Suprapubic Incision Research Articles

Prostatectomía transvesical con puerto único en un paciente con hiperplasia benigna de próstata

Benign prostatic hyperplasia is a common disorder for which there are many pharmacological and surgical treatments. In recent years it has been attempted to make surgical techniques less invasive, even in the case of large hyperplasias. Single-port Laparoscopic prostatectomy has emerged as an alternative. The case is presented of a 65 year-old patient who underwent laparoscopic transvesical single port prostatectomy, through a 3.5 cm suprapubic incision. The enucleation was finger assisted, achieving an operating time of 45 minutes. The estimated blood loss was 150 mL, and there were no complications. The hospital stay was 2 days, and the Foley catheter was removed after 5 days. The biopsy of the 100 g specimen extracted reported benign prostatic hyperplasia. This technique is shown to be a novel, short and safe method for the management of benign prostatic hyperplasia, but more experience and studies are needed.

Pregnancy success after hysteroscopic sterilization reversal.

To evaluate the effectiveness of hysteroscopic sterilization reversal by assessing pregnancy rates and identifying surgical complications. All patients at a single center undergoing elective reversal of hysteroscopic sterilization for fertility were followed from January 2009 to May 2014. Eligible patients met prespecified criteria for outpatient surgery. Patients underwent outpatient reversal using a transverse suprapubic abdominal incision with tubouterine implantation performed with either bilateral cornual or single transverse posterior-fundal uterine incisions. Patients were evaluated on postoperative day 1, called the following day, and e-mailed at 2 weeks and 12 months. Pregnancy outcomes were assessed through a 12-month questionnaire and self-reporting using an Internet-based patient portal. Univariate analysis of patient and operative characteristics was performed. Seventy patients underwent bilateral tubouterine implantation and completed at least 12 months of follow-up. All surgeries were outpatient without any immediate operative complications. Four patients had complications between 2 and 30 days, none requiring extended hospitalization. Women who became pregnant were younger (mean age 34 years) than those who did not become pregnant (mean age 38 years). Twenty-five patients (36%, 95% confidence interval [CI] 25-47%) reported a total of 31 naturally conceived pregnancies. Twenty-seven percent (19/70, 95% CI 17-37%) of those undergoing surgery subsequently reported live births. A single pregnancy complication of postpartum hemorrhage after cesarean delivery requiring transfusion was reported; no ectopic pregnancies were reported. Hysteroscopic sterilization can be reversed using tubouterine implantation and both pregnancy and live birth rates are promising.

Effectiveness of blinding: sham suprapubic incisions in a randomized trial of retropubic midurethral sling in women undergoing vaginal prolapse surgery

This planned secondary analysis of the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial assessed whether treatment knowledge differed between randomized groups at 12 months and whether treatment success was affected by treatment perception. Sham suprapubic tension-free vaginal tape (TVT) incisions were made in the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial participants randomized to no-TVT. Primary surgical outcomes and maintenance of blinding was assessed at 12 months. Knowledge of treatment assignment was compared between groups, and the relationship with treatment success rates was assessed. Prior to the 12 month postoperative visit, only 4% of treated participants (13 of 336) formally reported unmasking. At 12 months, 94% of the randomized participants (315 of 336) provided treatment knowledge data. Sixteen TVT participants (10%) reported treatment knowledge; most (n = 15, 94%) were correct; 17 of the sham participants (11%) reported treatment knowledge; half (n = 8, 47%) were correct. Similar proportions of unmasked participants who reported no treatment knowledge correctly guessed/perceived treatment assignment (sham, 46 [33%] vs TVT, 44 [33%]). We did not detect significant differences in treatment success rates based on perception within and across received treatment groups (perceived sham vs TVT overall [P = .76]). Of those receiving TVT, more participants perceiving TVT had treatment success compared with those who perceived sham (84% vs 74%; P = .29). Among sham participants, more participants perceiving sham had success compared with those who perceived receiving TVT (65% vs 56%; P = .42). Sham surgical incisions effectively mask TVT randomization. These findings may help to inform future surgical trial designs.

Total Laparoscopic Living Donor Right Hepatectomy.

