Peritoneal Entry Research Articles

Navigating the layers of concern for safe dry needling of the rectus abdominis: a cadaveric study

ABSTRACT Objectives To assess needle placement accuracy in the rectus abdominis (RA) muscle during dry needling (DN) without entering the peritoneum. Methods Two physical therapists performed DN on a cadaver, making 10 attempts each to needle the RA without entering the peritoneum. Techniques followed two common DN approaches. Ultrasound verified needle depth and safety. Results Seventy percent of attempts were recorded as safe needle placement, while 30% were unsafe. Accurate RA needle placement without peritoneal entry occurred in 55% of attempts. Discussion/Conclusion Inadvertent peritoneal needle placement during RA DN poses risks regardless of experience. Ultrasound guidance may enhance safety and precision in clinical practice.

Single-Port Robotic Radical Prostatectomy Using Transvesical and Transperineal Access in Patients with a Hostile Abdomen.

Introduction: Prostate cancer diagnosis and treatment is challenging in surgically complex patients. Radical prostatectomy can be performed without peritoneal entry using novel single-port (SP) transperineal (TP) and transvesical (TV) approaches. We sought to examine the outcomes of radical prostatectomy using novel TP and TV approaches in patients with extensive prior abdominal surgeries. Materials and Methods: From 2019 to 2023, 51 patients with extensive prior abdominal surgeries were identified who underwent TP (18) and SP TV (33) robotic radical prostatectomy. Indications included history of various surgeries with open laparotomy, including J-pouch reconstruction (22, 43%), active stoma (14, 27%), and open bowel resection (9, 18%). In all patients, 12/51 (24%) had a history of incisional hernia repair with mesh. A retrospective analysis was performed. Results: All cases were completed without open conversion, bowel injuries, or blood transfusions. Length of stay was 5.6 hours for TV and 22 hours for TP. No opioids were prescribed in 91% of TV vs 56% of TP. One intraoperative complication (ureteral injury) occurred in a patient undergoing the TP approach. Postoperative complications were noted in 14/51 (27%), including 10/18 (56%) TP vs 4/33 (12%) TV. High-grade complications (Clavien 3) occurred in three patients (6%, all TP). Pathologic staging showed pT3 in 26/51 (17 TV vs 9 TP), while the remainder were pT2. Biochemical recurrences were noted in four patients (8%, three TV and one TP). Immediate continence was noted in 30% of TV patients. Long-term continence after 12 months was 92% in TV and 67% in TP. Conclusions: In patients with extensive prior abdominal surgeries, radical prostatectomy is feasible using a TP or TV approach. No bowel injuries or open conversion were observed. The SP TV approach offers advantages of shorter hospital stay, shorter catheter duration, less opioid use, fewer complications, and improved continence recovery.

MP80-14 EXTRAPERITONEAL SINGLE-PORT ROBOTIC RADICAL PROSTATECTOMY IN OVER 700 PATIENTS: UPDATED MULTI-INSTITUTIONAL COHORT STUDY FROM THE SPARC COLLABORATION

