Pubic Hairline Research Articles

Hidden Port Site Incisions for Robotic Foregut and Hepatopancreatobiliary Operations: A Cosmetically Superior Approach.

While the widespread adoption of minimally invasive surgery has led to improved cosmesis for abdominal operations, visible scars on the abdomen may still have a negative psychosocial impact on patients, especially for those with poor healing. We have developed a cosmetically favorable, safe, and easily adaptable robotic technique for common foregut and hepatopancreatobiliary procedures with hidden incisions at the level of the pubic hairline to minimize visibility. This technique monopolizes on the unique advantages of the robotic platform to maximize cosmetic outcome while maintaining clinical outcomes and technical ease. Herein we describe how to accomplish this technique for three different procedures: anti-reflux operation, distal pancreatectomy, and small bowel resection. In our experience, this technique of hiding port site incisions at the level of the pubic hairline can be easily adopted for improved patient quality of life and cosmesis. We especially recommend this technique in patients with a history of hypertrophic or keloid scars.

Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction.

The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was -0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

PS-07-002 Penile augmentation by Division of the Suspensory Ligament of the penis and autologous fat injection: A 72-patient experience

To evaluate the outcome of penile augmentation (PA) surgery at one center. This was a retrospective review of patient outcomes after surgical PA from January 2018 to October 2018 at one centre. All patients underwent division of the suspensory ligament of the penis, with insertion of silicon buffer, and autologous fat injection. 60 patients underwent a standard halfmoon incision above the base of the penis in the pubic hairline and 12 patients had a V-Y-plasty incision. The following data were collected; pre and post-operatively: flaccid penis length and girth; patient reported satisfaction rates and complications. 72 patients were included the study. The mean patient age was 38 (26-62) years; mean follow-up period was 5 (1-9) months; mean pre-operative flaccid length and girth was 9.2 (6-14) cm and 8.8 (7-11.5) cm respectively; and the mean increase in flaccid penile length and girth was 4.4 (2-8) cm and 4.1 (2.5- 7.5) cm respectively. In terms of patient-reported treatment outcome: 50 patients reported very high satisfaction; 15 patients reported high satisfaction; 5 patients reported moderate satisfaction; and 2 patients low satisfaction. No serious complications were encountered, with the majority being managed conservatively: 5 patients who underwent V-Y-plasty incision developed superficial wound breakdown and infection which was managed conservatively; 5 patients developed phimosis which resolved spontaneously except in 1 patient who needed a circumcision; 5 patients had partial fat absorption with 3 requiring fat top-up; and 7 patients experienced the formation of a hard fat lump which was managed by hyalase injections in an outpatient setting.

Minilaparotomy Hysterectomy as a Suitable Choice of Hysterectomy for Large Myoma Uteri: Literature Review.

The objective of this paper is to propose minilaparotomy hysterectomy as the suitable choice for large uterus on the basis of our experienced case of performed minilaparotomy hysterectomy to 4,500 g myoma uteri and review published cases about this clinical condition. We presented a 44-year-old woman (gravida 0, virgin) who consulted our hospital because of the chief complaints of abnormal genital bleeding and hypermenorrhea. Transabdominal ultrasonography revealed that abdominal solid tumor reached over the navel. Her tumor was an indication of surgery; to do minilaparotomy hysterectomy with laparoscope was decided because her informed consent was obtained. A 6 cm transverse incision (Maylard incision) was made to the skin above the pubic hairline. At the end of surgery, the length of abdominal wound was 8.5 cm, operating time was 128 min, weight of resected myoma uteri was 4,500 g, and intraoperative blood loss was 895 mL. Blood transfusion was not done; postsurgical course was not a problem without anemia. We propose that a large uterine case in which it is difficult to perform vaginal or laparoscopic hysterectomy should be considered in order to select minilaparotomy hysterectomy up to around 5 kg weight of uterus, and the length of skin incision in minilaparotomy hysterectomy is necessarily <9 cm particularly in large uterus.

