Previous Abdominal Procedures Research Articles

The Effectiveness of Physical Therapy Interventions in Management of Diastasis Recti in Postpartum Females: A Narrative Review

Diastasis recti is a condition caused by increased intra-abdominal pressure which causes the linea alba to stretch resulting in a wider inter-rectus gap. It is most common after pregnancy but can also be caused by obesity or previous abdominal procedures. Research shows myofascial laxity affecting the entire front abdominal wall. Postpartum women have a doubling of the interrectus distance and pregnancy affects abdominal muscle strength with nulliparous women having a higher number of trunk flexors and rotators [1]. DRA is mostly treated conservatively. Patients referred to a physiotherapist receive training programmes that specifically target reducing IRD. Some studies recommend training with physiotherapist, while others let patients train on their own. Recommended frequency of training sessions varied from one to five sessions per week. The exercise interventions consist of the following: Core trainings, Breathing technique and Mindfulness teaching. This study aims to find out the effectiveness of different physical therapy interventions in the treatment of diastasis recti abdominis. The condition of diastasis recti abdominis has prevalence in postpartum females and it is important to address this for the welfare of women and required to explore the best physical therapy treatment available.

Abdominoplasty Combined with the Anterior Component Separation Technique for Reconstruction of Midline Large Ventral Hernias: Functional and Aesthetic Outcome Clinical Study

Abstract Background Large midline ventral hernias, diastasis of recti and the associated laxity and abdominal shape deformity, represent aesthetic and functional problems for the patients. So, the surgical treatment of both pathologies at the same time is highly recommended if the patient’s general condition permits. This can be achieved by a comprehensive technique incorporating abdominoplasty performed by a transverse lower abdominal incision into any of the hernia repair techniques. Objective The aim of this study is to evaluate the functional and aesthetic outcome of the combined abdominoplasty and anterior component separation technique in the management of midline ventral abdominal hernias. Patients and Methods This study is a prospective case control study that evaluates both functional and aesthetic outcome of performing abdominoplasty on patients with large midline ventral hernias. This study was conducted between December 2020 to March 2022 at the Plastic Surgery Department, Demerdash University Hospital, Cairo, Egypt. Study consisted of fifteen patients with different presentations of abdominal wall laxity and ventral hernias. Patients were evaluated regarding their age, BMI, degree of rectus diastasis, Pre-operative radiological findings, post Operative complication and hernia reoccurrence, patients’ satisfaction, and the pre-operative and post-operative umbilical measurements were compared. Results and Conclusion The current study showed that Abdomioplasty can be combined with complex hernia repair by anterior component separation technique within the same setting in high-risk patients safely with an excellent functional outcome and acceptable satisfactory aesthetic results. Although, this can be associated with an increased risk of postoperative surgical site complications such as; skin necrosis and wound infection. Patient characteristics associated with the development of complications following anterior component separation combined with abdominoplasty include obesity, previous abdominal procedures and previous pregnancies.

P387 Short and long-term outcomes of surgery for inflammatory (uncomplicated) ileocecal Crohn’s disease: multicentric retrospective analysis of 211 patients

Abstract Background Surgical management for patients with inflammatory ileocecal Crohn’s disease (CD) could be a reasonable alternative to second-line medical treatment. Methods A retrospective analysis of patients intervened for primary ileocecal CD with uncomplicated (inflammatory) phenotype at four referral hospitals during 2012-2021 was performed. The objective was to assess short and long-term outcomes of patients operated on for inflammatory, ileocecal CD. Patients operated on due to inflammatory ileocecal CD (last 50 cm of the terminal ileum and cecum), were considered eligible to participate in this study. Operations performed during a 9-year period (2012-2021) were considered for the study. Patients who were operated for CD for advanced structural bowel damage (fibrotic strictures or penetrating phenotype), those who had had previous abdominal CD-related procedures, and patients who had disease activity in other anatomical regions at the time of surgery, were excluded from the study. Results 211 patients were included. 43% of patients underwent surgery more than 5 years after diagnosis, and 49% had been exposed to at least one biologic agent preoperatively. 89% were operated by laparoscopy, with 1.6% conversion rate. The mean length of stay for patients was 5 days, with only 24 patients (11%) requiring a prolonged hospitalization. The complication rate was 23.7% (50 patients), but most complications were minor (Clavien-Dindo < IIIa), with only 11 patients (5%) presenting with major complications. Leak rate for patients who received a primary anastomosis was 2.9%. The median length of the resected bowel was 25 cm (7-92) and three patients (1.43%) received a stoma. Median follow-up was 36 (17-70) months. The endoscopic recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 56%, 52%, 45%, 38%, and 33%, respectively. The clinical recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 83%, 79%, 76%, 74%, and 74%, respectively. In multivariate analysis, previous biological treatment (HR=2.01; p=0.001) was associated with a higher risk of overall recurrence. Conclusion In this study, surgery in patients with primary inflammatory ileocecal CD is associated with good postoperative outcomes, low postoperative morbidity with reasonable recurrence rates. Further studies need to validate the present results.

