Repeat Laparoscopy Research Articles

Laparoscopic ileopexy for afferent loop syndrome after restorative proctocolectomy—a retrospective case series

BackgroundTo study the effect of laparoscopic ileopexy in patients with afferent-loop syndrome (ALS) after restorative proctocolectomy (RP).MethodIleopexy has been the treatment of choice in patients with ALS for the last 5 years at our department. All patients who had undergone ileopexy for ALS between January 2019 and August 2023 were identified. Data were extracted from the medical records. All patients were contacted and asked standardized questions regarding symptoms of ALS. A symptom score was calculated and compared before surgery and at the last follow-up.ResultsTen patients, who had undergone ileopexy for ALS, were identified. Eight of these (80%) had been admitted with small bowel obstruction due to ALS. The remaining 2 patients had other symptoms indicative of ALS. In all patients, ileopexy was immediately effective in reducing symptoms. Symptoms recurred after 16.5 weeks (2–80) in 8 patients. Repeat laparoscopy showed that the ileopexy had slipped in 6 of these. Six had a new ileopexy with mesh. Later, one of these developed recurrent symptoms and had a new mesh ileopexy performed. No mesh complications were seen. Symptom score was reduced from 6.5 (1–9) to 2 (0–7) (p = 0.02) at the last follow-up.ConclusionsIn this study, ileopexy is effective in reducing symptoms of ALS after RP. In a high proportion of patients, it is necessary to use mesh to ensure long-term fixation of the ileum.

Body Mass Index and Surgical Diagnosis of Endometriosis: Do Obese Patients Experience an Operative Delay?

Objectives: The objective of this study was to quantify the time to diagnosis of endometriosis by laparoscopy for patients of varying body mass index (BMI), as well as the safety of laparoscopy for endometriosis by BMI. Materials and Methods: We performed a retrospective cohort study of reproductive-age women receiving a primary laparoscopic diagnosis of endometriosis at an academic tertiary hospital from January 2017 to December 2020. Patients excluded were those undergoing repeat laparoscopy, with previously histologically diagnosed endometriosis, asymptomatic endometriosis, an unknown first gynecologic encounter, or an unknown initial BMI. Our primary outcome was time to surgical diagnosis of endometriosis by BMI class. Our secondary outcome was the evaluation of peri/postoperative risk of laparoscopy for endometriosis. Results: A total of 152 patients received a primary surgical diagnosis of endometriosis, including 44% normal or underweight patients, 29% overweight patients, and 27% obese patients. Obese patients experienced a delay from gynecologic presentation to diagnostic laparoscopy (18.4 months, interquartile range [IQR] 3.1–42.8) compared to overweight patients (9.0 months, IQR 2.5–23.2) and normal and underweight patients (3.8 months, IQR 1.1–17.0) (P = 0.02). Although a higher percentage of overweight and obese patients was Hispanic and non-Hispanic Black, multiple linear regression maintained a significant relationship between time to surgery and BMI (P = 0.03). Perioperative and postoperative complications did not differ by BMI class. There were no differences in repeat laparoscopy for endometriosis within 3 years by BMI (P = 0.99). Conclusion: BMI is independently associated with time to surgical diagnosis of endometriosis in our retrospective study. Diagnostic laparoscopy appears safe in obese patients, without significant perioperative morbidity.

Challenges in diagnostics and management of a dysgerminoma in a young female

Introduction: A rare case of dysgerminoma led to the prolonged and complex diagnostic journey of a young woman. Methods: The diagnostic process involved various imaging modalities, including ultrasound, FDG-PET/CT scan and MRI, alongside diagnostic laparoscopy. Additionally, methotrexate was administered based on provisional diagnosis to manage the patient’s condition. Results: Initial investigations suggested pregnancy of unknown location due to inconclusive ultrasound findings. Subsequent imaging with FDG-PET/CT initially appeared normal, but was followed by MRI, which revealed a solid mass on the right ovary. The definitive diagnosis of dysgerminoma was made during a repeat laparoscopy. The patient received oncologic treatment and recovered fully. Conclusion: This case emphasizes the challenges in diagnosing rare conditions, which may mimic common clinical diseases, as well as the importance of a comprehensive diagnostic approach.

