Three-port Technique Research Articles

Feasibility and Safety of Three-Port Laparoscopic Cholecystectomy Compared to Four-Port Laparoscopic Cholecystectomy.

BackgroundThe standard four-port laparoscopic cholecystectomy (LC) is the gold standard procedure. The various clinical trials and reports in the literature have suggested that the three-port technique LC can be done safely with acceptable results.Still, that the three-port LC offers any added benefits to the patient is a controversial issue especially in view of safety and feasibility. In this study, we report the experience of three-port LC compared to four-port LC technique, its safety, feasibility and outcomes.Materials and methodsA prospective randomized study was conducted between two groups which included 165 cases - 93 patients were included in three-port LC (Group A) and 72 patients in four-port LC (Group B). Operative time, intraoperative complications, postoperative pain, length of hospital stay, analgesics requirement, conversion to open and return to normal activities were parameters of evaluation.ResultsDemographic data was comparable in both the groups. Three-port LC Group A had lesser post-operative pain and analgesics requirements. The mean postoperative pain visual analogue scale (VAS) score on day 1 was (4.16 and 6.24), on day 7 was (1.26 and 1.81) in three-port group and in four-port LC group, respectively. The mean days of analgesics requirement were 2.56 days and 4.21 days among three-port group and four-port group, respectivelyLength of hospital stay was less and returning to work was early in three-port group. There was no statistical difference in operative time. The mean operative time among three-port LC group A and four-port LC group B was 36+/-8.6 minutes (30-68) and 39+/-7 minutes (30-90), respectively. The overall outcomes were comparable to four-port LC.ConclusionThree-port LC is a feasible and safe procedure for LC with satisfactory outcomes like lesser postoperative pain, postoperative stay and less scars, when performed by experienced hands, especially in acute cholecystitis. The use of fourth port should be done when required in a difficult situation.

TP6.1.8 Meta-analysis and trial sequential analysis of three-port versus four-port laparoscopic cholecystectomy (Level 1 Evidence)

Abstract Aims to compare the outcomes of three-port and four-port laparoscopic cholecystectomy. Methods In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port versus four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of the available evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Results Analysis of 2524 patients from 17 studies showed that three-port and four-port laparoscopic cholecystectomy techniques were comparable in terms of operative time (MD:-0.13,P=0.88), conversion to open operation (OR:0.80,P=0.43), gallbladder perforation (OR:1.43,P=0.13), bleeding from gallbladder bed (OR: 0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD:-0.00,P=0.81), bile or stone spillage (OR:1.67,P=0.08), port site infection (OR:0.90,P=0.76) and need for reoperation (RD:-0.00,P=0.94). However, the three-port technique was associated with lower VAS pain score at 12 hours (MD:-0.66,P<0.00001) and 24 hours (MD:-0.54,P<0.00001) postoperatively, shorter length of hospital stay (MD: -0.09, P = 0.41), and shorter time to return to normal activities (MD:-0.79,P=0.02). Conclusions Robust evidence (Level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

Videolaparoscopic MicroWave Ablation: An innovative technique to treat pancreatoblastoma liver metastases in children

The MicroWave Ablation (MWA) is a mini-invasive technique, based on dielectric heating, used to treat small hepatic tumors or liver metastases in the adult population. The heat-energy is delivered to the target area, causing tumor necrosis, usually under ultrasound or computed tomography guidance. This procedure can be performed as pure percutaneous or with laparoscopic assistance. A laparoscopic US-guided microwave ablation of the pancreatoblastoma hepatic metastasis was performed in an 11-year old girl. A standard three-port laparoscopic technique was used: the camera port at the umbilicus, and two working port at the upper right quadrant. After adhesiolysis, the intra-operative liver ultrasonography confirmed the pre-operative morphological imaging study and the nodules ablation was performed by using microwaves (MWA), emitted by AMICA probe (Apparatus for MICrowave Ablation; HS Hospital Service, Aprilia, LT, Italy), set at 40 W. Laparoscopic MWA is a tissue-sparing technique to treat in a mini-invasive fashion unresectable liver tumors or metastases. This technique has been extensively described in adult population, and rarely in children. These preliminary and satisfactory results make MWA promising when treating pediatric patients with malignant primary or secondary liver tumors. Further studies may provide data on its long-term efficacy and safety.

