Suprapubic Port Research Articles

Laparoscopic Pouch Surgery: Results After 20 Years

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is a curative operation for patients with mucosal ulcerative colitis that provides excellent quality of life. The operation has been performed in earnest since the 1980s, and reports of approaching the procedure with the laparoscopic technique were done in the early 1990s. Initially, there was no overwhelming support for the procedure as surgeons found significantly longer operating times and higher complication rates than in open operations. 1 But, as technology advanced and laparoscopic instrumentation improved with the advent of angled cameras, enhanced grasping instruments, and tissuesealing devices, the laparoscopic approach to IPAAs has been shown to be safe and effective. One must first define laparoscopic IPAA to really see where we have come over the last 20 years. There are several minimally invasive approaches to the procedure that have been described including the laparoscopically assisted approach, hand-assisted approach, single-incision approach, and robotically assisted approach. The most commonly performed procedures are the laparoscopically assisted or the hand-assisted approach. Port placement varies for the procedures, but a diamond approach with an umbilical port, leftand right-lower-quadrant ports, and a suprapubic port provides access to all quadrants of the abdomen for colonic mobilization and resection and facilitates laparoscopic mobilization of the rectum. Abdominal incisions to remove the specimen and format the pouch can be made either through the right-lower-quadrant stoma site, around the umbilicus, or through a Pfannenstiel incision. Safety and efficacy have been shown through several studies. Larson et al. published a comparison retrospective review of their experience comparing 100 laparoscopic IPAA patients to 200 IPAA patients. They found no difference in complication rates or short-term outcomes, but did see a significantly lower length of stay (4 vs. 7 days) with a significantly longer operative time (330 vs. 240 min) in the laparoscopic group. 2 Polle et al.

Laparoscopic Approach for Wilms Tumor

Traditionally, radical nephrectomy for Wilms tumor has been performed through an open approach. Advances in minimally invasive surgery have led to the application of these techniques to malignant lesions, including Wilms tumor. We aim to present our experience with laparoscopic nephrectomy (LN) for Wilms tumor. Four patients with Wilms tumor were treated preoperatively with chemotherapy and afterwards underwent an LN and lymph node sampling. Four ports were placed and the tumors were removed without morcellation in an endoscopic bag through an incision by extending the umbilical or the suprapubic port site. The average age at the time of surgery was 3 years and 7 months (range, 23 mo to 6 y). There were no intraoperative complications and the blood loss was minimal in all cases. The mean operative time was 125 minutes (range, 90 to 160 min). Among our patients, we had 2 stage IV and 2 stage I cases. The mean time of hospitalization was 3 days (range, 2 to 4 d). There were no long-term complications at the mean follow-up of 3 years and 6 months. LN for Wilms tumor may be considered as an option in selected patients. Minimally invasive surgery allows the surgeon to follow all the oncologic principles required for surgical treatment of this neoplasm and provides the advantages of these techniques for cancer patients. Preoperative chemotherapy is essential to decrease tumor size and facilitate the dissection avoiding tumor rupture.

Minilaparoscopic Versus Single-Port Total Hysterectomy: A Randomized Trial

Study ObjectiveTo compare perioperative outcomes and postoperative pain of minilaparoscopic (M-LPS) and laparoendoscopic single-site total hysterectomy (LESS). DesignProspectively randomized study (Canadian Task Force classification II-2). SettingDepartment of Obstetrics and Gynecology, Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome. PatientsA total of 86 patients underwent total hysterectomy. Seventy-one met the inclusion criteria and were included in this study. Three of them refused randomization, 34 were randomly assigned to undergo to single-port hysterectomy and 34 to undergo to minilaparoscopy. InterventionsThe operative technique is the same in the 2 groups with the exception of videolaparoscopy, port type, and some specific instruments. All surgical procedures were performed with an intrauterine manipulator. Single-port hysterectomy was performed through a multichannel single trocar inserted in the umbilicus. Minilaparoscopic hysterectomy was performed through one optical transumbilical 5-mm trocar and three 3-mm suprapubic ancillary ports. Measurements and Main ResultsSixty-eight patients met the inclusion criteria and were enrolled in the study. The baseline characteristics of the 2 groups were comparable. Median operative time was longer in LESS with respect to M-LPS (120 minutes vs 90 minutes; p = .038). There were no differences between the 2 groups for median estimated blood loss, ileus, and postoperative stay. Additional 5-mm port insertion was needed in 1 case (2.9%) in the M-LPS group and in 2 cases (5.9%) in the LESS group, respectively (p = .311). No patient had development of intraoperative or early postoperative complications. Patients in the M-LPS group experienced a minor pain at each evaluation, compared with patients who underwent LESS. The rescue analgesic requirement was similar in the 2 groups. ConclusionsLaparoscopic hysterectomy can be safely performed by M-LPS and LESS. M-LPS is associated with significantly lower operative time and less postoperative pain than LESS. Advantages of M-LPS hysterectomy than LESS have no noteworthy impact on the patients' early postoperative management. The decision on the best access to the hysterectomy might take into account the surgeon's skill and feeling with the different possible approaches.