OGC P11 Outcomes in patients with gastric cancer and positive peritoneal washings

Abstract Background The presence of positive cytological washings in the absence of overt peritoneal disease (P0C1) represents metastatic disease. Most centres advocate for neoadjuvant chemotherapy and full restaging including repeat laparoscopy and washings, with resection offered to those in whom restaging is negative. This approach was implemented at our institute in 2012 and when evaluated in 2015 was found to have very good results with 63% of patients resected and 90% 2-year survival. Since this time chemotherapy regimens have changed meaning this earlier approach requires additional scrutiny. Methods A retrospective review of a prospectively maintained database of all upper GI cancer patients treated at the Northern Oesophago-Gastric Unit (NOGU) was undertaken. All patients with adenocarcinoma of the stomach or gastroesophageal junction without metastases on imaging and who underwent staging laparoscopy between August 2012 and August 2022 were identified. Patients who had positive cytological washings without evidence of overt peritoneal disease were included in the analysis. Data were extracted including demographics, treatment data and oncological outcomes. Survival data were collected and patterns of recurrence determined. Results 630 patients underwent staging laparoscopy. Resectable P0C1 disease occurred in 55/630 (8.7%), and 48/55 commenced chemotherapy. Restaging occurred in 45/48 (93.8%) and 21/45 (46.7%) went on to have definitive surgery where 15/45 (33%) were resected. Recurrence occurred in 8/15 patients, 3 of which had peritoneal metastases. Median time to recurrence was 16 months (range: 6-34). A total of 9 patients died during follow up which occurred at a median of 14 months (range: 5 to 43). Overall median survival of the cohort was 28 months (range: 5 – 111), with survival of 60% and 25% at 2 and 5 years, respectively. Conclusions This study demonstrated 60% 2-year survival in patients treated with curative intent who initially had positive peritoneal cytology. We were not able to demonstrate a predominate pattern of peritoneal recurrence. Furthermore, 25% of patients survived for at least 5 years after surgery, indicating that this remains an acceptable approach to the management of P0C1 disease with current best practice chemotherapy regimens.

Laparoscopy in the management of post-cholecystectomy bile leaks

IntroductionOver 1% of cholecystectomies are complicated by a post-operative bile leak. Most bile leaks are managed with endoscopic retrograde cholangio-pancreatography (ERCP) with decompression of the biliary tree. This paper reports our outcomes of using early re-laparoscopy in the investigation and treatment of post-operative bile leak. Materials/patients and methodsWe analysed our prospectively compiled database to identify all patients suffering a bile leak after cholecystectomy. Demographic data, details of the index cholecystectomy, post-operative investigations and procedures, and readmissions to hospital were analysed. Results4870 cholecystectomies were performed between 2016 and 2020; 1793 (36.9%) were urgent cholecystectomies performed at the index admission. 41 patients were identified with unexpected post-operative bile leaks. 40 patients underwent urgent re-laparoscopy as initial management. 17 patients required ERCP subsequent to re-laparoscopy. Median post-operative stay was 5 days. No cases were converted to open surgery, and there were no mortalities. DiscussionUrgent repeat laparoscopy is an effective tool to manage an unexpected post-cholecystectomy bile leak. Re-laparoscopy allows thorough peritoneal washout and diagnosis of the cause of the leak, and provides definitive treatment for the majority of patients. It is associated with a short hospital stay with minimal morbidity and mortality.

Development of a laparoscopic technique for inguinal hernioplasty in standing horses.

