Supraumbilical Port Research Articles

Enhancing Safety in Left Ventricular Assist Device Implantation: Laparoscopic Technique for Driveline Tunneling.

Advancements in left ventricular assist device (LVAD) technologies have significantly lowered morbidity and mortality in patients with end-stage heart disease; however, they still carry significant risks. Though infrequent, intraabdominal injury during driveline tunneling can be catastrophic. Laparoscopic visualization can reduce these risks, especially benefiting patients with lower body mass indexes and thin abdominal walls. We present two cases of laparoscopic driveline tunneling. The laparoscopic procedure begins poststernotomy and preheparin administration to mitigate bleeding risks. Supraumbilical port placement is performed for optimal direct visualization of the abdominal space for accurate driveline tunneling. It involves careful management of insufflation pressure to prevent hemodynamic collapse by restricting venous return. This approach ensures that the driveline is positioned correctly without injury to any intraabdominal structures.

Comparison of gallbladder extraction via the subxiphoid port and the supraumbilical port during laparoscopic cholecystectomy: a prospective randomized clinical trial

Background: Postoperative pain after laparoscopic cholecystectomy (LC) is the most frequent postoperative complaint. To date, gallbladder extraction via the subxiphoid port (SXP) versus the supraumbilical port (SUP) is still controversial. Thus, we performed this randomized controlled trial to compare postoperative pain between the SXP and SUP for LC. Method: From June 2021 to June 2023, patients who met the inclusion criteria were randomly assigned to two groups. The perioperative data of both groups were recorded and compared. Results: A total of 253 patients were enrolled in the analysis. There were 126 in the SXP group and 127 in the SUP group. There was no significant difference between the two groups in terms of the duration of gallbladder extraction, whether the incision was extended, the least rate of pain, the average rate of pain, the right-now rate of pain, postoperative pain on the 5th, 7th, and 14th days, postoperative complications and Vancouver Scar scale (VSS). However, the SUP group had a lower the worst rate of pain (4.24±2.45 vs. 4.91±2.45, P=0.031) and 3 days of pain (3.35±1.57 vs. 3.75±1.52, P=0.045) than did the SXP group. The influence of pain on general activity (4.51±2.90 vs. 3.76±2.92, P=0.041), mood (3.62±2.66 vs. 2.92±2.36, P=0.028), walking ability (4.40±3.01 vs. 3.66±2.76, P=0.044), and enjoyment of life (3.19±2.68 vs. 2.32±2.34, P=0.007) in the SXP was more severe than that in the SUP. Conclusion: The extraction of the gallbladder via the SUP is superior to that via the SXP because the early postoperative 24-hour pain and pain on the third day are mild and do not increase the duration of gallbladder extraction or the risk of infection or hernia.

Incisional hernias following robotic-assisted laparoscopic prostatectomy: does the extraction site matter?

The incidence of incisional hernia (IH) following robotic-assisted laparoscopic prostatectomy (RALP) varies widely within the literature (0.4-9.7%). Whilst small hernias may go unnoticed, the potential exists for bowel strangulation and subsequent emergency surgery. We suggest that the extraction site may influence the rate of IH. A retrospective chart review of a single surgeon RALP series was undertaken. One hundred charts were sampled, of which 69 had sufficient data to be analysed. Prior to July 2017, specimen extraction had been via the supra-umbilical port site. After this time, specimens were extracted via a Pfannenstiel incision. Of the 69 patients, 24 underwent RALP prior to July 2017. Three patients developed IH at the supra-umbilical port extended for extraction site in the pre-2017 group and three patients developed IH at the supra-umbilical port (not extraction) site in the post-2017 group. The rate of IH was almost double in the pre-July 2017 group (12.5% vs. 6.7%). No patient developed an incisional hernia at the Pfannenstiel site in the post-2017 group. In our series, no patient developed a hernia at the Pfannenstiel site. This is in keeping with the reported < 1% IH rate following Pfannenstiel specimen extraction. Given that incisional hernias are a known complication of robotic surgery, thought should be given to changing the site of specimen extraction site to lower the rate of incisional hernias and the morbidity associated with such.