P433 Short-term outcomes of surgical treatment in primary ileocecal Crohn’s disease patients. Results of Crohn’s(urg) study, multicenter, retrospective, comparative analysis between indications for luminal and complicated phenotype

Abstract Background Recent evidence challenges the current standard of offering surgery to patients with ileocecal Crohn’s disease only when they present complications of the disease. Methods A retrospective, multicenter comparative analysis was performed including patients operated for primary ileocecal CD at 12 referral centers. Patients were divided in 2 groups, according to indication of surgery for inflammatory (ICD) or complicated (CCD) phenotype. Short-term results were compared. Patients operated on for primary isolated ileocaecal CD (last 50 cm of the terminal ileum and cecum), either for predominantly inflammatory phenotype or for complications of the disease (stricturing or fistulizing pattern), between January 2012 - December 2021 were considered eligible to participate in this study. Patients with previous abdominal procedures for CD, and patients who had activity of the disease in other intestinal segments other than the ileocaecal region at the time of surgery, were excluded from the study. Results 2013 patients were included, 291 (14.5%) in the ICD group. No differences were found between groups in time from diagnosis to surgery or in the levels of exposure to biologic drugs before indication of surgery. CCD patients had higher rates of low BMI, anemia (40.9 vs. 27%, p: < 0.001), and low albumin (11.3 vs. 2.6%, p: < 0.001). CCD patients had longer operations, lower rates of laparoscopic approach (84.3 vs. 93.1%, p: 0.001), and higher conversion rates (9.3 vs. 1.9%, p: < 0.001). CCD had longer hospital stay and higher postoperative complication rates (26.1 vs. 21.3%, p: 0.083). Anastomotic leakage and reoperations were also more frequent in this group. More patients in the CCD group required an extended bowel resection (14.1 vs. 8.3%, p: 0.017). In multivariate analysis, CCD was associated with prolonged surgeries (OR: 3.44, p: 0.001) and requirements of multiple intraoperative procedures (OR: 8.39, p: 0.030). Conclusion Indication of surgery in patients who present an inflammatory phenotype of CD was associated with better outcomes when compared to patients operated on for complications of the disease, without a difference between groups in time from diagnosis to surgery.

Do Small Scars Lead to Better Results? Analysis of Long-term Outcomes and Satisfaction of Patients Undergoing Anchor-line Abdominoplasty Following Massive Weight Loss.

Do smaller scars lead to higher patient satisfaction? The aim of this study is to analyze long-term satisfaction of patients who underwent abdominoplasty after massive weight loss. Patients inclusion criteria: no previous abdominal remodeling procedures, previous bariatric surgery followed by a weight loss of at least 30 kg, weight stability for at least one year, good understanding of the Italian language and standardized pre- and postoperative photographs. We divided the population in 2 groups based on the surgical procedure: group 1, conventional abdominoplasty, and group 2, anchor-line abdominoplasty. All patients presented scars in the epigastric and mesogastric region resulting from previous laparoscopic or laparotomic bariatric surgery and/or other laparoscopic or laparotomic procedures. At least 2 years after surgery, we administered the Italian version of the post-operative BODY-Q module and the SCAR-Q questionnaire. We enrolled 20 males and 69 females aged between 25 and 55 years, with a mean follow-up of 2 years. Analyzing the questionnaires, it resulted that patients undergoing anchor-line abdominoplasty were significantly more satisfied in the body perception of the result (p = 0.035) and in the satisfaction with abdomen domain (p = 0.0015) compared to the conventional abdominoplasty group. Scars assessment with the SCAR-Q did not show any significant differences between the groups. Despite its long scars, the anchor-line pattern shows an overall higher satisfaction, due to the possibility of reducing the abdomen both cranio-caudally and circumferentially. These findings might be an important guide when approaching abdominoplasty in post-bariatric patients, debunking the myth "shorter is better". This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Laparoscopic Versus Open Ventriculoperitoneal Shunt Placement: A Non-inferiority Study