Most previously described techniques for laparoscopic inguinal hernioplasty (IH) in horses require advanced laparoscopic skills. Our objective was to describe a new laparoscopic IH technique using a surgical anchoring system. Standing laparoscopic IH was performed unilaterally in eight experimental stallions, using the contralateral inguinal canal (IC) as a control. A polyether ether ketone harpoon was anchored in the craniolateral aspect of the vaginal ring, and an extracorporeal knot was used to fix the device. Clinical evaluation, including testicular palpation and lameness examination, was conducted before and for 4 weeks after surgery. Repeat laparoscopy was performed 28 days later. Standing laparoscopic IH was performed in all horses with a surgical time of 38 ± 12.85minutes. In two animals, a small peritoneal tear occurred that did not require repair. No other complications were recorded. On repeat laparoscopy, all devices were in place, and the IC remained partially closed in all horses. The procedure was performed on normal experimental horses and has not been employed on horses that have had an inguinal hernia. This new standing laparoscopic hernioplasty technique provides another potential method for simple partial closure of the IC in stallions at risk of or with history of inguinal herniation.

Risk of Repeat Laparoscopy Following Surgical Diagnosis of Endometriosis: Effects of Hysterectomy, Oophorectomy, & Psychiatric Disease

<h3>Study Objective</h3> To quantify rates of repeat laparoscopy following initial surgical diagnosis of endometriosis and investigate risk factors associated with repeat surgery. <h3>Design</h3> Retrospective chart review of patients with surgical pathology confirming endometriosis. This study met exemption criteria (45CFR 46.101b) following IRB review. <h3>Setting</h3> Academic tertiary hospital system. <h3>Patients or Participants</h3> Women ages 12-50 receiving a primary surgical diagnosis of endometriosis, Jan 2017 - June 2018. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Demographic variables, type of initial procedure (hysterectomy, oophorectomy, other laparoscopy), presence of psychiatric disease (defined by pre-determined clinical criteria) and repeat laparoscopy within 3 years of initial diagnosis. 136 patients met inclusion criteria. Initial surgeries included unilateral oophorectomy (8.1%), bilateral oophorectomy (3.7%), hysterectomy without oophorectomy (22.1%), hysterectomy with unilateral oophorectomy (5.9%), and hysterectomy with bilateral oophorectomy (6.6%). 53.7% underwent other laparoscopy not involving hysterectomy/oophorectomy. 66 patients (49%) met criteria for psychiatric disease. 15 patients (11%) underwent repeat laparoscopy. Comparing patients who underwent repeat laparoscopy with those who did not, there was no difference in age (35.7±5.9 vs. 37.9±11.1 years, respectively, p=0.46), BMI (26.2±7.0 kg/m² vs. 28.5±6.7 kg/m², p=0.22), or race/ethnicity (32% vs. 67% White, Chi-square p=0.55). There was no association between re-operation and psychiatric disease (RR=1.2, 95%CI: 0.48-3.06, p=0.79). Preservation of ≥1 ovary was not associated with re-operation (RR=0.87, 95%CI: 0.26-3.34, p=0.69). Uterine preservation may be associated with a greater risk of repeat laparoscopy, with a trend towards significance (RR=2.5, 95%CI: 0.98-6.40, p=0.09). <h3>Conclusion</h3> The 3-year repeat laparoscopy rate was 11%, consistent with prior literature. Psychiatric disease was not associated with re-operation. Uterine preservation at time of initial laparoscopy may be associated with re-operation, but ovarian preservation was not. While non-significant findings may be limited by underpowering due to a small sample size, these results may help inform counseling and surgical planning in the long-term management of endometriosis.

