Specimen Extraction Site Research Articles

Incisional hernia rate after laparoscopic colorectal resection is reduced with standardisation of specimen extraction.

Incisional hernia is a common complication of laparoscopic colorectal surgery. Extraction site may influence the rate of incisional hernias. Major risk factors for the development of incisional hernias include age, diabetes, obesity and smoking status. In this study, we investigated the effect of specimen extraction site on incisional hernia rate. Two cohorts of patients who underwent laparoscopic colorectal resections in a single centre in 2005 (n=85) and 2009 (n=139) were studied retrospectively. In 2005 all specimens were extracted through transverse muscle cutting incisions. In 2009 all specimens were extracted through midline incisions. Demographic variables, rate of incisional hernias and risk factors for hernia development were compared between the year groups. All patients had been followed up clinically for two years. A total of 224 patients (mean age: 67.5 years, standard deviation: 16.35 years) were included in this study. Of these, 85 patients were in the 2005 transverse group and 139 were in the 2009 midline group. The total incisional hernia rate for the series was 8.0% at the two-year follow-up visit. For the 2005 group, the incisional hernia rate was 15.3% (n=13) and for the 2009 group, it was 3.6% (n=5) (p<0.01). The body mass index was higher in patients who developed incisional hernias than in those who did not (p=0.02). The 2005 group had a significantly higher incisional hernia rate than the 2009 group. This is due to the differences in the incision technique and extraction site between the two groups.

Prospective assessment of trocar-specific morbidity in laparoscopy.

The purpose of the present study was to challenge the hypothetical advantage of single port laparoscopy (SPL) over conventional laparoscopy by measuring prospectively the morbidity specifically related to conventional trocar sites (TS). From November 2010 to December 2011, 300 patients undergoing various laparoscopic procedures were enrolled. Patient, surgery, and trocar characteristics were recorded. We evaluated at three time points (in-hospital and at 1 and 6 months postoperatively) specifically for each TS, pain (Visual Analog Scale), morbidity (infection, hematoma, hernia), and cosmesis (Patient Scar Assessment Score; PSAS). Patients designated their "worst TS," and a composite endpoint "bad TS" was defined to include any adverse outcome at a TS. We analyzed 1,074 TS. Follow-up was >90 %. Pain scores of >3/10 at 1 and 6 months postoperatively, were reported by 3 and 1 % of patients at the 5 mm TS and by 9 and 1 % at the larger TS, respectively (5 mm TS vs larger TS; p = 0.001). Pain was significantly lower for TS located in the lower abdomen than for the upper abdomen or the umbilicus (p = 0.001). The overall complication rate was <1 % and significantly lower for the 5 mm TS (hematoma p = 0.046; infection p = 0.0001). No hernia was found. The overall PSAS score was low and significantly lower for the 5 mm TS (p = 0.0001). Significant predictors of "bad TS" were larger TS (p = 0.001), umbilical position (p = 0.0001), emergency surgery (p = 0.0001), accidental trocar exit (p = 0.022), fascia closure (p = 0.006), and specimen extraction site (p = 0.0001). Specific trocar morbidity is low and almost negligible for 5 mm trocars. The umbilicus appears to be an unfavorable TS.

Laparoscopic resection of synchronous colorectal cancers in separate specimens.

Laparoscopic approaches are increasingly being used in patients with colorectal cancer, but the feasibility of laparoscopic resection of synchronous colorectal cancers in separate specimens remains unknown. In such cases, it is necessary to consider the site of port placement, sequence of dissection, choice of specimen extraction sites, specimen handling, and extracorporeal anastomosis sites. Moreover, the need for complete mesenteric dissection in two areas, removal of two separate specimens containing malignancies, and two anastomoses elicit unique questions related to technical considerations. The aim of this study was to determine the feasibility of laparoscopic resection of two separate specimens containing malignancies for multiple synchronous colorectal cancers. Between June 2001 and January 2013, 1341 patients with colorectal cancer underwent laparoscopic surgery at our institution. Of them, 11 patients underwent laparoscopy-assisted combined resection of two separate colorectal specimens for multiple synchronous primary colorectal cancers. We retrospectively reviewed their surgical outcomes. All procedures were completed laparoscopically without perioperative mortality. Patients underwent right-sided colon resection for right-sided cancer and left-sided or rectal resection for left-sided colon or rectal cancer. The median duration of surgery was 296 min, and the median blood loss was 65 mL. Median time to first postoperative liquid and solid intake was 1 day and 3 days, respectively. Most patients were discharged on postoperative day 8. With regard to postoperative complications, two patients had a surgical-site infection. Laparoscopic resection of two separate colorectal specimens for multiple synchronous primary colorectal cancers is a feasible and safe procedure.