Suprapubic‐assisted laparoendoscopic single‐site surgery (LESS) in urology: our experience

To report our experience with suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS) in urology. In all, 236 patients underwent SA-LESS A 5- and 10-mm (or two 5-mm) trocars were inserted at the medial margin of the umbilicus. A 10- or 5-mm trocar was inserted into the abdominal cavity below the ipsilateral pubic hairline. The technique for the SA-LESS is similar to that of the standard laparoscopy, with conventional instruments placed in the abdominal trocars, under direct vision achieved by a 10-mm conventional 30 ° or 5-mm flexible-tip 0 ° laparoscope placed through the trocar below the pubic hairline. SA-LESS was successfully completed in 229 patients, without the need for ancillary trocars or additional instruments. Six patients required conversion to standard laparoscopy because of intraoperative bleeding (five) and failure to progress (one). One patient underwent open conversion because of gradual bleeding during the dissection of a dense adhesive renal pedicle due to infection and fibrosis The various SA-LESS procedures performed included adrenalectomy (15), renal cyst excision (19), nephrectomy (78; simple 63, radical 15), nephroureterectomy (three), nephron-sparing surgery (three), heminephroureterectomy (five), pyeloplasty (nine), pyelolithotomy (six), and ureterolithotomy (98). The median operative time was 81, 106, 92, 140, and 85 min, and the estimated blood loss was 60, 205, 115, 75, and 55 mL for adrenalectomy, simple nephrectomy, radical nephrectomy, pyeloplasty, and ureterolithotomy, respectively. At a mean (range) follow-up of 14.8 (2-27) months there was a hidden umbilicus scar. The scar below the pubic hairline was not detectable because of pubic hair covering. SA-LESS appears to be feasible, safe and effective. Compared with umbilical LESS, the placement of a trocar at the umbilicus and below the pubic hairline not only decreases the difficulty of surgery but also leads to little postoperative pain and good cosmetic results.

V1729 LAPAROSCOPIC LIVING DONOR NEPHRECTOMY WITH THE USE OF 3 MM INSTRUMENTS AND LAPAROSCOPE

You have accessJournal of UrologyTransplantation and Urolithiasis1 Apr 2013V1729 LAPAROSCOPIC LIVING DONOR NEPHRECTOMY WITH THE USE OF 3 MM INSTRUMENTS AND LAPAROSCOPE Alberto Breda, Giuseppe Lucarelli, Oscar Rodríguez Faba, Lluís Gausa, Javier Ponce de León, and Humberto Villavicencio Alberto BredaAlberto Breda Barcelona, Spain More articles by this author , Giuseppe LucarelliGiuseppe Lucarelli Barcelona, Spain More articles by this author , Oscar Rodríguez FabaOscar Rodríguez Faba Barcelona, Spain More articles by this author , Lluís GausaLluís Gausa Barcelona, Spain More articles by this author , Javier Ponce de LeónJavier Ponce de León Barcelona, Spain More articles by this author , and Humberto VillavicencioHumberto Villavicencio Barcelona, Spain More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2930AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopy has become the standard of care for kidney retrieval during laparoscopic live donor nephrectomy (LLDN). In the donor population the cosmetic results are of great importance and multiple minimal invasive techniques have been developed. While robotic surgery has not gain in popularity in the LLDN population, single port surgery is becoming very attractive, even if technically challenging. On the contrary, needlescopic surgery may offer advantages over single port surgery due to the fact that it reproduces the standard principle of laparoscopy while minimizing the incision size. In this video we present our experience with LLDN with the use of 3 mm instruments and laparoscope. METHODS Between Nov 2010 and Oct 2012 all potential donors with a BMI<30 were consented to undergo a LLDN with the use of 3 mm instruments. In all cases a left kidney was preferred. All cases were performed through a transperitoneal access. Pneumoperitoneum was obtained with the Veress Needle. A 5 mm visiport was introduced at the level of the humbilicus. This was to allow the use of a 5 mm Ligasure and to guarantee the pneumoperitoneum that would not be otherwise possible to maintain through a 3 mm trocar. Four 3 mm trocars were introduced along the pararectal line at the tip of the 12th rib. A 3 mm optic was used together with 3 mm scissors and bipolar. At the end of the procedure, right before hilar clamping, a 5 cm Pfannestiel incision was performed at the level of the pubic hairline with the creation of a subcutaneous flap to the level of the umbilicus. A 15 mm trocar was thereafter inserted to allow the Endo-GIA entrance as well as the Endo-bag. RESULTS 7 LLDN were performed with this technique (4 M and 3F). The avarage age was 42 and the mean BMI was 25. Left LLDN was performed in all cases. Two donors had two arteries and a retroaortic vein. The other 4 donors had single artery and vein. Mean operative time was 164 minutes and mean warm ischemia time was 2.9 minutes. There were no intraopertive and postoperative major complications although one donor developed a subcutaneous seroma that was managed conservatively. All patients were satisfied with their cosmetic results as documented by the low score on the Patient Scar Assessment Questionnaire and Scoring System (PSAQ). CONCLUSIONS LLDN with the use of 3 mm instruments appears to be reproducible and safe since it preserves the general principle of laparoscopy while minimizing the incision size. We hope that this small study will serve as preliminary data for further investigation in the field of needlescopic surgery in LLDN. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e710 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alberto Breda Barcelona, Spain More articles by this author Giuseppe Lucarelli Barcelona, Spain More articles by this author Oscar Rodríguez Faba Barcelona, Spain More articles by this author Lluís Gausa Barcelona, Spain More articles by this author Javier Ponce de León Barcelona, Spain More articles by this author Humberto Villavicencio Barcelona, Spain More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Abdominoplasty Revision Using Tissue Expansion