175 Rare Complications and Management of Port Site Hernias (PSH) Following Robotic-Assisted Radical Prostatectomy (RARP)

Abstract Robot-assisted surgery has become increasingly prevalent in surgical practice and is very commonly performed in urological cancers especially of the prostate gland. Robotic surgical techniques are safe and reproducible; however, they have their associated complications. Risk factors such as the nature of cancer, learning curve of the surgery, experience of the surgeon and patient characteristics have been implicated for potential complications. Complications can range from bleeding, infection, bowel injury, ureteric and nerve damage. Port site hernias (PSH) are an infrequent complication with a reported incidence varying from 0.2–4.8%. Although uncommon, they can result in high morbidity due to bowel incarceration and strangulation. We report two cases of PSH from our large district general hospital, both at the supraumbilical port site after robotic assisted radical prostatectomy (RARP). The first case presented with complete evisceration and strangulation of a segment of small bowel and the second with bowel incarceration and small bowel obstruction. Our cases highlight potentially rare but severe complications of RARP that should be promptly recognised and urgently treated to prevent significant patient morbidity and mortality.

Intraperitoneal Instillation of Ropivacaine 0.375% with Dexmedetomidine vs Ropivacaine 0.375% with Clonidine for Postoperative Analgesia in Laproscopic Cholecystectomy: A Comparative Study

Introduction: Laproscopic Cholecystectomy is a standard technique for symptomatic cholelithiasis. It is most commonly performed day care surgery. On the day of surgery pt experiences vague abdominal and shoulder pain. As the discharge is delayed due to lack of adequate analgesia, provision of adequate analgesia is of utmost importance. Objective: To compare the efficacy of postoperative analgesia after intraperitoneal instillation of 0.375% Ropivacaine with Dexmedetomidine vs 0.375% Ropivacaine with Clonidine Materials and Methods: 40 patients posted for laproscopic cholecystectomy were randomly divided into two groups A and B. Group A received 20 ml of 0.375% Ropivacaine with 1mcg/ kg of Dexmedetomididne and Group B received 0.375% Ropivacaine with 1mcg/Kg Clonidine intraperitoneally through the 10mm supraumbilical port before closure. Pain was recorded on Visual Analog Scale at frequent intervals for 24 hrs postoperatively and categorised as either mild, moderate or severe. Inj. Diclofenac 75mg iv was administered as rescue analgesic in pts with moderate to severe pain. Results: PostoperativeVAS score showed a statistically significant difference between both groups with lower values in Group A compared to Group B. (P&lt; 0.05 ). The amount of rescue analgesia used was also less with dexmedetomidine as adjuvant. Conclusion: Ropivacaine 0.375% with 1mcg/kg Dexmedetomidine provided better postoperative analgesia and significantly less requirement of rescue analgesia as compared to 0.375% Ropivacaine with 1mcg/kg clonidine.

Prevalence of Complications in Laparoscopic Cholecystectomy in Extracting Gallbladder by Using Supra-Umbilical Port Versus Epigastric Port in Sulaimani Teaching Hospital: A Prospective Case Series Study

Background: Depending on the surgeon's preference, different locations for trocar incision can be used to extract the gallbladder. Some studies are claiming that epigastric port is better for retrieval due to easiness for the surgeon as there is no need to change the position of the telescope and readjustment of the surgeon’s position. Other studies show the superiority of umbilical port in terms of pain. Setting: Sulaimani Teaching Hospital. Aims: The current work aims at evaluating the port site for gallbladder retrieval in LCin terms of time for extracting the specimen, frequency of port site pain, surgical site infection, and incisional hernia. Patients and methods: This is a prospective randomized study including 108 patients who underwent laparoscopic cholecystectomy. It was conducted in Sulaimani Teaching Hospital from October 1st, 2020, to September 30th, 2021. Patients were divided into two groups matched in gender and age: Group A: Gallbladder was extracted from the epigastric port while in Group B: Gallbladder was extracted from the supra-umbilical port. Results: A two comparable groups of patients matched in gender and age were recruited with a mean age of 41.2 + 11.04 years ranged 20-68 years. Overall, 52.78 % (n=57) were female and 47.22% (n=51) were male with F/M ratio of 1.11/1. The time of the LCfor [21±4 min] was more in group B [n= 42, 38.9%] patients in contra to group A[n=37, 34.3%] patients, while for [33±2 minutes] it was more in group A [n= 6, 5.6% ] patients. Retrieval of the almost all the excised gall bladder (n=54, 98.18% patients) via supraumbilical port needs less time (≤5 minutes) in comparison to epigastric port (n=40, 75.47% patients). Conclusion: Based on these findings the safety and ease of supra-umbilical port for extraction of gallbladder during LChas been better than that in using epigastric port. Furthermore, it has taken less operative time with less patients complained of pain or surgical site infection, abscess, and port site incisional hernia.