Multivariate analysis of risk factors for surgical site infection after laparoscopic colorectal surgery

Surgical site infection (SSI) and incisional hernia (IH) are among the most common complications after colorectal surgery. While many risk factors for these complications are unavoidable, evidence suggests that use of Pfannenstiel incisions for specimen extraction during laparoscopic procedures may reduce their incidence. The objectives of this study were to identify risk factors for extraction site SSI (primary objective) and IH (secondary objective) in patients undergoing laparoscopic colorectal surgery. Patients who underwent laparoscopic colorectal resections at The Ohio State University Wexner Medical Center between January 2006 and October 2012 were included. In addition to reviewing medical records, data were gathered from patient questionnaires with a focus on two end points: extraction site SSI and IH. Univariate logistic regression analysis was performed to identify significant associations between the two end points and the following variables: age, gender, ASA (American Society of Anesthesiologists) score, cancer, inflammatory bowel disease (IBD), body mass index (BMI), diabetes, chronic obstructive pulmonary disease, use of immunosuppressant medications, chemotherapy, radiation therapy, smoking, surgical history, surgery duration, duration of follow-up, use of hand-assistance, and utilization of Pfannenstiel incisions for specimen extraction. Multivariate analysis was performed for significant variables. A total of 419 patients met the inclusion criteria. The incidence of SSI was 10.3%. Higher BMI, presence of IBD, younger age, and hand-assisted procedures were associated with a significantly higher risk of SSI. Use of Pfannenstiel extraction sites was associated with lower infection rates; however, this association was not statistically significant. IBD, BMI, and hand-assistance were statistically significant on multivariate analysis. Odds ratios for SSI with IBD, hand-assistance and BMI (per unit increase) were 3.3, 2.2, and 1.06, respectively. Alterations in surgical technique and specimen extraction site can reduce wound-related complications after laparoscopic colorectal resections. Remaining risk factors are largely nonmodifiable from a surgeon's perspective.

