Three-port Technique Research Articles

Transoral transvsetibular thyroidectomy: an initial approach and experience

<p class="abstract"><strong>Background:</strong> 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.</p><p class="abstract"><strong>Methods:</strong> 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. </p><p class="abstract"><strong>Results:</strong> 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.</p><p class="abstract"><strong>Conclusions:</strong> 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.</p>

Electron Microscopic Retina Changes in Rabbit Eyes with Perfluorocarbon Liquids Intravitreal Tamponade

Purpose. Analysis of electron microscopic changes in rabbit eyes with intravitreal tamponade of perfluorocarbon liquids (PFCL) (perfluoro-1,3-dimethylcyclohexane and perfluorodecalin).Material and Methods. The study was performed on Chinchilla breed rabbits. 25G vitrectomy with PFCL intravitreal tamponade was performed on 12 eyes of 6 rabbits (perfluorodecalin (Bausch+Lomb «Dk-line», USA) and perfluoro-1,3-dimethylcyclohexane (ZAO “Optimedservis”, Russia). Standard three-port vitrectomy technique was used. After removal of the vitreous body 2.5 ml of PFCL were injected in vitreous cavity. Research studies were performed in 5, 14 and 30 days after surgery by electron microscopy. Eyes were enucleated in 20 minutes after animal was killed by air embolization. Intact eyes were used as a control. All samples were prepared in same conditions. The damage of the retina architectonics and the presence of intracellular inclusions were evaluated.Results. Tamponade of the vitreous cavity by both types of PFCL in 5, 14 and 30 day caused following similar electron microscopic changes at date: swelling ganglion layer and dystrophy of inner and outer nuclear layer. Electron microscopic changes in outer nuclear layer appeared at 30 days. The photoreceptor neurons were characterized by single ultrastructural changes. Retina pigment epithelium cells had a typical ultrastructure.Conclusion. Intravitreal perfluoro-1,3-dimethylcyclohexane tamponade caused similar electron microscopic changes as well as perfluorodecalin in the experiment and it was relatively harmless to rabbit retina for up to 14 days. Irreversible changes in the retinal ultrastructure were not observed.

Three-port single-intercostal versus multiple-intercostal thoracoscopic lobectomy for the treatment of lung cancer: a propensity-matched analysis

BackgroundIn this retrospective study, we aimed to demonstrated that three-port single-intercostal (SIC) thoracoscopic lobectomy is an effective choice for lung cancer by comparing the perioperative outcomes of patients with non-small-cell lung cancer treated with three-port SIC and conventional multiple-intercostal (MIC) thoracoscopic lobectomy.MethodsFrom January 2013 to January 2018, 642 non-small-cell lung cancer patients underwent thoracoscopic lobectomy via a three-port SIC or MIC technique. Propensity-matched analysis incorporating preoperative clinical variables was used to compare the perioperative outcomes between the two groups.ResultsThe first 20 patients were excluded to account for the learning curve effect in the SIC group. Propensity matching yielded 186 patients in each group. A small percentage of patients had major morbidity, including 4.8% in the SIC group and 6.5% in the MIC group; there was no significant difference between the two groups. Although the total number of lymph nodes harvested (25.3 vs. 23.8, p = 0.160) and stations removed (6.5 vs. 6.7, p = 0.368) were similar between the two groups, more subcarinal lymph nodes were removed (6.9 vs. 5.2, p < 0.001) in the SIC group than in the MIC group. Furthermore, other perioperative outcomes in the SIC group were not fewer than those in the MIC group.ConclusionsBoth techniques are acceptable for the treatment of non-small-cell lung cancer. Three-port SIC VATS lobectomy can provide an alternative procedure in thoracoscopic surgery.

Transoral endoscopic thyroidectomy using vestibular approach: A single center experience.

