Small Abdominal Incision Research Articles

Comparative Study Of Proseal Laryngeal Mask Airway Versus Cuffed Endotracheal Tube In Patietns Undergoing Laparoscopic Cholecystectomy Under General Anesthesia

Background: LC is a surgical technique that uses a set of cameras and specially designed instruments to remove the gallbladder through a series of small abdominal incisions. Due to their low invasive nature, laparoscopic surgeries are considered day care procedures. As a result, patients undergoing laparoscopic procedures now get less invasive airway management, such as PLMA, rather than ETT. Nowadays, SADs are frequently employed in the control of airways, falling somewhere among tracheal tubes and face masks both in terms of structural placement and degree of invasiveness. These devices provide a hands-free approach to seal an airway against gas. The two most often utilized methods for managing airways are endotracheal intubation and LMA ProSeal The present study aimed to compare the efficacy and safety of ProSeal LMA with Endotracheal Tube in patients undergoing Laparoscopic Cholecystectomy under general anaesthesia. To compare ProSeal LMA and Endotracheal tube with respect to intra-operative haemodynamic responses in patients undergoing laparoscopic cholecystectomy under general anaesthesia. Materials and Methods: The study was carried out at the Department of Anaesthesiology, Katihar Medical College & Hospital, Katihar, Bihar, study was done for 1 Year, 60 individuals were enrolled, Group S (Study Group) with 30 patients received ProSeal LMA (PLMA) with an introducer and Group C (Control Group) with 30 patients received a cuffed Endotracheal Tube (ETT). Every variable was subjected to statistical analysis within the same individual and between 2 treatment categories using a suitable biostatistical methodology. Results:. The PLMA required fewer attempts for successful insertion compared to ETT (1.63±0.49 vs 2.03±0.89, p=0.034). NGT insertion was quicker with PLMA compared to ETT. The PLMA group showed lower EtCO2 levels at multiple time points compared to the ETT group. The PLMA group had a lower incidence of sore throat and nausea but a higher incidence of airway trauma compared to the ETT group. The PLMA group had a higher rate of device removal without complications (93.3% vs 80%) and smooth postoperative recovery (90% vs 80%) compared to the ETT group. Conclusion: In conclusion, our study demonstrates that the ProSeal Laryngeal Mask Airway (PLMA) offers several advantages over the conventional cuffed Endotracheal Tube (ETT) in patients undergoing laparoscopic cholecystectomy under general anesthesia. The PLMA was associated with easier insertion, more stable hemodynamics, effective ventilation, and a smoother postoperative course

An adult case of large defect of small mesenteric hiatal hernia causing small bowel obstruction

BackgroundSmall mesenteric hiatal hernias (SMHHs) are defined as a small group of internal hernias (IHs) that frequently diagnosed in children. However, SMHHs are relatively rare in adults. Bowel loop herniation via an abnormal mesenteric defect can lead to strangulated intestinal obstruction. Congenital SMHHs are commonly observed in pediatric patients, with some cases involving neonatal death.Case presentationA 24-year-old healthy male patient visited our hospital with a 2-day history of a sudden onset lower abdominal pain. He was initially diagnosed with enteritis. However, his symptoms worsened, and he was brought to our hospital. Contrast-enhanced computed tomography (CT) scan showed formation of a closed loop in the small intestine within the pelvis and signs of ischemia. As the patient was diagnosed with small bowel obstruction (SBO) caused by IH, emergency laparoscopic surgery was performed to loosen the obstruction. The patient was found to have ascites and small-bowel necrosis. A part of the small intestine that measured 30 cm was strangulated via a large-diameter defect (17 × 11 cm) in the ileal mesentery. Via a small abdominal incision, the necrotic bowel was resected, and the mesenteric defect was repaired.ConclusionSMHHs are rare in adults, and they should be considered as potential causes of strangulated intestinal obstruction in adults without a history of laparotomy or trauma.

Anterior retroperitoneal approach in constructing thymokidney organs in swine for xenotransplantation.