Background Cosmetic and functional demand by young donors is increasing in LDLT. We developed total laparoscopic donor right hepatectomy (LDRH) in adult living donors. Methods Total LDRH was performed in two young donors without vascular clamping. Findings After full mobilization of right liver, hilar dissection was done. Firstly, right portal vein was isolated under retracting common bile duct laterally. Right hepatic artery was cautiously dissected and isolated without injuring. An exact transection line was drawn during transient clamping of the hepatic artery and portal vein on the right side of the liver using bulldog clamp.Figure: No Caption available.Dissection was meticulously performed along the right side of the middle hepatic vein until the origin of middle hepatic vein until exposure of the hilar plate. Anterior section vein branches (V5 and V8) were finely dissected and were reconstructed using an artificial vascular graft. A modified extended right graft with preservation of the middle hepatic vein branches was extracted through the suprapubic incision. There was no complication in both donors and recipients. Postoperative hospital stay of donors was 10 and 8 days, respectively. After follow-up of more than one year, all donors and recipients live well with normal liver function.Figure: No Caption available.Conclusion Total LDRH was feasible in selected adult donors. If this procedure will be more standardized, total LDRH will be new option for adult LDLT, which meets demand by donors and diminish guilty feeling by recipients.

‘Minimum-incision’ endoscopically assisted transvesical prostatectomy: Surgical technique and early outcomes

ObjectiveTo describe the surgical technique and report the early outcomes of a ‘minimum-incision’ endoscopically assisted transvesical prostatectomy (MEATP) for managing benign prostatic obstruction secondary to a large (>80g) prostate. Patients and methodsIn a prospective feasibility trial, 60 men with large benign prostates underwent MEATP. The baseline and postoperative evaluation included the International Prostate Symptom Score (IPSS), a measurement of maximum urinary flow rate (Qmax), and the postvoid residual (PVR) urine volume. The adenoma was enucleated digitally through a 3-cm suprapubic skin incision, and haemostasis was completed with endoscopic coagulation of the prostatic fossa. Perioperative complications were recorded and stratified according to the modified Clavien–Dindo score. ResultsThe mean (SD, range) prostate weight estimated by ultrasonography was 102.9 (15.4, 80–160)g, the operative duration was 52 (8, 40–65)min, the haemoglobin loss was 2.1 (1, 0.4–5)g/dL, the catheterisation time was 5.2 (1.3, 4–9)days, and the hospital stay was 6.2 (1.4, 5–10)days. There were 21 complications recorded in 16 (27%) patients, and most (86%) were of grades 1 and 2. The most frequent complications were bleeding requiring a blood transfusion (8%), and prolonged drainage (5%). There was a significant improvement at 3months after surgery in the IPSS (8.6 vs. 21.6, P<0.001), Qmax (19.5 vs. 7.7, P<0.001), and PVR (15.8 vs. 83.9mL, P<0.001). ConclusionMEATP is feasible, safe and effective. Comparative studies and long-term data are required to determine its role in the surgical treatment of large-volume BPH.

Mini-Laparotomy Myomectomy: A Minimally Invasive Technique for a 40-Week Size Fibroid Uterus