Ventriculoperitoneal shunt (VPS) insertion into the abdominal cavity had been done for decades via an open approach. Recently, the laparoscopic insertion of the peritoneal portion of the shunt has become an option. The aim of this study is to compare outcomes between these two approaches. We performed a single institution retrospective review of 104 consecutive adult patients between 2015 and 2017. Patients had peritoneal catheters placed either via an open approach by the neurosurgical team, or laparoscopically by general surgeons. Patient demographics and outcomes were compared using a non-inferiority analysis. Independent variables in the analysis included patient age, gender, race, BMI, surgery performed, previous VPS placement, previous abdominal procedures, and VPS indication, while dependent variables included length of stay (LOS), estimated blood loss (EBL), occurrence of shunt failure, and postoperative complications. Cohort analysis included 62 open and 42 laparoscopic cases with similar baseline characteristics. In terms of patient outcomes, EBL and hospital stay duration were shown to be non-inferior in the open group as compared to the laparoscopic group. We could not prove non-inferiority based on risk for overall or distal shunt failure. Neurosurgeons may reasonably continue to place peritoneal shunt catheters using a “traditional” method.

MP07-05 RISK FACTORS ASSOCIATED WITH POST-OPERATIVE SMALL BOWEL OBSTRUCTION FOLLOWING ROBOTIC SACROCOLPOPEXY WITH 12-YEAR EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023MP07-05 RISK FACTORS ASSOCIATED WITH POST-OPERATIVE SMALL BOWEL OBSTRUCTION FOLLOWING ROBOTIC SACROCOLPOPEXY WITH 12-YEAR EXPERIENCE Cassandra Schuster, Benjamin Behers, Spencer Kortum, Genesis Dolgetta, Karim Ghazli, Victoria Bird, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , Benjamin BehersBenjamin Behers More articles by this author , Spencer KortumSpencer Kortum More articles by this author , Genesis DolgettaGenesis Dolgetta More articles by this author , Karim GhazliKarim Ghazli More articles by this author , Victoria BirdVictoria Bird More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy (RASCP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and provides durable repair of high grade prolapse. Given that the procedure has a trans-peritoneal component, there is a risk of reoperation due to small bowel obstruction (SBO). METHODS: Data was collected from an IRB-approved prospectively maintained database of RASCP in a tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port by a single surgeon. Commercially available 4×24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate the anterior and posterior dissections of the vaginal walls and are attached with running barbed suture with 16-20 sites of fixation. The long Y-arm of the mesh is trimmed to size for attachment to the anterior longitudinal ligament with GoreTex sutures. Posterior peritoneal flaps are created and the entirety of the mesh and repair is completely covered by peritoneum. No mesh or suture is left exposed. Mid-urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence. All patients for RASCP had stage 4 prolapse. There were no conversions from robotic to open. RESULTS: Between 2010 and 2022, 450 patients underwent RASCP at the same institution. 80 (17.8%) involved extensive lysis of adhesions (ELOS) and 370 did not code for ELOS. At mean 78-month (12–140 month) follow-up, there were 8 (1.8%) reoperations for SBO. 6/80 (7.5%) patients with ELOS had reoperations for SBO had ELOS. Age, BMI, procedure time, suture type, and brand of mesh were not associated with SBO. Only ELOS was found to be associated with SBO on multivariate analysis. Mean age was 66.1 years and mean BMI 28.2. Robotic console time between 59 and 123 min. All 8 reoperations for SBO had previous abdominal procedures, and 6 were coded as ELOS. There were no reoperations for SBO in patients with no previous abdominal surgery. CONCLUSIONS: RASCP is a safe and durable surgery for repair of POP. Risk of reoperation for SBO is associated with concomitant ELOS. In ELOS patients the risk of SBO is 7.5% and in patients without ELOS the risk is 0.5%. Although many patients presenting for RASCP have had previous abdominal operations, not all such patients require ELOS. For patients with histories of numerous prior bowel or abdominal surgeries who are at increased risk for ELOS at time of RASCP, careful patient selection is recommended and appropriate preoperative counseling suggested. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e86 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Benjamin Behers More articles by this author Spencer Kortum More articles by this author Genesis Dolgetta More articles by this author Karim Ghazli More articles by this author Victoria Bird More articles by this author Robert Carey More articles by this author Expand All Advertisement PDF downloadLoading ...