You have accessJournal of UrologyCME1 Apr 2023MP80-14 EXTRAPERITONEAL SINGLE-PORT ROBOTIC RADICAL PROSTATECTOMY IN OVER 700 PATIENTS: UPDATED MULTI-INSTITUTIONAL COHORT STUDY FROM THE SPARC COLLABORATION Ethan Ferguson, Jennifer L. Nguyen, Roxana Ramos, Grace Chen, Kennedy Okhawere, Samantha Wilder, Ruth Sanchez De La Rosa, Jaya Chavali, Indu Saini, James Peabody, Ketan K. Badani, Craig Rogers, Jeffrey Nix, Jean Joseph, Michael Stifelman, Simone Crivellaro, Mutahar Ahmed, Moses Kim, and Jihad Kaouk Ethan FergusonEthan Ferguson More articles by this author , Jennifer L. NguyenJennifer L. Nguyen More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Grace ChenGrace Chen More articles by this author , Kennedy OkhawereKennedy Okhawere More articles by this author , Samantha WilderSamantha Wilder More articles by this author , Ruth Sanchez De La RosaRuth Sanchez De La Rosa More articles by this author , Jaya ChavaliJaya Chavali More articles by this author , Indu SainiIndu Saini More articles by this author , James PeabodyJames Peabody More articles by this author , Ketan K. BadaniKetan K. Badani More articles by this author , Craig RogersCraig Rogers More articles by this author , Jeffrey NixJeffrey Nix More articles by this author , Jean JosephJean Joseph More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , Moses KimMoses Kim More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An extraperitoneal approach to single-port (SP) robot-assisted radical prostatectomy has been demonstrated with proposed benefits in decreased morbidity, single incision, and same-day discharge. We sought to determine the perioperative and early postoperative outcomes in a large, multi-institutional setting. METHODS: SP extraperitoneal radical prostatectomy was performed in 712 patients between February 2019 and October 2022. All procedures were performed by experienced robotic surgeons from eight tertiary medical centers. Data from baseline demographics, perioperative and early postoperative outcomes were collected prospectively and analyzed retrospectively RESULTS: All reported procedures were completed without open conversion, blood transfusions, or intraoperative complications. The median follow-up time was 11.7 months for the entire cohort. The median age, BMI and preoperative PSA were 64 years, 27.9kg/m2, and 6.4 ng/mL, respectively. About 30% of the patients had at least one previous abdominal surgery. On pathology, high risk disease was noted in 12% and lymph node involvement on final pathology was present in 5.8%. Extraprostatic extension was noted in 38% and positive surgical margins were present in 30.2% of cases. Lymphadenectomy was performed in 85% of patients and the median lymph node yield was 5 nodes. There were no intraoperative complications and inadvertent peritoneal entry with insufflation was rare (0.6%) and managed conservatively. Postoperative complications occurred in 11.8%. The median length of stay and foley catheter duration were 8 hours and 7 days, respectively. Postoperative recovery of continence was 69% at 3 months and 88% at 6 months. Recovery of potency was 35.6% at 6 months. CONCLUSIONS: Single-port extraperitoneal robotic radical prostatectomy is safe and feasible for management of clinically localized prostate cancer. Analysis from a large multi-institutional cohort shows promising single incision and short hospital length of stay without compromise in early functional or oncologic outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1157 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Ferguson More articles by this author Jennifer L. Nguyen More articles by this author Roxana Ramos More articles by this author Grace Chen More articles by this author Kennedy Okhawere More articles by this author Samantha Wilder More articles by this author Ruth Sanchez De La Rosa More articles by this author Jaya Chavali More articles by this author Indu Saini More articles by this author James Peabody More articles by this author Ketan K. Badani More articles by this author Craig Rogers More articles by this author Jeffrey Nix More articles by this author Jean Joseph More articles by this author Michael Stifelman More articles by this author Simone Crivellaro More articles by this author Mutahar Ahmed More articles by this author Moses Kim More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

The outcome of local excision of large rectal polyps by transanal endoscopic microsurgery.

Local excision of large rectal polyps can be an alternative for radical rectal resection with total mesorectal excision. We aim to report the functional and oncological outcomes of transanal endoscopic microsurgery (TEM) for patients with large rectal polyps. All demographic and clinical data of patients who underwent TEM for rectal polyp of 5 cm or more at the Hasharon Hospital from 2005 to 2018 were retrospectively reviewed. Twenty-eight patients were included. The mean age was 66 years. The mean polyp size was 6.2 cm (range: 5-8.5 cm) with a mean distance of 8.3 cm from the anal verge. Peritoneal entry during TEM was observed in five patients and additional laparoscopy after the completion of the TEM was performed in four patients. There were no major perioperative complications. Seven patients had minor complications. Final pathology revealed T1 carcinoma in five patients and T2 carcinoma in three patients. Re-TEM was performed in one patient with involved margins with adenoma. After a median follow-up of 64 months, one patient had local recurrence. TEM is an acceptable technique for the treatment of large polyps with minor complications and a reasonable recurrence rate. TEM may be considered regardless of the size of the rectal polyp.