ObjectiveMini-laparotomy myomectomy with morcellation is a safe and efficient alternative for uterine myomectomy of a large 40-week size fibroid uterus in a woman who had yet to complete childbearing.DescriptionThe patient presented in the video is a 38 year old para 1 female with a greater than 40-week fibroid uterus and desired future fertility. The video illustrates the surgical technique of a mini-laparotomy myomectomy. The myomectomy was performed through a 5 cm suprapubic incision at the site of the patient's prior Pfannenstiel incision. The Mobius elastic device was used as a self-retaining abdominal retractor. The myomas were then progressively morcellated using a scalpel in a similar fashion to vaginal morcellation. The endometrial cavity was not entered. The uterus was then repaired in multiple layers using Vicryl suture. The total weight of the uterine fibroids was 3641 gm. The patient conceived and had a successful pregnancy and delivery at term via cesarean section one year after her myomectomy.ConclusionThis case illustrates that mini-laparotomy myomectomy is a safe and effective alternative to standard laparotomy, laparoscopic, or robotic-assisted myomectomy.DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:Nora Bassiouni: Nothing to discloseJavier F. Magrina: Nothing to disclosePaul Magtibay: Nothing to disclose ObjectiveMini-laparotomy myomectomy with morcellation is a safe and efficient alternative for uterine myomectomy of a large 40-week size fibroid uterus in a woman who had yet to complete childbearing. Mini-laparotomy myomectomy with morcellation is a safe and efficient alternative for uterine myomectomy of a large 40-week size fibroid uterus in a woman who had yet to complete childbearing. DescriptionThe patient presented in the video is a 38 year old para 1 female with a greater than 40-week fibroid uterus and desired future fertility. The video illustrates the surgical technique of a mini-laparotomy myomectomy. The myomectomy was performed through a 5 cm suprapubic incision at the site of the patient's prior Pfannenstiel incision. The Mobius elastic device was used as a self-retaining abdominal retractor. The myomas were then progressively morcellated using a scalpel in a similar fashion to vaginal morcellation. The endometrial cavity was not entered. The uterus was then repaired in multiple layers using Vicryl suture. The total weight of the uterine fibroids was 3641 gm. The patient conceived and had a successful pregnancy and delivery at term via cesarean section one year after her myomectomy. The patient presented in the video is a 38 year old para 1 female with a greater than 40-week fibroid uterus and desired future fertility. The video illustrates the surgical technique of a mini-laparotomy myomectomy. The myomectomy was performed through a 5 cm suprapubic incision at the site of the patient's prior Pfannenstiel incision. The Mobius elastic device was used as a self-retaining abdominal retractor. The myomas were then progressively morcellated using a scalpel in a similar fashion to vaginal morcellation. The endometrial cavity was not entered. The uterus was then repaired in multiple layers using Vicryl suture. The total weight of the uterine fibroids was 3641 gm. The patient conceived and had a successful pregnancy and delivery at term via cesarean section one year after her myomectomy. ConclusionThis case illustrates that mini-laparotomy myomectomy is a safe and effective alternative to standard laparotomy, laparoscopic, or robotic-assisted myomectomy.DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS:Nora Bassiouni: Nothing to discloseJavier F. Magrina: Nothing to disclosePaul Magtibay: Nothing to disclose This case illustrates that mini-laparotomy myomectomy is a safe and effective alternative to standard laparotomy, laparoscopic, or robotic-assisted myomectomy.

Sham Incisions Effects on Treatment Masking and Outcome Perception

Sham incisions in surgical trials are intended to limit treatment knowledge and minimize influence on perceived success, although their effects on outcome perception are not known. The Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling (OPUS) trial randomized women to TVT vs. no TVT at vaginal prolapse surgery; the randomization included sham suprapubic TVT incisions to mask TVT assignment. In this planned secondary analysis, we assessed whether knowledge of treatment arm differed between randomized groups at 12 months and whether treatment success was affected by the perception of receiving active treatment (TVT).

Suprapubic Single-Incision Laparoscopic Left Hemicolectomy: An Alternative Non-Visible Scar

A 49-year-old patient was hospitalized for adenocarcinoma of the sigmoid colon; preoperative work-up did not show presence of secondary lesions. A suprapubic SILLH was proposed. The technique consisted of performing the procedure through an initial 3.5 cm horizontal suprapubic incision, localized in right iliac fossa, and with the insertion of three reusable trocars vertically in a pararectal axis for curved reusable instruments. The vascular plan (Fig. 1) was firstly controlled by clips and, after mobilization of the entire left and sigmoid colon, the upper rectum was transected and the specimen was removed from the same access; a classic circular transanal anastomosis was performed.

Pure Laparoscopic Right Hepatectomy in a Living Donor

After reporting the first laparoscopic hepatectomy in a living donor for pediatric liver transplantation, we now report a case of pure laparoscopic right hepatectomy for adult transplantation. A 50-year-old female volunteered for living donation to her sister who suffered from primary biliary cirrhosis. The volume of the planned hepatic graft (segments 5–8) was 620 cm3, representing 56% of her entire liver. Five ports were used in the donor to perform the operative procedure. The right hepatic artery and portal vein were isolated. Parenchymal division was performed using an ultrasonic dissector, bipolar coagulation and clips for hemostasis. Cholangiography was performed and the right bile duct was cut at the level of a marker thread. The right liver graft was placed in a bag and removed through a 10-cm suprapubic incision. The veins of segments 5 and 8 were recanalized and the graft was transplanted in the recipient. The postoperative course was uneventful for both the donor and recipient. This case offers evidence that the right liver can be procured via a total laparoscopic approach. This technique may allow for an early rehabilitation for the living donor.