Pseudomyxoma peritonei presenting with port site hernia

Pseudomyxoma peritonei (PMP) is a rare disease with an incidence of two per million. Acute appendicitis, ovarian mass, and abdominal distension are the most common presentations. A 72-year-old male patient with a history of laparoscopic cholecystectomy was admitted to the hospital with abdominal pain and increased supraumbilical port site swelling. Radiological examination revealed a mass in the terminal ileum and severe intraabdominal mucinous fluid. Intraabdominal gelatinous fluid protruding from the port site defect and a mass in the distal ap-pendix were observed during operation. He underwent a right hemicolectomy, ileocolic anasto-mosis and peritoneal debridement; cytoreductive surgery was administered two months later due to mucinous tumor of the appendix. There are only a few case reports describing PMP presen-ting with an incisional hernia after open surgical procedures. To the best of our knowledge, this report describes the first case of PMP presenting with a port site hernia after a laparoscopic in-tervention.

Laparoscopic Needle assisted Repair of Inguinal Hernia in Children in Manipal Teaching Hospital, Pokhara

Introduction: There are numerous minimally invasive surgical techniques for repair of congenital inguinal hernia (CIH) in children. We present a unique needle-assisted laparoscopic inguinal hernia repair using 20-gauge intravenous cannula. This study aims to evaluate the safety and feasibility of this technique.&#x0D; Methods: This prospective descriptive study was conducted in 50 patients; aged 1-13 years; from February 2018 to May 2019; either admitted with the diagnosis of CIH or detected incidentally when operated for some other surgical conditions. CIH was repaired using single supraumbilical port and 2-0 prolene suture passed through 20-gauge intravenous cannula. Statistical analysis was done using SPSS 20.&#x0D; Results: A total of 56 hernias were repaired in 50 patients out of which five cases were detected incidentally on patients undergoing laparoscopic appendectomy. The bilateral CIH was present in six cases. The mean operative time was 18.20 ± 4.57 minutes; 17.36 ± 3.83 minutes for unilateral hernia and 24.33 ± 5.20 minutes for bilateral hernia. There was no difference in operative time when compared between gender (p=0.26). The complications were recurrence in 1(1.78%) case, hematoma around deep ring in 2 (3.57%) cases and puncture site bleeding in 2 (3.57%) cases. There were 35 (70%) male and 15 (30%) female. The contralateral occult hernias were noted in 5 (10%) cases.&#x0D; Conclusions: Single port laparoscopic repair of inguinal hernia using a 20-gauge intravenous cannula with non-absorbable suture is a safe, effective and feasible in resource poor settings. The postoperative complications are minimal which is similar to past studies.

