emphasize the importance of pre-therapeutic biopsy in genital tract disease. <h3>Design</h3> Actinomycoses are opportunistic bacteria that can cause invasive, suppurative infections when mucosal barriers are compromised. Most cases are seen in patients with long-term use of intrauterine devices (IUDs). Infections are slow-growing and produce non-specific symptomatology, making initial misdiagnosis of malignancy or other pathologies common. This may lead to avoidable surgery, as most actinomycosis resolves with antibiotics alone. We present a case of isolated vaginal actinomycosis in a 66-year-old female without a history of IUD use, presenting with post-menopausal bleeding. She had a remote history of colpoperineorrhaphy with inorganic mesh placement, and a total abdominal hysterectomy and bilateral salpingectomy. Preoperative biopsy guided a less invasive surgical approach than that considered for malignancy. <h3>Setting</h3> The patient presented at her outpatient gynecologist. Biopsy revealed actinomycosis. Surgical excision occurred via a posterior approach with the patient in lithotomy position. <h3>Patients or Participants</h3> 66-year-old post-menopausal female without a history of IUD use, presenting with post-menopausal bleeding. <h3>Interventions</h3> The rectovaginal septum was dissected and 3.25cm x 1.5cm of tissue/mesh were excised. The healthy vaginal epithelium was reapproximated. The patient was treated with 6 weeks of ceftriaxone followed by 30 days of amoxicillin-clavulanate. <h3>Measurements and Main Results</h3> Histopathological report demonstrated acute and chronic inflammation, granulation tissue and no evidence of malignancy. The patient recovered well after surgery. <h3>Conclusion</h3> This case is notable for actinomycosis isolated to the vagina and in a female without concomitant IUD-use, suggesting a relationship between actinomycosis and <i>any</i> foreign body in the lower female genital tract. Actinomycosis should be considered for any slow-growing mass with foreign body presence. Preoperative biopsy or, at a minimum, intraoperative frozen section should be obtained to prevent unnecessary surgery.

Implementation of high-dose-rate brachytherapy for prostatic carcinoma in an unshielded operating room facility

PurposeThe purpose of the study was to describe our approach towards safe delivery of single-fraction high-dose-rate (HDR) brachytherapy (BT) boost in patients with prostate cancer in the setting of an unshielded operating room (OR). Methods and MaterialsA total of 95 patients received 15 Gy HDR BT boost. The procedure involved transrectal ultrasound–based catheter insertion and planning in the OR, after which the patient was moved to a shielded treatment room for radiation. This required three vital components: (1) an OR table capable of transporting the patient in lithotomy position, (2) robust motion management checks to ensure reproducibility of prostate and catheter positions in the treatment room before radiation delivery, (3) remote monitoring of patient vitals while under anesthesia, during the radiation. Initial viability of this approach was confirmed by assessing acute toxicities using the Common Terminology Criteria for Adverse Events v4.0 and American Urologic Association symptom scores. ResultsWe found good stability in prostate and catheter position, with less than 1 mm shifts in each direction due to patient transfer. The median baseline American Urologic Association score was 7 (3–11), which increased to 12 (7–17) at 4 weeks and 9 (5–14) at 3 months (p = 0.003). Common Terminology Criteria for Adverse Events ≥ grade 2 genitourinary and gastrointestinal toxicities were experienced by 7% and 0% patients, respectively, at 3 months posttreatment completion. ConclusionsSingle-fraction HDR prostate BT can be delivered safely in an unshielded OR facility with a distant shielded treatment room using rigorous motion management checks and supplementary procedural equipment.