Meta-analysis and trial sequential analysis of three-port vs four-port laparoscopic cholecystectomy (level 1 evidence).

To compare the outcomes of three-port and four-port laparoscopic cholecystectomy. In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port vs four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certaintyof evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2524 patients from 17 studies showed that both techniques were comparable in terms of operative time (MD:- 0.13, P = 0.88), conversion to open operation (OR:0.80, P = 0.43), gallbladder perforation (OR: 1.43, P = 0.13), bleeding from gallbladder bed (OR:0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD: - 0.00, P = 0.81), bile or stone spillage (OR:1.67, P = 0.08), port site infection (OR: 0.90, P = 0.76), port site hernia (RD: 0.00, P = 0.89), port site haematoma (RD: - 0.01, P = 0.23), port site seroma (RD: 0.00, P = 1.00), and need for reoperation (RD: - 0.00, P = 0.94). However, the three-port technique was associated with lower VAS pain score at 12h (MD: - 0.66, P < 0.00001) and 24h (MD: - 0.54, P < 0.00001) postoperatively, shorter length of hospital stay (MD:-0.09, P = 0.41), and shorter time to return to normal activities (MD: - 0.79, P = 0.02). Trial sequential analysis confirmed that the meta-analysis was conclusive with no significant risks of type 1 or type 2 error. Robust evidence (level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

Three port versus four port laparoscopic cholecystectomy: a prospective comparative clinical study

Background: Although, traditional laparoscopic cholecystectomy is performed using four-port technique, various modifications were made to further enhance the advantages of laparoscopic cholecystectomy. Aim of the study is to compare the results of three-port and four-port laparoscopic cholecystectomy at single centre in terms of technical feasibility, safety of the procedure, operative time, intra-operative complications, postoperative pain and post-operative analgesia requirement.Methods: It was a prospective comparative study conducted in the department of surgery Smimer medical college Surat, India from July 2018 to July 2019. The study was performed on all adult patients with ultrasound documented cholelithiasis. The total number of patients studied was 50 which were divided into two groups of 25 each.Results: Demographic data were comparable for both study groups. Patients in the 3-port group had shorter mean operative time (47.3±29.8 min versus 60.8±32.3 min) for the 4-port group (p=0.04). Post-operative requirement of analgesia was less in 3 port group as compared to 4 port group. Pain visual analog scale (VAS) score, intra operative complications, post- operative complications and return to normal activity were significant in our study. Hospital stay and patient satisfaction were non- significant.Conclusions: The three-port technique is as safe as the standard four-port technique and can be a viable alternative to four port cholecystectomy with an advantage of less analgesic requirement, early post-operative ambulance, early oral feed, and better cosmetic results.

Laparoscopy: A Better Approach for Perforated Duodenal Ulcer.

BackgroundLaparoscopic surgery is becoming the gold standard for most abdominal surgeries in recent times. Laparoscopic repair of perforated duodenal ulcer (PDU), however, is still an area of debate. The purpose of this study was to evaluate the safety and efficacy of laparoscopic repair of PDU versus open repair.MethodsIn this cross-sectional study, patients were consecutively sampled. Out of 101 patients with clinically diagnosed PDU, 36 patients underwent laparoscopic Graham patch repair and 65 underwent open Graham patch repair in a tertiary care academic hospital. Open repair was via upper midline incision, and laparoscopic repair by the three-port technique. The following stages were calculated: operative time, duration of postoperative analgesia, time taken to mobilize, and patient length of stay after the operation.ResultsThe mean operative time was somewhat longer in the laparoscopy group compared to the open repair group (74.01 vs 56.17 minutes, respectively). Mean postoperative analgesia requirement, time taken to mobilize, and hospital stay were significantly shorter after laparoscopy than after open repair (1.21 days, 9.32 hours, and 3.12 days vs 3.83 days, 16.20 hours, and 4.85 days, respectively). Three patients (8%) in the laparoscopy group and 35 (54%) in the open repair group had postoperative complications.ConclusionsLaparoscopic repair of PDU is a safe approach and better than open repair in terms of operative time with the right level of expertise only, postoperative analgesia requirement, mobilization, duration of hospital stay, and incidence of postoperative respiratory and wound complications.