Conversion to Open Surgery During Minimally Invasive Right Colectomy for Cancer: Results from a Large Multinational European Study.

Background: The risk of conversion to open surgery is inevitably present during any minimally invasive colorectal surgical procedure. Conversions have been associated with adverse postoperative and oncologic outcomes. No previous study has evaluated the specific causes and consequences of conversion during a minimally invasive right colectomy (MIS-RC). Materials and Methods: We analyzed the Minimally invasivE surgery for oncologic Right ColectomY (MERCY) study database including patients who underwent laparoscopic or robotic RC because of colon cancer between 2014 and 2020. Descriptive analyses were performed to determine the different reasons for conversion. Uni- and multivariate logistic regressions were run to identify potential variables associated with this outcome. Cox regression analyses were used to evaluate the impact of conversion on tumor recurrence. Results: Over a total of 1574 MIS-RC, 120 (7.6%) were converted to open surgery. The main reasons for conversion were procedural difficulties related to adherences from previous abdominal surgical procedures (39.2%), or owing to large tumor size or infiltration of adjacent structures (26.7%). Only 16.7% of the conversions were caused by intraoperative medical or surgical complications. Converted patients required longer operative times and developed more postoperative complications, both overall (39.2% versus 27.5%; P = .006) and severe ones (13.3% versus 8.3%; P = .061). Male gender (odds ratio [OR] = 1.89 [95% confidence interval: 1.31-2.71]), obesity (OR = 1.99 [1.4-2.83]), prior abdominal surgery (OR = 1.68 [1.19-2.37]), and pT4 cancers (OR = 4.04 [2.86-5.69]) were independently associated with conversion. Conversion to open surgery was not significantly associated with tumor recurrence (hazard ratios = 1.395 [0.724-2.687]). Conclusions: Although conversion to open surgery during MIS-RC for cancer is associated with worsened postoperative outcomes, it seems not to impact on the oncologic prognosis.

Surgeon and patient-specific factors influencing the decision for minimally invasive or open surgery in acute bowel obstruction: a retrospective single-center analysis.

PurposeDespite continuous improvement in minimally invasive surgery (MIS) and growing evidence for its superiority in procedures in various organ systems, a routinely application in patients with acute bowel obstruction (ABO) cannot be seen to date. Besides very general explanations for this attitude, not much is known about the decision process in a particular patient. This retrospective study aims at investigating surgeon- and patient-specific factors for or against MIS in acute bowel obstruction.MethodsA retrospective analysis of all patients undergoing either MIS or open surgery (OS) for ABO at a single center between 2009 and 2017 was performed. All available preoperative parameters were included in the analysis and subdivided into patient- (age, gender, BMI, previous abdominal procedures, inflammatory process, ASA score, bowel dilatation) and surgeon-specific (time of patient admission, senior surgeon performed the procedure or taught the case, availability of a surgical resident or junior doctor as assisting surgeon) factors. Statistical analysis was performed to reveal their influence on the surgeon’s decision for or against MIS.ResultsOf 106 patients requiring surgical intervention, 57 were treated by OS (53.77%) and 49 by MIS (46.23%). Patients with a higher ASA score (ASA III) and a bowel width of ≥ 3.8 cm in preoperative radiologic imaging were more likely to undergo OS (p < 0.01). Also, a late admission time to the hospital (x̄ = 14.78 h) was associated with OS (p = 0.01). Concerning previous abdominal surgical interventions, patients with prior appendectomy rather were assigned to MIS (p < 0.01) whereas those with prior colectomy to OS (p < 0.01).ConclusionsThe choice of procedure in patients with bowel obstruction is a highly individualized decision. Whereas scientifically proven parameters, such as high age and BMI, had no influence on the decision process, impaired general health condition (ASA score), high bowel width, previous surgical intervention, and a late admission time influenced the decision process towards open surgery.Trial registrationRetrospectively registered with the German Clinical Trials Register: DRKS00021600.

PRIMARY UMBILICAL ENDOMETRIOSIS: A RARE CASE REPORT

Umbilical endometriosis is a rarest form of extrapelvic endometriosis, incidence being 0.5% - 1% of all extrapelvic endometriosis. In primary umbilical endometriosis there is no history of any previous abdominal and pelvic invasive procedures. Most patients present with an umbilical nodule which is associated with cyclical pain and bleeding from the lesion during menstrual cycle. It is mainly diagnosed clinically and is conrmed by histopathology. Surgery is the treatment of choice. Pre and post operative hormonal supplementation results in better outcome

Enhanced Recovery Pathway Reduces Hospital Stay and Opioid Use in Microsurgical Breast Reconstruction: A Single-Center, Private Practice Experience.