Postoperative revision after abdominoplasty may be necessary at times to improve contour, remove asymmetries, revise the umbilicus, or improve the scar. This report describes the case of an abdominoplasty performed outside the United States that resulted in an inappropriately high and unattractive scar with an elevated pubic hairline. The patient presented to our clinic 2 years after her initial surgery, and a scar-lowering procedure was performed with the assistance of tissue expansion. The reconstructive effort was staged over a period of 4 months, with an initial procedure to repair several hernias, bury the umbilicus, and place a tissue expander. Over several months, 3.5 L of expansion was performed. During a subsequent surgery, the tissue expander was removed, and the scar was successfully lowered and improved. The healing was uneventful, and the patient was satisfied with the outcome. The final result is exhibited in 1-month follow-up photographs. 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 .

Suprapubic-assisted umbilical laparoendoscopic mini-dual-site surgery in the treatment of simple kidney cyst: Report of 26 cases

This study was designed to evaluate the safety and efficacy of suprapubic-assisted umbilical laparoendoscopic mini-dual-site surgery (SAU-LEMDS) with satisfied cosmetic outcome in minimal size of surgical incision for the treatment of simple kidney cyst at large size. Twenty-six consecutive patients (16 male and 10 female), aged 48.5 ± 4.1 years (range: 18 to 70 years), were enrolled in this study. All cases had simple kidney cysts including 18 cases on the left side and 8 cases on the right, with a mean cyst maximum diameter of 7.5 ± 0.8 cm. Under general anesthesia, the patients were placed in flank position with affected side elevated by 70°. Two trocars (5.5 mm in diameter) were inserted via the umbilical port. The third trocar was inserted into abdominal cavity above the pubic hairline for the placement of a 5-mm 30° laparoscope. The surgery procedures were successfully performed in the same manner as standard laparoscope-assisted kidney cyst decortication in all cases. The specimens were obtained through either of two umbilical ports without additional enlarge incisions. The mean operation time was 30 ± 8.2 min and the mean blood loss was 10.3 ± 2.1 ml. The duration of hospitalization was 4.2 ± 0.9 days, and the mean follow-up was two months (range: 1 to 3 months). Postoperatively, surgical wounds were small and healed well and cosmetic outcomes were satisfactory. No recurrent kidney cysts were found during follow up. SAU-LEMDS appears to be a feasible, safe and effective surgical option for simple kidney cyst, which not only leads to better cosmetic effects, but also decreases the complexity of umbilical laparoendoscopic single site surgery (U-LESS).