Thymokidneys (TK) have been constructed to transplant life-supporting kidney grafts containing donor thymic tissue to induce transplant tolerance. Historically, TKs were constructed by inserting pieces of thymus tissue under the kidney capsule using an intra-abdominal or posterior retroperitoneal (lateral/flank) approach. The intra-abdominal approach is technically easier but causes intra-abdominal adhesions and makes kidney procurement more challenging. The posterior retroperitoneal approach causes fewer complications, but thymus tissue implantation is technically demanding due to limited visibility and exposure of the kidney. We herein describe the anterior retroperitoneal approach that overcomes these challenges. 8-week-old GalTKO-swine (n = 2) were sedated, intubated, and draped. Cervical thymus lobes were isolated and excised. Via a small midline abdominal incision, the peritoneum was dissected bilaterally from the abdominal muscles, identifying both kidneys without entering the peritoneal cavity. Multiple thymus pieces were inserted under the kidney capsule. After 8 weeks, TKs were recovered for flow cytometric and histopathological analysis. In all kidneys, we successfully constructed TKs with functional thymus tissue under the kidney capsule, verified by histopathology and flow cytometry. No surgical complications were observed, and no adhesions were observed intra-abdominally nor around the kidney, as the peritoneum covered the implanted tissue. The anterior retroperitoneal approach to constructing thymokidneys is easy to perform, offers excellent kidney exposure, allows a larger volume of thymus tissue to be implanted, and decreases the risk of intra-abdominal adhesions. Such constructed TKs are easy to procure with minimal risk of injury to the vascularized thymus as the prerenal peritoneum covers it.

Cough and swallow after laparotomy in anesthetized cats

An anesthetized cat animal model was used to evaluate changes in cough and swallow after a small midline upper abdominal incision (laparotomy). Two additional conditions were tested: sealing the laparotomy with gentle suctioning via a small cannula, and subsequent closure of the abdominal wall with suture. These abdominal wall manipulations resulted in no changes in the cough reflex, but produced higher motor drive to pharyngeal musculature (thyropharyngeus and geniohyoid muscles) during swallow. Swallow-breathing coordination phase preference shifted towards swallow occurring more during the inspiratory phase. There were no significant changes in cough motor pattern, or cough and swallow number and temporal features. The respiratory changes were limited to reduced inspiratory motor drive to the diaphragm. The results are consistent with an important role of sensory feedback from the abdominal wall in regulation of swallow motor pattern. The level of reflex modulation may depend on the extent of injury and likely on its position in the abdomen.

Minimally invasive technique for gastric GIST at challenging locations: single incision surgical gastroscopy

Organ sparing resection of gastrointestinal stromal tumors (GISTs) located in the proximal stomach or esophagogastric junction can be challenging, resulting in proximal or total gastrectomy to facilitate a radical resection without tumor spill. We developed and evaluated a single incision surgical gastroscopy (SISG) procedure to provide a technically feasible alternative for the removal of gastric GISTs at these challenging locations. We developed an endoluminal resection of gastric GISTs through a small single abdominal incision and longitudinal ventral gastrotomy. Patients with a proximal tumor location, in whom a wedge resection was deemed challenging on pre-operative investigation were included in the current series. Safety, short-term oncological and surgical outcome were evaluated. We performed SISG in six consecutive patients with histopathological proven or suspected gastric GIST. In all patients, the procedure was performed successfully with no tumor rupture. The mean operative time was 61 min and there were no significant complications. Pathological examination showed a microscopically radical resection in all patients. Single incision surgical gastroscopy is a feasible technique with excellent short-term oncological and surgical outcomes. This technique serves as a good alternative for complicated resections for gastric GISTs at challenging locations.