This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization. A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol. Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001). ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay. Therapeutic, III.

Does Prior Abdominal Surgery Influence Peritoneal Transport Characteristics or Technique Survival of Peritoneal Dialysis Patients?

Introduction: Prior abdominal surgery may result in peritoneal membrane adhesions and fibrosis, compromising the success of peritoneal dialysis (PD). The impact of this factor on peritoneal membrane function and PD technique survival has not been adequately investigated. Methods: Following an observational, retrospective design, we studied 171 incident PD patients, with the main objective of analyzing the influence of prior abdominal surgical procedures (main study variable) on baseline and evolutionary peritoneal transport characteristics (main outcome) and PD patient and technique survival (secondary outcomes). Abdominal surgeries were categorized according to the degree of presumed injury to the peritoneal membrane. We also considered the additive effect of aggressions to the membrane during the first year on PD therapy. Results: All patients had a baseline peritoneal equilibration test with complete drainage at 60′, and 113 patients had a second study at the end of the first year. Sixty-one patients (35.7%) had a record of prior abdominal surgery, including 29 patients with at least one major intraperitoneal surgery, 22 having undergone minor intraperitoneal procedures, and 21 with a background of major abdominopelvic extraperitoneal surgery. We did not observe differences, at baseline or after 1 year, among patients with or without previous abdominal procedures regarding small solute transport, overall capacity of ultrafiltration, free water transport, small pore ultrafiltration, or peritoneal protein excretion. Stratified analysis, considering prior and first-year-on-PD peritoneal aggressions, did not reveal any differences, although in this case our analysis was hampered by a limited statistical power. Abdominal surgical events did not influence patient or PD technique survival. Conclusion: Prior abdominal surgical procedures do not appear to compromise peritoneal membrane function or technique survival in patients successfully started on PD.

Bridging-to-Surgery in Patients with Type 2 Intestinal Failure

AimType 2 intestinal failure (IF) is characterized by the need for longer-term parenteral nutrition (PN). During this so-called bridging-to-surgery period, morbidity and mortality rates are high. This study aimed to evaluate to what extent a multidisciplinary IF team is capable to safely guide patients towards reconstructive surgery. MethodsA consecutive series of patients with type 2 IF followed up by a specialized IF team between January 1st, 2011, and March 1st, 2016, was analyzed. Data on their first outpatient clinic visit (T1) and their last visit before reconstructive surgery (T2) was collected. The primary outcome was a combined endpoint of a patient being able to recover at home, have (partial) oral intake, and a normal albumin level (> 35 g/L) before surgery. ResultsNinety-three patients were included. The median number of previous abdominal procedures was 4. At T2 (last visit prior to reconstructive surgery), significantly more patients met the combined primary endpoint compared with T1 (first IF team consultation) (66.7% vs. 28.0% (p < 0.0001), respectively); 86% had home PN. During “bridging-to-surgery,” acute hospitalization rate was 40.9% and acute surgery was 4.3%. Postoperatively, 44.1% experienced a major complication, 5.4% had a fistula, and in-hospital mortality was 6.5%. Of the cohort, 86% regained enteral autonomy, and when excluding in-hospital mortality and incomplete follow-up, this was 94.1%. An albumin level < 35 g/L at T2 and weight loss of > 10% at T2 compared with preadmission weight were significant risk factors for major complications. ConclusionBridging-to-surgery of type 2 IF patients under the guidance of an IF team resulted in the majority of patients being managed at home, having oral intake, and restored albumin levels prior to reconstructive surgery compared with their first IF consultation.

Safety of Veress needle for laparoscopic entry in children: Myth or reality?