Small Bowel Injury During Peritoneal Entry at Cesarean Section: A Five-Year Case Series.

Introduction Small bowel injury during peritoneal entry may occur unexpectedly at cesarean section (CS) and may present unexpected management problems and prolonged postoperative hospital stay. Methods This was an observational study of patients who sustained inadvertent injuries compared to those who did not. Both study and control patients had the same number of previous cesarean sections. Findings In this study population, the frequency of small bowel injury during peritoneal entry was 0.0003/10,000 cesarean sections. The majority comprised serosal trauma (7/10) and tended to occur in females who had had two or more CS. Compared to patients with a similar number of previous cesarean sections, patients who sustained small bowel injuries in the index cesarean section were twice as likely to have had adhesiolysis of flimsy or dense lesions in the immediate preceding procedure. Conclusion Bowel injury during peritoneal entry at cesarean section is rare but may be frequently encountered in maternity units with high-volume CS rates.

An Incidental Discovery of a Serious Complication

An Incidental Discovery of a Serious Complication

Modeling Surgical Management of Uterine Atony Induced Postpartum Hemorrhage using Cadaver Dissection

IntroductionThere is a well‐documented disconnect that medical students experience when applying preclinical anatomical knowledge to clinical applications.1 According to the United States National Inpatient Sample, postpartum hemorrhage (PPH) carries an overall incidence of up to 3% of all U.S. deliveries; this study designates uterine atony as the most common etiology of PPH, causing at least 80% of PPH cases.2Thus, fourth year medical students preparing to enter into the specialty of obstetrics and gynecology should have in vivo exposure to the surgical management of uterine atony induced PPH prior to beginning residency. Modeling arterial ligation of the anterior division of the internal iliac artery using a cadaver model is a practical approach that most resembles an in vivo illustration of PPH surgical management while also maintaining a safe, controlled environment.ObjectiveIn efforts to provide fourth year medical students with exposure to PPH management, create a guide for ligation of the internal iliac artery’s anterior division using a cadaver model.Material and MethodsDissection was completed by two fourth year HWCOM medical students anticipating entry into the specialty of obstetrics and gynecology. After completion of anterior abdominal wall dissection and peritoneal entry, GI organ were retracted for full visualization of genitourinary structures. The following arteries were identified and skeletonized in the following fashion: common iliac artery, internal iliac artery, anterior division of the internal iliac artery, umbilical artery, obturator artery, and uterine artery. The anterior division of the internal iliac artery was identified and ligated 2 cm below the bifurcation of the common iliac artery to avoid unintentional ligation of the superior gluteal artery. A picture of the arterial ligation site was captured.Results/ImagesProper arterial ligation site of the internal iliac artery’s anterior division can be visualized in the appendix.Conclusion and Significance/ImplicationSurgical management of PPH requires both anatomical knowledge of arterial and pelvic anatomy but also spatial familiarity of structures in vivo. Performing the surgical management of PPH on a cadaver model could provide fourth year medical students an opportunity to learn the appropriate sites and steps and surgical arterial ligation in a less pressured environment before entering residency. Future implications of this study could combine virtual learning tools, such as anatomy mobile applications, to further aid in medical education’s exposure to PPH management and associated anatomy.