Right colectomy: Value of the totally laparoscopic approach

The role of laparoscopy for right colectomy remains controversial - largely because of a lack of standardization of the operative procedure, including a diversity of techniques including laparoscopy-assisted cases with extra-corporeal anastomosis and totally laparoscopic procedures with intra-corporeal anastomosis. The charts of all patients who underwent right colectomy by a totally laparoscopic approach in our service since 2004 were reviewed and pre-, intra-, and postoperative data were collected. Eighty-two patients underwent totally laparoscopic right colectomy; of these, 32 had a BMI greater than 20 kg/m2 (39%). The mean operative duration was 113 minutes. In most cases, the operative specimen was extracted through a supra-pubic Pfannenstiel incision measuring 4-6 cm in length. Three cases were converted to a laparoscopy-assisted technique (in order to control the ileo-cecal vascular pedicle because of extensive nodal invasion in two cases, and to evaluate a hepatic flexure polyp in the third case). Overall morbidity was 29.3% and parietal morbidity was only 9.8%; there was no difference in morbidity between obese patients (BMI>30 kg/m2) and non-obese patients (BMI<30 kg/m2). The mean duration of hospitalization was 9 days and two patients developed ventral hernia in the extraction incision in long-term follow-up. These satisfactory results show that the totally laparoscopic approach to right colectomy is technically feasible and safe, even in obese patients. In addition, the very low rate of parietal complications is an argument in favor of this approach.

Total gastrectomy for locally advanced cancer: the pure laparoscopic approach.

Total gastrectomy is the treatment of choice for adenocarcinoma of the upper and middle third of the stomach resected with curative intent. The laparoscopic approach allows satisfactory exploration of the peritoneal cavity and optimizes staging in borderline T3 or T4 tumours in patients affected by locally advanced tumours or intraperitoneal carcinomatosis. Laparoscopy can eliminate unnecessary laparotomies in 10 % of patients affected by these conditions with formal contraindications for resection [1]. Complete resection of the stomach associated with D2 lymph node dissection is also performed using a currently well-established technique [2, 3]. The specificity of laparoscopic gastric resection for cancer is that the stomach and the great omentum are withdrawn separately. Reconstruction of the digestive tract is more complex, and requires a variety of techniques (supra-umbilical mini-laparotomy, Orvil® technique, enlarging a port-site for passage of a circular stapler, mechanical side to side anastomosis, etc), but none of these has become the gold standard [4-7]. This explains the difficulties encountered in promoting the widespread use of minimally invasive resection in western countries. Scientific societies insist on the need for prospective studies to establish the place of laparoscopy for gastric cancer (prophylactic gastrectomy for CDH-1 related gastric cancer, < T3 Tumours, palliative gastrectomy) [4]. Here, we present our technique for total resection of the stomach and D2 lymph node dissection, which allows the manual creation of a feasible, safe, tension-free and effective esojejunal anastomosis. It can be performed by any surgeon familiar with laparoscopic surgery and the principles of oncologic resection. The cost is also relatively low because neither a circular stapler nor other special equipment is required. Finally, the incision for extraction of the specimen can be placed in any area of the abdomen (usually through a supra-pubic incision in our practice). mots cles : Gastric cancer, laparoscopy, total gastrectomy, lymphadenectomy, Intracorporeal anastomosis. The patient is placed in the French position, with an inclination of 5 to 10° in the reverse Trendelenburg position. The first surgeon stands between the legs of the patient, with an assistant on each side. Four 10 mm trocars are placed in the upper part of