IntroductionRecent reports suggested that blind laparoscopic entry techniques, including Veress needle (VN), might increase the risks of potentially fatal complications. Materials and methodsAll consecutive patients who underwent laparoscopy in two Pediatric Hospitals with the use of a Veress needle during a 14-year period have been included. In all cases the first trocar was a radially expanding one (STEP). Complications related to the insertion technique are reported as well as those related to the whole laparoscopic technique. ResultsA total of 3463 patients younger than 18 years of age underwent laparoscopy between January 2006 and December 2019. Of these, 205 (5.9%) were younger than 6 months of age at surgery. Two-hundred-eighty-four patients (8.2%) previously underwent abdominal surgery. During first trocar insertion no major or minor vascular injuries occurred. Two patients (0.06%) experienced bowel lesions. Nine (0.26%) experienced failed entry. Fourteen patients (0.4%) experienced postoperative issues related to trocars positioning, namely, 9 omental eviscerations through port site insertion and 5 cases of hemoperitoneum owing to epigastric vessels lesion during operative trocar positioning. No other issues strictly related to laparoscopic entry technique have been recorded during the study period. No specific risk factors predisposing to complications have been identified but the presence of a positive history of previous abdominal procedures proved to be significantly related to a higher occurrence of bowel injury during Veress needle insertion (p = 0.0067). Discussion and conclusionsAlthough with a number of biases and limitations, our study suggests that creation of pneumoperitoneum with VN combined to first trocar entry with STEP technology in children can represent a safe alternative. An exception is represented by patients who underwent previous abdominal surgeries who should be approached with caution, possibly with an open approach. Anyway, given the relatively poor quality of high-quality studies on this regard, we strongly support the implementation of well-designed RCT in children in order to answer this delicate topic. Type of studyRetrospective. Level of evidenceIV

Dr Jekyll and Mr Hyde.

On the 10 July 2018, the UK Independent Medicines and Medical Devices (IMMD) safety review led by Baroness Cumberlege implemented a hiatus in the use of vaginal meshes for incontinence and prolapse because of concerns about complications. The use of vaginal mesh for prolapse has seen a natural decline over the past decade (Jha Int Urogynecol J 2018;29:795–801) with robust evidence available to suggest outcomes for native tissue repair are not significantly inferior to mesh-reinforced repair (Glazener Lancet 2017;389:381–92). However, there was considerable concern in relation to incontinence that patients would be exposed to more complex procedures with a greater complication rate because they would no longer have access to synthetic slings. The two synthetic sling procedures performed for stress urinary incontinence (SUI) are the tension-free vaginal tape (TVT) retropubic and the TVT obturator. Recently, these two devices have been referred to in the press interchangeably. The devices are made from identical mesh and are the same in their composition, size and the amount that is embedded in the patient, with similar success rates. However, that is where the similarity ends. So how did the two types of synthetic tapes become the Jekyll and Hyde of continence surgery? The Scottish review of the use of transvaginal mesh implants found greater adverse effects with obturator synthetic tapes than with retropubic tapes (https://www.gov.scot/publications/scottish-independent-review-use-safety-efficacy-transvaginal-mesh-implants-treatment-9781786528711/). The review also identified a greater need for repeat SUI surgery following the transobturator approach beyond 12 months. In addition, the number of cases under review for litigious reasons was three times greater in the obturator group than in the retropubic group. In the 2006 National Institute of Health and Care Excellence (NICE) clinical guidance (CG 40) on the management of urinary incontinence, there was only a brief mention of obturator tapes and the advice was to make women aware of the ‘lack of long term data’. When this guidance was updated in 2013 (CG 171), this advice remained unchanged. In the recent NICE consultation document published in October 2018, the advice is more directive: ‘do not offer a transobturator approach unless there are specific clinical circumstances (for example, multiple previous abdominal procedures) in which the retropubic approach should be avoided’. Obturator tapes were developed to reduce the risk of bladder injury but have been associated with groin pain and obturator neuropathies. These present as pain and restricted mobility of the thigh and hip adduction, along with sensory loss and pain across the anterior thigh. Foot drop is another rare presentation. However, the greatest problem with obturator tapes is the difficulty of complete removal, which is hampered by their placement deep in the obturator foramen, requiring dissection of the groin (usually by a plastic surgeon). In the largest series of vaginal mesh removals for all indications, the commonest type of mesh removed was the obturator tape for incontinence (Miklos Surg Technol Int 2016;29:185–9) and the removal of these meshes also had the highest complication rates. Clinicians who traditionally undertook obturator tape placement should be aware that even if the temporary ban is lifted, they will have to change their practice, as this procedure has acquired the mantle of Mr Hyde and will be off limits in most future circumstances. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Accuracy of preoperative real-time dynamic transvaginal ultrasound sliding sign in prediction of pelvic adhesions in women with previous abdominopelvic surgery: prospective, multicenter, double-blind study.