Transanal Total Mesorectal Excision (TaTME): Experience in Klaipėda University Hospital

Introduction. Colorectal cancer ranks third on the list of the most common cancers. In 1979 R. J. Heald described total mesorectam excision (TME) which became a gold standard for rectal cancer treatment. This operation is performed all over the world open, laparoscopic and robotic. Operating on low and very low rectal cancer, distal bowel mobilisation if often the most difficult part of the operation. Aa a solution to this problem transanal abdominotransanal rectal resection (TATA) and transanal total mesorectal excision (TaTME) were proposed. This article reviews the experience and short-term postoperative outcomes of TaTME performed in Klaipėda University Hospital.Methods. The first stage of surgery was performed with patient placed in the prone jackknife (Kraske) position. Using electrocauthery circular mobilisation of the rectum was performed starting at least 1 cm from the lower edge of the tumour. Up to 10 cm of the rectum was mobilised from below. The second stage was performed with patient in lithotomy position. Laparoscopic TME was performed. For 11 (78.57%) patients hand sown anastomosis was performed and for 1 (7.17%) patient stapler was used. 2 (14.28%) patients underwent the Hartmann’s procedure.Results. In period 2018.03–2019.10 TaTME was performed for 14 patients. The medium tumour high counting from dentate line was 2.54 (±1.28). 13 out of 14 patients were operated from 8 to 12 weeks after chemoradiotherapy. All (100%) rectal resections were radical (R0). On average 11.43 (±3.78) lymphnodes were harvested. 5 (35.71%) patients had complications after surgery.Conclusions. TaTME performed at Klaipėda University Hospital is effective operation for rectal cancer treatment.

Comparison between stapler hemorrhoidectomy and open hemorrhoidectomy in the management of grade III and IV hemorrhoids: a prospective randomized study

Background: Haemorrhoids are one of the most common anorectal disorders. Haemorrhoids or piles are dilated veins of the anal canal and are more common in obesity, constipation and pregnancy. Classically they occur in the 3, 7 and 11 o'clock position with the patient in lithotomy position. Symptoms of haemorrhoids are per rectal bleeding and prolapse. Bleeding is bright red in colour and which is painless. The aim of the study was to compare the early results in 60 patients randomly allocated to undergo either stapled or open hemorrhoidectomy.Methods: Out of 60 patients, 30 (50.0%) patients underwent hemorrhoidectomy by Open Milligan-Morgan’s method were classified as Group A while rest 30 (50.0%) patients underwent hemorroidectomy by Stapler method after anal stretching, these patients were classified as Group B.Results: Pain score of majority of patients of Group A was ≥7 (76.7%), only 6.7% had pain score &lt;3 and rest 16.7% had pain score 3 to 6. On comparing the difference of pain in passage of first stool among patients of Group A and Group B statistically was found to be highly significant. Pain in follow up at 3, 7 and 15th day was also significantly higher in group A in comparison to group B.Conclusions: Of the 60 patients in the current study, 32 are still in the follow up with the maximum follow up period of 11 months. There was no case of recurrence of haemorrhoids in this study. The factor of cost was not evaluated in the study since the hospital stay as well as stapling instrument was totally free in U.P, UMS, Saifai.

Focal cryotherapy: step by step technique description

ABSTRACTIntroduction and objective:Focal cryotherapy emerged as an efficient option to treat favorable and localized prostate cancer (PCa). The purpose of this video is to describe the procedure step by step.Materials and methods:We present the case of a 68 year-old man with localized PCa in the anterior aspect of the prostate.Results:The procedure is performed under general anesthesia, with the patient in lithotomy position. Briefly, the equipment utilized includes the cryotherapy console coupled with an ultrasound system, argon and helium gas bottles, cryoprobes, temperature probes and an urethral warming catheter. The procedure starts with a real-time trans-rectal prostate ultrasound, which is used to outline the prostate, the urethra and the rectal wall. The cryoprobes are pretested and placed in to the prostate through the perineum, following a grid template, along with the temperature sensors under ultrasound guidance. A cystoscopy confirms the right positioning of the needles and the urethral warming catheter is installed. Thereafter, the freeze sequence with argon gas is started, achieving extremely low temperatures (-40°C) to induce tumor cell lysis. Sequentially, the thawing cycle is performed using helium gas. This process is repeated one time. Results among several series showed a biochemical disease-free survival between 71-93% at 9-70 month- follow-up, incontinence rates between 0-3.6% and erectile dysfunction between 0-42% (1–5).Conclusions:Focal cryotherapy is a feasible procedure to treat anterior PCa that may offer minimal morbidity, allowing good cancer control and better functional outcomes when compared to whole-gland treatment.

