Peritoneal Flap Research Articles

OV15 EMERGENCY SURGERY OF OBSTRUCTED VENTRAL HERNIA USING TAPP TECHNIQUE: A SAFE AND FEASIBLE APPROACH

Abstract Aim to explain and show the feasibility of laparoscopic TAPP technique in emergency procedures Material and Methods we present a 71-year-old female with personal history of obesity (BMI 32) and a laparoscopic right hemicolectomy performed in 2018, presenting at the ER with a 24-hour intestinal obstruction due to incarcerated ventral incisional hernia. Results laparoscopic reduction of the hernia contents was achieved without need of intestinal resection, prior to access to the preperitoneal space, creating a peritoneal flap that was dissected around the hernia. Following closure of the hernia defect, a polypropylene mesh was placed and the peritoneal flap closed. There were no intraoperative or postoperative events and patient was discharged on 3rd POD. Conclusions laparoscopic approach to emergency hernias in selected patients doesn’t differ from elective surgery, and offers great advantages in terms of evaluation of the incarcerated elements, and postoperative recovery, especially in obese patients where a conventional open approach has higher morbidity.

An Alternative Option for Gender-affirming Revision Vaginoplasty: The Tubularized Urachus-peritoneal Hinge Flap

INTRODUCTION: Peritoneal vaginoplasty has been reported for congenital and primary gender-affirming cases, but few have reported its use to treat postoperative neovaginal shortening after penile-inversion vaginoplasty. Recent adaptations of peritoneal vaginoplasty are modifications of the Davydov procedure, wherein peritoneum of the bladder, rectum, and Pouch of Douglas are incorporated to lengthen the vaginal canal. Here we describe our alternative technique using a single urachus-peritoneal hinge flap and discuss its proposed advantages. METHODS: We performed retrospective review of all trans-women with post-penile-inversion vaginoplasty vaginal canal shortening who underwent revision surgery with our technique. All cases were performed via combined trans-perineal and robotic-laparoscopic approaches. Preoperative and postoperative neovaginal circumference and depth were recorded. With a dilator in the canal, the peritoneum and terminal canal-end were incised and spatulated. The anterior canal-remnant epithelial edge was sutured to the anterior peritoneal edge. A midline, inferiorly based peritoneal flap (min.12-cm width) was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The flap’s free end was flipped posteriorly and sutured to the posterior edge of the open canal remnant, to create a peritoneum-lined pouch. The pouch’s lateral edges were sutured together. We confirmed water-tight closure. Patients resumed dilation on POD 8 and douching on POD 10. RESULTS: Five patients underwent peritoneal vaginoplasty with our technique from 5/2019 to 8/2020. Mean age was 32 years. Preoperative: mean canal girth was >12 cm, and depth was 8.6 (±1.8) cm. Immediate postoperative: mean girth was still >12 cm; depth was 16.8 (±1.2) cm (mean increase: 8.2 cm). At a mean follow-up of 1 year: mean girth was 11–12 cm, and depth was 13.5 (±1.8) cm (mean increase: 4.9 cm). There were no immediate complications. One patient developed anastomotic stenosis at 6 weeks postoperative, managed conservatively with dilation under anesthesia. All five patients endorse satisfactory sexual function; 3 of 5 report vaginal receptive intercourse. CONCLUSIONS: Early results suggest that our peritoneal vaginoplasty technique is a safe and effective option to treat neovaginal shortening. Advantages over existing techniques include: (1) No resting tension on peritoneal sutures, (2) Option for layered closure with omental interposition, and (3) Total exclusion of the rectum and Pouch of Douglas. Due to limited available peritoneum, we reserve this technique for cases where there is adequate residual canal girth and at least 6–7 cm of residual depth.

Laparoscopic Peritoneal Pull through Vaginoplasty with Ovarian Hitching to Facilitate Transvaginal Oocyte Retrieval for Mrkh Syndrome