V265 ABDOMINOVAGINAL TECHNIQUE FOR COMPLETE REMOVAL OF RETROPUBIC MESH SLINGS

You have accessJournal of UrologyFemale Voiding Dysfunction (Pelvic Reconstruction & Incontinence)1 Apr 2013V265 ABDOMINOVAGINAL TECHNIQUE FOR COMPLETE REMOVAL OF RETROPUBIC MESH SLINGS Denise Chow, Forrest Jellison, Lisa Rogo-Gupta, Leah Nakamura, Chad Baxter, Ja-Hong Kim, Larissa Rodriguez, and Shlomo Raz Denise ChowDenise Chow Los Angeles, CA More articles by this author , Forrest JellisonForrest Jellison Los Angeles, CA More articles by this author , Lisa Rogo-GuptaLisa Rogo-Gupta Los Angeles, CA More articles by this author , Leah NakamuraLeah Nakamura Los Angeles, CA More articles by this author , Chad BaxterChad Baxter Los Angeles, CA More articles by this author , Ja-Hong KimJa-Hong Kim Los Angeles, CA More articles by this author , Larissa RodriguezLarissa Rodriguez Los Angeles, CA More articles by this author , and Shlomo RazShlomo Raz Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1648AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We have encounterd a growing number patients presenting with suprapubic, pelvic and vaginal pain due to mesh slings. When conservative measures fail, patients may undergo partial or total removal of their sling mesh. Total removal of retropubic mesh is a challenging procedure. The objective of this video is to present an abdominovaginal approach for complete removal of a retropubic mesh sling. METHODS A retrospective study was performed to identify patients with complications from sling procedures. Patients who underwent removal of retropubic mesh were identified. Data was obtained including symptoms, operative time, length of hospital stay, blood loss, and complications. Technique of retropubic mesh sling removal: 1) Bilateral oblique distal vaginal incisions are made 2) Vaginal epithelium is dissected away from the periurethral fascia 3) Mesh is isolated and the retropubic space is entered 4) Anterior vaginal wall flap is created 5) The mesh is transected in midline and dissected free transvaginally 6) Suprapubic incision made and mesh identified 7) Retropubic space is entered superiorly freeing the mesh from the pubic bone. 8) Mesh is carefully passed under finger control from the suprapubic region to the vaginal incision and mesh is dissected free RESULTS Between 2001 and 2012, 117 patients underwent removal of a suburethral mesh sling alone. Patients with mesh placed for prolapse were excluded. Sixty-eight of these patients had retropubic slings removed. Sixteen of these patients had complete mesh removal with the novel abdominovaginal approach (mean age 52, range 30-65 years). Pre-operative symptoms included pain in 88%, recurrent urinary tract infections in 25%, urinary incontinence in 69%, and mesh exposure in 25%. Average operative time was 124 minutes (57–195 minutes). Average length of hospital stay was 2 days (1–7 days). Average estimated blood loss was 266mL (100–850mL). Only 1 patient had perioperative complications requiring a blood transfusion. Follow up data is available for 10 patients (mean 10.6 months). Four patients underwent additional autologous rectus fascial slings for incontinence. One patient had persistent pain postoperatively. CONCLUSIONS Complete retropubic mesh sling removal is feasible using this abdominovaginal approach. There is minimal perioperative associated morbidity associated. There is a 25% risk of needing a second procedure for incontinence however almost all patients had improvement in their pain. Long term outcome date is still forthcoming with approach. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e108-e109 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Denise Chow Los Angeles, CA More articles by this author Forrest Jellison Los Angeles, CA More articles by this author Lisa Rogo-Gupta Los Angeles, CA More articles by this author Leah Nakamura Los Angeles, CA More articles by this author Chad Baxter Los Angeles, CA More articles by this author Ja-Hong Kim Los Angeles, CA More articles by this author Larissa Rodriguez Los Angeles, CA More articles by this author Shlomo Raz Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

The use of an acellular collagen matrix in penile augmentation: A pilot study in Saudi Arabia