8724 Routes of Specimen Extraction in Laparoscopic Surgery

<h3>Study Objective</h3> To demonstrate the operative techniques of three entry methods for in-bag, extracorporeal specimen morcellation including vaginal approach, umbilical mini-laparotomy and suprapubic mini-laparotomy. <h3>Design</h3> We present a surgical video with narration which demonstrates three entry techniques for specimen morcellation. <h3>Setting</h3> Morcellation is a surgical technique which has been used for decades to allow removal of the uterus through the vagina or smaller abdominal incisions². Electromechanical morcellation gained popularity in the early 1990s due its ease of use and efficiency, however concern for the spread of cancer cells in cases of uterine sarcomas led to the practice of manual morcellation using containment bags¹. The American College of Obstetricians and Gynecologists continues to endorse a minimally invasive approach to hysterectomy when possible if the specimen is too large to be removed intact or removing the uterus intact through an abdominal incision². <h3>Patients or Participants</h3> Patients undergoing laparoscopic hysterectomy. <h3>Interventions</h3> We demonstrate three entry routes for manual uterine morcellation: vaginally following colpotomy, umbilical mini-laparotomy and suprapubic mini-laparotomy. <h3>Measurements and Main Results</h3> Specimen extraction via minimally invasive routes. <h3>Conclusion</h3> Vaginal entry following colpotomy, umbilical mini-laparotomy and suprapubic mini-laparotomy are three safe, effective entry methods for the morcellation of large, fibroid uteri which offers a minimally invasive approach for the removal of uterine specimens following laparoscopic hysterectomy.

Impact of Intraoperative Tumor Spillage in Uterine Leiomyosarcoma: a Retrospective Single-Institution Analysis.

Uterine leiomyosarcoma is a rare female reproductive system tumor which is difficult to distinguish from uterine leiomyoma preoperatively. Manual and power morcellation are used to remove the large uterus through the vagina or small abdominal incision. Worse outcome with use of power morcellation is now clear but impact of manual morcellation on survival outcome not established till date. The objective of the present study was to find impact of tumor spillage and to evaluate influencing factors for oncological outcome and prognosis in uterine leiomyosarcoma patients. This is a single-institutional retrospective cohort study including all uterine leiomyosarcoma patients from January 2005 to December 2017. Role of intraoperative tumor spillage and other influencing factors on oncological outcome were assessed. Thirty-three patients with median follow-up period of 49.7months were evaluated. Stage 1 and absence of tumor spill had significant association with prolonged progression-free survival. Stage 1 uterine leiomyosarcoma (56.8 vs 6.8months, p = < 0.001), intraoperative tumor spillage (p = 0.03) and progression-free survival > 15months (68.5 vs 12.2months, p = < 0.001) were favourable prognostic factors to predict better survival outcome but unable to establish significance on multivariate analysis. Survival plot did not reach median limit for stage I uterine leiomyosarcoma patients with preoperative suspicion. Age, site of recurrence and mitotic index had no significant association with better survival in the present study. Stage I disease and absence of tumor spillage during surgery improved progression-free survival but did not affect overall survival. Progression-free survival more than 15months can predict better overall survival.

Laparoscopic Partial Resection of the Urinary Bladder for Colorectal Cancers With Suspected Urinary Bladder Invasion

Introduction Although partial cystectomy has been performed by laparoscopy in patients with benign disease, there have only been a few reports regarding the laparoscopic partial resection of urinary bladder–adherent colorectal cancer. This study was conducted to evaluate the short-term surgical outcomes of laparoscopic partial resection of urinary bladder–adherent colorectal cancer. Case presentation Between April 2014 and February 2017, 6 patients with colorectal cancers that were adherent to the urinary bladder underwent laparoscopic colorectal cancer resection combined with partial cystectomy. Their surgical outcomes were reviewed retrospectively. The primary colorectal cancer was located in the sigmoid colon in 5 patients and the upper rectum in 1 patient. None of the patients required conversion to open surgery. The median duration of surgery was 411 minutes, and the median amount of intraoperative blood loss was 284 mL. In the patients with sigmoid colon cancer, the bladder was primarily closed under direct visualization via the small lower abdominal incision used to remove the tumor. In the patient with upper rectal cancer, the bladder was primarily closed laparoscopically. None of the patients demonstrated urinary leakage on retrograde cystography or anastomotic leakage, and there were no cases of perioperative mortality or morbidity. None of the patients developed recurrence of cancer at the median follow-up of 21 months. Conclusion Laparoscopic partial resection of urinary bladder–adherent colorectal cancer produces good short-term outcomes without increasing morbidity. Performing bladder closure under direct visualization via a small lower abdominal incision might be useful in selected patients.

Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy.

Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy.

Minimally Invasive Open Conversion for Late EVAR Failure

With the increasing use of endovascular aortic aneurysm repair (EVAR), open repair after aortic stent grafting is of growing interest. The surgical conversion treatment may be a very challenging process with high mortality and in-hospital complication rates. The aim of this article is to present our experience in patients with EVAR failure treated by minimally invasive open conversion (MOC) and its technical aspects. A retrospective study was conducted on a prospectively compiled computerized database of consecutive patients treated by MOC at our institution between May 2014 and June 2018. Indications for treatment were endoleaks with sac growth at least >5mm in the last 6months and failure of previous endovascular tentative for aneurysm sealing. Demographics of the patients, reason for conversion, previous endovascular procedures, surgical outcomes, and survival were reviewed. MOC was performed by a small abdominal incision, infrarenal clamping, and partial explantation of the endograft in all patients. A total of 10 patients were treated during the study period. The mean interval to MOC after EVAR was 45.1months (range, 14-128). Indications for MOC included type Ia endoleak in three patients (30%), persistent type II EL in four (40%), and type III EL in one patient (10%), indeterminate or type V EL in two (20%). At 30 days, no deaths or reinterventions were reported, and major complication rate was 10% (one postoperative pneumonia). At mean follow-up of 22.9±15.9months, no reinterventions were described. Death rate was (20%) with one aneurysm-related death (10%) for graft infection 32months after MOC and one (10%) cardiac event at 18months. Despite the potential high risk of open conversion, MOC appears to be a safe surgical solution for EVAR failure. This potentially challenging operation may be improved with minimally invasive techniques that are presented.

Needlescopic surgery for very low rectal cancer with no abdominal skin incision.

Needlescopic surgery (NS) is a minimally invasive operation beyond traditional laparoscopic surgery. This study aimed to describe NS for intersphincteric resection (ISR) and abdominoperineal resection (APR) for low rectal cancer without a small abdominal skin incision for extracting the specimen and to evaluate the safety and feasibility of the operation. From January 2011 to April 2016, 36 patients underwent NS for either ISR or APR. By definition, NS for ISR or APR at our institution uses three 3-mm ports and two 5-mm ports at the umbilicus and in the right lower quadrant. The specimen was extracted through the anus or the perineal wound. The feasibility of this operation was determined based on short-term outcomes and pathological findings. No patients required conversion to open surgery. The mean operation time was 299 minutes, and the mean estimated blood loss was 30 mL. Postoperative complications higher than Clavien-Dindo grade III occurred in 2.8% of patients (n = 1). The median number of harvested lymph nodes was 16 (range, 0-30), and in no case was there a positive circumferential resection margin. Needlescopic surgery for ISR or APR is technically safe and feasible for low rectal cancer based on the short-term outcomes and the oncological quality, particularly when compared to conventional laparoscopic surgery as described in previous reports.

Autologous transobturator midurethral sling.

The aim of this study is to describe a novel transobturator midurethral sling surgery technique by using rectus abdominis fascia. A 54-year-old woman complaining of urinary leakage during effort was diagnosed as pure stress urinary incontinence after detailed questioning, pelvic examination, uroflowmetry and measurement of residual urine volume. She was anxious about complications related to synthetic meshes. However, she was not interested in relatively morbid surgeries such as colposuspension and pubovaginal sling. Autologous transobturator midurethral sling was discussed with the patient. The patient approved the surgery and the surgery was planned. A 5 cm rectus fascia was harvested via suprapubic incision and non-absorbable stay sutures were placed on its' both edges. Anterior vaginal incision together with paravaginal dissection was performed, as in classical transobturator sling surgery. Groin puncture and blind dissection of adipose tissue was performed. C-shaped trocars were inserted, and advanced through groin punctures and brought up to midurethral incision by finger guidance. Stay sutures were transported via C-shaped trocars to the groin puncture in both sides. Graft was positioned on the midurethral part without any tension and stay sutures were tied to create a tissue bridge on obturator membrane. Incisions were closed and vaginal tampon was placed. Patient was discharged at the first postoperative day. At postoperative third and sixth months, patient was totally dry and did not have any voiding complaints. Small abdominal and vaginal incisions were clean, as well. Autologous transobturator midurethral sling surgery is a safe, effective and feasible surgical option for stress urinary incontinence in the era which mesh-related concerns are rising. Studies with larger volume and long-term follow up periods are needed.