Robotic surgery techniques for obese patients

The current article reviews a single surgeon, single institution robotic assisted radical prostatectomy (RARP) outcomes of 153 cases in which outcomes were stratified based on the World Health Organization cutoff body mass index (BMI) values for normal-weight, overweight and obese.1 Significant findings included increased length of stay (4.3 vs. 2.9 days) during the initial 50 cases, however this was not observed when analyzing the entire cohort. Unfortunately, there is no clear explanation as to why obese men had a prolonged hospital stay during the initial learning curve. Overall operating room time and blood loss were statistically comparable between the 2 groups, however a trend toward increased values was seen in the obese cohort. Recently, Wiltz and colleagues reported on their evaluation of BMI impact on perioperative functional and oncological outcomes in a large RARP cohort.2 In their study, 945 men were included with all patients evaluated with the UCLA-PCI-SF36v2 validated, quality-of-life questionnaire preoperatively and postoperatively to 24 months. A similar BMI stratification was used for outcomes analysis. Their data demonstrated that, preoperatively, obese men had a significantly greater percentage of medical comorbidities (p < 0.01) as well as a baseline erectile dysfunction (lower mean baseline SHIM score p = 0.01] and UCLA-PCI-SF36v2 sexual function domain scores [p = 0.01]). Compared with the current study, the Wilts study demonstrated that operative time was significantly longer in obese patients when compared with normal and overweight men (234 min vs. 217 min vs. 214 min; p = 0.0003). This result was particularly pronounced during the initial 100 robotic-case experiences. No difference in mean hospital stay was noted. Although overall complication rates were comparable between groups, a greater incidence of case abortion caused by pneumoperitoneal pressure with excessive airway pressures was noted in obese men. Interestingly, urinary continence and potency outcomes were significantly lower for obese men at both 12 and 24 months (all p < 0.05). The authors conclude that surgeons early in their RARP learning curve should proceed cautiously with surgery in these technically more difficult patients or reserve such cases until the learning curve has been surmounted. These details, including inferior urinary and sexual outcomes, should be discussed with obese patients during preoperative counselling. Minimally invasive radical prostatectomy (MIRP) in obese men can be more challenging for several technical reasons. These include the potential for restricted instrument range of motion and reach due to a thicker abdominal wall (Fig. 1), as well as decreased intra-pelvic working space due to increased omental fat. Troubleshooting due to excess subcutaneous fat and/or visceral fat can help explain the increase in surgical time. Newer generations of the DaVinci console, with longer instrument reach, may help minimize such limitations. Exposure and closure of the specimen extraction site are often challenging in obese men. Moreover, variation in equipment (bariatric instruments and longer trocars) is often required. Fig 1 Impact of abdominal wall thickness (skin to peritoneal distance) on trocar range of motion. A) In the lean male, the rigid trocar has a greater range of motion with less tissue resistance compared to B) male with thick “belly fat” which ... Unfortunately, when using BMI to group patients into obesity categories (which is often the case in published MIRP outcomes series), one must be aware of the limitations of this measure.3 In essence, BMI assesses the entire body mass without differentiating between its components, namely muscle, visceral fat, subcutaneous fat, bone and fluid. It does not help specify those men with thick abdominal walls or those with excess omental/visceral fat. Waist-to-hip ratio (WHR) and waist circumference (WC) are other simple measurements to determine obesity. Waist circumference, 1 of the 5 specific criteria of the metabolic syndrome, has an important advantage over BMI; WC can be appreciated after a patient commits to resistance exercise or weight training. An increase in muscle mass from exercise can actually cause an increase in BMI (and actually facilitate MIRP). However, this does not occur when using WHR or WC. These measures, more so in WHR, better reflect an increase in visceral fat and a relative lack of gluteal muscle.4 Because WHR and WC are more sensitive markers for central obesity, they may better indicate risk associated with obesity with robotic surgical outcomes. Future studies should be encouraged to confirm the consistency of these results in RARP patients.

Port-Site Metastasis After Robot-Assisted Partial Nephrectomy

Introduction: With the increasing use of minimally invasive techniques in the management of urologic malignancies, reports of port-site metastasis (PSM) have raised concerns regarding the oncologic safety of these approaches.1 The first urologic PSM was reported in 1994, after lymph node dissection for bladder transitional cell carcinoma.2 Using multi-institutional, international data, an estimate for the incidence of PSM in urologic surgery has been reported to be 0.09%,3 and a contemporary review found 51 cases of urologic PSM reported in literature.4 However, renal cell carcinomas (RCC) represent a minority of these reported cases (8/51), and none occurred after robot-assisted partial nephrectomy (RAPN). We present a video describing our case of RCC-PSM after RAPN and demonstrating our technique for laparoscopic resection of the recurrent mass. Patients and Methods: In October 2011, a 68-year-old man underwent RAPN for an incidentally discovered 4-cm right renal mass with a nephrometry score of 10a. At no point during the resection was the mass violated. The final pathology demonstrated a 3.9-cm solid, Fuhrman grade III, clear-cell RCC with negative margins. In March 2012, routine follow-up CT scan revealed a 1.7-cm mass located on the abdominal wall, associated with an RAPN port site, and no other evidence of disease recurrence. Of note, the involved port site was the camera port site, not the specimen extraction site. The patient was completely asymptomatic. Ultrasound-guided biopsy demonstrated metastatic RCC, and in the absence of other metastatic disease, the patient was scheduled for resection of the PSM. With the patient in the left lateral decubitus position, a retroperitoneal approach was used to facilitate visualization of the intraperitoneal PSM. Once the retroperitoneal space was developed, the peritoneum was entered. The mass was well visualized and was circumferentially excised with wide margins. The mass was placed in an entrapment sack. The posterior rectus fascia was reinforced with a 2-0 polygalactin suture, which was secured with Weck Hem-o-lok clips (Teleflex, Research Triangle Park, NC). Hemostasis was ensured as the insufflation pressure was decreased to five mmHg, and the specimen was extracted, and the port-sites were closed. Results and Conclusions: The total operative time was 76 minutes, with a minimal (<10 mL) blood loss. The patient tolerated the procedure well and was discharged home on postoperative day one. The final pathology of the PSM demonstrated a 3.4-cm clear-cell RCC, granular variant, with negative margins. At present, one-month follow-up CT scan has demonstrated no evidence of disease recurrence or metastasis. The patient will be followed closely, with planned repeat imaging in six months. Although technique-related factors pertaining to specimen extraction have been implicated as a cause of PSM, our patient experienced recurrence at the camera port site, underscoring the importance of tumor and local wound-related factors in PSM. Several studies have also suggested that insufflation/desufflation during laparoscopic surgery may have an impact on the movement of tumor cells within the peritoneal cavity, potentially causing implantation at the port sites.5,6 Laparoscopic resection is a feasible minimally invasive alternative to open excision of PSM. No competing financial interests exist. Runtime of video: 5 mins 30 secs

