Subcutaneous Tunnel Research Articles

Laparoscopic hepaticoplasty using gallbladder as a subcutaneous tunnel for hepatolithiasis

To investigate the feasibility, efficacy and safety of laparoscopic hepaticoplasty using gallbladder as subcutaneous tunnel and sphincter-of-Oddi preservation for hepatolithiasis. From January 2010 to July 2013, six patients with hepatolithiasis were treated at our institution. All the patients underwent laparoscopic surgery. The procedures included common hepatic duct exploration, stone clearance by fiberoptic choledochoscopy, hilar bile duct hepaticoplasty with preservation of the sphincter of Oddi, anastomosis between the hilar bile duct and neck of the gallbladder, and establishment of a subcutaneous tunnel with the gallbladder. Two patients underwent left lateral hepatectomy simultaneously. Clinical data including operation time, intraoperative blood loss, operative morbidity, hospital mortality, stone clearance, and recurrence rate were analyzed. All patients successfully completed laparoscopic surgery. The mean length of hospital stay was 4.5 ± 0.9 d (range: 3-6 d). The mean blood loss of the hepatectomy was 450 mL (range: 200-700 mL), and the blood loss of the other four was 137 ± 151 mL (range: 50-400 mL). The mean operative time was 318 ± 68 min (range: 236-450 min). The operative morbidity and hospital mortality were zero. The immediate stone clearance rate was 100%. All patients were followed up for an average of 17 mo (range: 7-36 mo). One of the six patients had abdominal mass with pain, and subcutaneous tunnel cholangiography showed severe gallbladder-biliary anastomotic stricture at 4 mo postoperatively. There was no stone recurrence and no cholangitis during follow-up. Laparoscopic hepaticoplasty using gallbladder with a subcutaneous tunnel and preserving the sphincter of Oddi is feasible, safe and effective for hepatholithiasis.

Single-port laparoscopic placement of peritoneal dialysis catheter: A safe and effective technique

Background/Aim: Laparoscopic techniques for placement of peritoneal dialysis catheters are becomingincreasingly popular. Currently, there are several techniques for such laparoscopic approach. The aim ofthis study is to describe our technique and outcomes of using single port laparoscopic placement of peritoneal dialysis catheters. Patients and methods: Laparoscopic implantation of peritoneal dialysis catheters was performed in 64 consecutive patients.The technique was performed via a single port inserted in the supra-umbilical region. The tip of the catheter was placed in the true pelvis while its deep cuff was placed into the rectus sheath. A subcutaneous tunnel was created to the selected exit site of the catheter. Mean duration of surgery, hospital stay, morbidity, mortality, and catheter survival were assessed. Results: The mean operating time was 22 ± 7 minutes. The mean post-operative hospital stay was 2 ± 1 days.There were no conversions from laparoscopy to conventional catheter insertion methods. No exit-site or tunnel infections, hemorrhagic complications, abdominal wall hernias, or catheter cuff extrusions were detected. No mortality occurred in this series of patients. Catheter survival was 100% and 96.8% at 6 months and one year respectively Conclusion: The laparoscopic method described in this study is compliant with consensus guidelines for the best-demonstrated practices in peritoneal dialysis access placement. The results reported in this paper support the opinion that laparoscopic placement of peritoneal dialysis catheter should become the standard care for clinical practice. The use of single-port technique is safe, effective and reproducible method.

Adult-Type Intrathoracic Xanthogranuloma: Excision and Reconstruction Using a Latissimus Dorsi Muscle Flap

Adult-Type Intrathoracic Xanthogranuloma: Excision and Reconstruction Using a Latissimus Dorsi Muscle Flap

A novel adaptation of laparoscopic Tenckhoff catheter insertion technique to enhance catheter stability and function in automated peritoneal dialysis