Background:Thyroid Natural Orifice Transluminal Endoscopic Surgery (NOTES) or transoral endoscopic thyroidectomy using vestibular approach is a recent advance embraced by the surgical community because of its potential for a scar-free thyroidectomy. In this article, we present our initial experience with this technique.Materials and Methods:We used a three-port technique through the oral vestibule, one 10 mm port for the laparoscope and two additional 5 mm ports for the endoscopic instruments required. The carbon dioxide insufflation pressure was set at 12 mm of Hg. Anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch, and the thyroidectomy was done using conventional laparoscopic instruments and a harmonic scalpel.Results:From May 2016 to December 2017, we have performed ten such procedures in the Department of General Surgery in our hospital, which is a tertiary referral center. Six patients had solitary thyroid nodules, for which a hemi-thyroidectomy was done. Four patients had multi-nodular goiter and total thyroidectomy or near-total thyroidectomy was done. The preoperative fine-needle aspiration cytology (FNAC) was suggestive of Bethesda class 2 lesions in all the patients with multinodular goiter and in five of the six patients with solitary nodular goiter. Only one patient with solitary nodular goiter had a Bethesda class 3 lesion on FNAC. The final histopathological report of the specimen was benign, either colloid goiter, or degenerative nodule in all cases of multinodular goiter and in four cases of solitary thyroid nodule. In one Bethesda class 2 solitary nodule, the histopathological report was suggestive of follicular carcinoma; in the Bethesda class 3 solitary nodule, the histopathological report was suggestive of follicular variant of papillary carcinoma. No complication such as temporary or permanent vocal cord paralysis, hypoparathyroidism, subcutaneous emphysema, pneumomediastinum, tracheal injury, esophageal injury, mental nerve palsy, or surgical site infection was found postoperatively. However, two patients developed small hematomas in the midline.Conclusion:Transoral endoscopic thyroidectomy is a safe, feasible, and minimally invasive technique with excellent cosmetic results.

Laparoscopic 'steering wheel' derotation technique for midgut volvulus in children with intestinal malrotation.

Introduction:Since the first description by William Ladd, the Ladd's procedure has been the surgery of choice for the correction of malrotation. The laparoscopic Ladd's procedure is becoming popular with the advent of minimal access surgery and is described in the literature. Various techniques of the Ladd's procedure have been described but none of them describes the stepwise technique for derotation of volvulus which is the most difficult and confusing part of the surgery. We describe ‘steering wheel’ technique for easy derotation of volvulus associated with malrotation.Method:A total of 62 patients were diagnosed to have an intestinal malrotation between 2010 and 2017. All cases which had complete non-rotation with a midgut volvulus were reviewed. Out of these, 48 patients were operated with open technique and 14 patients were subjected to the laparoscopic correction.Technique:Using three-port technique, stepwise derotation of volvulus is done which simulates the rotation of steering of car at an acute turn and has been described in four simple steps. This technique also stresses the importance of the release of Ladd's band before derotation.Results:Of 62 patients diagnosed with malrotation, 14 (22.6%) patients underwent the laparoscopic Ladd's procedure. The mean age was 26 + 8 months, mean weight was 10 + 2 kg and included eight males (57%) and six females (43%). There was only one (7.14%) conversion to open technique, due to a huge dilatation of duodenum causing difficulty in dissection in a patient with malrotation without volvulus. The laparoscopic Ladd's procedure took an average time of 70 ± 15 min.Conclusion:The laparoscopic ‘steering wheel’ derotation technique is easy and provides a stepwise description of the laparoscopic derotation of volvulus associated with malrotation in children.

219: Feasibility and safety of three- and single-port fetoscopy for spina bifida in the fetal lamb

New endoscopic prenatal spina bifida (SB) repair techniques are being proposed. These should be preclinically validated. Two-layer SB-repair has been shown feasible and effective in the fetal lamb model. Herein, we assessed the feasibility and safety of three- and single-port fetoscopic 2-layer SB repair modifications. We used a standardized skin-defect fetal lamb model (100 days; term 145 days). We first performed a 7.5cm- hysterotomy, inserted a microcatheter in the fetal carotid artery and under the skin nearby a 4x2cm lumbar skin marking and closed the uterus. Animals were randomly assigned to either three (0.8 and 2x0.3cm) or single (1.5cm) port uterine cannulation. We performed a 10-step simulated fetoscopic 2-layer closure of skin defect, fascial incision and mobilization, with coverage by a subcutaneous collagen patch and running skin closure under humidified warmed CO2 insufflation. Primary outcomes were persistent normal pH (pH=7.25±0.04) (safety) and postoperative watertightness of the skin closure in ≥70% of cases (feasibility). Secondary outcomes were fetal and maternal acid- base status, hemodynamics, fetal survival and operation times. Surgeons had a prior training for this procedure on a high-fidelity in vivo trainer. Twelve fetuses (one per ewe) were operated (pneumamnion 5±1mmHg), 7 in the 3-port and 5 in the single-port group. All but one in the 3-port group, survived. Compared to base line, three-port fetoscopy induced acidosis from 60 min onwards and hypercarbia from 30 min (Fig. 1), and in single-port fetoscopy acidosis occurred from 30 min onwards and hypercarbia from 60 min (Fig. 2). Fetal pO2, base excess, lactate and heart rate as well as maternal hemodynamics (systolic and diastolic blood pressures, heart rate) and acid-base status remained normal (Fig. 1&2). In the three-port technique, 5/7 (71%) closures were watertight as compared to 2/5 (40%) in the single-port group. Operation times were long and comparable (insufflation: 202±37min; fetal repair: 141±34 min in three port group; and 177±20 min and 137±17 min in the single port group). Under humidified and warmed CO2 pneumamnion, three-port and single-port fetoscopic SB closures induced fetal acidosis within one hour. In this experiment, watertightness was more frequently achieved with the three-port technique.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Arthroscopic reconstruction of anterior cruciate ligament with femoral tunnel made by three-portal technique