SUGAMMADEX ANAPHYLAXIS

<h3>Introduction</h3> Sugammadex is a neuromuscular reversal agent used at the conclusion of surgeries to reverse the effects of rocuronium and vecuronium. It was first used in 2008 and the incidence of anaphylaxis has been estimated to be around 0.02%. We report a case of anaphylaxis to sugammadex which manifested abruptly with hypotension, diaphoresis, and dyspnea but with absence of rash. <h3>Case Description</h3> A 71YOF underwent an uncomplicated laparoscopic cholecystectomy. At the end of the procedure, patient received 200mg sugammadex IV and within 3 minutes she became hypotensive, diaphoretic, and dyspneic. She did not have a rash. She never received this medication before. She received IV fluids and she was started on phenylephrine drip. Patient was initially phenylephrine refractory but after 10 minutes her hypotension resolved. The diagnosis was unclear, therefore a repeat laparoscopy to rule out bleeding was performed and intraoperatively transesophageal echocardiogram showed normal left ventricle function, but minimal filling. The blood loss was estimated to be 30 ml. Due to high suspicion, Sugammadex was preemptively listed as an allergy. One hour after her symptoms began, tryptase level was 48.7 mcg/L, followed by 61.5 mcg/L 2.5 hours later. Baseline tryptase was 4.5 mcg/L. At a follow up visit, skin prick testing to sugammadex was positive with a 1:1 concentration and to intradermal testing with a 1:1000 concentration. Skin testing of other agents which were administered prior to sugammadex were negative. <h3>Discussion</h3> Although rare, rapid recognition of possible sugammadex anaphylaxis, despite the lack of rash, is very important for adequate treatment and further testing.

Outcomes after Laparoscopic Excision of Bladder Endometriosis Using a CO2 Laser: A Review of 207 Cases in a Single Center

Assess efficacy, safety, fertility outcomes and recurrence after laparoscopic resection of bladder endometriosis (BE) using a CO2 laser. Retrospective cohort study. University gynecologic surgery unit, referral center for endometriosis. A total of 207 women having undergone laparoscopic BE excision between January 1998and January 2019. None. Intra- and postoperative complication rates. Disease recurrence and fertility outcomes in patients with a minimum 1-year follow-up (n=176) for "isolated" and "non-isolated" BE groups. Forty-three patients presented with isolated BE. Bladder "shaving" without mucosae opening was performed in 50.7% cases. No intraoperative complications were noted. One postoperative grade 3 complication was related to BE excision: a bladder breach requiring closure by repeat laparoscopy. Mean (± SD) follow-up was 7.05 (± 4.65) years. In patients wishing to conceive (n=132), the total pregnancy rate (PR) was 75% (48.5% spontaneous), 76.19% in the isolated BE group (56.3% spontaneous). Among the 94 patients with previous infertility, 74.5% conceived, 50% spontaneously. No statistical difference was found in PR and need for in vitro fertilization between isolated and nonisolated BE groups. BE recurrence rate was 3.4%. No difference was observed between groups with full-thickness bladder resection (4/88) and shaving (2/88) (p=.406). Age at surgery (hazard ratio 0.91 [0.84-0.98], p=.016) and postoperative pregnancy (hazard ratio 0.07 [0.01-0.91], p=.042) showed influence on disease recurrence. The study demonstrates that laparoscopic BE removal is feasible with very low complications rates and was associated with high PR (both spontaneous and in vitro fertilization), even in patients with previous infertility. BE recurrence is lower than for other endometriosis locations. Bladder endometriosis; Laparoscopy; Deep infiltrating endometriosis; Fertility; Partial bladder resection.

Assessment of Treatment Response after Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC) for Appendiceal Peritoneal Metastases.