Automated peritoneal dialysis (APD) normally takes place overnight. Maintaining a stable PD catheter position, independent of body position, omental wrapping or catheter displacement secondary to bowel movements is essential in maintaining effective catheter function. We developed a new procedure of catheter placement through combining and adapting several previously described operative techniques including laparoscopic placement of a curled double cuff Tenckhoff catheter with subcutaneous tunneling superior to the rectus sheet, an oblique course through the abdominal wall, deep entry into the pelvic peritoneum and directed placement of the curled tip within the pouch of Douglas. Retrospective analysis of catheter function was conducted, evaluating catheter position, function, complication rate and catheter survival against findings for current insertion techniques described within literature. Between March 2009 and November 2011, 54 patients underwent PD catheter insertion. The observation period was an average of 343 ± 273 days. All patients received abdominal plain film showing optimal catheter position in 89 %. Reported catheter function was very good in 85.2 %, with no or few alarms per week during APD, moderate in 9.3 % with occasional minor dysfunctions (≤ 2 alarms per night), and poor in 5.6 %, with regular alarm disturbance. In one case, primary dysfunction led to catheter replacement. At completion, stable catheter function with occasional minor dysfunction was achieved in 52 of 54 cases. Catheter-related complications (leakage, hydrocele formation, infection and need for replacement) were observed in 14.8 %. At the end of the observation period, 55.6 % of catheters remained in use. Patient dropout occurred through death (18.5 %), renal transplantation (7.4 %), renal recovery (1.9 %), removal secondary to infection or dysfunction (9.3 %) and conversion to HD due to poor dialysis quality (7.4 %). The above technique combines and optimises previously described laparoscopic catheter implantation techniques, allowing increased catheter stability resulting in an undisturbed catheter function suitable for APD.

English

Case report A 23-year-old woman had a recurrence of malignant schwannoma in her right neck. After wide resection of the tumour and partial resection of trapezius muscle (Figure 1), a flap was designed according to the size and shape of the defect (Figure 2). Harvesting of the flap was performed by making an incision along the length of the latissimus dorsi muscle. After dissection down to muscle, the flaps were elevated anteriorly and posteriorly, exposing the entire muscle. The muscle was then divided from its attachments and elevated to the level of its thoracodorsal pedicle. The subcutaneous tunnel was made from the insertion of the muscle to the neck defect anterior to the axilla and the muscle passed through (Figure 3). The donor-site defect is closed primarily. Closed suction drains are employed at the donor and recipient sites, but not within the tunnel created to pass the flap pedicle (Figure 4). After surgery, the arm is kept flexed across the chest for seven days.

Pedicled rectus abdominis muscle and fascia flap sling the bulbar urethra for treatment for male-acquired urinary incontinence: report of ten cases

Male urinary incontinence is relatively common complication of radical prostatectomy and of posterior urethroplasty following traumatic pelvic fracture. Here, we investigate the use of pedicled rectus abdominis muscle and fascia flap sling of the bulbar urethra for treatment for male-acquired urinary incontinence. Ten patients with acquired urinary incontinence were included in the study. Urinary incontinence was secondary to TURP in three patients and was secondary to posterior urethroplasty performed following traumatic pelvic fracture in seven patients. Pedicled rectus abdominalis muscle and fascial flaps, approximately 2.5 cm wide and 15 cm long, were isolated. The flaps were inserted into a perineal incision through a subcutaneous tunnel. The free end of the flap was sectioned to form two muscle strips, each 3 cm in length, and inserted into the space between bulbar urethra and corpus cavernosa. After adequate sling tension had been achieved, the two strips of muscle were anastomosed around the bulbar urethra using a 2-zero polyglactin suture. The patients were followed up for between 12 and 82 months (mean 42.8 months). Complete continence was achieved with good voiding in seven of the 10 patients. In other three patients achieved good voiding following catheter removal, but incontinence was only moderately improved. A pedicled rectus muscle fascial sling of the bulbar urethra is an effective and safe treatment for male patients with mild to moderate acquired urinary incontinence, but it may not be suitable for severe incontinence or for patients with weak rectus abdominalis muscles.