<h3>Study Objective</h3> Video demonstration of laparoscopic peritoneal pull through vaginoplasty using the midline bands and mobilization of ovaries in the pelvis to facilitate transvaginal oocyte retrieval in a case of MRKH. <h3>Design</h3> Interesting case video. <h3>Setting</h3> Lithotomy. <h3>Patients or Participants</h3> Case of MRKH Syndrome. <h3>Interventions</h3> Laparoscopy. Bladder and rectum was dissected away from midline band between the Uterine buds. NeoVagina created vaginally making a U-shaped incision at the perineum. Peritoneal flaps made using the midline band. This band was cut. The vaginal vault opened using a sponge on holder inserted through the neovagina. The right and left peritoneal flaps were pulled down to the introitus to line the anterolateral part of neovagina and stitched at the end, smooth surface facing out. Releasing incisions made around the ureter, to prevent kinking.The rectovaginal peritoneal was brought down and stitched at the introitus to line the posterior surface of vagina. The neoapex made by passing a circumferential suture of the peritoneum. A mould made was inserted in the neovagina. Ovaries were mobilized into the pelvis and hitched in the POD, after making releasing incisions over the infundibulopelvic and the round ligament to facilitate transvaginal oocyte retrieval. <h3>Measurements and Main Results</h3> Post surgery mould kept for 4 days. A vaginal dilator for 3 to 6 months. Tranvaginal oocyte retrieval planned after 12 weeks. Now 6 weeks post-surgery and can use the vaginal dilator 10 hrs/day. <h3>Conclusion</h3> A peritoneal pull through vaginoplasty can be performed for a case of MRKH using the peritoneum covering the midline band for lining the anterolateral surface of neovagina and rectovaginal peritoneal lining the posterior surface of neovagina. Since this patient needs IVF and surrogacy, the oocyte retrieval in a case of MRKH is a challenge since the ovaries are high at the pelvic brim. The ovaries can be mobilized into the pelvis and a tranvaginal oocyte retrieval can be performed.

MP04-11 LAPAROSCOPY ASSISTED PERITONEAL PULL-THROUGH VAGINOPLASTY IN TRANSGENDER WOMEN, AN OLD TECHNIQUE IN MODERN TIME

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I (MP04)1 Sep 2021MP04-11 LAPAROSCOPY ASSISTED PERITONEAL PULL-THROUGH VAGINOPLASTY IN TRANSGENDER WOMEN, AN OLD TECHNIQUE IN MODERN TIME Marta Bizic, Borko Stojanovic, Marko Bencic, Slavko Matic, and Miroslav Djordjevic Marta BizicMarta Bizic More articles by this author , Borko StojanovicBorko Stojanovic More articles by this author , Marko BencicMarko Bencic More articles by this author , Slavko MaticSlavko Matic More articles by this author , and Miroslav DjordjevicMiroslav Djordjevic More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001971.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The gold standard in genital gender affirming surgeries (GGAS) is penile inversion vaginoplasty. In cases in whom penile skin is lacking. Either because of medication with puberty blockers or radical circumcision, or inadequate penile skin length, different options for neovaginal reconstruction must be offered to the patients. We asses laparoscopy assisted peritoneal pull-through vaginoplasty in combination with penile skin flaps for transgender women. METHODS: During two years period (March 2018-June 2020), we performed 47 primary laparoscopy assisted peritoneal pull-through vaginoplasties in transgender women. The surgery consisted of complete penectomy to the pubic bones in all patients, bilateral orchiectomy in 42 patients (5 patients had bilateral orchiectomy, prior the GGAS), clitoroplasty, urethroplasty, vulvoplasty and vaginoplasty using peritoneal flaps in combination with inverted penile skin flap. In two patients in whom lichen sclerosis was suspected removal of the affected skin was performed before creation of the neovagina. Two peritoneal flaps were dissected from the posterior aspect of the bladder and anterior aspect of the rectum in about 5cm in width and about 7cm in length and anastomosed with interrupted sutures with asymmetrically fashioned penile skin flap in order to prevent neovaginal stenosis. Vaginal packing is placed for the period of 5 days postoperatively, together with two drains. Urinary catheter is placed for urine derivation for 2 weeks. Compressive dressing is applied. RESULTS: Follow-up ranged from 6 to 23 months (mean 13 months). All patients were instructed to perform regular dilation of their neovagina for the first 12 months postoperatively by a pelvic floor physiotherapist. Even though peritoneum was found to produce some lubrication, patients were advised to use the lubricant during the sexual intercourse. Complications occurred in 5 of our patients: 3 had prolonged hematoma of the labia majora, one had neovaginal introitus dehiscence and one had superficial necrosis of the left labia majora. None of the complications required additional surgeries. The depth of the neovagina at the control check-up in 6 months after surgery was 14.7±0.5cm, while width was about 3.4±0.4cm. Majority of patients (≈96%) were satisfied with the new genitals, sensitivity, lubrication and possibility of engaging in sexual intercourse according to self-reports. One patient required reduction of the size of her clitoris because of hypersensitivity and the other one requested laser treatment of the incisional scars. CONCLUSIONS: Albeit known for quite a long time in vaginal reconstruction for cis-women languishing over vaginal agenesis and different states of vaginal absence, peritoneal pull-through vaginoplasty offers promising outcomes in transgender women GGAS that will give self-lubricating neovagina, with insignificant scarring and complications and high degree of patient's satisfaction. Source of Funding: / © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e71-e71 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marta Bizic More articles by this author Borko Stojanovic More articles by this author Marko Bencic More articles by this author Slavko Matic More articles by this author Miroslav Djordjevic More articles by this author Expand All Advertisement Loading ...