Endoscopic thyroidectomy: a single institute prospective observational study in India

Background: Endoscopic thyroidectomy (ET) is now an accepted treatment for benign and certain malignant thyroid diseases. It is clearly evident that ET is mainly done to lessen pain and avoid scar in the neck. Any procedure which involves using the endoscope to remove thyroid is often collectively called “endoscopic thyroidectomy.” In this article, we would like to share our institute experience in doing ET.Methods: We did ET on 85 patients from November 2014 to October 2019 mostly by the three-port technique. Preoperative assessment was done and surgery was done on those who met the inclusion criteria. All the cases were done with the insufflation of carbon dioxide gas. Per operative events were noticed and all the patients were followed up at least for 3 to 6 months postoperatively.Results: The mean age of the patient is 38 years and the majority are females (92.94%). Out of 85 cases, one case was converted to an open method (1.18%). The average operative time to complete the procedure was 67 minutes. Most of the cases were discharged on 2nd to 3rd postoperative days. Few patients had complications like hematoma/seroma formation, paresthesia over the infraclavicular region, skin thermal injury, vascular injury, and tracheal injury.Conclusion: ET gives excellent cosmesis and lessens the post-operative pain and thus lesser hospital stay even though the extent of the dissection is more than the conventional method. It has variable complications according to the techniques adopted and the size/volume of the surgically excised thyroid gland.

Safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights.

One strategy thought to reduce direct costs associated with robotic surgery is minimizing the number of robotic arms used for a surgery. We aim to demonstrate the safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights. Retrospective cohort study in a tertiary care university hospital of consecutive patients undergoing a three-port robot-assisted hysterectomy for benign indications. All surgeries were performed between 2012 and 2018 by fellowship-trained minimally invasive gynecologic surgeons. Data from 232 patients were collected. Eighty-eight (37.9%) patients had a uterine weight < 250g, 63 (27.2%) had a uterine weight between 250 and 500g, 51 (22.0%) had a uterine weight between 500 and 1000g, and 30 (12.9%) had a uterine weight ≥ 1000g. Multivariable regression analysis revealed no statistically significant differences between uterine weight groups and time spent in PACU, the total length of hospital stay, or direct cost. When setting the < 250g as referent, patients with uterine weights between 500 and 1000g, and more than 1000g had an operative time that was on average 23.4% and 91.6% longer than patients with uterine weight < 250g, respectively (p < 0.01). Patients with uterine weights between 500 and 1000g and more than 1000g had an EBL that was on average 35% and 156% higher than patients with uterine weight < 250g, respectively (p < 0.01). Our data support the safety and feasibility of the three-port robot-assisted hysterectomy technique across uterine weights.

Isolated Arthroscopic Radial Styloidectomy: The Three-Portal Approach.

Background The current gold-standard technique for radial styloidectomy is arthroscopic. The use of only two dorsal portals may not allow a crystal-clear view of the dorsal arthritic rim of the radius because of the dorsal capsule synovitis. Objectives To propose a new technique for isolated arthroscopic radial styloidectomy. The addition of a volar radial portal and a sequential procedure are presented. Patients and Methods Two trochars for alternatively viewing from volar radial or 3-4 are used. A 1-2 portal is used for instrumentation with a motorized burr. We have been using the three-portal technique in 34 cases (26 isolated). Results This modification of the classic arthroscopic radial styloidectomy is technically easy and the view of the dorsal rim of the radius provides a clear definition and treatment of the dorso-radial arthritic pathology. Conclusions The authors recommend this technical trick to perform an easy and comprehensive isolated palliative or curative arthroscopic radial styloidectomy.

Modified transperitoneal versus retroperitoneal laparoscopic radical nephroureterectomy in the management of upper urinary tract urothelial carcinoma: Best practice in a single center with updated results.