Two-step tunneling technique of deep brain stimulation extension wires—a description

While a significant body of literature exists on the intracranial part of deep brain stimulation surgery, the equally important second part of the intervention related to the subcutaneous tunneling of deep brain stimulation extension wires is rarely described. The tunneling strategy can consist of a single passage of the extension wires from the frontal incision site to the subclavicular area, or of a two-step approach that adds a retro-auricular counter-incision. Each technique harbors the risk of intraoperative and postoperative complications. At our center, we perform a two-step tunneling procedure that we developed based on a cadaveric study. In 125 consecutive patients operated since 2002, we did not encounter any complication related to our tunneling method. Insufficient data exist to fully evaluate the advantages and disadvantages of each tunneling technique. It is of critical importance that authors detail their tunneling modus operandi and report the presence or absence of complications. This gathered data pool may help to formulate a definitive conclusions on the safest method for subcutaneous tunneling of extension wires in deep brain stimulation.

Prevenzione delle infezioni catetere venoso centrale correlate (CRBSI)

L'uso dei cateteri venosi centrali (CVC) temporanei o permanenti è in costante aumento tra i pazienti emodializzati, ma questi dispositivi sono gravati da numerose complicanze, potenzialmente anche gravi. Tra queste, sicuramente le infezioni sono quelle con un maggiore impatto su morbilità e mortalità. Le infezioni correlate al CVC possono interessare il sito di emergenza del catetere e il tratto sottocutaneo dei cateteri tunnellizzati o, nei casi più gravi, possono determinare batteriemie e/o setticemie (CRBSI, catheter related blood-stream infections). Importante è la loro prevenzione attraverso l'educazione del personale sanitario che gestisce tali dispositivi, associata a un buon protocollo di utilizzo degli stessi. Infatti, è dimostrato che, con un adeguato protocollo di inserimento e di gestione dei CVC, le CRBSI possono essere significativamente ridotte, al di sotto di 1 episodio ogni 1000 giorni-catetere.

A New Technique for Long Time Catheterization of Sacral Epidural Canal in Rabbits

IntroductionIn this study we aimed to develop a simple and practical technique for chronic sacral epidural catheterization of rabbits. MethodsWe included ten rabbits weighing 2-2.5kg in the study. After anesthesia and analgesia, we placed an epidural catheter by a 2cm longitudinal skin incision in the tail above the sacral hiatus region. We confirmed localization by giving 1% lidocaine (leveling sensory loss and motor function loss of the lower extremity). The catheter was carried forward through a subcutaneous tunnel and fixed at the neck. ResultsChronic caudal epidural catheter placement was succesful in all rabbits. The catheters stayed in place effectively for ten days. We encountered no catheter complications during this period. The localization of the catheter was reconfirmed by 1% lidocaine on the last day. After animals killing, we performed a laminectomy and verified localization of the catheter in the epidural space. ConclusionsVarious methods for catheterization of the epidural space in animal models exist in the literature. Epidural catheterization of rabbits can be accomplished by atlanto-occipital, lumbar or caudal routes by amputation of the tail. Intrathecal and epidural catheterization techniques defined in the literature necessitate surgical skill and knowledge of surgical procedures like laminectomy and tail amputation. Our technique does not require substantial surgical skill, anatomical integrity is preserved and malposition of the catheter is not encountered. In conclusion, we suggest that our simple and easily applicable new epidural catheterization technique can be used as a model in experimental animal studies.

GW24-e0801 Left heart atrial and ventricular epicardial dual chamber pacing through a left lateral thoracotomy to treat paediatric complete atrioventricular block

ObjectivesTo investigate the feasibility, advantages and efficacy for implantation of left heart atrial and ventricular epicardial dual chamber pacemaker to treat paediatric complete atrioventricular block.Methods11 children with medine age 4.0...