Simple SummaryPressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is an emerging treatment modality for patients with peritoneal cancer with good safety profile and promising early response rates. The aim of this study was to analyze survival and surrogates for oncological response after PIPAC ± systemic chemotherapy for appendiceal tumours. Median overall survival of this cohort was 30 months from time of diagnosis and 22 months from PIPAC1 (per protocol) comparing favorably with 20.4 months of OS reported for patients with palliative chemotherapy alone. However, without prospective comparative data, the role of PIPAC for appendicular cancer with peritoneal metastases remains unclear.Background The aim of this study was to analyse survival and surrogates for oncological response after PIPAC for appendiceal tumours. Methods This retrospective cohort study included consecutive patients with appendiceal peritoneal metastases (PM) treated in experienced PIPAC centers. Primary outcome measure was overall survival (OS) from the date of diagnosis of PM and from the start of PIPAC. Predefined secondary outcome included radiological response (RECIST criteria), repeat laparoscopy and peritoneal cancer index (PCI), histological response assessed by the Peritoneal regression grading system (PRGS) and clinical response. Results Final analysis included 77 consecutive patients (208 PIPAC procedures) from 15 centres. Median OS was 30 months (23.00–46.00) from time of diagnosis and 19 months (13.00–28.00) from start of PIPAC. 35/77 patients (45%) had ≥3 procedures (pp: per protocol). Objective response at PIPAC3 was as follows: RECIST: complete response 4 (11.4%), 11 (31.4%) partial/stable; mean PRGS at PIPAC3: 1.8 ± 0.9. Median PCI: 21 (IQR 18–27) vs. 22 (IQR 17–28) at baseline (p = 0.59); 21 (60%) and 18 (51%) patients were symptomatic at baseline and PIPAC3, respectively (p = 0.873). Median OS in the pp cohort was 22.00 months (19.00–NA) from 1st PIPAC. Conclusion Patients with PM of appendiceal origin had objective treatment response after PIPAC and encouraging survival curves call for further prospective evaluation.

Combination of plastic surgery of the pyeloureteral junction with kidney transposition and nephropexy in hydronephrosis of a dystopic kidney

Introduction. Obstruction of the pyeloureteral junction is the most common anomaly of the upper urinary tract. Irrespective of the causes, narrowing of the ureteropelvic junction leads to abnormal urine outflux, increased intrarenal pressure, gradual sclerosis of renal parenchyma, loss of kidney function. In some cases, obstruction of the ureteropelvic junction can be accompanied by dystopic kidney, nephroptosis, abnormal location of the main and accessory renal vessels which requires correction of the standard surgical treatment.The study objective is to evaluate the effectiveness of combination of laparoscopic pyeloplasty with kidney transposition and nephropexy in obstruction of the pyeloureteral junction of a dystopic kidney.Materials and methods. Medical records of 8 patients who underwent surgery in the Kracnoyarsk Regional Clinical Hospital between 2017 and 2021 were analyzed. Obstruction of the pyeloureteral junction was confirmed clinically by ultrasound of the kidneys, excretory retrograde pyelography, contrast-enhanced spiral computed tomography.Results. In all of the 8 patients, lumbar dystopia of the affected kidney was diagnosed, in 25 % pathology was accompanied by nephroptosis, in 50 % of cases by abnormal location of the main and accessory renal vessels. All patients underwent laparoscopic plastic surgery of the pyeloureteral junction per Anderson–Hynes with antegrade ureter stenting, kidney transposition, nephropexy. Mean operative time was 190 ± 39 min, no intraoperative blood loss was observed. Ureteral catheter was removed at day (6.3 ± 2.2). Hospital length of stay was 9.3 ± 3.7 days. In 1 patient, postoperative period was complicated by suture breakage in the posterior wall of the pyeloureteral anastomosis which required repeat laparoscopy to correct suture defect. Time of ureteral stent implantation was 34.6 ± 8.5 days. Control examination showed full remission of pain syndrome. Excretory urography showed full outflow of the contrast agent after examination with furosemide in 100 % of cases.Conclusion. Combination of laparoscopic plastic surgery of the pyeloureteral segment with kidney transposition and nephropexy is an effective minimally invasive operation for treatment of ureteropelvic junction stricture of a dystopic kidney.

Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis.

Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ. All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included. A total of 120 patients [median age 21.68 (range 9-90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8-131) months' follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination. 87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.