ObjectiveRadical nephroureterectomy remains the gold standard for the surgical treatment of upper urinary tract urothelial carcinoma (UTUC). Based on previous research, we prospectively compared the advantages of transperitoneal laparoscopic radical nephroureterectomy (TLNU) with a three-port technique in a single position versus retroperitoneal laparoscopic radical nephroureterectomy (RLNU).MethodsWe evaluated 48 patients diagnosed with UTUC at our institution from January 2015 to October 2019. The patients underwent either TLNU (n = 24) or RLNU (n = 24). We randomly assigned the patients to each technique group based on their body mass index because our experience has shown that the body mass index is the main interfering factor for this surgery. The baseline characteristics and perioperative outcomes were compared between the groups.ResultsWe found no significant differences in the baseline characteristics, time until recovery of intestinal function, or postoperative hospital stay between the two groups. However, the TLNU group had a shorter operation time and better postoperative pain control than the RLNU group.ConclusionModified TLNU is associated with a shorter operative time and less severe postoperative pain compared with RLNU. Both techniques are safe and reliable with adequate management, and their therapeutic effects are comparable in other aspects.

Primary laparoscopic approach to repair perforated peptic ulcer. A retrospective cohort study

Perforated peptic ulcer is a serious complication of peptic ulcer disease and carries high risk for morbidity and mortality. Although the incidence of peptic ulcer disease has decreased in recent decades, the percentage of patients with perforated peptic ulcer requiring emergency surgery remains constant. The use of laparoscopic management as a first choice for the treatment of the perforation is growing but is not routine in many centers. Clinical and surgical data on 42 patients underwent surgical treatment for perforated peptic ulcer from January 2012 to December 2016 were collected. Laparoscopic repair of the perforation with a three-port technique was made in all cases. The Boey scoring system was used to predict the prognosis. All patients underwent suture-closure of the ulcer, and omental patch through laparoscopy without conversion to open surgery. Duodenal leakages occurred in 3 patients (7.1%), then treated with a conservative approach and resolved on the 10th postoperative day. Two patients (4.7%) had deep space infections in the first week after surgery, therefore subdiaphragmatic and pelvic abscess were drained by ultrasound guidance. Four patients (9.5%) died up to 30-day post-surgery due to progression of multisystem organ failure in absence of leakages or infections. All these patients were American Society of Anesthesiologists Classification >III and Boey Score 3. Our data show that a primary laparoscopic approach in patients with peptic ulcer perforation is associated with postoperative advantages and acceptable rates of morbidity and mortality, essentially related to high Boey Score. Therefore, we suggest that the surgical repair of PPU could be always started laparoscopically.

Gasless Trans-Umbilical Laparoscopically-Assisted Appendectomy in the Pediatric Population: An Early Experience

Background: The aim of this study is to determine the feasibility and safety of the single-port gasless trans-umbilical laparoscopically-assisted appendectomy in the pediatric age group at a single center in a tertiary university hospital in Jordan. Methods: Between April 2018 and July 2019, the surgical records of all patients aged between 0 and 13 years treated with trans-umbilical laparoscopic-assisted appendectomy TULAA for a suspected appendicitis following a clinical, laboratory and ultrasound findings were reviewed retrospectively. Baseline characteristics, white blood cell count, operative time, intraoperative findings, need for additional trocars or for conversion, length of hospital stay and surgical complications were reported.Results: 36 cases were included in the study, 23 (64%) were completed successfully using the gasless TULAA technique. Gas insufflation was needed in 10 (28%) cases and only 3 (8%) had to be converted to the three-port laparoscopic appendectomy technique. There was no significant difference between the gaseous and gasless groups in terms of baseline characteristics, BMI, surgery duration, postoperative recovery period or length of stay. However, the group of patients who needed gas insufflation to complete the procedure had a higher white blood cell count compared to the gasless group. The surgery was completed successfully by senior general surgery residents in 27 (75%) cases while the consultant’s intervention was needed in the remaining cases. The gasless TULAA group were less likely to require complex analgesia (i.e., IV analgesia) compared to the gasless group (OR=0.683).Conclusions: Gasless TULAA is a feasible procedure that can be performed safely by surgical residents as an initial approach for all grades of acute appendicitis in the pediatric age group.

A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction.

A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry. This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes. The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%). The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR. Retrospective case series; level of evidence, 4.

Transoral endoscopic thyroidectomy using the vestibular approach with an endoscopic retractor in thyroid cancer: experience with the first 132 patients.