Laparoscopic radiation spacer for unresectable liver tumors

Background: Radiation therapy is an option for localized, unresectable, hepatic malignancies (both primary and metastatic). The ability to deliver optimized doses of radiation can be hindered by adjacent structures, most typically bowel. For patients in this situation, we have adopted an approach consisting of placement of a customized biologic mesh-based spacer to move adjacent viscera away from the radiation field. This video demonstrates our approach. Methods: Following IRB approval, patients undergoing surgical placement of spacers to facilitate radiation therapy were identified. A single case was video-taped and we describe the clinical case corresponding to this video. Case: The patient is a 59 year old male with Child-Pugh A compensated alcoholic cirrhosis who was being monitored and found to have a 7-mm enhancing lesion in the liver in May of 2014, which was enlarging on surveillance imaging in October 2014, up to 2.7 cm. Radiographic features were consistent with hepatocellular carcinoma. Results: Liver transplant evaluation was performed and the overall consensus was for locoregional therapy at that time. Initial attempt for RFA was made, however, on CT scan the lesion was in close proximity to the duodenum. RFA was not performed and instead alcohol ablation followed by transarterial chemoembolization was undertaken. Recurrent disease in August and November 2015 was treated with TACE. He continued to have progressive disease in the form of enlarging lesion. After multidisciplinary discussion, repeat locoregional radiation therapy was agreed upon. Given the proximity of the duodenum, he was referred to HPB surgery for spacer placement to facilitate safe administration of radiation. The video shows the technique of laparoscopic spacer placement. Shown in the video is the site of HCC in segment 4 of the liver as well as its proximity to the duodenum and colon. An open Hasson technique was used to gain entry into the abdomen and three 5 mm ports were placed based on the location of the target lesion. After sizing the area needed for spacer placement, Surgimend mesh was folded and a pocket created with a running #1 prolene suture. The spacer was introduced by extending the supraumbilical port and was positioned underneath the liver followed by a single tacking suture between the stomach and the liver and a single tacking suture between the spacer and mesentery of the right colon to secure the mesh in appropriate position. Fiducials were placed using a clip applier surrounding the visualizable lesions within the liver. Postoperative scan shows full expansion of the spacer. The patient had no complications following surgery and started radiation therapy 11 days after surgery (50 Gy in 5 fractions, photon). Conclusion: For patients with unresectable tumors, that are amenable to radiation therapy, placement of a spacer to allow for safe administration of full doses of radiation is a feasible strategy to address proximity of adjacent organs and critical structures. There is minimal morbidity associated with these procedures in our limited experience, including in patients with cirrhosis.

The Effect of Age and Body Mass Index on the Surgical Anatomy of Supraumbilical Port Insertion: Implications for Laparoscopic and Robotic Surgery

Background: Minimally invasive surgery is the preferred approach for performing many gynecologic procedures. Occasionally, supraumbilical port placement may be preferable to optimize visibility and maneuverability although the risks of complications are less well characterized compared to umbilical entry. Methods: We conducted a retrospective review of computed tomograms from 92 patients to evaluate the anatomic considerations for umbilical and supraumbilical port entry based on patient age, body mass index (BMI), parity, abdominal wall thickness, and distance to the great vessels. Results: Supraumbilical entry was not associated with differences in distance to the great vessels compared to the umbilicus. However, supraumbilical location and BMI were associated with greater abdominal wall thickness. Age and BMI were associated with greater distance to the great vessels, while age was associated with thinner abdominal wall. Multiple linear regression confirmed independent effects of age and BMI. No association between parity and distance to retroperitoneal vessels was observed. Conclusion: Younger patients may be at increased risk for great vessel injury and pre-peritoneal insufflation. Obese patients may be at risk for pre-peritoneal insufflation, while patients with BMI < 30, particularly with a skin-to-aorta distance < 7 cm, may be at an increased risk for great vessel injury. Surgeons should consider these factors when considering supraumbilical port entry.

Laparoscopic Extended Pelvic Lymph Node Dissection During Radical Cystectomy: Technique and Outcomes

Abstract Introduction: Laparoscopic radical cystectomy (LRC) is both safe and efficacious. Extending the laparoscopic limit by doing extended pelvic lymph node dissection (PLND) and then doing external diversion by a small Pfannenstiel incision can further decrease the morbidity of the procedure while maintaining oncologic efficacy. We intend to perform and evaluate laparoscopic extended PLND (EPLND) in patients undergoing LRC with ileal diversion by a four-port split-and-roll technique. Materials and Methods: The essential steps of the procedure include patient in steep 45° Trendelenburg position with the surgeon and camera assistant on left position, 12 mm supra umbilical port for camera, 12 mm dissection port at the previously marked ileal conduit site, 5 mm retraction, and assistant port in left and right quadrant. Root of bowel mesentery is reflected cranially to expose aortic bifurcation. The packet is longitudinally divided anterior to the artery (iliac and aorta) using the split-and-roll technique...