To investigate the role of the transvaginal sonographic (TVS) sliding sign in predicting pelvic adhesions in women with previous abdominopelvic surgery. This was a multicenter, prospective, interventional, double-blind study of patients with a history of abdominopelvic surgery who were undergoing laparoscopy or laparotomy during the 6-month period from March to August 2016 in one of three academic obstetrics and gynecology departments. Prior to surgery, patients were examined by TVS to assess the vesicouterine pouch, uterus, ovaries and pouch of Douglas, using the TVS pelvic sliding sign. Ultrasound findings and medical and surgical data were recorded. We assessed the accuracy of the preoperative TVS sliding sign in the prediction of pelvic adhesions overall and in each compartment separately. During the study period, complete TVS sliding sign and laparoscopic or laparotomic data were available for 107 women. Their mean age was 44.0 (95% CI, 41.6-46.4; range, 20-79) years. Their mean parity was 2.0 (95% CI, 1.7-2.3; range, 0-9) and the mean number of previous abdominal surgical procedures per patient was 1.3 (95% CI, 1.2-1.5; range, 1-4). Adhesions were noted in 27/107 (25.2%) patients. The TVS sliding sign had a sensitivity of 96.3% and specificity of 92.6% in predicting pelvic adhesions. There was a significant relationship between adhesions in each compartment and the TVS sliding sign (P< 0.05). The TVS sliding sign is an effective means to detect preoperatively pelvic adhesions in patients with previous abdominopelvic surgery. Use of such a non-invasive and well-tolerated technique could help in the planning of laparoscopy or laparotomy and counseling of these patients. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Dilemma with leakage after sleeve gastrectomy

Objective The aim of this study was to evaluate methods of diagnosis and management of leakage after sleeve gastrectomy to decrease morbidity and mortality of this complication. Background Leakage is the commonest and most feared early complication in bariatric procedures. Leakage can occur from any site of staple line. Incidence of leakage after sleeve gastrectomy is in the range of 1–3%. Risk factors for leaks and complications were increasing weight, male sex, multiple comorbidities, previous abdominal procedures, or revisional surgery. Tachycardia with a heart rate in excess of 120 beats per minute was a good indicator of leakage. Patients and methods The study was conducted on 12 cases that had leakage after sleeve gastrectomy, where four cases were diagnosed early and were managed by re-exploration and repair of the site of leakage with feeding jejunostomy and eight cases were diagnosed late and managed as follows: five cases by gastric stent and pigtail for drainage of collection, two cases by exploration, and one case by pigtail insertion and conservative treatment. Results In this study, four cases experienced mortality owing to delay in diagnosis and septicemia. Two cases develop gastropleural fistula. There was long hospital stay. Two cases developed incisional hernia, and one case developed deep venous thrombosis (DVT). Conclusion Management of leakage in bariatric procedures requires early diagnosis and precise decision making tailored according to every case.

Transvaginal natural orifice transluminal endoscopic surgery: a new approach to ovarian cystectomy

To demonstrate a new approach for performing an ovarian cystectomy via transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as an alternative for a laparoscopic ovarian cystectomy. Stepwise explanation of the technique using original video footage. Hospital. Fourteen patients who provided informed consent and were treated transvaginally to remove a benign ovarian cyst. The patient was placed in the lithotomy position under general anaesthesia. A 2.5-cm posterior colpotomy was made. The pouch of Douglas was opened and a transvaginal natural orifice transluminal endoscopic surgery (vNOTES) port was inserted transvaginally. A pneumoperitoneum was created, and the ovarian cyst was identified. Conventional endoscopic instruments and a standard endoscope were inserted transvaginally through the vNOTES port. The ovarian cortex was incised over the cyst using cold scissors. The cyst was dissected from the ovarian cortex by a combination of blunt and sharp dissection. Ovarian hemostasis was achieved using bipolar forceps. The ovarian cyst was removed through the colpotomy in an endobag. The vNOTES port was removed, and the colpotomy was sutured using a resorbable suture. The following data were collected: age, body mass index, parity, number of previous abdominal procedures, ovarian cyst diameter, operating time, length of hospital stay, and visual analog scale score. Successful minimally invasive ovarian cystectomy via vNOTES without abdominal scars. An ovarian cystectomy was successfully completed in all patients without conversions to standard laparoscopy, and no complications occurred. A fertility sparing cystectomy was performed via vNOTES in all patients; no ovariectomies were performed. All patients were discharged within 30hours, and nine patients were discharged within 12hours. Benign ovarian cysts can be treated by vNOTES through a posterior colpotomy via the pouch of Douglas. In a low-resource setting, a self-constructed gloveport and standard reusable endoscopic instruments can be used. In a first-world setting the surgical time can be reduced using a commercially available vNOTES port. Transvaginal natural orifice transluminal endoscopic surgery provides a new, less invasive approach for performing an ovarian cystectomy. This first IDEAL (idea, development, exploration, assessment, long-term study) stage 1 study confirms the feasibility of vNOTES ovarian cystectomy although it remains a novel approach that requires further investigation. It can provide improved patient comfort and better cosmetic results.