Surgical principles of vaginal hysterectomy with cervical elongation

A review of strategies and key surgical principles for approaching the difficult anterior and posterior peritoneal entry encountered during vaginal hysterectomy with cervical elongation. Cervical elongation is a known entity among pelvic surgeons, however it lacks a universal quantitative definition. In the literature, it has been variably defined by pathologic measurements, POP-Q exam, or surgeon’s perception. One study found that cervical elongation was present in 16-40% of patients undergoing vaginal hysterectomy for pelvic organ prolapse and was associated with increased operative time. Unfortunately, cervical elongation is often discovered for the first time intraoperatively, at which time it can make anterior and posterior entry difficult due to altered anatomy.1–6 When cervical elongation is discovered, patience is key. This video highlights four surgical principles we have adopted from the laparoscopic approach to assist in safe completion of the procedure. First, continue to completely excise the vaginal attachments to the cervix. This will allow the uterus to begin to descend into the operative field and improve exposure/visualization. Two, as the cardinal ligament is reached, separate the leaves of the broad ligament to visualize the uterine vessels. Isolate the descending uterine branches at the 3 and 9 o’clock position. Three, continue to secure the uterine vessels laterally until the lower uterine segment is reached. Four, once the ascending branches of the uterine artery are isolated, the vesicouterine peritoneal fold can be approached from lateral to medial and anterior entry accomplished. Cervical elongation is difficult to predict. When encountered, we've found it helpful to adopt strategies from laparoscopy. These techniques may be applied in other scenarios where anterior or posterior entry is difficult.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Anterior Entry in Patients with Prior Cesarean Section

Study Objective The objective of this video is to demonstrate the use of vNOTES technique for performing vesicouterine dissection to obtain entry into the anterior peritoneal space in patients with prior Cesarean section and resultant vesicouterine scarring Design Case report. Setting Case was performed at an academic medical center with patient placed in the dorsal lithotomy position. Screen was positioned near the patient's head and facing towards the feet with surgeons positioned between the legs to operate within the vaginal orifice. Patients or Participants Patient undergoing vNOTES hysterectomy for the indication of abnormal uterine bleeding and pelvic pain. Patient had undergone prior cesarean section. Interventions vNOTES technique was used to facilitate visualization and access for development of the vesicouterine space and allow anterior peritoneal entry in the setting of scarring secondary to prior cesarean section. Measurements and Main Results Patient underwent total hysterectomy and bilateral salpingectomy with minimal blood loss and without intraoperative or postoperative complications. Conclusion vNOTES allows use of the natural vaginal orifice with improved visualization and access for dissection of vesicouterine adhesions allowing safe entry into the anterior peritoneal cavity and offers an alternative to abdominal laparoscopy in situations where a traditional transvaginal approach may not be feasible. The objective of this video is to demonstrate the use of vNOTES technique for performing vesicouterine dissection to obtain entry into the anterior peritoneal space in patients with prior Cesarean section and resultant vesicouterine scarring Case report. Case was performed at an academic medical center with patient placed in the dorsal lithotomy position. Screen was positioned near the patient's head and facing towards the feet with surgeons positioned between the legs to operate within the vaginal orifice. Patient undergoing vNOTES hysterectomy for the indication of abnormal uterine bleeding and pelvic pain. Patient had undergone prior cesarean section. vNOTES technique was used to facilitate visualization and access for development of the vesicouterine space and allow anterior peritoneal entry in the setting of scarring secondary to prior cesarean section. Patient underwent total hysterectomy and bilateral salpingectomy with minimal blood loss and without intraoperative or postoperative complications. vNOTES allows use of the natural vaginal orifice with improved visualization and access for dissection of vesicouterine adhesions allowing safe entry into the anterior peritoneal cavity and offers an alternative to abdominal laparoscopy in situations where a traditional transvaginal approach may not be feasible.

Urinary bladder injury during cesarean delivery: risk factors and the role of retrograde bladder filling.