Objective To evaluate the clinical outcomes of arthroscopic reconstruction of anterior cruciate ligament (ACL) with femoral tunnel made by three-portal technique. Methods From February 2014 to May 2015, fifty-five ACL rupture patients (38 males and 17 females) with mean age 31.46±7.34 (range, 16 to 48) who underwent single-bundle ACL reconstruction with femoral tunnel made by three-portal technique by the same surgeon were followed up. The average preoperative duration was 15.39±18.57 (range, 5 to 180) days. All patients presented the positive Lachman test, of which 32 patients had 1 grade pivot-shift test, 15 patients 2 grade and 8 patients 3 grade. At final follow-up, the International Knee Documentation Committee (IKDC) and Lysholm scores were used to estimate knee joint function, while the Lachman test and pivot-shift test were used to estimate knee joint stability. Results All patients were followed up for 26.73±5.23 (range, 21 to 34) months. The femoral tunnel positions were accurate without fracture of the back walls in all patients. The mean length of femoral tunnel was 38.58±3.76 (range, 35 to 42) mm, and the mean angles of femoral tunnel on coronal plane was 49.32°±2.45° (range, 45° to 52°). All patients presented negative Lachman test. Fifty-one patients presented negative pivot-shift test, while the remaining 4 patients had 1 grade of the rotational laxity. Forty-nine patients showed normal range of motion, while two had 5° flexion deficit, one had less than 5° flexion deficit and three had 5° hyper-extension loss. Furthermore, the IKDC score significantly was improved from 73.31±5.83 preoperatively to 94.63±3.16 at the latest follow-up (t=10.14, P<0.001). The Lysholm score significantly was increased from 66.35±8.91 preoperatively to 95.32±4.25 at final follow up (t=12.76, P<0.001). Conclusion Arthroscopic reconstruction of ACL with femoral tunnel made by three-portal technique is an reliable technique with the advantage of simple procedure and accurate femoral tunnel position in surgery. Key words: Knee Joint; Anterior cruciate ligament reconstruction; Arthroscopy

Limax Nd:YAG laser-assisted thoracoscopic resection of pulmonary metastases; a single centre's initial experience.

Pulmonary metastasectomy and indeed redo-pulmonary metastasectomy are now commonly performed thoracic surgical procedures. The air-sealant, haemostatic, and necrotic properties of the KLS Martin Limax Nd:YAG laser at 1.318μm make it an ideal tool for limited lung resection such as metastasectomy. We present our initial experience of thoracoscopic laser metastasectomy. We reviewed data from the first seven patients in our unit to undergo thoracoscopic laser metastasectomy, in particular, patient age, gender, primary malignancy, primary treatment, complications, length of stay (LOS), and final histopathology. All procedures were performed using a two- or three-port thoracoscopic technique with some lesions requiring CT-guided wire localisation. A single drain was inserted via the camera port site and was removed upon confirmation that there was no air leak. Seven patients underwent thoracoscopic laser wedge metastasectomy of eight lesions in our centre between February 2017 and October 2017. The median age was 61years. The primary disease was colorectal carcinoma in five cases, eccrine carcinoma in one case, and high-grade uterine leiomyosarcoma in one case. Only one patient had a prolonged air leak in the other six cases; the drain was removed on post-operative day 1. The median post-operative LOS was 1day. All patients had confirmed metastatic disease with clear resection margins on histopathology. In our early experience, thoracoscopic laser wedge metastasectomy is a safe and efficient method for performance of pulmonary metastasectomy. We experienced a low complication rate and a short post-operative stay.