Suprapubic approach for laparoscopic appendectomy

Objective:To evaluate the results of laparoscopic appendectomy using two suprapubic port incisions placed below the pubic hair line.Design:Prospective hospital based descriptive study.Settings:Department of surgery of a tertiary care teaching hospital located in Rohtas district of Bihar. The study was carried out over a period of 11months during November 2011 to September 2012.Participants:Seventy five patients with a diagnosis of acute appendicitis.Materials and Methods:All patients underwent laparoscopic appendectomy with three ports (one 10-mm umbilical for telescope and two 5 mm suprapubic as working ports) were included. Operative time, conversion, complications, hospital stay and cosmetic results were analyzed.Results:Total number of patients was 75 which included 46 (61.33%) females and 29 (38.67%) males with Mean age (±Standard deviation {SD}) at the time of the diagnosis was 30.32 (±8.86) years. Mean operative time was 27.2 (±5.85) min. One (1.33%) patient required conversion to open appendectomy. No one patient developed wound infection or any other complication. Mean hospital stay was 22.34 (±12.18) h. Almost all patients satisfied with their cosmetic results.Conclusion:A laparoscopic approach using two supra pubic ports yields the better cosmetic results and also improves the surgeons working position during laparoscopic appendectomy. Although, this study had shown better cosmetic result and better working position of the surgeon, however it needs further comparative study and randomized controlled trial to confirm our findings.

A novel modification of conventional laparoscopic myomectomy using manual assistance for multiple uterine myomas

To evaluate the efficacy and feasibility of finger-assisted laparoscopic myomectomy for multiple myomas. A total of 565 patients with symptomatic myomas underwent finger-assisted laparoscopic myomectomy between January 2006 and March 2011 to remove multiple myomas at our center. Laparoscopic myomectomy technique was modified, and involved the insertion of two fingers into the vagina to elevate the uterus, while one or two fingers of the other hand were inserted into the abdomen through a suprapubic 15-mm trocar port for palpation of small myomas, which did not distort the uterine contour. The mean (SD; range) patient age was 38.26 years (5.84; 25-48 years). The diameter of the largest myoma in each case was 6.13 cm (1.21; 4-15 cm). The total number of myomas enucleated in the initial enucleation was 2228. There were 597 additional myomas enucleated with finger-assisted guidance. The mean diameter of the additionally enucleated myomas was 1.1 cm (range, 0.2-2.5 cm), which was significantly smaller than those of the initially enucleated myomas (p=0.002). The mean operative time was 97.1 min (30.2; 35-180 min). The decrease in postoperative hemoglobin concentration was 1.6g/dL (0.7; 0.4-3.2g/dL). During the operation, no patients required a blood transfusion. Six patients developed postoperative fever. There was no occurrence of bowel or urinary tract injury. The mean postoperative hospital stay was 3.2 days (0.9; 2-6 d). All procedures were successfully completed without the need for laparotomy. Finger-assisted laparoscopic myomectomy is a feasible and safe approach in the surgical treatment of multiple myomas.

Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series

The use of laparoscopy as a diagnostic and therapeutic tool is being used increasingly in the emergency setting with many of these procedures being performed by trainees. While the incidence of iatrogenic injuries is reported to be low, we present six emergency or expedited cases in which the bladder was perforated by the suprapubic trocar. Three cases were related to the management of appendicitis, two to negative diagnostic laparoscopies for lower abdominal pain and one to an ectopic pregnancy. Management of the bladder injuries varied from a urinary catheter alone to laparotomy with debridement of the abdominal wall due to sepsis and later reconstruction. Four of the six cases were performed by registrars. Although the incidence of bladder injury is low, its importance is highlighted by the large number of laparoscopies being performed. In addition to catheterisation of the patient, care must be taken with the insertion of low suprapubic ports and consideration should be made regarding alternative sites. Adequate laparoscopic supervision and training in port site planning is required for surgical trainees.