Intracorporeal ileocolic anastomosis: a review

This study is a narrative review of the current literature regarding intracorporeal ileocolic anastomosis in laparoscopic right colon resection for benign or malignant diseases of the right colon and terminal ileum. The search strategy included Medline, Embase, CINAHL, ACP Journal Club, and Cochrane databases with laparoscopic right colectomy and intracorporeal anastomosis as keywords. All retrieved references were screened by two independent blinded reviewers. Thirteen papers including 611 patients undergoing laparoscopic right colon resection with intracorporeal ileocolic anastomosis for benign or malignant diseases of the right colon and terminal ileum were identified. There were eight case series and five case control studies. Anastomoses were fashioned as antiperistaltic or isoperistaltic, totally stapled or stapled/handsewn. The mesenteric defect was mostly left open. Overall operating time ranged from 53 to 360 min. The most common specimen extraction site locations were periumbilical, suprapubic, or transvaginal with a median incision length ranging from 3 to 6 cm. The overall rate of surgical site infection was 2.7 %. The anastomotic leak rates varied from 0 to 8.5 %. Postoperative mortality was 0.12 %. Intracorporeal ileocolic anastomosis following laparoscopic resection of the right colon is not commonly performed, but offers potential benefits if carried out by experienced surgeons in selected patients.

Colorectal natural orifice transluminal endoscopic surgery (NOTES) and transvaginal/transrectal specimen extraction

Advancements in minimally invasive surgery have both revolutionized laparoscopy and set the stage for the advancement of endoscopic surgery to the forefront of modern medicine. Natural orifice transluminal endoscopic surgery (NOTES) has now become a subject of great interest to surgeons worldwide who wish to reduce the morbidity associated with abdominal operations. However, the application of NOTES to colorectal surgery has thus far been limited due to the complex dissection, anastomosis and specimen extraction typically required when operating on the large bowel. For this reason, laparoscopic-assisted natural orifice surgery has been the means by which most surgeons have begun to incorporate natural orifice surgery into their established practices. Transanal endoscopic surgery, transvaginal-assisted laparoscopy and transrectal specimen extraction are all emerging techniques that may be currently employed, in a hybrid manner, with traditionally accepted laparoscopic operations in order to transition toward less invasive surgery and even pure NOTES. To this end, the vagina appears to be the most practical and widely used site of specimen extraction and adjunct access site for laparoscopic hybrid operations. An accompanying video demonstrates the authors' preferred technique for transvaginal and transrectal specimen extraction.

Left-Sided Ileostomy at Specimen Extraction Site in Laparoscopic-Assisted Low Anterior Resection for Rectal Cancer