Transoral endoscopic thyroidectomy using the vestibular approach (TOETVA) is a novel technique for thyroid cancer surgery. We aimed to review our initial experiences with TOETVA for the management of thyroid carcinoma, using retrospective analyses of a larger single-center case series. From September 2016 to April 2018, 132 patients with thyroid cancer underwent TOETVA. A three-port technique through the oral vestibule was used to perform endoscopic thyroidectomy with ipsilateral central compartment dissection using conventional laparoscopic instruments, and an endoscopic retractor that we developed. All patients had papillary thyroid carcinoma. Less-than total or total thyroidectomy with ipsilateral central compartment node dissection was performed (124 vs. 8). The mean operation time was 87.6min (range 56-213min). The average number of lymph nodes resected was 2.6 (range 1-12). Six patients experienced transient hoarseness, which was resolved within 3months. Most of the patients were discharged within 3days after surgery. In this large series from a single center, we found that TOETVA with the endoscopic retractor can be performed safely and radically in selected patients with thyroid cancer.

Three-port versus conventional four-port laparoscopic cholecystectomy: a comparative study

Objectives This prospective comparative study aims at evaluating the feasibility of three-port technique without affecting safety and at comparing the outcome of three-port and four-port techniques. Patients and methods This study included 94 patients with symptomatic gallstone disease and gallbladder polyp in Surgical Department, Minia University Hospital, from beginning of 2018 to beginning of 2019. Patients who were unwilling to be a part of the study, jaundiced patients with radiologically evidence of common bile duct stones, patients unfit for general anesthesia, patients with liver cirrhosis, patients with portal hypertension, patients with coagulopathy, patients with acute pancreatitis, patients with generalized peritonitis, or patients with malignancy were excluded. All patients were operated by the same operating team. Patients were randomized for three-port laparoscopic cholecystectomy (LC) group (45 patients) or four-port LC group (49 patients). Numeric Pain Rating Scale, operative time, operative difficulty, intraoperative and postoperative complications, duration required to stop oral analgesics, and duration required to return to normal activity were recorded. Results Numeric Pain Rating Scale, required number of diclofenac ampoules, duration required for oral analgesia, and duration required to return to normal activity were significantly less in three-port group. Other parameters were comparable between the two groups. Conclusion It seems that three-port LC is a safe and feasible technique with superior clinical outcomes to four-port LC.

Retrospective Study of Three-port versus Standard Four-port Laparoscopic Cholecystectomy: A Single Surgical Unit Experience of 1456 Patients

Introduction: Although laparoscopic surgeries have proven beyond doubt their benefit in terms of early recovery, better patient care and cost-effectiveness, the quest for reduction in either the size or number of ports still continues. Aim: To compare the safety, outcome, and advantages between three-port versus four-port Laparoscopic Cholecystectomy (LC) in acute and chronic cholecystitis. Materials and Methods: Medical records of 1456 patients that underwent LC (three- or four-port) for acute and chronic cholecystitis from January 2015 to December 2019 (60 months) were retrospectively analysed. All patients were given the same anaesthetic drugs for induction and maintenance, with standard anaesthetic protocol. The results were compared for both the techniques in terms of operating time, conversion rate, intraoperative complications, immediate postoperative complications, pain score, analgesic requirement and hospital stay. Results: Total 1456 patients underwent LC; 1282 were female and 174 were male. The mean age of the patients was 39.2 years (range 18-70 years). The three-port LC technique was performed on 816 (56.04%) patients, while the traditional four-port LC technique was performed on 640 (43.96%) patients. Visual Analog Score (VAS) in the postoperative period at six hour was 2.11±0.82 in three-port group versus 3.17±1.12 in four-port group, this suggests that there was a significant difference in pain in these two groups in the early postoperative period (p&lt;0.001). In three-port group, the requirement of analgesic drug was significantly less as compared to four-port group (2.86±0.98 versus 3.22±0.87; p&lt;0.001). There was no statistically significant difference in the mean operating time, duration of hospital stay, intra and postoperative complications, days to return to normal activity, satisfaction score and conversion rate (p=0.087, p=0.061, p=0.578, p=0.555, p=0.572 and p=0.145, respectively). Conclusion: Three-port LC is a feasible, effective and safe technique that further enhances the surgical outcome in terms of postoperative pain, fewer needs for analgesic medication.