Management of Acute Disease in the Remnant Gallbladder: The Effectiveness of Repeat Laparoscopy

Introduction: Subtotal cholecystectomy has become a widely accepted alternative for patients presented with acute cholecystitis resulting in significant inflammation and anatomic distortion. Recurrent cholecystitis of the remnant gallbladder is an accepted complication of this procedure. International studies have shown completion cholecystectomy to be the definitive management of recurrent cholecystitis. Few investigators in the United States have focused on management of this scenario, and to this point open surgical approach has been recommended. Methods: Cholecystectomies undertaken by one hepatobiliary surgeon over a two-year period from 2017-2019 were reviewed. Cases of patients with previous cholecystectomy who then presented with acute cholecystitis and underwent laparoscopic completion cholecystectomy were compiled and reviewed to determine interval from initial cholecystectomy, operative time, use of intraoperative cholangiography, use of intraoperative indocyanine green (ICG), placement of drain, and total length of hospital stay (LOS). Results: Seven patients met inclusion criteria. The mean interval from initial cholecystectomy was 22 months (range 3-89 months with one patient presenting an unknown length of time from initial operation). Mean operative time was 119 minutes (range 79 minutes to 141 minutes). Five patients had an intraoperative cholangiogram and one case was completed with intraoperative ICG. A drain was left at the completion of three out of seven cases. Average LOS was less than one day (range 0-2) with three patients discharged in good condition post-operative day 0. Conclusions: Laparoscopy is a safe and effective approach to completion cholecystectomy for patients with recurrent cholecystitis that avoids an open surgical procedure.

Successful Colonoscopy-assisted Cecostomy Tube Replacement to Salvage Lost Cecostomy Tract Access in Children.

Cecostomy tubes are commonly used for antegrade enema delivery in children with spinal defects and anorectal malformations to help address chronic constipation and fecal incontinence. Once surgically or radiologically placed, cecostomy tubes require changes by a percutaneous approach, which may be unsuccessful requiring repeat laparoscopy or open surgery to re-establish the cecostomy tract. The role of colonoscopy assistance to salvage lost cecostomy access in children who fail percutaneous replacement is not well described. The primary aim was to describe the safety and effectiveness of a colonoscopy-assisted approach to re-establish lost cecostomy access in children. This was a retrospective cohort study of the methods, success and complication rates associated with colonoscopy assisted cecostomy tube replacement in children between 2000 and 2017 at a pediatric tertiary care center. Ninety-five patients with 841 attempted procedures were included with only 1% of procedures requiring endoscopic assistance. These included 7 colonoscopy-assisted cecostomy tube replacement procedures in 6 patients (median age 9.2 years, median weight 26.3 kg, 33% girls). The most common reason for using colonoscopy assistance was a failed percutaneous approach. The colonoscopy-assisted approach was successful in all cases without documented complications. Colonoscopy-assisted cecostomy tube replacement is safe and highly successful in re-establishing lost cecostomy access in children after failed attempts with percutaneous or fluoroscopic-guided approaches.

Repeat staging laparoscopy for gastric cancer after preoperative therapy.

Staging laparoscopy is recommended before preoperative therapy in patients with locoregional gastric cancer, but yield of repeated diagnostic laparoscopy at the time of resection is unknown. Retrospective review of a prospective database of patients with gastric adenocarcinoma (1994-2016) who had negative staging laparoscopy followed by preoperative therapy and subsequent attempted resection. Primary outcome was positive exploration (peritoneal or unresectable disease) at the time of resection. Multivariable logistic regression identified factors associated with positive exploration. Of the 451 patients with attempted resection, 54 (12.0%) had positive explorations, including 48 with peritoneal disease. Patients with positive explorations were more likely to be female and have poorly differentiated tumors, linitis features, and signet-ring morphology. There was no significant difference by exploration results in age, race, clinical stage, or delayed definitive surgery. Positive explorations were independently associated with poor differentiation (OR 4.6, 95%CI 1.4-15.3; P = 0.01) and linitis (OR 4.2, 95%CI 1.9-9.2; P < 0.001). Positive explorations were seen in 14.0% of patients with poor differentiation, 36.6% of patients with linitis, and 5.8% of patients with neither linitis nor poor differentiation. Despite negative pretreatment laparoscopy, post-treatment repeat laparoscopy may prevent non-therapeutic laparotomies. At a minimum, we recommend selective repeat laparoscopy for patients with linitis features.