Prophylactic ileostomy is usually created at the right lower quadrant (RLQ) because of its vicinity to the ileocecal valve. In the laparoscopic procedure, however, another wound is required for stoma, resulting in a scar after takedown. This study assessed the feasibility of left-sided ileostomy (LI) at the specimen extraction site in laparoscopic-assisted low anterior resection (LAR) for rectal cancer. One hundred five patients underwent laparoscopic LAR with diverting ileostomy for rectal cancer. Among them, 82 (78.1%) received preoperative chemoradiotherapy (CRT). Diverting stomas were created in the RLQ in 49 (46.7%) and in the left lower quadrant in 53 patients (53.3%). We compared surgical morbidity and recovery data between the right-sided ileostomy (RI) and LI groups. The two groups were similar with regard to age, sex, type of CRT, distance from the anal verge, and TNM stage. Parastomal hernia developed in 3 patients (1 in RI, 2 in LI) and postoperative ileus in 10 patients (4 in RI, 6 in LI). The frequency of complications showed no difference between the two groups (10.2% in RI, 14.3% in LI; P=.53). There was also no difference in terms of time to resumption of regular diet (2.9 versus 3.2 days; P=.25) or length of hospital stay (7.9 versus 7.7 days; P=.61). LI in laparoscopic LAR was not associated with increased postoperative morbidity or delay in postoperative recovery. Because it can provide better cosmesis, it would be a possible option for diversion in laparoscopic LAR.

Laparoscopic right colon resection with intracorporeal anastomosis

This study was performed to evaluate short-term clinical outcomes of laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon. This was a retrospective study of selected patients who underwent laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon for tumors or Crohn's disease by a single surgeon from July 2002 through June 2012. Data were retrieved from an Institutional Review Board-approved database. Study end point was postoperative adverse events, including mortality, complications, reoperations, and readmissions at 30 days. Antiperistaltic side-to-side anastomoses were fashioned laparoscopically with a 60-mm-long stapler cartridge and enterocolotomy was hand-sewn intracorporeally in two layers. Values were expressed as medians (ranges) for continuous variables. There were 243 patients (143 females) aged 61 (range = 19-96) years, with body mass index of 29 (18-43) kg/m(2) and ASA 1:2:3:4 of 52:110:77:4; 30 % had previous abdominal surgery and 38 % had a preexisting comorbidity. There were 84 ileocolic resections with ileo ascending anastomosis and 159 right colectomies with ileotransverse anastomosis. Operating time was 135 (60-220) min. Estimated blood loss was 50 (10-600) ml. Specimen extraction site incision length was 4.1 (3-4.4) cm. Conversion rate was 3 % and there was no mortality at 30 days, 15 complications (6.2 %), and 8 reoperations (3.3 %). Readmission rate was 8.7 %. Length of stay was 4 (2-32) days. Pathology confirmed Crohn's disease in 84 patients, adenocarcinoma in 152, and other tumors in 7 patients. Laparoscopic intracorporeal ileocolic anastomosis following resection of the right colon resulted in a favorable outcome in selected patients with Crohn's disease or tumors of the right colon.

High incidence of symptomatic incisional hernia after midline extraction in laparoscopic colon resection

The incidence of incisional hernia has not decreased despite the use of laparoscopy for colon resections. The objective of this study is to evaluate the impact of the incision used for specimen extraction on the incidence of incisional hernia after laparoscopic colectomy. Patients who underwent laparoscopic colectomy without stoma at a single university tertiary-care centre from 2003 to 2009 were identified from an operating room database. Patients were contacted by telephone for participation, and underwent physical examination ± ultrasonography for incisional hernia at the specimen extraction site and completed the Body Image Questionnaire. Specimen extraction incisions were classified into midline, transverse and Pfannenstiel groups. Out of a total of 251 patients, 99 patients agreed to participate (68 midline, 7 transverse, 24 Pfannenstiel), while 73 patients refused consent and 79 patients could not be contacted. Patients who refused consent were older (69.8 vs 62.4 years, p = 0.001) but otherwise were similar to participants with respect to gender, malignant disease, postoperative complications and extraction site. Mean length of follow-up was 37.0 months. The overall incidence of incisional hernia was 21% (21/99), being 29 % (20/68) after midline incision compared with 14 % (1/7) after transverse and 0 % (0/24) after Pfannenstiel incisions (p = 0.002). Of patients with incisional hernia, 47 % (10/21) were symptomatic. Patients with incisional hernia had lower cosmetic score (14.4 vs 17.7, p = 0.02) compared with those without, but there was no difference in body image score. There were no differences in body image or cosmesis between the three incisions. There is a high incidence of symptomatic incisional hernia after midline specimen extraction in laparoscopic colectomy, which negatively impacts cosmesis. The risk of hernia may be lower with the use of a transverse or Pfannenstiel incision for specimen extraction.