Surgical anatomy of supraumbilical port placement: implications for robotic and advanced laparoscopic surgery

To describe the surgical anatomy of the supraumbilical region and to provide guidelines for insertion technique. Educational video. Tertiary university hospital. A study population of 92 women. Abdominal thickness was measured from the skin to the anterior peritoneum. Distance to the aorta and the IVC was measured from the anterior peritoneum to the most superficial border of the vessel. Mean values are presented for the distances from the umbilicus to the aorta and the IVC and at 1-cm increments cephalad to the umbilicus. Pearson correlation coefficients and 95% confidence intervals were calculated to describe the association between BMI and the distance and thickness measurements. Abdominal wall thickness, distance to the aorta and inferior vena cava. Abdominal wall thickness increases the more cephalad above the umbilicus. The distance to the great vessels decreases at 1-cm increments above the umbilicus until 2 cm. The greatest distance from the entry point to the aorta and the IVC is at 5 cm above the umbilicus. However, the abdominal wall is also the thickest at this point, particularly in obese patients. Thus, the overall distance from the skin to the great vessels is reduced as BMI increases. The distal end of the falciform ligament, which is a fold of the peritoneal ligament, is on average 6.5 cm from the umbilicus. It is prudent for the surgeon to be cognizant of distance variations and risk of vessel injury with obese patients. If the supraumbilical entry is necessary, it is recommended to do so at 5 cm cephalad to the umbilicus. These anatomical relationships should be considered to avoid injury to the aorta and the IVC as well as intraligamentary preperitoneal insufflation.

Surgical anatomy for supraumbilical port placements: implications for laparoscopic surgery

Our objective is (1)to establish the location of the aorta and the inferior vena cava(IVC)in relationship to and at 1 cm increments above the umbilicus(1-5 cm)and(2)to determine how these relationship vary as a function of abdominal wall thickness(AWT)and patient body mass index (BMI).

Reparación de hernias incisionales durante la abdominoplastia tras cirugía bariátrica

ObjectiveBody contouring surgery is in high demand following the increase in bariatric surgery. The aim of this study was to evaluate the results of the repair of incisional hernias following bariatric surgery with concomitant abdominoplasty. Methods72 patients underwent body contouring surgery following massive weight loss. The surgery was performed, on average, 28 months after gastric bypass. They were reviewed retrospectively for demographic data, pre- and post- operative weight status, co-morbidities and complications and reoperation rate and for the incidence of incisional hernias. ResultsA total of 9 patients (12.5%) had hernia repair in combination with abdominoplasty. Gastric bypass laparoscopic approach comprising 5 patients and the open approach comprising 4, one conversion. Average body mass index at the time of abdominoplasty was 27.8kg/m2. Comorbid conditions included diabetes mellitus and smoker use. Hernias were in supra umbilical midline port and in the laparotomy. We repaired these hernias using primary closure in 6 patients and poliypropylene mesh in 3. Complications arisen: 2 developed a wound infection and umbilical necrosis and one developed a hematoma. ConclusionThe use of laparoscopic in bariatric surgery has decreased the incisional hernias. The repair of incisional hernias following bariatric surgery with concomitant abdominoplasty is an adequate alternative procedure that does not add considerable morbidity, may reduce recurrence rates and improve aesthetic results. Moreover, the repair is associated with frequent local postoperative complications that don’t affect the result of surgical treatment and the hospital stay.