Left atrial and ventricular epicardial dual chamber pacing through a left lateral thoracotomy to treat pediatric complete atrioventricular block

To investigate the feasibility, advantages and efficacy of implantation of left atrial and ventricular epicardial dual chamber pacemaker to treat pediatric complete atrioventricular block. Eleven children with median age 4.0 years (0.5-7.6 years) diagnosed as complete atrioventricular block resisting to drug therapy received implantations of left atrial and ventricular epicardial dual chamber pacemakers. Six were male and five female. Temporal or permanent right ventricular pacing was used for all of them before implantation of left atrial and ventricular epicardial dual chamber pacemakers. Three cases showed cardiac dysfunction. Left lateral thoracotomy was performed at 4th intercoastal space along anterior axillary line under general anesthesia, the pericardium was incised vertically anterior to the phrenic nerve, two pacing leads were individually located at left atrial appendage and left ventricular lateral wall. After all the parameters were detected to be satisfactory, a pouch was made at left abdomen under coastal margin. Dual chamber pacemaker was connected with pacing leads through subcutaneous tunnels. The sizes of heart chambers, cardiac functions, parameters of pacemaker, sensitivity, pacing status, PR interval and QRS interval were closely followed up post-operatively. Implantations of pacemakers were successful for all of the patients with no complications associated with operations. Preoperative electrocardiograms showed QRS interval (180 ± 33)ms under right ventricular pacing, it decreased to (140 ± 24)ms after implantation of left atrial and ventricular epicardial dual chamber pacemaker, significantly lower than right ventricular pacing (t = 8.8, P < 0.05) . Atrioventricular (AV) interval was set at 90 ms, PR interval (124 ± 4)ms. Echocardiograms performed within 2-3 days after implantation of left atrial and ventricular epicardial dual chamber pacemakers showed that for the 3 cases who were previously under right atrial and right ventricular dual chamber pacing presenting cardiac dysfunction, their left ventricular diastolic diameter (LVDd) decreased from (46.3 ± 12.5) (32.0-55.0) ms to (44.7 ± 12.0) (31.0-53.0) mm and left ventricular ejection fraction (LVEF) increased from 30% ± 15% (18%-47%) to 44% ± 18% (33%-65%). During 2-14 months' follow up, LVEF increased progressively which became significantly higher than before (65% ± 8% vs. 30% ± 15%, t = 5.6, P < 0.05) . Cardiac chamber sizes and left ventricular systolic function for the other 8 patients maintain normal during follow up. Pacing status and sensitivity were satisfactory for all these patients during follow up. Implantation of left atrial and ventricular epicardial pacemaker might be considered for children diagnosed as complete atrioventricular block for whom endocardial pacemaker could not be implanted, due to its utmost protection for cardiac function with minimal injury and its ability to prevent or reverse pacemaker syndrome. Left atrial and left ventricular epicardium should be regarded as the first-choice and routine locations for epicardial pacing.

Subxyphoid Thyroidectomy

The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance. This is a single-cadaver feasibility study. A single, 2.2-cm subxyphoid incision was used for access. The platform's 55-cm flexible sheath was secured to the operating table rails and introduced into the subcutaneous space. A flexible pediatric endoscope was simultaneously introduced with 2 interchangeable 4-mm instruments. Blunt dissection and electrocautery were used to create the tunnel in the otherwise free central plane. The thyroid was dissected using a superior to inferior technique while maintaining the critical steps of traditional thyroid surgery. A Veress needle introduced through the lateral neck provided additional retraction. The total operating time was 2.5 hours. The subcutaneous tunnel was safe and accommodated the DDES well. Visualization was adequate. Graspers, scissors, and hook cautery were used to complete the lobectomy. The ergonomics, articulation, and strength of the instrumentation were sufficient. Subxyphoid thyroidectomy is technically possible and avoids the difficulties inherent to a transaxillary approach while still avoiding cosmetically unappealing cervical scars. Continued technological refinement will only expand the therapeutic possibilities of flexible endoscopy while minimizing the physical insult to patients and maximizing aesthetics for patients.