ObjectivesTo assess the use of an acellular collagen matrix (Pelvicol, Bard Medical, Covington, GA, USA), a successful agent for reconstructive surgery, for enhancing penile girth. Patients and methodsBetween June and December 2011, 18 patients (mean age 24years, range 19–38) had their penis augmented with Pelvicol; the mean (range) penile circumference was 9.2 (7–13) cm before treatment. They were divided into two groups; the first (10 patients) had a Pelvicol sheet of 8×12cm inserted through a V–Y suprapubic incision and wrapped around the shaft in a bilayer under the dartos fascia, but not covering the urethra, with division of the suspensory ligament. The second group of eight patients had the Pelvicol inserted through a subcoronal degloving incision and placed in one layer. The penile circumference was measured at 6 and 12months after surgery. Patient satisfaction at 1year after surgery was assessed as ‘poor’, ‘unsatisfied’, ‘moderately satisfied’, ‘highly satisfied’, or ‘excellent’. ResultsThe mean (range) increase in girth (circumference) was 2.8 (2–3.2) cm in group 1 and 1.7 (1.2–2) cm in group 2. In group 1, two patients were highly satisfied, four moderately satisfied and four unsatisfied; in group 2, three were moderately satisfied and five unsatisfied. Complications were common in both groups, with five patients in group 1 and three in group 2 developing severe penile oedema and ischaemic shaft ulcers. Removal of the graft was required in two patients in each group. ConclusionThis pilot study shows that Pelvicol is not an ideal option for enhancing penile girth, and the method of placement did not apparently influence the result.

Laparoscopic Lower Anterior Rectal Resection Using a Curved Stapler: Original Technique and Preliminary Experience

Laparoscopic low anterior rectal resection (LLAR), allowing better visualization and rectal mobilization, can reduce postoperative pain and recovery. A contour curved stapler (CCS) is a very helpful device because of its curved profile that consents better access into the pelvic cavity and allows to perform rectal closure and section in one shot, especially in the presence of a narrow pelvis, complex anatomy, or large tumors. We developed an original technique of laparoscopic rectal resection using CCS. Between 2005 and 2009, in 36 cases, we performed LLAR with a three-trocar technique, starting with mobilization of left colonic flexure followed by the section of inferior mesenteric vessels. The rectum was prepared up to the levator ani with total mesorectal excision. The Lapdisc was inserted trough a suprapubic midline incision, allowing the CCS stapler placement into the pelvic cavity. After the rectal section, the anastomosis was then performed with a circular stapler. Ileostomy was performed if neoadjuvant radiotherapy and chemotherapy have been carried out or if the anastomosis was below 4 cm from the anal verge. Mean operative time was 135 minutes and no intra- or postoperative bleeding occurred. In 27 patients we performed temporary ileostomy. In two cases we observed anastomotic leakage; one of these patients already had ileostomy. No anastomotic stenosis occurred after one-year follow-up. This procedure simplifies the section of the lower rectum, reduces leaking rate resulting from technical difficulties, and does not nullify the benefits of laparoscopy.