Effective Treatment for Incarcerated Obturator Hernia With Bowel Dilatation by Combined Laparoscopy and Preperitoneal Approach: A Case Report

Background: We report a case of a 90-year-old woman with intestinal obstruction due to left-sided incarcerated obturator hernia, which was revealed using computed tomography. Methods: Emergency surgerywas performed using laparoscopy, which showed a dilated small intestine and bilateral obturator hernia in the intraperitoneal space. After reducing incarceration of the small intestine using laparoscopy, we approached the bilateral preperitoneal space and inserted a Kugel patch via a small lower abdominal median incision (approximately 4 cm). Results: The patient was discharged on postoperative day 10 and showed no recurrence at the 18-month follow-up. Although relatively rare, obturator hernia can significantly cause intestinal obstruction. It has no specific clinical symptoms and is thus often difficult to diagnose. Treating obturator hernia is essential; however, mesh infection, recurrence, and opposite side of the obturator hernia should be carefully monitored. Conclusions: Although laparoscopy is used for treating obturator hernia, it may be difficult in patients with intestinal obstruction. In this case, a surgical technique combining laparoscopy and preperitoneal space approach via a small lower abdominal median incision was used to effectively treat an incarcerated occult bilateral obturator hernia.

Study on the Application and Classifcation of the Laparoscopy Pouch

With the development of minimally invasive surgery, many open surgery has been replaced by intracavity surgery. In laparoscopic surgery, an electric fibroid morcellator must be used to remove large tissue specimens from a small abdominal incision. Of course, there are some complications in the use, in order to follow the principle of no tumor, the doctor used the laparoscopic pouch in clinical operation to reduce the risk of spreading potential tumor tissue. There are various kinds of pouches, which are classified according to their existing state before use, it can be classified into two categories:overlapping and non-overlapping. The advantages and disadvantages of different bags and pockets are also analyzed. It provides a theoretical basis for technological innovation and equipment improvement.

Autologous Rectus Fascia Graft Interposition Repair of Urethrocutaneous Fistulae in Female-to-Male Metoidioplasty Patients

To describe our technique and outcomes using an autologous rectus fascia interposition graft for repair of recurrent urethrocutaneous fistulae (UCF) following metoidioplasty. A circumferential incision is made to the skin surrounding the UCF and carried to the level of the underlying subcutaneous tissues. The inner fistula skin edges are closed with a running 5-0 monofilament absorbable suture to obliterate the urethral side. The length of the urethral wound is measured and an appropriate sized rectus fascia graft harvested from a small transverse lower abdominal incision that is also used for concomitant percutaneous suprapubic tube placement. Prior to outer skin closure with a running 5-0 monofilament absorbable suture, the fascial graft is spread-fixed between the urethra and skin to avoid overlapping suture lines. A 10-French urethral catheter is removed after 10 days and the suprapubic catheter removed after 2-3 weeks. Three patients have undergone repair of recurrent UCF with this technique since February 2017. All patients had undergone metoidioplasty with a mean time to fistula occurrence of 3.2 months. Mean number of prior UCF repairs was 3.0. With a median follow-up since repair of 7.0 months (range 4-8), no patient has reported UCF recurrence. UCF following metoidioplasty is a difficult surgical complication. Fistula closure with interposition of autologous rectus fascia allows for separation of suture lines and encourages healing without extensive reconstruction.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant: Our Experience of Two Patients