V07-02 AN ALTERNATIVE OPTION FOR GENDER-AFFIRMING REVISION VAGINOPLASTY: THE TUBULARIZED URACHUS-PERITONEAL HINGE FLAP

You have accessJournal of UrologySexual Dysfunction & Transgender (V07)1 Sep 2021V07-02 AN ALTERNATIVE OPTION FOR GENDER-AFFIRMING REVISION VAGINOPLASTY: THE TUBULARIZED URACHUS-PERITONEAL HINGE FLAP Nance Yuan, Amit Gupta, and Maurice Garcia Nance YuanNance Yuan More articles by this author , Amit GuptaAmit Gupta More articles by this author , and Maurice GarciaMaurice Garcia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002034.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peritoneal vaginoplasty has been reported for congenital and primary gender-affirming cases, but few have reported its use to treat post-op neovaginal shortening after penile-inversion vaginoplasty (PIV). Recent adaptations of peritoneal vaginoplasty are modifications of the Davydov procedure, wherein peri-rectal/peri-vesical peritoneum are incorporated to lengthen the vaginal canal. Here we describe our alternative technique using a single urachus-peritoneal hinge flap and discuss proposed advantages. METHODS: We performed retrospective review of all trans-women with post-PIV vaginal canal shortening who underwent revision surgery with our technique. All cases were performed via combined trans-perineal and robotic-laparoscopic approaches. Pre-op and post-op neovaginal circumference and depth were recorded. With a dilator in the canal, the peritoneum and terminal canal-end were incised and spatulated. The anterior canal-remnant epithelial edge was sutured to the anterior peritoneal edge. A midline, inferiorly based peritoneal flap (min. 12-cm width) was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The flap’s free end was flipped posteriorly and sutured to the posterior edge of the open canal remnant, to create a peritoneum-lined pouch. The pouch’s lateral edges were sutured together. We confirmed water-tight closure. Patients resumed dilation on POD 8 and douching on POD 10. RESULTS: Five patients underwent peritoneal vaginoplasty with our technique from 5/2019 to 8/2020. Mean age was 32. Pre-op: mean canal girth was >12 cm, and depth was 8.6 (±1.8) cm. Immediate post-op: mean girth was still >12 cm; depth was 16.8 (±1.2) cm (mean increase: 8.2 cm). At mean follow-up of 1 year: mean girth was 11-12 cm, and depth was 13.5 (±1.8) cm (mean increase: 4.9 cm). There were no immediate complications. One patient developed anastomotic stenosis at 6 weeks post-op, managed conservatively with dilation under anesthesia. All 5 patients endorse satisfactory sexual function; 3/5 report vaginal receptive intercourse. CONCLUSIONS: Early results suggest that our peritoneal vaginoplasty technique is a safe and effective option to treat neovaginal shortening. Advantages over existing techniques include: 1. No intra-op or post-op resting tension on peritoneal sutures, 2. Option for layered closure with omental interposition, and 3. Total exclusion of the rectum. Due to limited available peritoneum, we reserve this technique for cases where there is adequate residual canal girth and at least 6-7 cm of residual depth. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e551-e551 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nance Yuan More articles by this author Amit Gupta More articles by this author Maurice Garcia More articles by this author Expand All Advertisement Loading ...

Penile Inversion Vaginoplasty with Robotically Assisted Peritoneal Flaps.