Robot-assisted extralevatory abdominoperineal extirpation of the rectum with transabdominal levator transеction in a patient in lithotomy position

Objective : to evaluate safety and efficacy of robot-assisted extralevatory abdominoperineal extirpation of the rectum with transabdominal levator transеction in a patient in lithotomy position. Materials and methods. Within this study, we analyzed clinical observations of several patients who underwent robot-assisted extralevatory abdominoperineal extirpation of the rectum with transabdominal levator transеction at lithotomy position, conducted in the Saint Petersburg City Hospital No 40 during 2015–2016. We assessed the main intraoperative characteristics, postoperative complications, and pathological features of removed organs. Results and discussion. We analyzed the data on 5 patients. All of them underwent R0 resection. The number of resected lymph nodes varied from 15 to 21. Maximum blood loss was 100 ml. The duration of surgery was between 150–210 min. One patient had a postoperative complication – intrapelvic bleeding in the early postoperative period. Conclusion . The use of the described surgical method allowed to perform R0 resections in all patients without losing the advantages of minimally invasive surgery, including small blood loss, early recovery of peristalsis, and rapid rehabilitation of the patients.

Comparison of prostate contours between conventional stepping transverse imaging and Twister-based sagittal imaging in permanent interstitial prostate brachytherapy.

PurposeTo compare prostate contours on conventional stepping transverse image acquisitions with those on twister-based sagittal image acquisitions.Material and methodsTwenty prostate cancer patients who were planned to have permanent interstitial prostate brachytherapy were prospectively accrued. A transrectal ultrasonography probe was inserted, with the patient in lithotomy position. Transverse images were obtained with stepping movement of the transverse transducer. In the same patient, sagittal images were also obtained through rotation of the sagittal transducer using the “Twister” mode. The differences of prostate size among the two types of image acquisitions were compared. The relationships among the difference of the two types of image acquisitions, dose-volume histogram (DVH) parameters on the post-implant computed tomography (CT) analysis, as well as other factors were analyzed.ResultsThe sagittal image acquisitions showed a larger prostate size compared to the transverse image acquisitions especially in the anterior-posterior (AP) direction (p < 0.05). Interestingly, relative size of prostate apex in AP direction in sagittal image acquisitions compared to that in transverse image acquisitions was correlated to DVH parameters such as D90 (R = 0.518, p = 0.019), and V100 (R = 0.598, p = 0.005).ConclusionsThere were small but significant differences in the prostate contours between the transverse and the sagittal planning image acquisitions. Furthermore, our study suggested that the differences between the two types of image acquisitions might correlated to dosimetric results on CT analysis.

Laparoscopic Transperitoneal Approach for Vesicovaginal Fistula Repair: the First Experience

Objective: To report our first experience in transperitoneal laparoscopic repair of vesicovaginal fistula in Dr. Hasan Sadikin Hospital.&#x0D; Method: A 31-year-old female presented with vesicovaginal fistula&#x0D; after cesarean section. Patient complained of urinary incontinence&#x0D; since 5 years ago. After a failed trial of conservative treatment with&#x0D; catheter drainage, a transperitoneal laparoscopic repair was performed.&#x0D; Initially, cystoscopy was performed to confirm the fistula location&#x0D; and for bilateral ureteric catheterization. A 4-port technique&#x0D; was performed with the patient in lithotomy position and slightly&#x0D; Trendelenburg. Without opening the bladder, the fistula tract was&#x0D; excised and the bladder was separated from the anterior vaginal&#x0D; wall. Both the bladder and vaginal walls were then closed separately&#x0D; using intracorporeal suturing, interposed with the omentum.&#x0D; Result: Total operative time was 270 minutes. Normal diet was resumed on day 1, drain was removed on the first day after surgery,&#x0D; and the patient was discharged on the second day with an indwelling&#x0D; catheter. Surgical wound showed good cosmetic result and no&#x0D; leakage was identified from cystogram after 2 weeks. The catheter&#x0D; was removed after 2 weeks.&#x0D; Conclusion: Laparoscopic transperitoneal repair of vesicovaginal&#x0D; fistula with omentum inteposition is feasible in Dr. Hasan Sadikin&#x0D; Hospital with good outcome, short hospital stay, and good cosmetic&#x0D; result.&#x0D; [Indones J Obstet Gynecol 2014; 4: 223-225]&#x0D; Keywords: laparoscopy, vesicovaginal fistula