Avoiding extraction site herniation after laparoscopic right colectomy

Transverse abdominal wall incisions are favoured as part of enhanced recovery programmes. We explored the use of rectus-preserving extraction site incisions in laparoscopic right colectomy. The approach involved minimal anterior abdominal wall disruption with preservation of the rectus abdominis muscle: the rectus abdominis muscle extraction site (RAMES). In 15 patients, a RAMES was used electively in right colectomy for malignancy. The median wound length was 6cms. There was no clinical or radiological evidence of incisional herniation in the 15 patients at 12-month and in the 12 survivors at 24-month follow-up. An anatomical dissection at specimen extraction site reduces early incisional herniation rates and should be of benefit in the longer term.

Incorporation of laparoscopic D2 dissection into the management of gastric adenocarcinoma (GCa) in a community-based setting.

117 Background: A recent meta-analysis suggests that lymph node (LN) retrieval may be inferior when gastrectomy for GCa is performed laparoscopically rather than open. The purpose of this study was to examine the pathologic evaluation, postoperative morbidity and receipt of adjuvant treatment associated with adoption of D2 lymphadenectomy in a community setting. Methods: Routine D2 LN dissection was instituted as part of laparoscopic GCa resection at two community hospitals in Toronto in July 2008. Sequential cases up to Feb 2011 were identified and charts reviewed retrospectively. LN retrieval, margin status, morbidity, mortality and receipt of adjuvant treatment were examined. Results: Twenty-nine patients were identified; 69% were male and the median age was 69 (28-84). All patients underwent D2 lymphadenectomy, 10 with total gastrectomy (TG) and 19 with subtotal (STG). Pathologic evaluation showed that all patients underwent an R0 resection. Median number of LNs retrieved was 32 (15-62) and 93% of patients had adequate LN assessment according to AJCC 7 staging criteria. Sixty-five percent of patients had nodal metastases. There were 8 major complications in 7 patients including 3 post-operative deaths (10% mortality): one patient died in hospital from anastomotic leak and two after discharge from PE (1) and evisceration through the specimen extraction site (1). Four patients commenced neoadjuvant chemotherapy, but only 2 completed the planned pre-operative regimen. Ten additional patients started post-operative adjuvant chemo-radiotherapy, but only 5 completed it. Fifteen patients received no adjuvant treatment. Reasons for lack of adjuvant treatment were: early stage (n=4), medically unfit (2), post-operative death (2), patient declined (5) and early post-operative distant metastatic disease (2). Conclusions: Laparoscopic gastrectomy with D2 lymphadenectomy can be performed in a community setting with excellent margin status and LN retrieval results and complication rates comparable to those previously reported in prospective trials of open resection. Barriers to receipt/completion of adjuvant therapy in this setting should be explored.

What Is the Most Preferred Wound Site for Laparoscopic Donor Nephrectomy?: A Questionnaire Assessment

Although specimen extraction site selection for laparoscopic donor nephrectomy (LDN) is relatively flexible and is mostly selected by surgeons from the patient's standpoint, the patient's request may differ from the medical worker's recommendation. The cosmetic aspect may also differ with age, gender, and the extent of medical knowledge. We performed an unsigned questionnaire assessment of individual preferences for LDN wound sites. Between August 2007 and October 2008, we surveyed LDN wound site preferences among 148 physicians, 263 nurses, and 266 outpatients of urology at Akita University Hospital. They were questioned for their age, gender, occupation (medical worker or not), and for the most preferred surgical wound site among the following: A, lower vertical midline: B, upper vertical midline: C, anterior subcostal: D, Pfannenstiel: E, Gibson: and F, subcostal flank. The valid response rate was 93.5% (677/724). Wound sites preferred (ranked in descending order) were F (48.3%), D (25.6%), E (10.5%), A (9.0%), C (5.2%), and B (1.4%). The subcostal flank incision was the most preferred in almost all the categories. Second preferences were Pfannenstiel incisions in women and incisions on the lower abdomen in men. Overall, flank and lower abdominal incisions tended to be preferred, and mid and upper abdominal incisions tended to be avoided. Medical workers selected the subcostal flank and Pfannenstiel incisions more frequently than outpatients. With increasing age, the selection rates of the Gibson and the lower vertical midline incisions increased, whereas the subcostal flank and the Pfannenstiel incisions decreased. The subcostal flank was the most preferred LDN sites. Age, gender, and the extent of medical knowledge may influence the individual preferences for LDN wound sites.