Jun, Min S. D.O.; Gonzalez, Eduardo M.D.; Zhao, Lee C. M.D.; Bluebond-Langner, Rachel M.D. Author Information

Robot-assisted Kidney Transplantation.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

Evaluation of Mesh Infection in Patient with Laparoscopic Inguinal Hernia Repair: A Retrospective Study

Aim: To evaluate Post-Laparoscopic infection in Mesh followed by inguinal hernia repair. Study design: A retrospective study Place and Duration: This study was conducted at Jinnah Postgraduate and Medical Centre Karachi from April 2021 to April 2022 Methodology: A total of 80 participants were included in the study. All the patients had an extensive infection in the mesh followed by mesh hernia repair through laparoscopy. The preoperative workup was done for all the patients before a laparoscopic excision of mesh. A drain was placed in the preperitoneal space after the removal of the mesh. Closure of the peritoneal flap was done after that with a 3/0 absorbable suture. Result: The course of the operation was uneventful for all the patients. Only two patients required a sigmoidectomy for the repair of the fistula. Three patients presented with contralateral side infection and mesh residues around the pubic. A second laparoscopy was done on those three patients. Recurrence of hernia was seen in four of the cases observed on follow-up. Conclusion: Laparoscopic removal of the mesh is a superior approach to the open surgical removal of the mesh for the treatment of mesh infection. However, prevention of infection by prophylactic antibiotics, maintaining an aseptic environment during hernia repair surgery, and proper sterilization of the instruments can prevent the infection. Keywords: laparoscopic, mesh infection, inguinal hernia repair

Peritoneal flap hernioplasty for repair of incisional hernias after orthotopic liver transplantation

BackgroundRepair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in the context of lifelong immunosuppression. The peritoneal flap hernioplasty addresses this problem by using flaps of the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space, exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. We report our short and long-term results of 26 consecutive liver transplant cases with incisional hernias undergoing repair with the peritoneal flap technique.MethodsPost-OLT patients undergoing elective peritoneal flap hernioplasty for incisional hernias from Jan 1, 2010–Nov 1, 2017 were identified from the Lothian Surgical Audit system (LSA), a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in Feb 2020.ResultsA total of 517 liver transplantations were performed during the inclusion period. Twenty-six of these (18 males, 69%) developed an incisional hernia and underwent a peritoneal flap repair. Median mesh size (Optilene Elastic, 48 g/m2, BBraun) was 900 cm2 (range 225–1500 cm2). The median time to repair following OLT was 33 months (range 12–70 months). Median follow-up was 54 months (range 24–115 months) and median postoperative stay was 5 days (range 3–11 days). Altogether, three patients (12%) presented with postoperative complications: 1 with hematoma (4%) and two with chronic pain (8%). No episodes of infection or symptomatic seroma were recorded. No recurrence was recorded within the follow-up period.ConclusionRepair of incisional hernias in patients following liver transplantation with the Peritoneal Flap Hernioplasty is a safe procedure associated with few complications and a very low recurrence rate. We propose this technique for the reconstruction of incisional hernias following liver transplantation.

Robotic Peritoneal Flap Revision of Gender Affirming Vaginoplasty: a Novel Technique for Treating Neovaginal Stenosis

ObjectivesTo present the technique and early outcomes of salvage neovaginal reconstruction using robotic dissection and peritoneal flap mobilization. MethodsTwenty-four patients underwent robotic peritoneal flap revision vaginoplasty from 2017 to 2020. A canal is dissected between the bladder and rectum towards the stenosed vaginal cavity, which is incised and widened. Peritoneal flaps from the posterior bladder and pararectal fossa are advanced and sutured to edges of the stenosed cavity. Proximal peritoneal flap edges are approximated to form the neovaginal apex. Patient demographics, comorbidities, surgical indications, and operative details are described. Outcome measures include postoperative neovaginal dimensions and complications. ResultsMean age at revision was 39 years (range 27-58). All patients had previously undergone PIV, with revision surgery occurring at a median 35.3 months (range 6-252) after primary vaginoplasty. Surgical indications included short or stenotic vagina or absent canal. Average procedure length was 5 hours. At mean follow up of 410 days (range 179-683), vaginal depth and width were 13.6 cm (range 10.9-14.5) and 3.6 cm (range 2.9-3.8), respectively. There were no immediate or intraoperative complications related to peritoneal flap harvest. No patient had rectal injury. One patient had post-operative canal bleeding requiring return to the operating room for hemostasis. ConclusionsRobotic peritoneal flap vaginoplasty is a safe, novel approach to canal revision after primary PIV with minimal donor site morbidity.