Minimally Invasive Suprapubic Laparoscopic Donor Nephrectomy

Abstract Introduction: There is an increasing discrepancy between the number of patients awaiting transplantation and the number of available transplantable organs. To increase the donor pool, live...

Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery

INTRODUCTION:The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA).MATERIALS AND METHODS:All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot.RESULTS:A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay.CONCLUSION:This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.

Therapeutic Laparoscopy for High-Grade Intestinal Obstruction

Abstract Background: High-grade intestinal obstruction with massive abdominal distension is considered to be an absolute contraindication to laparoscopy. However, improvements in skill level and operator experience makes therapeutic laparoscopy in the above context possible.1–3 Aim: To present video material demonstrating the diagnostic and therapeutic value of laparoscopy, for nonadhesive, high-grade intestinal obstruction, in children. Methods: Two patients, a 4- and a 15-year-old, with no previous abdominal surgery, present with a 24-hour history of abdominal colic, bile-stained vomiting, and massive distension. Abdominal X-ray confirms high-grade distal small bowel obstruction. Emergency laparoscopy via an umbilical (10 mm) and 2 suprapubic ports (5 mm) established the cause of obstruction to be caused by a vitello-diverticular band and a constrictive Meckel's band with volvulus, respectively. A therapeutic division of the band and unravelling of the Meckel's instantly relieved the obstruction. Both d...

Suprapubic transvesical single-port technique for control of lower end of ureter during laparoscopic nephroureterectomy for upper tract transitional cell carcinoma

Context:Various minimally invasive techniques – laparoscopic, endoscopic or combinations of both - have been described to handle the lower ureter during laparoscopic nephroureterectomy but none has received wide acceptance.Aims:We describe an endoscopic technique for the management of lower end of ureter during laparoscopic nephroureterectomy using a single suprapubic laparoscopic port.Materials and Methods:Transurethral resectoscope is used to make a full thickness incision in the bladder cuff around the ureteric orifice from 1 o’clock to 11 o’clock. A grasper inserted through the transvesical suprapubic port is used to retract the ureter to complete the incision in the bladder cuff overlying the anterior aspect of the ureteric orifice. The lower end of ureter is subsequently sealed with a clip applied through the port. This is followed by a laparoscopic nephrectomy and the specimen is removed by extending the suprapubic port incision. Our technique enables dissection and control of lower end of ureter under direct vision. Moreover, surgical occlusion of the lower end of the ureter prior to dissection of the kidney may decrease cell spillage. The clip also serves as a marker for complete removal of the specimen.Results:Three patients have undergone this procedure with an average follow up of 19 months. Operative time for the management of lower ureter has been 35, 55 and 40 minutes respectively. A single recurrence was detected on the opposite bladder wall after 9 months via a surveillance cystoscopy. There has been no residual disease or any other locoregional recurrence.Conclusions:The described technique for management of lower end of ureter during laparoscopic nephroureterectomy adheres to strict oncologic principles while providing the benefit of a minimally invasive approach.

Laparoscopic totally extraperitoneal repair without suprapubic port: comparison with conventional totally extraperitoneal repair

PurposeWe have treated 24 patients through laparoscopic totally extraperitoneal (TEP) repair without suprapubic port by using reliability and reducing the invasiveness of two surgery. This study is aimed to assess the safety and feasibility of the TEP repair without suprapubic port compared to conventional TEP repair.MethodsFrom September 2007 to 11 May 2010, we compared two groups that suffer from inguinal hernias. One is comprised of 24 patients who were treated without suprapubic port laparoscopic totally extraperitoneal repair (Group A), and the other is comprised of 100 patients who were treated with conventional laparoscopic totally extraperitoneal repair (Group B). Data regarding patient demographics (sex, age, site of hernia, and the type of hernia), operating time, postoperative hospital stay, the use of analgesics, and complications were prospectively collected.ResultsThere was no significant difference noted between two groups in relation to sex, age, site, and the type of hernia. The mean operating time and postoperative hospital stay was longer for the Group B (62.9 minutes, 3.55 days) than for the Group A (59.0 minutes, 2.54 days) (P = 0.389, P < 0.001). Postoperative urinary retention, seroma, wound infection were respectively 4.2%, 8.3%, 0% in Group A, and 12.0%, 8.0%, 7% in group B. There was difference between the two groups, but not statistical significance. Group B used more analgesics than Group A (0.33 vs. 0.48), but it wasn't significant statistically (P = 0.234).ConclusionAlthough prospective randomized studies with long-term follow-up evaluation are needed to confirm our study between laparoscopic totally extraperitoneal repair without suprapubic-port and conventional laparoscopic totally extraperitoneal repair, our method have some advantages in postoperative pain, urinary retention, operating time, postoperative hospital stay, and cosmetic effect.