Urinary bladder injury during cesarean delivery is an uncommon complication with substantial maternal morbidity. The aim of this study was to identify possible risk factors for bladder injury during cesarean delivery and to describe the role of retrograde bladder filling in the assessment of bladder wall integrity. A retrospective cohort study at a large tertiary referral center. Women who underwent cesarean delivery between 2003 and 2017 were included. Women diagnosed with urinary bladder injury were compared to women who did not have such injuries. Data retrieved included demographic characteristics, general medical history, obstetric history and intra-partum and intra-operative data. Information regarding use of retrograde bladder filling intra-operatively was retrieved as well. During the study period, 21,177 cesarean deliveries were performed of which 68 (0.3%) cases of urinary bladder injury were identified. Two-thirds of injuries were located at the urinary bladder dome with the remaining third located at the posterior bladder wall. Most injuries were formed during uterine incision extension (60.0%) followed by peritoneal entry (22.0%). Following uni- and multivariate analyses, three parameters remained independent risk factors for bladder injury: urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of the uterine incision extension. In 15.4% of cases in which retrograde bladder filling was utilized following bladder repair, leakage of fluid was evident. Urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of uterine incision extension are independent risk factors for urinary bladder injury during cesarean delivery.

Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients

Video-Assisted Peritoneal Dialysis Placement in COVID-19 Patients

Distance of Cervico-Vaginal Junction to Anterior Cul-de-sac during Vaginal Hysterectomy in Patients with and without Prior Cesarean Section

Study Objective Incomplete dissection of vaginal attachments to cervix during vaginal hysterectomy (VH) can lead to incorrect plane and injury to the bladder. This study aims to compare the mean distance between the cervico-vaginal (CV) incision to the anterior cul-de-sac (AC) during VH between women with and without a history of cesarean section (CS). Design Prospective cohort study of women who underwent VH. Intraoperative measurements taken: Distance from external cervical os to initial incision at CV, distance from CV to peritoneal entry into the AC, and distance from AC to the uterine fundus. Measurements were compared between patients with and without CS. We determined that 40 patients were needed to study our primary outcome: 20 CS and 20 non-CS. Setting VH performed in high lithotomy position. Patients or Participants Women who were undergoing VH for benign gynecologic conditions were included. Patients were excluded if gynecologic malignancy, prior vaginal or pelvic radiation, and/or presence of lower anterior uterine segment myoma. Interventions N/A Measurements and Main Results Preliminary data are presented (incomplete accrual as yet of patients due to the COVID19). Of the 35 patients with complete data, 23 (62.1%) had vaginal delivery(ies) only, 12 (32.4%) had at least one CS. The mean distance from CV to AC entry in all patients was 5.0 (1.55) cm, 5.4 (1.92) cm with CS, and 4.79 (1.31) cm without CS (p=0.27). The mean distance of the AC entry to fundus was longer in patients without CS (6.48cm vs 4.49cm, p=0.01). This finding remained significant when we controlled for both uterine length and weight. Conclusion Preliminary data suggests that in CS patients, the mean distance from the initial incision to AC tended to be greater and distance of AC to fundus was significantly shorter compared to non-CS patients.

970 POEM+F – IDENTIFYING AND UNDERSTANDING THE TECHNICAL NUANCES AND CHALLENGES WHILE PERFORMING A PROCEDURE IN EVOLUTION