Combined repeat laparoscopy and transanal endolumenal repair (hybrid approach) in the early management of postoperative colorectal anastomotic leaks: technique and outcomes.

Few clear recommendations exist for the management of colorectal anastomotic leaks, often based on surgeon preferences or institutional protocols. The primary goal was to evaluate the feasibility and safety of the combined laparoscopic and transanal (hybrid) approach to treat postoperative colorectal anastomotic leaks. The secondary goals included comparison of outcomes following early (< 5days after initial resection) versus late (≥ 5days) detection of leaks. Sixteen hemodynamically stable patients, with anastomotic dehiscence < 50% of the circumference after laparoscopic anterior resection underwent repeat laparoscopy (lavage/drainage) and transanal endolumenal repair (7 low (< 5cm from the anal verge) with an ordinary anoscope and 9 high (≥ 5cm from the anal verge) with a transanal endoscopic operations (TEO®) platform). The median delay to detection and management was 4.5days. The procedure was feasible in 13/16 patients (3 patients required conversion to laparotomy). Primary healing of the anastomosis was obtained in 14 patients (13 with the combined procedure, one after conversion). Two patients (1 early, 1 late) sustained persistent purulent discharge via their drain, but the repair healed secondarily. All patients requiring conversion to laparotomy (n = 3) or sustaining intra-operative complications (n = 3) were in the delayed group. No patients required further intervention or died. Protective stomas, created either at index surgery (n = 7) or at re-operation (n = 9), were closed in 14/16 patients within 6months and no anastomotic sinus, persistent or recurrent fistula, was noted at 1-year follow-up. This is a single-center study consisting of small sample size. Combined repeat laparoscopy and transanal endolumenal repair is feasible and safe, potentially reducing postoperative morbidity associated with repeat laparotomy and anastomotic leaks. Early detection and re-intervention are fundamental to success. Currently missing from the International Study Group of Rectal Cancer recommendations, laparoscopy and endolumenal repair could be added as a therapeutic option in Grade B.

Role for laparoscopy in the management of bile duct injuries.

Common bile duct (CBD) injury is the most serious complication of laparoscopic cholecystectomy. Recently, laparoscopic techniques have been used in the management of postoperative bile leak and CBD injury; this literature has not been reviewed. We reviewed the literature on CBD injury, the approach to its diagnosis and management, and reports of laparoscopic management techniques. We combined this review with our experience in laparoscopic methods to highlight diagnostic and therapeutic options. Laparoscopic techniques can be used to prevent, diagnose and treat CBD injuries. Intraoperatively, CBD injury can be prevented in the case of short cystic duct with the use of a loop ligature or transfixing suture, and it can be diagnosed using intraoperative cholangiography or other visualization techniques. When CBD injury is suspected postoperatively, repeat laparoscopy can be used to control sepsis with abdominal washout; as a diagnostic tool to guide management; and, in some settings, as a therapeutic tool for suturing small duct leaks, drain insertion and postoperative endoscopic retrograde cholangiopancreatography with sphincterotomy. Definitive laparoscopic repair is possible when certain criteria are met. Open surgery should be considered when the CBD is small, the injury occurred more than 72 hours previously, injury or anatomy are complex, port positioning is awkward for repair, or local experience is limited with laparoscopic management. There is an emerging role for laparoscopy in the management of CBD injuries. More case reports and series are needed to show the safety and efficacy of this technique, encourage its wider adoption, and allow outcomes assessment on a larger scale.