Transvaginal natural-orifice transluminal endoscopic surgery: a new approach to myomectomy

To demonstrate a new approach for performing a myomectomy via transvaginal natural-orifice transluminal endoscopic surgery (vNOTES) as an alternative to laparoscopic myomectomy. Stepwise explanation of the technique with the use of original video footage. Hospital. Eight patients were treated transvaginally for intramural, subserosal, and pedunculated myomas. In case of a posterior myoma, a 2.5-cm posterior colpotomy was made under general anesthesia. The pouch of Douglas was opened and a vNOTES port was inserted transvaginally. In case of an anterior myoma, an anterior colpotomy was made and the peritoneum was opened between the uterus and the bladder. A vNOTES port was inserted transvaginally. A pneumoperitoneum was created and the myoma was identified. With the use of conventional endoscopic instruments and a standard endoscope, all inserted through the vNOTES port, the uterine serosa was incised over the myoma and the myoma was resected. After achieving hemostasis the uterine scar was sutured in two layers with the use of a standard absorbable suture or an autolocking suture. An adhesion-preventing barrier was applied over the uterine scar. The myoma was removed through the colpotomy in an endobag. The vNOTES port was removed and the colpotomy was sutured with the use of an absorbable suture. The following data were collected: age, body mass index, number of previous abdominal procedures, myoma size, myoma weight, operating time, length of hospital stay, visual analog scale pain score, and serum hemoglobin drop. Successful minimally invasive myomectomy via vNOTES without abdominal scars. All fibroids were successfully removed via vNOTES without complications or conversions to standard laparoscopy. No peri- or postoperative complications occurred. All patients were discharged within 24 hours, two of them within 12 hours. Anterior myomas can be resected through an anterior colpotomy and posterior myomas can be resected through a posterior colpotomy via the pouch of Douglas. In a low-resource setting, a self-constructed gloveport can be used and the uterine scar can be sutured via vNOTES with the use of a standard absorbable suture. In a first-world setting, the surgical time can be reduced with the use of an autolocking suture and a commercially available vNOTES port. Myoma types 0-2 can be resected hysteroscopically. Myoma types 3-7 are traditionally resected via laparotomy, laparoscopy,or transabdominal robotic surgery. vNOTES provides a new less invasive approach for the resection of myoma types 3-7. This first IDEAL stage 1 study confirms the feasibility of vNOTES myomectomy. It remains, however, a novel approach that requires further investigation. It can provide better cosmetic results and improved patient comfort.

Primary Placement of Incisional Negative Pressure Wound Therapy at Time of Laparotomy for Gynecologic Malignancies.

Wound complications are an important cause of postoperative morbidity amongst patient with gynecologic malignancies. We evaluated whether the placement of prophylactic negative pressure wound therapy (NPWT) at the time of laparotomy for gynecologic cancer surgery reduces wound complication rates. A retrospective analysis of patients undergoing laparotomy with primary wound closure performed by a gynecologic oncologist at a single academic institution over a 5-year study period was performed. Patients who had placement of prophylactic NPWT dressing were compared with patients with a standard closure. Postoperative outcomes were examined. A total of 230 patients were identified: 208 women received standard wound care, 22 received NPWT. Groups were similar in age, prevalence of diabetes, tobacco use, and number of previous abdominal procedures. Intraoperative factors including length of procedure and transfusion requirements were similar. Body mass index for patients receiving standard treatment was 30.67 compared with 41.29 for NPWT group (P < 0.001). Incidence of all wound complications was 19.7% for those receiving standard treatment versus 27.3% for NPWT group (P = 0.40). Length of hospital stay was similar between the 2 groups (5.25 vs 6.22 days, P = 0.20). There were 3 hospital readmissions for wound complications-none occurred in women with a prophylactic NPWT dressing. Despite significantly higher obesity rates, patients with prophylactic NPWT dressing placement had similar rates of wound complications. Our findings suggest a potential therapeutic benefit in the use of prophylactic NPWT for the reduction of wound complications in this high-risk gynecologic oncology patient population.