A comparison of outcomes of four ports versus three ports laparoscopic cholecystectomy

Background: Conventional laparoscopic cholecystectomy is performed using four ports. With increasing surgeon experience, there is a trend towards performing it using three ports. The aim of this study was to compare the three-port laparoscopic cholecystectomy with the conventional four-port technique in terms of safety, benefits and feasibility in a teaching hospital and private hospital setups.Materials &amp; Methods: A retrospective review of medical records was performed on patients who underwent laparoscopic cholecystectomy at KIST Medical College and Teaching Hospital and Om Hospital &amp; Research Center P. Ltd by a single laparoscopic surgeon. The review included demographics, operating time, analgesics requirement, post- operative hospital stay and intra-operative and post-operative complications. The data were tabulated in MS-Excel and statistically analyzed using SPSS statistics software, version 21.Results: There were 150 patients included in this study with 75 patients in each three and four-port groups. The demographics were comparable in both groups. 7.3% were diagnosed with acute calculous cholecystitis, 76.7% with chronic calculous cholecystitis and 3.3 % were gall bladder polyps. Four-port technique was generally required for the acute calculous cholecystitis which was statistically significant. The three-port group had a shorter mean operative time than the four-port group. There was no statistically significant difference in the doses of analgesics requirement and mean post-operative hospital stay in both groups. There were no major intra and post-operative complications in both groups. Four-port technique was commonly done in teaching hospital and the three-port in private hospital.Conclusions: There is significant number of laparoscopic cases being performed using three ports and we concluded that the three-port laparoscopic cholecystectomy is safe and feasible in experienced hand although there is no significant benefit. The study also showed an increasing use of four-port technique in the teaching institution which is better to clearly visualize the anatomy of the Calot’s triangle. So we recommend using the four-port technique for teaching the beginners and as the experience is gained, we can gradually shift to three-port technique and at the same time we shouldn’t hesitate to convert to four-port in difficult cases.JMMIHS.2018;4(1):66-71

Electron Microscopic Changes of Rabbit Retina after Chromovitrectomy Using Combined Dyes (Experimental Study)

Purpose: to evaluate on experimental model electron-microscopic changes of rabbit retina after staining of the posterior eye segment with combined dyes based on Trypan blue and Brilliant blue G for the assessment of their safety. Methods. The study was performed on Chinchilla breed rabbits. Combined dyes based on Trypan blue and Brilliant blue were used: MembraneBlue-Dual (DORC, Netherlands) and “Staining solution for ophthalmic surgery” (JCS “Optimedservis”, Russia). Standard three-port vitrectomy technique was used. After vitreous removal dyes were injected in vitreous cavity and exposed for 10 seconds and then removed. The vitreous cavity was filled by a balanced salt solution. An electron-microscopic evaluation was performed on 5, 14 and 30 days after surgery. Eyes were enucleated in 20 minutes after animal was killed by air embolization. Intact eyes were used as a control, all samples were prepared in same сonditions. The damage of the retina architectonics and the presence of intracellular inclusions were evaluated. Results. The staged character of pathomorphological changes was revealed. On the 5th day moderate edema and hydropic dystrophy of neurons were registered. On the 14th day, there was no negative dynamics. On day 30, the signs of edema and dystrophy of neurons practically disappeared, which may indicate a fundamental reversibility of the registered changes. Conclusion. Investigated dyes for staining intraocular structures based on Trypan blue and Brilliant blue did not cause significant histomorphological changes and toxic effects on retinal cell structures. Detected electron microscopic changes were insignificant, had reversible character and could be mostly caused by a surgical injury.

99: Robot-assisted hysterectomy: Comparison between the three-port and multiport techniques across uterine weights

99: Robot-assisted hysterectomy: Comparison between the three-port and multiport techniques across uterine weights

72: Robot-assisted myomectomy: Comparison between the three-port and multiport techniques

72: Robot-assisted myomectomy: Comparison between the three-port and multiport techniques

Optimized thoracoport design for the thoracoscopic procedure during minimally invasive esophagectomy.