Technical Modifications in Laparoscopic Appendectomy

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

New Use of Foley Catheter for Exposing the Urethral Stump During Vesicourethral Anastomosis in Laparoscopic Radical Prostatectomy

To describe a technique to facilitate the urethral stump exposure and aid the suture placement of vesicourethral anastomosis during laparoscopic radical prostatectomy. A 10-F Foley catheter is introduced in an antegrade fashion via the 12-mm suprapubic midline port into the urethral stump. The catheter balloon is positioned in the bulbous urethra and inflated with 2 mL of sterile water. With the balloon inflated, the Foley catheter can be gently pulled by the laparoscopic forceps, and thereby the urethral stump is everted and becomes clearly visible. Six patients underwent laparoscopic radical prostatectomy with this technique. No complications developed during follow up. Use of a Foley catheter for laparoscopic vesicourethral anastomosis is simple and easy and provided good surgical results in our experience.

Same Setting Laparoscopic Antegrade Continence Enema and Antegrade Bladder Neck Injection for Constipation and Urinary Incontinence in the Spina Bifida Population

Fecal impaction and urinary incontinence and are among the most important problems in patients with spina bifida. We report our preliminary results with a minimally invasive approach to these 2 problems, that is same setting laparoscopic antegrade continence enema and antegrade bladder neck injection. We reviewed the charts of all patients who underwent same setting laparoscopic antegrade continence enema and antegrade bladder neck injection between January 1, 2006 and August 1, 2008. Demographic data, surgical indications, operative details and results were recorded. Surgical steps were uniform in all cases. Diagnostic laparoscopy was performed. Two additional 5 mm trocars were placed. The appendix was mobilized to reach skin in the right lower quadrant. The antegrade continence enema channel was matured. A small percutaneous cystotomy was then created via the suprapubic port site. The cystoscope was passed suprapubically and dextranomer/hyaluronic acid was injected in the bladder neck. A suprapubic tube was placed. We performed a total of 10 same setting laparoscopic antegrade continence enemas with antegrade bladder neck injection in 4 males and 6 females with a mean age of 9.4 years (range 6 to 13). All patients had a smooth walled bladder on cystogram, and good capacity, good compliance and low leak point pressure on urodynamics. There were no intraoperative complications and all patients were discharged home within 24 hours. At an average 18-month followup (range 12 to 27) all 10 patients were continent of stool and reported marked improvement in daily care. No patient experienced stool or gas leakage via antegrade bladder neck injection. Seven of 10 patients (70%) were continent of urine and no longer wore diapers. Same setting laparoscopic antegrade continence enema with antegrade bladder neck injection is a safe, efficacious, reasonably simple minimally invasive approach to severe constipation and urinary incontinence in patients with spina bifida.

Endo-Satinsky Clamp for Rectal Transection During Laparoscopic Total Mesorectal Excision

We describe a technique of intracorporeal rectal transection using an endo-Satinsky clamp during laparoscopic total mesorectal excision. We use an abdominal approach through 5 trocars. The rectum and mesorectum are mobilized completely. A flexible trocar is placed at the site of a 12-mm right lower abdominal port after the trocar originally placed there is pulled out. The 12-mm trocar originally placed in the right lower abdomen is moved to the suprapubic site, in which a Pfannenstiel incision is anticipated. The endo-Satinsky clamp is inserted through the flexible trocar, and the rectum is grasped with the endo-Satinsky clamp just above the anticipated point of transection. The endostapler is introduced through the 12-mm suprapubic port and is positioned just distal to the clamp. The rectum is then transected. The transected bowel is resected extracorporeally. Anastomosis is completed intracorporeally by use of a double-stapling technique. From February 2007 to March 2009, we performed low anterior resection with use of the endo-Satinsky clamp for 11 patients with rectal cancer (laparoscopic, 10 patients; robot-assisted, 1 patient). There were no operative complications or deaths. Mean operation time was 179.5 minutes (range, 120-265 min). The average number of cartridges used for rectal transection was 1.6 per patient. The endo-Satinsky clamp is a useful device for rectal transection and irrigation. The use of this device makes it easier to place an endostapler just distal to the clamp and to transect the rectum in a more appropriate position.