Laparoscopic ureterolithotomy for the management of distal ureteric giant calculi in the endourology era – case report &amp; Brief review of literature

Background: The novel concept of endourology was first introduced to the world in 1978 by three legendary doctors Elwin Fraley, Arthur Smith, and Paul Lange. Fast forward 40 years, endourology today mostly rules the overall management of the majority of urinary tract calculi with some rare exceptions. Large, giant, massive distal-impacted ureteric calculi seem to be one such subset of exceptional situation, where laparoscopic ureterolithotomy (LUL) may have an edge over endourological manipulation. Even though LUL is a well-recognized option, the usage of the same is declining ever since the advent of endourology and its advances. This article brings to light the importance of the role and relevance of LUL versus endourology for the management of select large, giant ureteric stones and aims to bring to light certain inherent combined advantages of LUL versus endourology, such as effectiveness, short learning curve, single-staged nature of procedure, and being minimally invasive. Case Presentation: A 30-years-old female presented to our clinic with complaints of right flank pain and recurrent episodes of Urinary tract infection for the past 4 months. Clinical evaluations/investigations revealed a large distal ureteric calculus with a poorly functioning right kidney without any underlying anatomic/metabolic abnormality. The patient underwent LUL with a modified three-port technique and a large stone of 3.5 × 2 cm was retrieved uneventfully with the placement of a Double J stent. Conclusion: LUL is the preferred therapeutic surgical management modality of choice for select uncomplicated giant/large ureteric calculi, as it is coupled with the dual advantage of being minimally invasive and is accompanied by complete clearance with minimal morbidity thereby acting as a bridge to combine the positives of both endourological and open procedures. We encourage researchers to consider LUL in the minimally invasive management of select large impacted distal ureteric calculi in the otherwise anatomically normal renal units.

Patient and Surgeon Candidacy for Transoral Endoscopic Thyroid Surgery.

The transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly cutaneous scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, and (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule; one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle medial edges. TT is done fully endoscopically using conventional endoscopic instruments.

Safety and feasibility of three port procedure in laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is widely accepted gold standard technique for management of cholelithiasis and has undergone many refinements including decrease in size and number of ports. Many researchers have claimed that three-port laparoscopic cholecystectomy is safe and feasible method for management of cholelithiasis but still it is not performed widely by the surgeons. Objective of our study was to assess the safety and feasibility of three-port laparoscopic cholecystectomy by comparing the various defined parameters with the standard four-port laparoscopic cholecystectomy.Methods: The study included 100 patients and was divided equally in 2 groups. Patients in Group A underwent laparoscopic cholecystectomy by three-port technique and in Group B were operated by four-port technique. Patients in both the groups were compared in terms of operative time, intra-operative complications, post-operative pain, post-operative complications and cosmesis outcome.Results: The mean operative time was similar in both groups. Intra-op and post-op complications were also similar. 3 patients in Group A needed fourth port and 1 patient in both group required conversion to open cholecystectomy. Mean pain score and requirement of parentral analgesia was found to be lower in Group A. Duration of hospital was similar in both the groups. Patients in group A had slightly better cosmetic outcome.Conclusions: Three-port laparoscopic cholecystectomy is a minimally invasive, safe and feasible technique and is not difficult to master than other advanced techniques. In experienced hands, laparoscopy cholecystectomy can be initially started with three-ports and can be converted to four-port if rarely necessary.

Transoral transvsetibular thyroidectomy: an initial approach and experience

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective of the study was to record our intial experience of transoral transvestibular thyroidectomy and to ascertain the problems faced, their possible solutions and further suggestions.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Inclusion criteria were unilateral thyroid swelling, patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 8 cm; (b), USG estimated gland volume ≤40 ml, nodule size ≤50 mm, A benign tumor, such as a thyroid cyst, single-nodular goitre, or multinodular goitre. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and Harmonic. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; All transoral transvestibular thyroidectomy procedures were performed successfully with no conversions. The mean operative time was 112.5 (90-180) min. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Transoral transvestibular thyroidectomy may provide a method for ideal cosmetic results. It also provides a wide and enhanced endoscopic view. Though more study and further instrumental development is required to fully embrace this procedure a preliminary experience show encouraging results.&lt;/p&gt;