Peroral endoscopic myotomy (POEM) is an accepted treatment modality for achalasia cardia (AC). Post POEM gastroesophageal reflux (GER) has emerged as a frequent adverse event. POEM + endoscopic fundoplication (POEM+F) has been described as a novel NOTES procedure thatcombines endoscopic fundoplication along with POEM. POEM+F is an evolving procedure. This video case series demonstrates technical nuances of POEM+F. 20 consecutive patients with EGD and high resolution esophageal manometry proven type II AC underwent POEM+F over 10-month period (Feb. to Nov. 2019).POEM+F performed after obtaining informed consent. All procedures performed under general anesthesia by single operator. Standard anterior POEM performed using gastroscope with distal transparent attachment. Procedure modified from original with intent to simplify it. After completing full-thickness myotomy across gastroesophageal junction (GEJ), 5.7mm ultra-slim gastroscope introduced alongside gastroscope into gastric fundus. Using double endoscope transillumination, serosa overlying the myotomy divided to enter peritoneum. Scope angled upwards & leftwards to reach gastric fundus; fundus grasped & withdrawn into tunnel to simulate wrap. Procedure continuously monitored by ultra-slim gastroscope.Spot on fundic serosa marked. Gastroscope reintroduced into peritoneal cavity carrying 3cm endoloop grasped in a reconstrainable clip. Endoloop fixed to fundus and proximally to end of myotomy & peritoneal opening. Endoloop tightened, loop tail trimmed and mucosal incision closed. Following modifications from original – [1] double endoscope trans-illumination to identify peritoneal entry; [2] Decompressing gastric lumen to facilitate grasping of fundus; [3] re-constrainable clip to grasp fundus; [4] Marking location on fundus for fixing endoloop; [5] Use of detachable endoloop to reduce friction within esophagus and tunnel; [6] Avoiding perigastric fat while fixing loop and clips on fundus; [7] Abdominal paracentesis to reduce capnoperitoneum. Follow up EGD performed at one-month. Total N = 20 (11 males, mean age – 40.9 years [18 – 67]). Mean total procedure time = 77.5min (Range 55 – 145). Mean procedure time for additional fundoplication = 42.5min (Range 30 – 105). Fundal wrap was intact in all patients at follow up EGD after 1 month. No immediate or delayed adverse events encountered. All patients resumed oral diet after 24 hours and discharged within 48 hours. POEM+F is a safe and feasible procedure. Modifications in technique described in video may help to simplify the procedure.Efficacy of POEM+F for prevention of post POEM GER needs further evaluation by larger studies with longer term follow-up.

42: What do residents want in a surgical video? Trainee perspectives on the vaginal hysterectomy

To describe the critical components and features of an educational vaginal hysterectomy surgical video from the resident perspective. Our secondary aim was to compare junior and senior level resident responses. Individual semi-structured qualitative interviews were conducted with Ob/Gyn residents from two separate academic-based residency programs. Participants were selected based on key informant sampling in which individuals known to be interested in vaginal surgery or gynecologic sub-specialty training were invited to participate. Investigators explored 4 principal topic areas: 1) Components of high-yield vaginal hysterectomy videos; 2) Supplemental features for educational videos; 3) Differences between high and low quality surgical videos; 4) Barriers to viewing video prior to surgery. Individual qualitative interviews were transcribed verbatim, coded and analyzed by two independent reviewers using NVivo12 Pro. Eighteen residents participated in qualitative interviews with 12 (67%) senior level residents (post-graduate year 3 or 4) and 6 (33%) junior level residents (post-graduate year 1 or 2). All residents had completed 10 or less vaginal hysterectomies at the time of the interviews. Gynecology residents characterized high-yield vaginal hysterectomy videos as short, accessible surgical videos available on mobile applications (Figure 1). Residents desired videos that highlight and provide insight into challenging techniques: anterior peritoneal entry, uterosacral pedicles and vaginal cuff closure. With regards to desired supplemental material, senior level residents identified intraoperative complications and troubleshooting as important whereas junior level residents identified instrumentation and anatomy review. Trainees described high quality videos as those with adequate visualization, graphics to demarcate anatomy overlaid on the dissection, review of challenging techniques and descriptive audio. Low quality videos were described as long duration, poor visualization and inadequate audio explanation. Resident awareness and video accessibility were common barriers that prevented residents from viewing vaginal hysterectomy videos prior to surgery. The importance of an accessible mobile application with short, descriptive videos were congruent across all resident experience levels. Gynecology residents desire short, app-based vaginal hysterectomy videos that are easily accessible. Understanding residents’ perspective can aid educators to create videos directed toward resident learning preferences.