Study ObjectiveTo report the first ever laparoscopic-assisted live donor uterus retrieval in 2 patients for uterus transplant. DesignCase study (Canadian Task Force classification III). SettingGalaxy CARE Laparoscopy Institute, Pune, India. PatientsTwo patients with absolute uterine factor infertility with their mothers as donors. InterventionsIn vitro fertilization and uterine transplant. Measurements and Main ResultsA 12-member team was formed, and approval for transplant was obtained from the institutional review board. Pretransplant, in vitro fertilization for both patients was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus and harvested vessels were retrieved by a small abdominal incision to prevent injury and infection. The uterus was transplanted in the recipients by end to side anastomosis of the harvested vessels to external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 6 months were measured. Operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. Recipient surgery time was 4 hours. There were no intraoperative or immediate postoperative complications. Both the recipients started menstruating after 34 days and 48 days, respectively, and have had 6 cycles of menses at regular intervals. Uterine artery Doppler showed good flow in both patients. Hysteroscopy-guided cervical biopsies were used as a method of surveillance of graft rejection after uterine transplant. Office hysteroscopy was done after 2 months in both patients, and hysteroscopy-guided endometrial and cervical biopsies were taken. Minimal slough was seen on the endometrium in the patient with Mayer-Rokitansky-Küster-Hauser syndrome, which was removed. Repeat hysteroscopy after 10 days showed a healthy endometrium. ConclusionsLaparoscopic-assisted uterus donor retrieval is feasible and affords all the advantages of a minimally invasive technique, thereby reducing the morbidity of the procedure. It helps in better dissection of the vessels, shortens the operative time, and helps to minimize tissue handling of the harvested uterus and vessels.

Surgical specimen extraction via a prophylactic ileostomy procedure: A minimally invasive technique for laparoscopic rectal cancer surgery.

AIMTo retrospectively evaluate the safety and feasibility of surgical specimen extraction via a prophylactic ileostomy procedure in patient with rectal cancer.METHODSWe systematically reviewed 331 consecutive patients who underwent laparoscopic anterior resection for rectal cancer and prophylactic ileostomy in our institution from June 2010 to October 2016, including 155 patients who underwent specimen extraction via a prophylactic ileostomy procedure (experimental group), and 176 patients who underwent specimen extraction via a small lower abdominal incision (control group). Clinical data were collected from both groups and statistically analyzed.RESULTSThe two groups were matched in clinical characteristics and pathological outcomes. However, mean operative time was significantly shorter in the experimental group compared to the control group (161.3 ± 21.5 min vs 168.8 ± 20.5 min; P = 0.001). Mean estimated blood loss was significantly less in the experimental group (77.4 ± 30.7 mL vs 85.9 ± 35.5 mL; P = 0.020). The pain reported by patients during the first two days after surgery was significantly less in the experimental group than in the control group. No wound infections occurred in the experimental group, but 4.0% of the controls developed wound infections (P = 0.016). The estimated 5-year disease-free survival and overall survival rate were similar between the two groups.CONCLUSIONSurgical specimen extraction via a prophylactic ileostomy procedure represents a secure and feasible approach to laparoscopic rectal cancer surgery, and embodies the principle of minimally invasive surgery.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant

Study ObjectiveThe authors present the first ever laparoscopic-assisted uterus retrieval in a live donor for uterus transplant. DesignA step-by-step surgical demonstration. SettingGalaxy CARE Laparoscopy Institute, Pune, India. PatientsTwo patients, ages 21 and 26 years, with Mayer-Rokitansky-Küster-Hauser syndrome and Asherman syndrome, respectively, with their mothers as donors. InterventionsA 12-member team was formed. After a review of the available literature on uterine transplant, a protocol was formulated and submitted to the Institutional Review Board (IRB). Approval from the Institutional Review Board was obtained. Thorough screening of the candidates was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus was retrieved through a small abdominal incision, to prevent any injury to the uterus and harvested vessels. Uterus was transplanted in the recipients by end-to-side anastomosis of the harvested vessels to the external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Measurements and Main ResultsSurgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 4 months. The operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. The recipient surgery was completed in 4 hours. There were no intraoperative or immediate postoperative complications. Both recipients started menstruating after 34 days and 48 days, respectively, and have had 3 cycles of menses at regular intervals to date. After discharge, follow-up cervical biopsies at 3 weekly intervals showed no signs of rejection. Uterine artery Doppler ultrasound showed good flow in both patients. ConclusionLaparoscopic-assisted donor retrieval is feasible and affords all advantages of a minimally invasive technique. It helps in better dissection of vessels, shortens the operative time, and helps minimize tissue handling, thereby reducing the morbidity of the procedure.