Surgical Site Infection Rates Following Laparoscopic Urological Procedures

Surgical site infections have been categorized by the Centers for Medicare and Medicaid Services as "never events". The incidence of surgical site infection following laparoscopic urological surgery and its risk factors are poorly defined. We evaluated surgical site infection following urological laparoscopic surgery and identified possible factors that may influence occurrence. Patients who underwent transperitoneal laparoscopic procedures during a 4-year period by a single laparoscopic surgeon were retrospectively reviewed. Surgical site infections were identified postoperatively and defined using the Centers for Disease Control criteria. Clinical parameters, comorbidities, smoking history, preoperative urinalysis and culture results as well as operative data were analyzed. Nonparametric testing using the Mann-Whitney U test, multivariable logistic regression and Spearman's rank correlation coefficient were used for data analysis. In 556 patients undergoing urological laparoscopic procedures 14 surgical site infections (2.5%) were identified at mean postoperative day 21.5. Of the 14 surgical site infections 10 (71.4%) were located at a specimen extraction site. Operative time, procedure type and increasing body mass index were significantly associated with the occurrence of surgical site infections (p = 0.007, p = 0.019, p = 0.038, respectively), whereas history of diabetes mellitus (p = 0.071) and intraoperative transfusion (p = 0.053) were found to trend toward significance. Age, gender, positive urine culture, steroid use, procedure type and smoking history were not significantly associated with surgical site infection. Body mass index and operative time remained significant predictors of surgical site infection on multivariate logistic regression analysis. Surgical site infection is an infrequent complication following laparoscopic surgery with the majority occurring at the specimen extraction site. Infection is associated with prolonged operative time and increasing body mass index.

Laparoscopic Colectomy: Complications Causing Reoperation or Emergency Room/Hospital Readmissions

The purpose of this study was to determine the incidence of complications causing reoperation or emergency room(ER)/hospital readmission after laparoscopic colectomy (LC). We retrospectively reviewed a prospectively managed database of 358 patients undergoing LC. Nonhand assisted LC was jointly performed by two surgeons assisted by a general surgery resident. Trochar site fascial wounds larger than 5 millimeters were not closed for the first 283 cases, mesenteric defects were not closed. Forty-one patients (11%) required reoperation. Of the 19 hernias (17 incisional, 2 mesenteric), seven caused early postoperative obstructions either within the first week of surgery or within 4 days after discharge. Twelve hernias presented in a delayed fashion and were repaired months later. Eight hernias occurred at trochar sites, nine at specimen extraction sites, and two were in the mesenteric defect. There were eight adhesive small bowel obstructions, five were treated with early reoperation. Other causes included perforations in six cases (2%), anastomotic leak in seven cases (2%) and bleeding in two cases (0.5%). Fifty-nine (16%) separate patients required evaluation in the ER. Fifty-three patients had one ER visit, six patients had two. Causes included nausea and vomiting in 19 cases (5%), wound infection in 16 cases (4%), pain in 13 cases (4%), fever in five cases (1%), thrombosis in four cases (1%); 46 were admitted to the hospital, 70 per cent were discharged within 4 days. Eleven per cent of patients required reoperation after LC, usually for hernias or adhesive small bowel obstruction. Fifty-three per cent of the hernias could have been avoided by routine closure of the fascia. An additional 16 per cent of patients required ER evaluation for complications. Of these, 78 per cent were admitted, 70 per cent were discharged within 4 days. LC is not without potential complications and is not necessarily a less morbid operation.