Totally extraperitoneal approach for open complex abdominal wall reconstruction.

Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175min, median blood loss 100mL, and median length of stay 4days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28months postoperatively. TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.

Feasibility of transanal total mesorectal excision (taTME) using the Medrobotics Flex® System.

The use of transanal total mesorectal excision (taTME) for treatment of rectal cancer is growing, but anatomic constraints prevent access to the proximal rectum with rigid instruments. The articulated instrumentation of current surgical robots is promising in overcoming these limitations, but the bulky size of current platforms inhibits the proximal reach of dissection. Flexible robotic systems could overcome these constraints while maintaining a stable platform for dissection. The goal of this study was to evaluate feasibility of performing taTME using the semi-robotic Flex® System (Medrobotics Corp., Raynham, MA) in human cadavers. taTME was performed by two surgeons in six fresh human cadaveric specimens using the Flex® System, with or without transabdominal laparoscopic assistance. Both mid- and low-rectal lesions were simulated. Metrics including quality of visualization, maintenance of pneumorectum, maneuverability of instruments, effectiveness of pursestring suture placement, and dissection in an anatomically correct plane were evaluated. The semi-robotic endoluminal platform allowed for excellent visualization, insufflation, and dissection during taTME. Adequate pursestring occlusion of the rectum was achieved in all six cases. In cadavers with simulated mid-rectal lesions (N = 4), dissection and anterior peritoneal entry was achieved in all cases, with abdominal assistance utilized in two of four cases. In cadavers with simulated low-rectal lesions (N = 2), dissection was incomplete and aborted due to difficulty maneuvering instruments in close proximity to the rigid transanal port. Use of the Flex® system for taTME is feasible for mid-rectal dissection. Advantages over the traditional multi-armed robot include longer reach of instruments with the ability to dissect up to 17cm from the anal verge, as well as tactile feedback. The current design of the flexible platform does not permit safe dissection in the distal rectum, although this constraint may be resolved with future adjustments to the equipment.

Peritoneal perforation during transanal endoscopic microsurgery is not associated with significant short-term complications.

In patients treated by transanal endoscopic microsurgery (TEM), breach of the peritoneal cavity is a feared intraoperative challenge. Our aim is to analyze predictors and short-term outcomes of patients with peritoneal perforation (TEM-P) when compared to similar patients with no peritoneal compromise (TEM-N). At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for all patients treated by TEM is maintained in a prospectively populated database. A retrospective review was performed and two groups were established for comparison: TEM-P and TEM-N. Statistical analysis was performed using student's t or chi-squared test, where appropriate. Of 619 patients treated by TEM between 2007 and 2016, 39 (6%) patients were in the TEM-P group and 580 (94%) in the TEM-N group. There were no differences between the groups in patient age, gender, histology, or tumor size. Patients who had peritoneal perforations had more proximal lesions (11 vs. 7cm, p < 0.0001), anterior lesions (56 vs. 43%, p < 0.05), and longer operations (80 vs. 51min, p < 0.005). While most defects were closed endoluminally, 2 patients with perforation were converted to transabdominal surgery. There was a difference in overall hospital stay with TEM-P patients staying on average 2days in hospital with fewer patients managed as day surgery (31 vs. 73%, p < 0.0001). There were no mortalities or significant 30-day complications in the TEM-P group and only one patient required readmission. The St. Paul's Hospital TEM experience suggests patients with peritoneal breach during TEM can be safely managed with outcomes similar to patients without peritoneal entry. Proximal, anterior lesions are at highest risk of peritoneal perforation.