The Misgav-Ladach Method of Cesarean Section

Cesarean section (CS) is the most common intraperitoneal surgical procedure in obstetric and gynecologic practice. The most common method during the late 20th century was the Pfannenstiel-Kerr (PK) method, which uses a curved transverse suprapubic incision in the abdominal skin, a transverse lower uterine segment incision, including a double-layer uterine suture, and peritoneal closure. In the 1970s, the Joel-Cohen technique was developed to cause the least damage to tissues, avoid superfluous steps, and make the intervention the simplest possible. This technique was adopted at the Misgav-Ladach hospital in Jerusalem and underwent further changes to become the modified Misgav-Ladach (MML) technique, which was believed to make the procedure more acceptable to clinicians and patients. This 9-year prospective study was performed to compare the MML with the classic PK technique for intraoperative and short-term postoperative outcomes. Women undergoing an elective or emergent CS were selected for either the MML or PK technique according to surgeons’ preferences; patients were not randomized. All CSs were performed under general anesthesia. Intravenous analgesics were administered to all patients on postoperative day 1 (POD 1), and anticoagulant therapy was administered to all patients for 10 days after the CS. Main outcome measures were the duration of surgery, analgesic requirements, febrile morbidity, postoperative antibiotic use, postpartum endometriosis, wound complications, and hospitalization time. Wound complications were evaluated on POD 3. The outcomes for the techniques were compared using the χ2 test for proportions and Student t test for continuous variables. In a secondary analysis, outcomes were compared between women who delivered in 2003–2004, the first 2 years of the study, and women who delivered in 2010–2011, the last 2 years, when the MML technique had become the method of choice for all primary CSs. In the PK procedure, the uterine incision was closed in 2 layers (endometrium and myometrium separated) with a continuous suture. Visceral and parietal peritoneum was closed with a continuous suture and the rectus muscles with 3 to 5 interrupted approximating sutures. The transversely incised fascia was closed with a continuous suture, and the subcutis was sutured in interrupted stitches. For the MML procedure, the uterine incision was closed in 1 layer with continuous suture reapproximating the full thickness of the myometrium, with additional hemostatic stitches if required. The suture was usually unlocked. The skin was closed with widely spaced sutures. Postpartum care for both procedures were similar with intravenous hydration on the day of the surgery, catheter removal on POD 1 or 2, drinking 12 to 24 hours postoperatively, and regular diet from POD 2 or 3. Stitches were removed on POD 7. A total of 4336 women underwent the MML technique, and 608 underwent the PK technique. The obstetric characteristics and indications for CS did not differ significantly between the 2 groups. Compared with the PK technique, the MML technique was associated with a shorter operative time (13.4 ± 7.4 vs 19.1 ± 6.8 minutes), less surgical material (3.5 ± 2.5 vs 7.9 ± 2.1), lower requirements for postoperative analgesics (5.01 ± 4.7 vs 8.9 ± 1.4 doses), and lower rates of febrile morbidity (1.27% vs 6.6%) and wound infections (1.64% vs 4.9%). By the end of the study period, nearly all CSs were performed using the MML technique. Analysis of outcomes comparing 2003–2004 with 2010–2011 showed shorter operative times (17.9 ± 1.3 vs 14.2 ± 6.3 minutes), less surgical material (6.3 ± 4.7 vs 3.7 ± 2.1), lower requirements for postoperative analgesics (9.1 ± 4.7 vs 6.6 ± 2.2 doses), and lower rates of febrile morbidity (5.4% vs 1.2%), wound infections (6.8% vs 1.6%), and dehiscence (3.1% vs 1.4%) in 2010–2011. Because of the many technical differences between these 2 methods, the differences in outcomes may be secondary to specific steps of the procedures instead of the overall technique. The MML technique seems to be the least traumatic surgical procedure. Controversy still exists over the impact of the single- versus double-layer closure of the uterus on the risk of uterine rupture at the next pregnancy and on the choice between parietal and visceral closure of the peritoneum. The results suggest that the MML technique might lead to better short-term postoperative outcomes, especially in reduction of pain and postoperative complications compared with the PK technique.

Feasibility of laparoscopically assisted extracorporeal cystectomy via single suprapubic incision using an adjustable-view laparoscope to treat large benign ovarian cysts: comparison with conventional procedure

ObjectiveTo demonstrate the feasibility of minimally invasive surgery using a novel optical device to treat large benign ovarian cysts and to compare the safety of the procedure with that of conventional laparoscopically assisted multiport extracorporeal cystectomy. Study designTwenty-one patients with large benign ovarian cysts underwent laparoscopically assisted extracorporeal ovarian cystectomy via a single suprapubic incision using a novel 10-mm rigid laparoscope with an adjustable direction of view and a multiport device, between October 2010 and July 2012. The surgical outcomes were retrospectively compared between these patients (Group A) and 32 patients who underwent the conventional 3-port laparoscopically assisted extracorporeal procedure between January 2009 and September 2010 (Group B). Data were statistically analyzed using the Mann–Whitney U-test or Fisher's exact test. ResultsNone of Group A required conversion to conventional multiport laparoscopy. The total duration of surgery, elapsed time between skin incision and the start of pneumoperitoneum, and time required for intra- and extra-corporeal manipulations did not significantly differ between the groups. The time required for skin closure, however, was significantly decreased in Group A compared with Group B (13.0±3.5 vs. 20.2±4.8min, P=0.005). The volume of blood loss and postoperative blood findings were similar to those associated with the conventional procedure. Postoperative visual analog pain scales at 3h were significantly lower in Group A than in Group B (3.7±2.6 vs. 4.8±2.0, P=0.04). Postoperative complications did not arise after either procedure. ConclusionLaparoscopically assisted extracorporeal cystectomy via a single suprapubic incision is a feasible and safe alternative to conventional multiport cystectomy for treating large benign ovarian cysts.