Needle-Assisted Laparoscopic Inguinal Hernia Repair in Children: Experience in Chittagong, Bangladesh

Purpose: There are numerous procedures of minimally invasive surgery for repair of inguinal hernia in children including percutaneous techniques. We describe here our technique of using 18G or 20G needle in a very simple and effective way for this purpose. Methods: Needle-assisted laparoscopic percutaneous repair internal ring was performed in 55 children between 1st November 2010 and 31st July 2011. An 18G or 20G needle and a 3/0 polyglycolic acid thread were used. A 5-mm supraumbilical port for 30? 5 mm telescope and a 3-mm port in iliac fossa opposite to the lesion to handle the thread intra-abdominally were used. Results: Age ranged from 3 months to 12 years and 40 were males. Seven cases were bilateral making total 62 lesions. Mean operating time was 30.54 ± 5.84 min (range 20–42) and there was no intraoperative complication. Postoperatively five cases had transient hydrocele which resolved spontaneously. One case recurred after 2 months. Conclusions: Needle-assisted laparoscopic inguinal hernia repair in children is a simple and effective technique that can be performed routinely in resource poor countries. DOI: http://dx.doi.org/10.11593/bje.2013.0102.0011 Bangladesh Journal of Endosurgery Vol.1(2) May 2013: 7-10

Laparoscopic stripping ovarian cystectomy in children without use of electrocautery in residual ovarian bed: experience in Chittagong, Bangladesh

Objective: Laparoscopic excision has now become the standard treatment option for benign ovarian cysts. Stripping is an effective and popular technique practiced by the surgeons for ovarian cyst excision. Use of electro-cautery in the residual ovarian bed is blamed for the reduction of ovarian reserve. Our experience of laparoscopic stripping technique without use of electro-cautery in the remaining ovarian tissue is described. Materials and Methods: From 1 January 2006 to 31 December 2010, 26 cases were considered for laparoscopic stripping ovarian cystectomy. Using mono-polar hook cautery a flap was marked and raised on cyst wall and serous fluid sucked out. A plane was then created between inner and outer linings of the cyst wall, and inner lining peeled off. Warm normal saline wash was then given and the stripped lining was brought out through supra-umbilical port. Patients were followed up at 15 days, 1 month, 3 months, 1 year and then yearly with ultrasonogram at 3 months and 1 year. Patient’s age, operative time and outcome, blood loss and complications were studied retrospectively. Results: Age ranged from 3.5 to 16 years. Presenting complaints included: abdominal pain (11), abdominal swelling (8) and palpable abdominal lump (7). Average operative time was 40.30 minutes and operative blood loss ranged from 10 to 36 ml. There was no intra or post-operative complication. There was no recurrence of cyst confirmed by ultrasonography at 3 months and 1 year. Conclusions: Avoiding use of electro-cautery during ovarian cystectomy by stripping technique can prevent damage and reduction in ovarian reserve. DOI: http://dx.doi.org/10.11593/bje.2013.0101.0007 Bangladesh Journal of Endosurgery Vol.1(1) January 2013: 26-28

Robot-Assisted Upper Para-Aortic Lymphadenectomy Techniques Using Only Three Robotic Arms

We would like to demonstrate robot-assisted upper para-aortic lymphadenectomy using only two robotic instrumental arms without changing the position of the patient. We utilize the supraumbilical port location which allows for greater access to the aortic lymph nodes. The right arm was placed 10 cm lateral 1 cm inferior to the endoscope. The left arm was placed 12 cm lateral and 2 cm inferior to the endoscope. A 12 mm sized assistant port was placed between the endoscope and left arm. After completing pelvic lymphadenectomy, presacral and bilateral lower para-aortic lymph nodes were dissected with ureters retracted laterally by the assistant.

Variance in Abdominal Wall Anatomy and Port Placement in Women Undergoing Robotic Gynecologic Surgery