V1885 ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARY DIVERSION USING A MODIFIED PFANNENSTIEL INCISION

You have accessJournal of UrologyOncology, Bladder Oncology1 Apr 2012V1885 ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARY DIVERSION USING A MODIFIED PFANNENSTIEL INCISION Devendar katkoori, Ahmed Eldefrawy, Rajinikanth Ayyathurai, and Murugesan Manoharan Devendar katkooriDevendar katkoori Miami, FL More articles by this author , Ahmed EldefrawyAhmed Eldefrawy Miami, FL More articles by this author , Rajinikanth AyyathuraiRajinikanth Ayyathurai Miami, FL More articles by this author , and Murugesan ManoharanMurugesan Manoharan Miami, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2040AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic assisted laparoscopic radical cystectomy (RARC) is gaining popularity. A completely intracorporeal procedure is technically difficult and time consuming procedure. Most surgeons perform the diversion using small midline incision, which is also used for specimen retrieval. We report our technique of RARC with modified Pfannenstiel incision. METHODS Cystectomy is performed using da Vinci robotic platform in a standard fashion. Bilateral pelvic lymph node dissection (BPLND) is done and the robot is undocked; 8-10 cm transverse curvilinear incision is made along pubic hairline centered over symphysis pubis. V-shaped incision (limbs of V at 30° angle, prevents inadvertent entry into inguinal canal) is made in the anterior rectus sheath with midpoint 2 cm above symphysis pubis. Rectus sheath is reflected and V-incision is converted into Y-incision by vertical incision on the inferior leaflet of rectus sheath towards pubic symphysis. Rectus muscles are separated. Specimen is extracted, neobladder (NB) / ileal conduit (IC) is performed and diversion completed via the incision. RESULTS 30 patients underwent RARC since April 2008. Median age was 65 yr (44-85). All had extracorporeal urinary diversions. Ratio of IC vs. NB was 6.5:3.5. The EBL was 275 (175-375ml), mean operating time was 5±0.8 hr. No intraoperative visceral injuries were noted. Two patients had positive surgical margins. Mean number of lymph nodes removed was 12±3. No incision hernia noted. CONCLUSIONS RARC with modified Pfannenstiel incision is feasible, less time consuming, facilitates NB/IC reconstruction. The incision heals with a cosmetic scar and low risk of Incisional hernia. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e761 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Devendar katkoori Miami, FL More articles by this author Ahmed Eldefrawy Miami, FL More articles by this author Rajinikanth Ayyathurai Miami, FL More articles by this author Murugesan Manoharan Miami, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Remote access laparoscopic (REAL) surgery: A novel approach for single-port surgery without a visible scar

Single-port laparoscopic surgery usually uses the transumbilical approach. However, the transumbilical incision may be associated with a high frequency of wound-related complications, including trocar site hernia and infection. Therefore, we developed remote access laparoscopic (REAL) surgery, a new access technique for single-port surgery within the pubic hairline. This study reports on a technique developed at our institution and describes our preliminary results. Ten patients with cholecystolithiasis underwent REAL surgery. A single 2.5-cm transverse incision was made medially within the pubic hairline area, and a SILS Port was inserted. A 5-mm flexible endoscope and an articulating grasper or a long laparoscopic grasper were used. Dissection of the gallbladder was achieved with laparoscopic ultrasonic shears just as in the conventional laparoscopic cholecystectomy. All procedures were successfully performed without conversion to conventional laparoscopic technique. There were no postoperative complications, and outpatient evaluation showed a clean scar within the pubic hair area in all patients. Our early experience shows that REAL surgery is feasible and safe. This novel access technique can preserve the native umbilicus and provides an invisible scar that is concealed within the pubic hair.

Technical Modifications in Laparoscopic Appendectomy

The technique of laparoscopic appendectomy has been modified several times in the past 20 years. In this report, we have described our modifications regarding the position of ports placement and closure of the base of appendix. Three surgeons successfully performed laparoscopic appendectomy in 108 cases with these modifications during the 3-year period. The first 10 mm port is placed in the periumbilical region. The second 10 mm and third 5 mm ports are inserted in the left and right side of abdomen below the pubic hairline respectively. Then the telescope is transferred from the periumbilical to the left suprapubic port. This mode of access leads to optimal ergonomics and cosmesis. For securing the base of appendix, only one Hem-o-lok clip (nonabsorbable polymer clip) is applied on each side. The use of Hem-o-lok clip is simple, safe and decreases the time and cost of laparoscopic appendectomy.

The Alternative to Laparoendoscopic Single-Site Surgery: Small Strategic Laparoscopic Incision Placement (SLIP) Nephrectomy Improves Cosmesis Without Technical Restrictions

The latest attempt to improve the cosmesis of laparoscopic surgery is laparoendoscopic single-site surgery (LESS). We present our initial experience with an alternative procedure with similar cosmetic benefit but without technical limitations. Small strategic laparoscopic incision placement (SLIP) nephrectomy is performed transperitoneally, generally using three 5-mm ports (one in the umbilicus) and one 12-mm port placed below the pubic hairline, such that only two 5-mm scars are visible without close inspection. We assessed our first 21 procedures, which included all but five of the standard transperitoneal nephrectomies by a single surgeon from June 2008 through July 2009. These were matched 1:2 (exactly by gender and American Society of Anesthesiology score, and then closest in age and body mass index) from 96 patients undergoing similar standard transperitoneal laparoscopic procedures from 2005 through 2008. The SLIP and control groups were well matched, with mean age and body mass index differing by only 3.6 years and 1.1, respectively. Of the SLIP patients, 34% were obese or morbidly obese, and a trainee was the primary surgeon in 81% of cases. Mean operative time was 23 minutes longer in the SLIP cases. There was no difference between groups in estimated blood loss, complication rate, or convalescence. Like LESS, SLIP nephrectomy provides improved cosmesis. Unlike LESS, it is only slightly more difficult to perform than standard laparoscopic nephrectomy and can be performed in technically challenging cases (obesity, large specimen, etc). Similar to the literature on LESS, there is no convalescence benefit to SLIP nephrectomy; the advantage over standard laparoscopy is purely cosmetic.