Peritoneal flap for lymphocele prophylaxis following robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection: study protocol and trial update for the randomized controlled PELYCAN study

BackgroundData from interventional studies suggest that a peritoneal flap after pelvic lymph node dissection (LND) during laparoscopic, robotic-assisted radical prostatectomy (RARP) may reduce the rate of symptomatic lymphoceles in transperitoneal approach. However, most of these studies are not conducted in a randomized controlled fashion, thus limiting their scientific value. A recent prospective, randomized, controlled trial (RCT) did not show superiority of a peritoneal flap while further trials are lacking. Therefore, the aim of the presented RCT will be to show that creating a peritoneal flap decreases the rate of symptomatic lymphoceles compared to the current standard procedure without creation of a flap.Methods/designPELYCAN is a parallel-group, patient- and assessor-blinded, phase III, adaptive randomized controlled superiority trial. Men with histologically confirmed prostate cancer who undergo transperitoneal RARP with pelvic LND will be randomly assigned in a 1:1 ratio to two groups—either with creating a peritoneal flap (PELYCAN) or without creating a peritoneal flap (control). Sample size calculation yielded a sample size of 300 with a planned interim analysis after 120 patients, which will be performed by an independent statistician. This provides a possibility for early stopping or sample size recalculation.Patients will be stratified for contributing factors for the development of postoperative lymphoceles. The primary outcome measure will be the rate of symptomatic lymphoceles in both groups within 6 months postoperatively. Patients and assessors will be blinded for the intervention until the end of the follow-up period of 6 months. The surgeon will be informed about the randomization result after performance of vesicourethral anastomosis. Secondary outcome measures include asymptomatic lymphoceles at the time of discharge and within 6 months of follow-up, postoperative complications, mortality, re-admission rate, and quality of life assessed by the EORTC QLQ-C30 questionnaire.DiscussionThe PELYCAN study is designed to assess whether the application of a peritoneal flap during RARP reduces the rate of symptomatic lymphoceles, as compared with the standard operation technique. In case of superiority of the intervention, this peritoneal flap may be suggested as a new standard of care.Trial registrationGerman Clinical Trials Register DRKS00016794. Registered on 14 May 2019.

Vaginal Canal Reconstruction in Penile Inversion Vaginoplasty with Flaps, Peritoneum, or Skin Grafts: Where Is the Evidence?

To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited. A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion. Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low. Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

Clinical Importance of a Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles after Robot-Assisted Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review and Meta-Analysis

Background: Robot-assisted radical prostatectomy (RARP) including pelvic lymph node dissection (PLND) is the current state of the art in surgical therapy of localized prostate cancer with intermediate or high risk. PLND in particular is associated with morbidity inherent to this method; the rate of symptomatic lymphoceles (sLCs), for example, ranges up to 10%. Objective: Various intraoperative modifications have been developed with the aim of reducing the sLC rate. Based on current studies, a peritoneal interposition flap (PIF) appears to be one of the most effective methods for this purpose. Under the criteria of a systematic review, 5 retrospective studies have been identified until now, 4 of which showed a positive effect of PIF on the sLC rate. Results and Limitations: A total of 1,308 patients were included in the aggregated analysis of these 5 studies. The amount of sLCs was 1.3% (8/604) and 5.7% (40/704) in the PIF and standard groups, respectively (p < 0.001). The resulting odds ratio (OR) was 0.23 (95% confidence interval [CI]: 0.05–0.99), taking in­to account a noteworthy heterogeneity of the 5 studies (Q = 9.47, p = 0.05; I² = 58%). In addition, a prospective randomized and blinded study (Pianoforte trial) with corresponding sLC rates of 8.3% (9/108) versus 9.7% (12/124) (p = 0.820) exists. In this study, the OR was 0.85 (95% CI: 0.34–2.10, p = 0.722). Conclusion: Despite positive results from retrospective studies with indirect evidence, the role of the PIF in the reduction of sLC in RARP could not be conclusively assessed yet. The results of the first prospective randomized study do not show a positive effect of PIF, declaring a research gap for further studies with direct evidence.