Study Objectives To estimate whether variability in the size and ratios of the lower and upper abdomen exist in women undergoing robotic gynecologic surgery and whether demographic variables are significantly associated, and to determine the association between abdominal wall dimensions and supraumbilical robotic port placement. Design Prospective cohort study (Canadian Task Force classification II-2). Setting University teaching hospital. Patients Seventy-eight women undergoing robotic surgery between May 2008 and March 2009. Intervention Measurements from the symphysis pubis to the umbilicus (lower abdomen), umbilicus to the xyphoid process (upper abdomen), and distance between the anterior superior iliac crests were obtained at surgery. A multiple linear regression model was created to determine the relationships between abdominal wall measurements, demographic variables, and need for supraumbilical robotic port placement. Measurements and Main Results Fifty-six white and 22 black women were enrolled. Mean lower abdominal length was significantly affected by body mass index (BMI) (p <.001) and race (p = .006), with white women having longer measurements (17.1 cm vs 15 cm). Mean lower abdominal width was independent of age (p = .95) or race (p = .98), but was significantly correlated with BMI (p <.001). Mean upper abdominal length correlated with BMI (p <.001) and age (p = .03) but not race (p = .13). Ratios of bottom to top were significantly affected by race (p = .002) and age (p = .008) but not BMI (p = .07). Adjustments to port placement above the umbilicus were made in 44 of the 74 women (59.5%). Those who required supraumbilical port placement had a significantly shorter mean (SD) distance between the symphysis pubis and the umbilicus (14.99 [1.36] vs 18.55 [2.21]; p <.001). Conclusions Significant variability in abdominal wall anatomy exists in women undergoing robotic gynecologic surgery, and the need for supraumbilical robotic port placement is common.

Multipurpose surgical robot as a laparoscope assistant

This study demonstrates the effectiveness of a new, compact surgical robot at improving laparoscope guidance. Currently, the assistant guiding the laparoscope camera tends to be less experienced and requires physical and verbal direction from the surgeon. Human guidance has disadvantages of fatigue and shakiness leading to inconsistency in the field of view. This study investigates whether replacing the assistant with a compact robot can improve the stability of the surgeon's field of view and also reduce crowding at the operating table. A compact robot based on a bevel-geared "spherical mechanism" with 4 degrees of freedom and capable of full dexterity through a 15-mm port was designed and built. The robot was mounted on the standard railing of the operating table and used to manipulate a laparoscope through a supraumbilical port in a porcine model via a joystick controlled externally by a surgeon. The process was videotaped externally via digital video recorder and internally via laparoscope. Robot position data were also recorded within the robot's motion control software. The robot effectively manipulated the laparoscope in all directions to provide a clear and consistent view of liver, small intestine, and spleen. Its range of motion was commensurate with typical motions executed by a human assistant and was well controlled with the joystick. Qualitative analysis of the video suggested that this method of laparoscope guidance provides highly stable imaging during laparoscopic surgery, which was confirmed by robot position data. Because the robot was table-mounted and compact in design, it increased standing room around the operation table and did not interfere with the workspace of other surgical instruments. The study results also suggest that this robotic method may be combined with flexible endoscopes for highly dexterous visualization with more degrees of freedom.

Laparoscopic surgical management of perforative peritonitis in enteric fever: a preliminary study.

Early surgery in enteric perforation is the only accepted form of treatment in modem day medicine and gives excellent results. Exploratory laparotomy continues to be the mainstay of surgical treatment and several different procedures are recommended in literature. Between January 1998 and November 2001, we have successfully managed 6 consecutive cases of enteric perforation laparoscopically with complete resolution of the disease. There were 4 males and 2 females in our study. The mean time of presentation to us was 38 hours after the perforation (range 22 hours to 63 hours). The mean age was 32 years (range 28 years to 43 years). All patients presented with free air under the diaphragm. A laparoscopic approach was carried out through a 10 mm supraumbilical port and two 5 mm additional ports in the midline infraumbilical area and the left iliac fossa area. Simple one layer closure of the perforation was carried out with 2-0 silk intracorporeally and the peritoneal cavity was washed out and adequately drained. All perforations were localised to the terminal ileum and were single in number. The mean operating time was 54 minutes-(range 42 to 75 minutes). All patients received parenteral ofloxacin and metrogyl. Postoperative recovery was uneventful in all patients and there were no major complications. All patients were discharged from hospital by the 4th postoperative day. Follow up over a period of 12 to 16 months revealed all patients to be in normal health. We strongly recommend a first line laparoscopic approach in all patients with typhoid perforation; as it is a safe and effective method of managing such cases.