Supra-Pubic Single Incision Cholecystectomy

IntroductionSurgery is moving towards less invasive and cosmetically superior approaches such as single incision laparoscopy (SIL). While trans-umbilical SIL is gaining popularity, incisions may lead to post-operative deformations of the umbilicus and the possibility of an increased rate of incisional hernias. Access within the pubic hairline allows preservation of the umbilicus and results in a scar which is concealed within the pubic hair. MethodsSupra-pubic single incision cholecystectomy was performed in a 30-year-old patient with symptomatic gallstones. A 2.5-cm transverse incision was placed within the pubic hairline and a subcutaneous tunnel was formed. Three 5-mm ports were introduced into the tunnel and perforated the anterior rectus sheath superior to the skin incision. The surgical procedure was then undertaken with conventional laparoscopic instrumentation. The adjacent 5-mm incisions were merged for gallbladder removal. The entry site was closed under direct vision. ResultsThe above procedure was technically feasible and without complication. Operative time was 45 min, and the patient was discharged 5 h post-operatively. ConclusionsSupra-pubic single incision laparoscopic cholecystectomy may offer a more cosmetically appealing result than standard umbilical access. The operation can be performed by surgeons skilled in single incision techniques with good result.

Cosmetic Laparoscopic Cholecystectomy

The cosmetic outcome and recovery time of laparoscopic cholecystectomy has been improved by modifying the operation technique and reducing the number and size of trocars. The next step to improve cosmetic results is moving two trocars below the pubic hairline. We describe our experience in performing cholecystectomy by a combination of European technique using three trocars and moving two ports below the pubic hairline. The results of 72 patients, ASA physical status I and II, who underwent cosmetic laparoscopic cholecystectomy between January 2002 and May 2005 are presented. The median operating time was 33.3 +/- 9.9 min and postoperative hospital stay was 2.2 +/- 0.6 days. No patients required additional trocars or conversion to open cholecystectomy. There were no intraoperative or postoperative complications, and all patients reported satisfaction with their postoperative cosmetic results. According to our experience, cosmetic laparoscopic cholecystectomy is a safe procedure with good cosmetic results; however, its use should be based on careful evaluation in each individual case.

Minilaparotomy hysterectomy: a valid option for the treatment of benign uterine pathologies

Objective: To evaluate feasibility and outcome of minilaparotomy hysterectomy in a consecutive series of patients. Study design: Cohort analytic study. From October 1995 to March 2001, 148 out of 228 (65%) consecutive hysterectomies for benign gynecologic disease were performed by an abdominal route. Minilaparotomy hysterectomy (transversal cutaneous incision <10 cm, within the pubic hair) was attempted in all patients with benign uterine disease and contraindications for vaginal surgery. Surgical parameters were prospectively assessed in terms of length of incision, operative time, estimated blood loss, duration of ileus, perioperative complications and length of postoperative stay. Results: A minilaparotomic approach was performed in 118 patients (80%). Conversion to Pfannenstiel was necessary in three cases. The minilaparotomy incision, 8 cm (range 6–10) of median length, was performed below the pubic hair line. The median operating time was 50 min (range 34–88). No intraoperative complications or perioperative blood transfusions were reported, while minor postoperative complications occurred in 16 patients (14%). The median postoperative stay was three days (range 2–5). Conclusions: The minilaparotomy hysterectomy is feasible in the majority of women undergoing hysterectomy for benign disease. Because of the excellent outcome achieved, it should be considered a valid alternative to the classic abdominal hysterectomy.

Concurrent radical retropubic prostatectomy and inguinal hernia repair through a modified Pfannenstiel incision.