Subcutaneoscopic excision of external angular dermoid cyst in children without conspicuous scarring

External angular dermoid cysts are benign lesions that are excised through an incision over the eyebrow. This leaves a visible scar that may not be cosmetically acceptable. Herein, we describe a minimally invasive subcutaneoscopic technique that involves placing incisions above the hairline to avoid scarring on the face. This is a retrospective review of three consecutive cases of dermoid cysts. Each patient underwent subcutaneoscopic excision between March 2012 and September 2012. With the patient under general anesthesia, a 6-mm incision was made on the scalp above the hairline. After a wide subcutaneous tunnel was created, a 5-mm port with a 30° telescope was placed for an optical port. Insufflation was done with CO2 at pressure of 8 mmHg and flow rate of 1 L/min. Two para-optical stab incisions were used to insert a 3-mm Maryland dissector and a 3-mm hook for dissection. The cyst was excised and removed through one of the ports. All three cases underwent successful subcutaneoscopic excision without the need for conversion. The mean operative time was 42 min. There were no complications, and all patients had excellent cosmesis. Subcutaneoscopic excision of dermoid cyst is a technically feasible procedure in pediatric patients, as demonstrated by our three cases. It provides excellent cosmesis and avoids scarring on the face.

Orthodromic Transfer of the Temporalis Muscle in Incomplete Facial Nerve Palsy

BackgroundTemporalis muscle transfer produces prompt surgical results with a one-stage operation in facial palsy patients. The orthodromic method is surgically simple, and the vector of muscle action is similar to the temporalis muscle action direction. This article describes transferring temporalis muscle insertion to reconstruct incomplete facial nerve palsy patients.MethodsBetween August 2009 and November 2011, 6 unilateral incomplete facial nerve palsy patients underwent surgery for orthodromic temporalis muscle transfer. A preauricular incision was performed to expose the mandibular coronoid process. Using a saw, the coronoid process was transected. Three strips of the fascia lata were anchored to the muscle of the nasolabial fold through subcutaneous tunneling. The tension of the strips was adjusted by observing the shape of the nasolabial fold. When optimal tension was achieved, the temporalis muscle was sutured to the strips. The surgical results were assessed by comparing pre- and postoperative photographs. Three independent observers evaluated the photographs.ResultsThe symmetry of the mouth corner was improved in the resting state, and movement of the oral commissure was enhanced in facial animation after surgery.ConclusionsThe orthodromic transfer of temporalis muscle technique can produce prompt results by applying the natural temporalis muscle vector. This technique preserves residual facial nerve function in incomplete facial nerve palsy patients and produces satisfying cosmetic outcomes without malar muscle bulging, which often occurs in the turn-over technique.