Back to basics – cutting the cord on umbilical infections

Surgical site infections (SSIs) are a significant cause of postoperative morbidity with laparoscopic surgery associated with lower SSI rates. However, a departmental change in our unit to increased laparoscopic colorectal surgery resulted in increased wound infection rates at umbilical specimen extraction sites, the cause of which we attempted to elucidate. Prospectively collected data over an 18-month period (April 2008 to September 2009) for laparoscopic colorectal operations in a busy teaching hospital were retrospectively analysed, focusing on operation performed, whether pre-operative skin cleansing was employed, nature of specimen extraction excision, and rate of umbilical wound infection. Comparison was made with open colorectal procedures performed in the preceding year. In total, 275 laparoscopic colorectal operations were performed. Over the first 8 months there was a significant increase in infection rates when compared with open procedures over a similar time period (23.5% vs 8.0%; P = 0.0001). Changing practice to use pre-operative skin cleansing and an incision that skirted around, as opposed to traversing, the umbilicus reduced umbilical infection rates significantly from 23.5% to 11.6% (P = 0.01). Patients undergoing right hemicolectomy benefitted more (reduction of 30.0% to 6.9%; P = 0.04) than those undergoing anterior resection (26.8% vs 15.6%, P = 0.13). Umbilical incisions, when extended for specimen extraction, are particularly prone to infection following colorectal surgery but rates can be reduced by simple measures such as pre-operative umbilical cleansing and avoidance of the umbilicus in the incision, without the need for drastic and costly changes in technique or antibiotic prophylaxis.

M1536 Laparoscopic Colectomy: Does the Location of the Specimen Extraction Site Matter?

M1536 Laparoscopic Colectomy: Does the Location of the Specimen Extraction Site Matter?

Laparoscopic Intracorporeal Ileocolic Resection for Crohn's Disease

The aim of this study was to assess the impact of laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis on the outcome of patients with terminal ileal Crohn's disease. Prospective data on patients undergoing laparoscopic ileocolic resection for Crohn's disease confined to terminal ileum and cecum with or without fistulas were reviewed. Exclusion criteria were frozen abdomen, recurrent Crohn's disease following resection, and perforated Crohn's disease. Laparoscopic ileocolic resection involved a lateral-to-medial approach encompassing ten sequential steps. Values were medians (range). From January 1992 to June 2006, 80 laparoscopic ileocolic resections were attempted with a 1.2 percent conversion rate. Sixty-two women and 18 men, age 40 (19-55) years, had a body mass index of 26 (18-37) and an American Society of Anesthesiologists' score of 1 (1-3), and 23.7 percent had previously undergone abdominal surgery. Operating time was 155 (130-210) minutes. Estimated blood loss was 250 (50-600) ml. Length of the skin incision at the specimen extraction site was 35 (30-44) mm. The complication/reoperation rate was 7.5 percent. The readmission rate was 3.7 percent. Except for smoking (P < 0.005), there were no significant differences between patients with and those without complications. The recurrence rate was 30 percent (24 of 80). The median time to recurrence was 64 months. Laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis resulted in a favorable outcome in selected patients with refractory terminal ileal Crohn's disease.

Prospective Randomized Comparison of Laparoscopic and Hand-Assisted Laparoscopic Radical Nephrectomy

The majority of localized renal cancers are currently managed by laparoscopic radical nephrectomy, with or without the hand-assist device. In this prospective randomized study, we evaluated the patient outcomes with a standard laparoscopic radical nephrectomy (LRN) versus a hand-assisted laparoscopic radical nephrectomy (HALN). Over a 3-year period, we randomly assigned 21 patients with a localized renal mass of 10 cm or larger to a LRN group with intact specimen extraction or a HALN. The trocar size and sites, the position of the hand-assist device, and the specimen extraction sites were standardized. Patient characteristics, surgical complications, postoperative pain, and convalescence were evaluated. Twelve patients underwent LRN and 9 patients underwent HALN. Both groups had similar body mass indices (BMI), mean tumor diameter (LRN, 5.8 cm; HALN, 5.6 cm), and American Society of Anesthesiologists (ASA) scores. The HALN cohort was significantly older (mean age = 68 years) than the LRN cohort (mean age = 54 years) (P = 0.019). Perioperatively, both groups had similar mean times to oral intake and discharge (LRN 2.6 days and HALN 3 days, P = 0.6). Although both groups reported similar postoperative pain scale scores on day 1, at 1 and 3 months. Two patients in each group had complications (LRN 16% and HALN 22%). In comparing HALN and LRN, there was no difference in the majority of operative and postoperative parameters, including hospital stay and postoperative pain. However, LRN patients had a significantly shorter convalescence with quicker return to normal activities and work than the HALN group. Part of the delay in long-term convalescence parameters may be due to the older patients in the HALN cohort.