To describe a technique for concurrent radical retropubic prostatectomy (RRP) and inguinal hernioplasty, using a modified Pfannenstiel incision. RRP is usually done through a midline lower abdominal incision but some patients with localized prostate cancer have an inguinal hernia. Concurrent inguinal hernia repair at the time of RRP with the usual method is only possible by either a preperitoneal mesh repair or formal hernioplasty, requiring an additional incision(s). A 10-12 cm Pfannenstiel incision is made along the pubic hairline centred over the pubic symphysis, and a 'Y'-shaped incision in the rectus sheath. The rectus muscle is split vertically along the midline, followed by RRP. After removing the prostate and completing the anastomosis, the surgeon identifies the inguinal canal along the inferior and lateral aspect of the transverse incision and uses a formal tension-free hernioplasty with a 3 x 5 cm polypropylene mesh. We used this technique in fifteen concurrent inguinal hernioplasties (two bilateral hernias and thirteen unilateral) at the time of RRP, with no additional incisions, using the formal tension-free Lichtenstein technique. One patient with bilateral hernias had a right indirect inguinal hernia, and all the remaining men had a direct inguinal hernia. All patients were discharged 2 days after surgery, with no complications associated with the procedure and no recurrences; however, the follow-up was short (mean 5.5 months). A modified Pfannenstiel incision is ideal for concurrent RRP and inguinal hernioplasty, providing excellent exposure of the pelvic structures and allowing the surgeon to use a formal tension-free mesh hernioplasty through the same incision. Wound healing and cosmetic results are excellent.

Extraperitoneal Approach to Laparoscopic Burch Colposuspension

Study Objective To evaluate 3-year outcomes of extraperitoneal laparoscopic colposuspension in treating genuine stress incontinence Design Retrospective review (Canadian Task Force classification II-2). Setting University-based, tertiary-level center for endoscopic surgery. Patients One hundred sixty women with genuine stress incontinence with bladder neck hypermobility. Intervention Extraperitoneal space was created with CO 2 through a 10-mm midline port 2 cm above the pubic hairline. A pair of sutures was inserted at the level of midurethral and urethrovesical junction, fixing them to Cooper's ligament on each side with proper tension. Measurements and Main Results Of 160 women, 10 were lost to follow-up. On follow-up questionnaire sent to 150 patients, 148 (98.7%) were pleased with the results of surgery. Stress incontinence was cured in 136 women (90.7%) after a minimum of 3 years' follow-up. Conclusion Cure rates for extraperitoneal colposuspension were similar to those reported for traditional laparoscopic or laparotomy Burch procedures; however, this is a more direct method to expose the space of Retzius, thus eliminating the need to open and close peritoneum.

Laparoscopic removal of a 5-cm subserous pedunculated myoma with small instruments

A mobile, subserous, pedunculated myoma was located on the anterior surface of the uterus in a 45-year-old woman. Bipolar coagulation was performed on the pedicle, and the myoma was dissected with an electrical morcellator and removed through the umbilicus. This technique required placement of one 5- to 12-mm cannula in the umbilicus and two 2-mm miniports at the pubic hairline. This technique is easy to perform, and the patient benefits from minimal postoperative pain and excellent cosmetic results.

A New Method for the Relief of Adult Phimosis

Infantile circumcision is not ordinarily performed in Japan. Adult circumcision causes esthetic problems with scarring and color change, especially in Asian patients. We report our experience with 10 adults who underwent a new method of surgery for correction of phimosis via a longitudinal incision of the prepuce along the constricted area ventrally to release constriction, followed by transverse closure of the wound; removal of excess skin by pinching at the dorsal root of the penis, incising circumferentially except for 2 cm. of ventral skin, and closing the dorsal wound. Functional results in all cases were satisfactory and preputial constriction was fully relieved. Cosmetic results were superior to those of conventional circumcision and dorsal slit methods of adult circumcision because contrasting coloration was obscured behind pubic hair and scarring was coincidental with or beneath the pubic hairline.

Minilaparotomy Recommended for Most Programs: Simpler and Safer Than Laparoscopic Sterilization

Minilaparotomy is a simple surgical procedure requiring only basic instruments with no blind insertion of sharp instruments (as with the trocar in laparoscopy) and not requiring insufflation. Instead, a 1-2 inch incision is made just above the pubic hairline, the tubes are located with the aid of a uterine manipulator, and a standard Pomeroy tubal ligation is performed. The abdominal wall is closed in layers. The entire procedure takes 15-30 minutes. Bleeding from the mesosalpinx is less likely because tubal ligation involves less trauma than fulguration or application of a clip or band. In addition, small blood vessels which may be injured are easily clamped or ligated. In those women in which it is not suitable (when the uterus is enlarged, or in fixed retroversion, or when the woman is obsese) a modified procedure involving an incision rather than a trocar puncture of the abdomen is recommended. Because the equipment needs no care beyond sterilization, minilaparotomy is the sterilization procedure of choice for large-scale programs in developing countries.