Cephalic Vein Harvest for Deep Inferior Epigastric Perforator Salvage

Sir: The need for venous flow augmentation is relatively common in deep inferior epigastric perforator flap surgery, particularly so in irradiated internal mammary vessels and the presence of a dominant superficial venous system. Sbitany et al.1 showed in their large series of 1201 free deep inferior epigastric perforator and transverse rectus abdominis musculocutaneous flaps that 11 of these flaps (0.9 percent) exhibited intraoperative venous congestion. Previously described recipient venous sources include the lateral thoracic vein,2 external jugular vein,3 thoracodorsal vein, intercostal vein, cephalic vein,4 and basilic vein. By far the most commonly used is the cephalic vein, which is the first-choice vessel in our practice, as it has consistent anatomy, lying in the subcutaneous tissue above the brachial fascia on the anterolateral aspect of the arm. If the contralateral deep inferior epigastric perforator flap is used, the superficial inferior epigastric vein will lie in the upper lateral quadrant of the flap after inset. This is ideally placed for anastomosis after a cephalic vein turndown. Previous relevant techniques described include the deltopectoral groove, infraclavicular fossa, and anterior axillary skin incision.5 These incisions lead to visible scarring. The indication for venous augmentation is based on multiple intraoperative factors such as the flap perfusion when islanded on the abdomen, the tension or turgor of the superficial inferior epigastric vein, and the degree of flap venous congestion after anastomosis. We do not routinely perform augmentation in all cases; we do so only when there is a need for improving venous outflow. An L-shaped incision is marked out on the medial aspect of the arm with the vertical passing parallel to but posterior to the anterior axillary fold (Fig. 1). The length of the horizontal limb varies according to the length of cephalic vein required. This in turn depends on the type of mastectomy scar. A longer length will be required for a periareolar skin-sparing mastectomy when compared with a more traditional horizontal/oblique mastectomy incision. With careful dissection, the cephalic vein is easily identified sitting on top of the brachial fascia. The vein is then dissected out cranially, ligating any branches in the process. Using optimal retraction, our incision allows the vein to be followed into the deltopectoral groove. It is easier to follow the vein from distal to proximal into the deltopectoral groove in the chest rather than identifying the vein from under the mastectomy flap and dissecting laterally. The vein is then turned down through a subcutaneous tunnel from the flap recipient site. This novel incision has been performed in seven cases over the past 2 years. We have had no donor-site morbidity, although bruising in the upper arm is common. The upper arm incision is a novel aesthetically pleasing technique, which is simple and easily performed. Dissecting the vein from lateral to medial allows for easy identification of the vein under the mastectomy flap. The resulting scar is not seen when standing with arms by the side, and heals well (Figs%. 2 and 3). This technique averts the need for visible deltopectoral incisions or multiple stab incisions in the upper arm when a greater length is required. It is often particularly useful in irradiated axillae, whereby dissection of the cephalic vein in the deltopectoral groove can often be challenging.Fig. 1: Illustrations depicting the upper arm incision.Fig. 2: A well-hidden scar in the patient while standing.Fig. 3: A closeup of the healed scar.DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.

Prevention of Catheter-Related Blood Stream Infections (CRBSI)

The use of temporary or tunneled central venous catheters (CVC) is increasing worldwide in hemodialysis patients, but their numerous and potentially severe complications should be taken into account. Among the possible complications, infections are certainly those with the greater impact on morbidity and mortality. Catheter-related infections can affect the CVC exit site, the subcutaneous tunnel or, in the most severe cases, can induce bacteremia and sepsis (CRBSI, catheter-related blood stream infections). CRBSI prevention is of the utmost importance and can be achieved through educational activities for the dialysis personnel and through the use of specific protocols for CVC insertion and management. Indeed, it has been demonstrated that these measures allow a significant reduction of the number of CRBSI, to less than 1 episode per 1,000 catheter days.

Superselective intra-arterial chemotherapy for oral cancer by subcutaneous implantation of an intra-arterial catheter and an infusion reservoir: A new chemotherapy method to improve the quality of life and curative effect.

6096 Background: We have developed a superselective intra-arterial chemotherapy (iaCT) approach for oral cancer, in which intra-arterial catheter is retrogradely inserted via the superficial temporal artery (STA) and/or occipital artery (OA). This approach increases chemotherapy efficiency but remarkably decreases activities of daily living (ADL) because the catheter penetrates the skin over the approaching artery (STA/OA). Methods: This study assessed our new outpatient iaCT approach involving implantation of an intra-arterial catheter connected to a subcutaneous infusion reservoir. We included 10 patients who had oral cancer treated using outpatient iaCT: tongue carcinoma, 7; cheek mucosal carcinoma, 1; upper gingival carcinoma, 1; palatal carcinoma, 1. In this approach, the STA or OA or both were percutaneously dissected out, a catheter was inserted, and the catheter tip was superselectively placed in the tumor-feeding artery. The extra-arterial catheter portion was implanted through a subcutaneous tunnel and was connected to a subcutaneous infusion reservoir implanted around the mastoid process. The patients were discharged after catheterization, and the chemotherapeutic agent was intra-arterially administered at the Outpatient Chemotherapy Center of Rinku General Medical Center once or twice a week. Intra-arterial infusion was repeated 6 times per course. Results: The response rate was 100%, i.e., 8 cases of CR and 2 of PR; patients with PR underwent surgery.Their ADLs were scarecely disturbed exept for ambulatory visits. Conclusions: In this approach, the catheter is completely implanted subcutaneously; therefore, usual catheter-related issues (e.g., infection, catheter fall out) rarely occur. Because this leads to very good ADLs, outpatient chemotherapy can be safely performed. Consequently, the quality of life (QOL) improves and medical expenses decrease.Our new outpatient iaCT approach improves QOL of and curative effects for oral cancer patients if the ambulatory convenience and the performance status are good.