Treatment of umbilical hernia and recti muscles diastasis without a periumbilical incision

Postpartum rectus diastasis eventually combined with umbilical hernia is a condition that is frequently treated by plastic surgeons and general surgeons. Standard treatment of this condition is abdominoplasty with a periumbilical incision, which often results in an umbilical incision or an inverted-T scar. Limited incision abdominoplasty differs from traditional abdominoplasty by disconnecting the umbilical stalk from the abdominal wall during flap dissection, thus allowing the resection of excess skin above and under the umbilicus without causing periumbilical scarring. We conducted a retrospective cohort study of women undergoing a limited scar abdominoplasty without a periumbilical incision for the treatment of a separation of the recti muscles and/or an umbilical hernia. We recorded the postoperative complications and patient satisfaction with the results of the treatment. We operated on 50 patients from 2002 to 2010. We followed the patients for 2-8 years. The most common complication, as with other abdominoplasty procedures, was minor dehiscention in the middle part of the wound, which occurred in 16 % (n = 8) of the patients. All of these complications were treated conservatively. No recurrence of diastasis or umbilical hernia was observed. Extended miniabdominoplasty with a low suprapubic incision and umbilical caudalization for treating the diastasis of the abdominal rectus muscles and/or an umbilical hernia is an excellent method that results in a small, hidden scar. This method is especially beneficial for young, slim women with an abdominal wall deformity after pregnancy.

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.

Single-Incision Laparoscopic Ventral Hernia Repair with Suprapubic Incision

Although natural orifice transluminal endoscopic surgery promises truly scarless surgery, this has not progressed beyond the experimental setting and a few clinical cases in the field of ventral hernia repair. This is mainly because of the problem of sterilizing natural orifices, which prevents the use of any prosthetic material because of unacceptable risks of infection. Single-incision laparoscopic ventral hernia repair has gained more wide-spread acceptance by specialized hernia centers. Even so, there is a special subset of patients who are young and/or scar conscious and find any visible scar unacceptable. This study illustrates an innovative way of performing single-incision laparoscopic ventral hernia repair by a transverse suprapubic incision below the pubic hair/bikini line in 2 young male patients who had both umbilical and epigastric hernias as well as attenuated linea alba in the upper abdomen. Both patients underwent successful laparoscopic repair, and both were highly satisfied with the procedure, which produced no visible scars on their abdomen. Willingness to adopt new innovative procedures, such as single-incision laparoscopic surgery, has allowed modification of the incision site to produce invisible scars and hence become highly attractive to the young and scar-phobic segment of the population.

Can a curved stapler made for open surgery be useful in laparoscopic lower rectal resections? Technique and experience of a single centre

BackgroundThe use of laparoscopy to perform lower anterior rectal resection is increasing worldwide because it allows better visualisation and rectal mobilisation and also reduces postoperative pain and recovery. The Contour Curved Stapler (CCS) is a very helpful device because of its curved profile that enables better access into the pelvic cavity and allows rectal closure and section to be performed in one shot. In this paper, we present an original technique to use this device, made for open surgery, in laparoscopy and the results of our experience. MethodsWe retrospectively evaluated the data of all patients who underwent lower laparoscopic anterior rectal resection and in which the CCS was used to perform section of the rectum between September 2005 and September 2011.To perform section of the rectum a Lapdisc® was inserted through a 6–7 cm supra-pubic midline incision to allow placement of the CCS into the pelvic cavity. Patients' biographical and surgical data such as sex, age, indication for surgery, infection, anastomotic leakage or stenosis and staple-line bleeding were prospectively collected in a computerised database and evaluated. ResultsBetween September 2005 and September 2011, we performed 45 laparoscopic lower rectal resection using CCS, 27 male and 18 female with a mean age of 61 years (range 40–82 years) and a mean body mass index (BMI) of 26.5 kg/m2 (range 16.5–35 kg/m2). In 29 cases a temporary ileostomy was performed. Mean operative time was 131 min (range 97–210 min). In all cases it was possible to perform a lower section of the rectum with CCS. No intraoperative or postoperative staple line bleeding occurred. In two patients we observed anastomotic leaks and in one of these a temporary ileostomy was performed. None of the patients showed an anastomotic stenosis at 1-year follow-up colonoscopy. ConclusionsThis study shows that CCS enables section of the lower rectum to be easily performed, especially in adverse anatomical condition, and the technique proposed by us allows the use of this stapler without giving up the benefits of laparoscopic access.