A study on plication of piles

Background: Haemorrhoids are specialized, highly vascularized ‘cushions’ forming discrete masses of thick sub-mucosa containing blood vessels, smooth muscles and elastic and connective tissues limited to the anal canal and perianal area. The cause of haemorrhoids remains unknown. Numerous factors contribute to haemorrhoidal diseases such as constipation, prolonged squatting, pregnancy, aging, hereditary, portal hypertension, abdominal tumor and defecation habits. Methods: This prospective study was carried out in the department of surgery, GMCH, Udaipur, Rajasthan, India from June 2014 to December 2015 after taking the permission from institutional ethics committee. Patients from both sexes of various age groups having haemorrhoids and associated anorectal pathology such as fissure were included. Patients with prolapsed piles, thrombosed piles and piles secondary to anorectal tumor were excluded from the study. Preoperative Bisacodyl 2 tablets at night before operation and Sodium picosulphate enema was given early morning on the day of surgery to ensure a clear visualization of anal canal. Operative technique: With the patient in lithotomy position after appropriate anesthesia anal stretching was done and thereafter tissue forceps was applied to the skin tags corresponding to the three major piles. A Babcock forceps was then applied to the pile mass above the level of pectinate line. Then the held pile mass was transfixed and ligated with silk 1-0 atraumatic needle suture at the proximal end of the internal haemorrhoids in order to occlude the superior haemorrhoidal vessel as they enter the internal haemorrhoids. If there were any small secondary pile the same procedure would be done. A small piece of gauge soaked with 2% xylocaine jelly would be left in anus as dressing. Results: Total 50 patients of piles were examined and most of the patients were between 31-50 years of age (60%) with males preponderance. All the patients in this study had bleeding per rectum as the main symptom. Among all patients 60% received some form of conservative treatment and partially relieved. Out of 50 patients, 38% had 1st degree piles, 58% had 2nd degree piles and rest had 3 rd degree piles. In this study of plication of piles 94% of cases had no pain, 6% of cases who had pain were also suffering from fissure. The results of plication of piles are satisfactory and only 2% of the patients had pain for which long term analgesics were given. Conclusions: The treatment of haemorrhoids has been widely discussed and various methods are being employed by majority of surgeons throughout the world. In the plication of piles one should appreciate the fulfilment of above mentioned requirements.

Development of an operative suspension system for the performance of MRI-OR-guided laparoscopic anoplasty.

MRI-guided laparoscopic assisted anorectoplasty (MRI-LAARP), a new approach for surgical correction of high imperforate anus, does not bisect the sphincter complex as in the PSARP and is able to pull the neorectum through the entire sphincter complex unlike the LAARP. There is no available MRI-compatible device to position and transport patients during this procedure. We report on the design of such a device here. The device was constructed from 1.0″ polyvinylchloride tubing and poly-methyl methacrylate (Plexiglass(®)) platform. The device has a stable, rigid base on which platform is secure. An adjustable and removable superstructure is secured to this base to suspend legs for lithotomy position. MRI-LAARP has been performed on 6 patients. The device has performed well and meets requirements set forth in development including construction with MRI-compatible materials, size fitting in the MRI bore, ability to hold patient in lithotomy position, ability to position and support MRI flex coils, and providing stability while transporting to a separate OR with needle in position. This device provides a stable structure to position and transport a patient with a needle in a tenuous position without dislodgement allowing this procedure, and potentially other procedures, to be done in hospitals without MROR capability.