A Modified Method in Laparoscopic Peritoneal Catheter Implantation: The Combination of Preperitoneal Tunneling and Pelvic Fixation

Introduction. Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease (ESRD). Although not as widely used as hemodialysis, CAPD has clear advantages, especially those related to patient satisfaction and simplicity. Peritoneal dialysis (PD) catheter insertion can be accomplished by several different techniques. In this study, we aimed to evaluate our results obtained with peritoneal dialysis catheter placement by combination of pelvic fixation plus preperitoneal tunneling. Material and Methods. Laparoscopic peritoneal catheter implantation by combining preperitoneal tunneling and pelvic fixation methods was performed in 82 consecutive patients with end-stage renal disease. Sex, age, primary disease etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and catheter survival rates and surgical technique used were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results. Mean follow-up period was 28.35 ± 14.5 months (range of 13–44 months). Mean operative time was 28 ± 6 minutes, and mean duration of hospital stay was 3 ± 1 days. There were no conversions from laparoscopy to other insertion methods. None of the patients developed serious complications during surgery or the postoperative period. No infections of the exit site or subcutaneous tunnel, hemorrhagic complications, abdominal wall hernias, or extrusion of the superficial catheter cuff was detected. No mortality occurred in this series of patients. Catheter survival was found to be 92% at 3 years followup. Conclusions. During one-year followup, we had seven patients of migrated catheters due to separation of pelvic fixation suture from peritoneal surface, but they were reimplanted and fixated again laparoscopically with success. Over a three-year followup period, catheter survival was found to be 92%. In the literature, similar catheter survival rates without combination of the two techniques are reported. As a conclusion, although laparoscopic placement of PD catheters avoids many perioperative and early complications, as well as increasing catheter free survival period and quality of life, our results comparing to other studies in the literature indicate that different laparoscopic placement methods are still in debate, and further studies are necessary to make a more accurate decision.

PP162: Superselective intra-arterial chemotherapy for oral cancer with implanted infusion reservoir: A new chemotherapy method to improve both the curative effect and the ouality of life

Introduction We have developed a superselective intra-arterial chemotherapy (iaCT) approach for oral cancer, in which intra-arterial catheter is retrogradely inserted via the superficial temporal artery (STA) and/or occipital artery (OA). This approach increases curative effect but remarkably decreases activities of daily living (ADL) because the catheter penetrates the skin over the approaching artery, tempral area and/or occipital area. Purpose We device the method to improve the ADL of patients with intra-arterial catheter by subcutaneous implantation of an intra-arterial catheter connected to a subcutaneous infusion reservoir. Materials and methods We have used this approach for 46 patients who had oral cancer treated using iaCT. In this approach, the catheter was superselectively placed in the tumor-feeding artery by cut-down of STA and/or OA. The extra-arterial portion of catheter was connected to a infusion reservoir implanted subcutaneously around the mastoid process through the subcutaneous tunnel. The catheter and reserver was completely placed under the skin, so there was little possibility of catheter-related infection and displacement of catheter from intended position. The chemotherapeutic agent was intra-arterially administered through the reservoir by penetration the overlying skin with Huber needle. Results This method have improved the ADL of patients without the least loss of curative effect. It is enebled even to discharge the Hospital and to receive out-patient chemotherapy, while they continue almost the same lifes as former days. Conclusions In this approach, the catheter is completely implanted subcutaneously; therefore, usual catheter-related issues (e.g., infection, catheter fall out) rarely occur. Because this leads to very good ADLs, even outpatient chemotherapy can be safely performed.

Perineal reconstruction with an extrapelvic vertical rectus abdominis myocutaneous flap.

Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion. A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction. The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months. Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.