285: Total Laparoscopic Hysterectomy for a Blind Uterus

To present a case of cervical uterine dysgenesis and a symptomatic uterine myomata operated with laparoscopy. A laparoscopic procedure that closely resembles a laparotomy approach. The Mount Sinai Hospital of Queens. A 48 year old woman with primary amenorrhea and pelvic pain. During vaginal examination no cervix was found, a round mass was seen and palpated at the vault. Sonographic study showed a uterus with fluid in the endometrial cavity and a low segment myoma. A tenaculum was placed at the uterine fundus via a suprapubic port. A sponge and stick was placed vaginally into the posterior formix. A laparoscopy posterior entrance to a circular colpotomy was done. The uterus was vaginally extracted. The case was successfully done via laparoscopy. Laparoscopic hysterectomy in cervical dysgenesis is different than when the cervix is present. No uterine manipulator could be used in such cases. This procedure could be done, observing similar steps as when laparotomy is performed.

Suprapubic-assisted cystoscopic excision of intravesical tension-free vaginal tape

We report on a 56-year-old woman with irritative voiding symptoms, which started 4 months after undergoing a TVT procedure for stress incontinence (SI). Evidence of the mesh coming through the left bladder wall did not emerge until cysto-urethroscopic examination 2 years after surgery. Excision was done via transurethral cystoscopy with the aid of endoscopic scissors placed through a 5-mm suprapubic port inserted into the dome of the bladder, thus avoiding laparotomy. A Foley catheter was left in for 3 days, and after removal, the patient’s symptoms disappeared almost completely.

Assessment of a method to expel intraperitoneal gas after gynecologic laparoscopy

To assess a method using instillation of saline to expel all residual intraperitoneal CO2 after laparoscopy. If successful, this would enable clinicians to use radiography as a simple diagnostic test to detect bowel perforation following laparoscopic surgery. Cohort study (Canadian Task Force classification II-2). Department of Endo-Gynecology, Royal Hospital for Women, Sydney, Australia. Thirty women undergoing elective gynecologic laparoscopic surgery. At completion of surgery, the patient remained in maximum head- down position as the abdomen was filled with up to 1 L of normal saline. The suprapubic port remained open to allow the CO2 to escape as it was displaced by the saline. Closure of abdominal ports was completed in routine manner. Erect upper abdominal radiographs were taken 24 hours after surgery, and measurements of any subdiaphragmatic gas were recorded. If gas was evident at 24 hours, a repeat radiograph was performed at 48 hours. Of the 30 patients recruited, four did not complete the study protocol. There was evidence of subdiaphragmatic gas in 25 (96%) of 26 patients on the radiograph taken 24 hours postsurgery. The median volume of gas was 12.9 mL (range 0-2003 mL; IQ range 2.0-144 mL). Of the patients that had a second radiograph, 76% still had subdiaphragmatic gas present. This method for displacement of residual intraperitoneal gas at the end of laparoscopy does not appear to be effective.

An optimal, cost-effective laparoscopic appendectomy technique for our surgical residents.

Since early 1999, we have implemented a standardized technique for laparoscopic appendectomy, which is simple, safe and easily learned and mastered by our residents. Besides superior ergonomics, it offers cosmetic advantages. It is inexpensive as only reusable instruments are used. It incorporates useful modifications, such as the use of suprapubic ports, inferior approach with repositioning of the videoscope from the umbilical port to the left suprapubic port, laparoscopic gauze swabs and instrument-assisted knotting, as well as skeletonization of the appendix. We analyze the outcome of this technique between January 2000 and December 2002. The overall conversion rate of 713 laparoscopic appendectomies was 8.7%, which is comparable with the "best" rates in international literature. Operative times (mean, 59.0 minutes) and the complication rate (6.7%) compared favorably with previous reports on resident training. In summary, our residents feel comfortable with our standardized approach, while producing acceptable results with low cost.

No Recurrence of Mature Ovarian Teratomas After Laparoscopic Cystectomy

Mais, Valerio; Ajossa, Silvia; Mallarini, Giorgio; Guerriero, Stefano; Oggiano, Marco,/FN> P.; Melis, Gian B.