Surgical Video Tutorial: Treatment of Congenital Vaginal Agenesis: Laparoscopic Modified Davydov in 8 Steps

To describe the different steps of the Davydov surgical technique for creating a neovagina, emphasizing visualization of the rectovesical cleavage and peritoneal-vaginal anastomosis by laparoscopic and vaginal approaches. Production of a step-by-step surgical video tutorial with narrative video footage. Uterovaginal agenesis is a rare congenital defect, observed in 1 case per 4000 to 5000 newborn female infants [1]. Vaginal agenesis treatment can be performed by different nonsurgical and surgical techniques that are based on neocavity creation. The Davydov intervention uses the pelvic peritoneum as "covering" tissue for a neocavity and avoids the use of allogenic or autologous transplants, traction devices, or specialized surgical equipment. It is a minimally invasive technique that provides long-term functionality and anatomically satisfying results [2]. We treated an 18-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome who underwent the Davydov procedure after dissatisfaction with the Franck self-expansion method. We created a neovagina using peritoneal flaps that were obtained after rectovesical cleavage by laparoscopic approach and were then fastened to the introitus by vaginal approach. Finally, the vaginal vault was reconstructed laparoscopically, and an intravaginal dilator was left in place. The result after 1 year showed the transition from a narrow vaginal dimple 2 cm in length to a neovagina 10 cm in length, permeable, well epithelialized, and correctly healed without associated stenosis. Sexual intercourse is satisfying for both partners. The Davydov technique is less invasive than other surgical techniques and allows good outcomes [3,4] without the invasive use of sigmoidal grafts, cutaneous flaps, or prostheses. It should be proposed to patients experiencing failure with the Franck nonsurgical method.

Peritoneal Pocket Hernia—Avoidable Complication Following TAPP with Meticulous Closure Technique of Peritoneal Flaps

The paper presents the case of a young woman, 29 years of age recently operated by TAPP for right inguinal hernia, who was readmitted to our clinic for intense pain in the lower abdominal floor and right iliac fossa with features of intestinal obstruction of 24 h of duration. Intraoperatively, we observed intestinal occlusion due to an incarcerated ileal loop at the level of a peritoneal gap of approximately 2 cm in diameter, in the flap suture area, after transabdominal preperitoneal patch technique (TAPP). Moreover, the phlegmonous appendix was encountered in the properitoneal space, fixed at the level of the polypropylene mesh. Appendectomy and peritoneal defect closure were performed, with quick postoperative recovery. In recent years, minimally invasive techniques are increasingly being adopted for the repair of inguinal hernias because in addition to the rapid recovery and aesthetic advantage they are associated with a low risk of complications, and the use of the net meshes reduces the recurrence rate to 1–6%. In the case presented, the early postoperative complication was major and rare, associating intestinal obstruction with ileal loop incarceration in a peritoneal breach with acute phlegmonous appendicitis. This complication could be easily avoidable with meticulous closure of peritoneal flap after the TAPP procedure, preventing the contact between the intraperitoneal viscera and the mesh. In any patient following laparoscopic surgery, relaparoscopy must be performed sooner rather than later for timely diagnosis and management of a complication.

Peritoneal flap mesh hernioplasty: A reliable option for difficulty in closure of complex ventral hernia: A case report

Peritoneal flap mesh hernioplasty is a technique to deal with complex ventral hernias in which primary closure of the defect is not attainable. We are here presenting a case report of a 50-year-old gentleman with huge complex ventral hernia with loss of domain. The patient also had overlying ulcerated and blackish colored skin. Botulinum toxin was infiltrated into the muscles of anterior abdominal wall and was followed by peritoneal flap mesh hernioplasty after one month. The final outcome was complete closure of the midline with a healthy skin with no evidence of abdominal compartment syndrome. There was no evidence of early recurrence on follow up.&#x0D; Owing to the favorable outcome in this case, suitability of peritoneal flap mesh hernioplasty technique in treatment of complex ventral hernia could be explored further where closure of the primary defect is difficult.