Protective measures in laparoscopic resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery

To introduce the use of a self-made specimen protective sleeve in laparoscopic resection for upper or mid rectal cancer and sigmoid colon cancer with transrectal specimen extraction surgery and the improvement of implantation method, so as to avoid and reduce bacterial contamination and tumor cell dissemination in abdominal cavity. During June 2015 and May 2017, 48 cases of high located rectal or sigmoid colon cancer were operated laparoscopically with natural orifices specimen extraction surgery (NOSES) using a self-made specimen protecting sleeve. Operation indication: (1) Rectum and sigmoid colon cancer with the distance of more than 6 cm from tumor inferior margin to dentate line. (2) The maximum diameter of intestine together with mesangial and tumor <7 cm by intraoperative judgment. (3) No anal and distal rectal surgery, no anorectal stenosis or lack of expansion capacity caused by trauma. (4) No ulcerative colitis, Crohn's disease or radiation proctitis. After transecting the rectum, the specimen protective sleeve was inserted through the right lower 12 mm main Trocar (This sleeve was tailored from the laparoscopic protective sleeve produced by China 3L Corporation, which was intercepted with 25-35 cm from one end of the sleeve according to the length of distal rectal retention. One end was ligated and the other was open with a ligature band. About 5 ml paraffin oil was used to rinse and lubricate during the operation). The rectal stump retained 7-8 cm in abdominal cavity. The transanal ligation part of the protective sleeve was cut off, then the stapler nail seat was inserted and specimen was pull out through the sleeve and rectum. There were 30 males and 18 females. The average age was (64.5±14.1) years, the BMI was (25.4±3.9) kg/m2, the tumor diameter was (3.3±1.1) cm, the maximum diameter of specimen was (5.4±1.5) cm and the length of specimen was (18.6±4.3) cm. Among these 48 cases, specimens of 36 patients were pulled out through inside of the sleeve easily, while specimens of 12 patients were quite difficult with resistance. Of 12 cases, 7 needed the help of transverse forceps, 4 needed to make 1 cm incision in pull-through bowel and insert a suction to decrease the volume of large specimens with gathering of gas and fluid, and 1 received small abdominal incision to remove specimen and perform intestinal reconstruction due to big specimen (the diameter of tumor and mesentery was 7.5 cm). Specimen tears of 6 patients didn't result in dissemination thanks to the specimen protecting sleeve. The operation time was (113.2±76.1) min, the bleeding amount was (38.5±17.3) ml, the time to first oral intake was (47.9±4.4) h, and the postoperative hospitalization length was (8.5±1.7) d. Anastomotic leakage occurred in 1 case (2.1%). No intra-abdominal and trocar infection, and obstruction were found. The use of protective sleeve and the improvement of the method of intraperitoneal implantation can effectively reduce the abdominal contamination during the specimen extraction. It can be applied to big specimens as well.

Strategy and technique for simultaneous resection of rectal cancer and liver metastasis

Rectal cancer with simultaneous liver metastasis is very common clinically. R0 surgical resection both for the original and metastatic tumor can achieve much better long-term oncological results. The operation types include traditional open procedures for both rectal cancer and liver metastatic resection; combination of laparoscopic resection of the rectal cancer and open procedure resection of the liver metastatic lesion; traditional laparoscopic-assisted rectal and liver metastatic tumor resection with small abdominal incision and total laparoscopic natural orifice specimen extraction surgery(NOSES) without abdominal incision. Due to the complexity of rectal anatomy and treatment strategy, leading to the difference from colon cancer with liver metastasis, and due to the effect of laparoscopic treatment, especially the 3D laparoscopy, patient selection for simultaneous resection should be well planned and individualized by surgeons based on conditions of themselves and patients.