Comparison of Single Incision and Conventional Laparoscopic Surgery for Surgical Sterilization

Objective: To compare the intraoperative characteristics and postoperative pain levels of single incision and conventional laparoscopic surgeries performed for surgical sterilization.Study Design: A single center prospective observational study was conducted to compare the conventional and single incision laparoscopic (SIL) partial salpingectomies performed for surgical tubal sterilization. In total of 110 women, 62 in the conventional laparoscopy and 48 in the SILS group participated in the study. The main outcome measures were peritoneal entry time, total operation time, amount of bleeding, intraoperative complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay. Statistical analysis was accomplished using the chi-square test or Mann Whitney U test, where appropriate.Results: Demographical findings did not differ between the two groups (p&gt;0.05). Similarly, total operation time, rates of intraoperative complications, conversion to laparotomy, length of hospital stay, pre and postoperative hematocrit levels were not significantly different between the groups. Peritoneal entry time was shorter in the SIL group (7.1 min. vs. 4.8 min., p&lt;0.001). Additional analgesic requirements, postoperative pain scores in the recovery room and at 6th, 12th, and 24th hours were not different between the groups (p&gt;0.05).Conclusion: SILS seems a safe and feasible alternative to conventional laparoscopy for surgical tubal sterilization.Keywords: Partial salpingectomy, Tubal ligation, Contraception, Surgical sterilization, Single Incision Laparoscopy

27: Vaginal hysterectomy: Techniques for peritoneal entry

Vaginal hysterectomy is the approach of choice when performing hysterectomy for benign indications. Anterior and posterior entries into the peritoneal cavity are necessary and crucial steps in performing this procedure, however factors such as uterine size, past surgical history (including C section), and degree of uterine descent can make these steps challenging. We present three surgical cases and describe several techniques for safe and efficient entry into the peritoneal cavity during vaginal hysterectomy. In the first example anterior cul de-sac entry is demonstrated. After incising the vaginal mucosa, sharp dissection is carried out with Metzenbaum scissors. A Babcock clamp is used to provide traction on the anterior vagina/bladder while counter-traction is placed on the cervix. Once the bladder is dissected off of the cervix, the peritoneum is grasped with tonsil clamps and entered sharply. In the second example, we perform initial peritoneal entry into the posterior cul-de-sac. The surgeon’s fingers are passed anteriorly into the vesicouterine space and deflect the bladder cephalad as anterior dissection is performed. The surgeon’s fingers also provide traction on the anterior vagina as it is dissected off of the cervix. In the third example, the urinary catheter balloon is used to identify the distal boarder of the bladder. We use Allis clamps to demarcate the dissection boundaries. Again, after a posterior entry is achieved and the surgeon’s fingers are used to deflect the bladder cephalad while performing the anterior dissection. These surgical techniques focus on safe and efficient entry into the peritoneal cavity and aim to decrease inadvertent injury to bladder and rectum. By adding these dissection methods to their repertoire, surgeons can become more comfortable performing vaginal hysterectomy, and minimize conversion to abdominal procedures.

Trans-anal minimally invasive surgery: A new technique to avoid peritoneal entry

IntroductionTransanal minimally invasive surgery (TAMIS) is a valuable surgical option for removal of rectal polyps and early rectal cancers. A potential complication of this technique is abdominal entry if the lesion is located above the peritoneal reflection. We present the first case series describing the use of a laparoscopic stapling device to remove a sessile lesion, and seal the resulting defect simultaneously with full thickness excision of the rectal lesion, avoiding abdominal entry. Presentation of casesFive patients with rectal lesions between 8 and 14 cm from the anal verge are described in this case series. Each underwent a stapled-TAMIS procedure as the lesion was suspected to be above the peritoneal reflection. The goal specimen was achieved in each procedure. DiscussionThis article demonstrates the feasibility of a novel technique to remove sessile polyps in the upper rectum using laparoscopic staplers trans-anally through the TAMIS port. More studies and long-term follow-up are needed to evaluate the oncologic outcomes including the recurrence rate for those lesions removed with a stapler. ConclusionFor rectal lesions suspected to be above the peritoneal reflection, a stapled resection through a TAMIS port could prove be a valuable addition to the standard excisional approach to TAMIS.