Clinical analysis of robot-assisted laparoscopic transabdominal preperitoneal inguinal hernia repair

Objective: To explore the clinical value of robot-assisted laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. Methods: We performed a retrospective review of 23 consecutive patients who underwent robotic inguinal hernia repair from January 2018 to December 2019 at Beijing United Family hospital. The patients were all male with mean age 48.8 (17-72) years and BMI 25.8 (21.2-32.6)kg/m(2). Data examined included perioperative bleeding, operative times, length of stay, pain scale ratings and postoperative complication. Results: There were no major complications during the surgeries including no significant intraoperative bleeding, injury to the vas deferens or major vascular structures. There were no conversions to open. No patients received prophylactic antibiotics according to our hospital policy. No surgical site infections were found. All patients were discharged home within the 24-hour postoperative period. The mean operating time of 13 cases of unilateral hernia was 121 (82-165) min, and that of 10 cases of bilateral hernia was 166 (100-315) min. The mean intraoperative blood loss was 13.3 ml (5-25 ml). The average pain score in recovery was 0.96 (0-3). The total length of stay was 28.4 (24.2-37.5) h. During a follow-up period of 3-18 months, none of the patients experienced a recurrent hernia. None experienced chronic pain or discomfort in the operative field. Conclusions: The robotic surgical platform facilitates a new safe, minimally invasive approach to groin hernia. Because of improved ergonomics, visualization and wristed instrumentation, the robotic approach enabled creation of larger peritoneal flaps and had the potential for less injuries. The major advantage to the patient is a shorter hospital stay, and more rapid postoperative recovery and decreased postoperative pain, lower complications and recurrences.

P. Zweifel. Eine neue Vereinfachung der Stumpfbehandlung bei der Myomektomie. (Centralbl. F. Gynäk., 1894, No. 14, p. 321). New simplification of the way to care for the leg with myomectomy

After the usual ligation of broad ligaments from the anterior surface of the tumor, resp. of the uterus, the peritoneal flap is separated, based on the bottom, correspondingly the thickness of the cervix, and at the base of the flap through the thickness of the cervix, catgut ligatures are carried out sagitally and frontally, when tightening which the neck lasts for 3-4 tied areas.

Surgical Options for Patients Seeking Gender-Affirming Surgery

To describe the surgical treatments available to transgender women and men desiring gender-affirming surgery (GAS). Transgender patients who undergo GAS have high satisfaction and improved quality of life. Masculinizing procedures include chest reconstruction, facial masculinization surgeries, hysterectomy with bilateral salpingo-oophorectomy, metoidioplasty, and phalloplasty. Feminizing procedures include facial feminization surgeries, chondroplasty and voice surgeries, breast augmentation, orchiectomy, and genital surgeries, such as vaginoplasty and vulvoplasty. Vaginoplasty can be performed with inversion of penile skin, sigmoid colon, or peritoneal flaps. The most common GAS surgery in the United States is chest masculinization surgery. Major complications after penile-inversion vaginoplasty are infrequent. A wide range of surgical options exist for the treatment of gender dysphoria. In recent years, systematic reviews and meta-analysis data have shown high satisfaction and more consistent complication rates for GAS. Limited, multicenter data exist regarding surgical techniques, outcomes, and complications.

Modified Technique of Doubly Folded Peritoneal Flap Interposition in Transabdominal Vesicovaginal Fistula Repair: Our Experience of 36 Cases

Purpose: Correction of vesicovaginal fistula (VVF) using interpositional flaps is an established procedure. In open repair, omental flap gives good results. However, its availability in all the cases is questionable. We utilized our technique of doubly folded peritoneal flap and assessed the outcome of the repair. Methods: Retrospective observational study included 36 cases of open VVF repair, performed during 2010–2019. Preoperative clinical examination, cystoscopy, and imaging were performed routinely. Open transvesical repair as described by O’Conor was performed and doubly folded peritoneal flap was utilized. Intra- and postoperative parameters were recorded. The outcome was assessed after 21 days of catheter removal. A minimum of 6 months of follow-up was done. Results: Mean age was 44 ± 18 years, and 97.2% of VVF were iatrogenic, mainly after hysterectomy (75.0%) and caesarean section (22.2%). Fistula size ranged from 0.6 to 5.5 cm. Five cases had multiple fistulas and 3 cases were recurrent. Mean flap length and width were 8.0 ± 2.4 and 5.1 ± 1.1 cm, respectively. Mean operative time and estimated blood loss were 94 ± 15 min and 155 ± 45 mL, respectively. Fourteen of 36 patients developed complications of Clavien-Dindo grade I/II. Thirty-five out of 36 cases (97.2%) were cured and remained dry for 6 months after surgery. Three cases reported de-novo urgency and were treated medically. Satisfaction level was good in 91.2% of cases. Conclusion: Transvesical repair using doubly folded peritoneal flap provides an excellent and durable outcome. It is a suitable alternative to the omental interpositional flap.