Management of endometriosis‐related pelvic pain

Key content The variable signs and symptoms of endometriosis contribute to significant diagnostic delay. Empirical hormonal treatment of endometriosis‐related pain with cycle suppression may be considered without a definitive diagnosis of endometriosis. When considering laparoscopy to diagnose and treat endometriosis, a balance must be found between the need to avoid the very long diagnostic delays currently experienced and the likelihood of treatment benefits, set against the cost and risk of laparoscopy. Treatment for endometriosis‐related pain symptoms includes a range of medical and surgical options with varying levels of evidence. Minimally invasive surgery should be performed by a surgeon trained to undertake surgical treatment for mild to moderate disease, thereby avoiding the need for repeat laparoscopy in the absence of severe disease, i.e. a ‘see and treat’ policy. Women with deep infiltrating endometriosis should be referred to an accredited endometriosis centre, such as the British Society for Gynaecological Endoscopy (BSGE) in the UK. Learning objectives To understand the diagnostic difficulties surrounding endometriosis diagnosis and management. To identify the supporting evidence for treating endometriosis‐related pain. Ethical issues When should laparoscopy for women with minimal endometriosis symptoms be performed? Should radical surgery always be performed in women in whom deep infiltrating endometriosis is found?

Laparoscopic Embryo Transfer in Pigs: Knowledge for Surgical Procedures

The objective of the study was to describe and improve a technique for laparoscopic embryo transfer into the oviduct and uterine horns of pigs and to evaluate the feasibility and safety of this method. Fourteen female pigs were randomly allocated into groups A and B: three portals were used for group A, and the simulation of embryo (0.9% NaCl, 0.2 mL) was injected into the tip of uterine horn; three or four portals were used for group B, and the injection set of the oviduct was inserted through the abdominal orifice of uterine tube into the oviduct to inject the simulation of embryo. The repeat laparoscopy was performed on the 21st day. Three pigs randomly selected from each groups were repeated the same procedure three times, and then were euthanized on the 21st day after the last surgery and a complete necropsy performed. Laparoscopic embryo transfer was performed successfully in all pigs without major intra-and post-operative complications. The average surgical time which accomplished procedures for groups A and B was 18.6 min (range, 28−14 min) and 37.4 min (range, 53−29 min). Postoperatively, none of pigs appeared to abnormal signs. This study demonstrated that laparoscopic embryo transfer could be easily accomplished by using the special-purpose equipment and increasing reuse time of a female recipient.

Laparoscopic abomasal cannulation in sheep

Abomasal cannulation, an important research tool in experimental procedures, provides a method for the placement of an abomasal cannula in sheep. The aim of this study was to describe a technique for laparoscopic abomasal cannulation in sheep. It was performed in six anaesthetised sheep positioned in dorsal recumbency using three portals in the abdomen. The first absorbable traction suture was placed 1 cm cranial to the determined abomasal cannula site. A stab incision was made with a laparoscopic monopolar hook electrode in the middle of a purse-string suture placed around the abomasal cannula site. The T-shaped cannula was inserted into the abomasum lumen through the stab incision, and the second traction suture was then placed 1 cm caudal to the abomasal cannula site. The T-shaped abomasal cannula was pulled out of the abdominal cavity through the exit wound located 3-5 cm lateral and 10-12 cm cranial to the right side of the umbilicus. The two traction sutures were tied. The T-shaped cannula was secured to the skin with a finger-trap suture. Repeat laparoscopy was performed 1 month later. Firm adhesion between the abomasum and abdominal wall was observed in all sheep, with no evidence of leakage or peritonitis. No major intraoperative or postoperative complications were encountered. The median surgical time was 49 min, with a range from 42 to 58 min. The abomasal contents were collected easily. In conclusion, laparoscopic abomasal cannulation is safe and easy to perform. Its low complication rates and the "ideal" placement of the tube into the abomasum make it an especially attractive alternative to traditional surgical abomasal cannulation in veterinary practice.