Minimally invasive esophagectomy has several benefits as an effective alternative treatment for esophageal cancer. The three-phase esophageal resection may be the most popular approach to esophagectomy. Numerous thoracoport designs are available for the thoracoscopic procedure. The present study aims to contribute a distinctive three-port technique that is designed to minimize surgical trauma and facilitate operation during the thoracoscopic procedure. In this paper, we describe and demonstrate the details of the port design and each operation step. Based on our practical experience, the rational combination of the port design and instrument usage of the three-port technique makes the thorascopic procedure more convenient.

Transoral endoscopic thyroidectomy via a vestibular approach: why and how?

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel, scar-free surgical procedure that does not require visible incisions. Indications for TOETVA are as follows: predicted gland width on diagnostic imaging ≤10 cm; a thyroid volume outline of <45 mL or dominant nodule dimension of ≤50 mm; three or four Bethesda lesions; a primary papillary microcarcinoma without local or distant metastasis; and patient request for optimal esthetic results. Contraindications are as follows: patients unfit for general anesthesia; precedent radiation in the head, neck, upper mediastinum; antecedent neck surgery; recurrent goiter; a gland volume of >45 mL or main nodule diameter of >50 mm; and documentation of lymph node or distant metastases, tracheal/esophageal infiltration, preoperative laryngeal nerve palsy, hyperthyroidism, mediastinal goiter, or an oral abscess. Patients with poorly differentiated or un-differentiated cancer, dorsal extrathyroidal radius, and/or lateral neck metastasis are not suitable for TOETVA. Following the introduction of a robotic surgical system, enabling a three-dimensional surgical view and the use of articulating instruments, TOETVA became suitable for most differentiated thyroid cancers without evidence of extensive extrathyroidal invasion or lateral neck metastasis. The procedure is performed using a vestibular approach and three-port technique; a 10-mm port is used for the 30° endoscope, two 5-mm ports are used for the dissecting and coagulating instruments, and an 8-mm port is placed in the axillary fold during the robotic procedure to enhance fine countertraction of tissue for radical oncological dissection. TOETVA follows surgical planes and is probably the best scar-free approach to the thyroid, given the short distance between the gland and intraoral incisions.

Transoral thyroidectomy: advantages and limitations.

In this opinion paper of the Journal of Endocrinological Investigation, leading experts in the field report on their current clinical experience with a novel approach for thyroid gland surgery, namely, "transoral thyroidectomy" (TOT). This feasible and novel surgical procedure does not require visible incisions and is, therefore, a truly scarless surgery. Patients meeting the following criteria can be considered as candidates for TOT: (a) an ultrasonographically (US) estimated thyroid diameter ≤10cm; (b) US-estimated gland volume ≤45mL; (c) nodule size ≤50mm; (d) presence of a benign tumor such as a thyroid cyst or a single- or multi-nodular goiter; (e) Bethesda 3 and/or 4 category and (f) papillary microcarcinoma without the evidence of metastasis. The procedure is conducted via a three-port technique at the oral vestibule using a 10-mm port for the 30° endoscope and two additional 5-mm ports for the dissecting and coagulating instruments. TOT is performed using conventional endoscopic instruments and is probably the best scarless approach to the thyroid because of the short distance between the thyroid and the incisions placed intra-orally that do not result in any cutaneous scar and upon following the surgical planes. Experts in TOT organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologist to develop the standards for practicing this emerging technique.

Transoral endoscopic thyroidectomy: preliminary experience in Italy.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10cm; (b) US estimated gland volume ≤45mL; (c) nodule size ≤50mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (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 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6mmHg. 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 intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59-118) min for lobectomy and 107.6 (99-135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.

Three-Port, Two Located on the Pfannenstiel Line, Laparoscopic Cholecystectomy Comparison with Traditional Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is seen as a gateway to minimally invasive surgery. We defined a new three-port technique with different port sites and compared the postoperative results with traditional four-port LC procedure in a case-match study. Between June 2012 and May 2013, 104 consecutive patients underwent three-port LC by same experienced surgeon. In the same center, 2963 consecutive patients underwent four-port LC, and of these 2963 patients, a matched group of 104 patients was selected. Data included patient age, gender, body mass index, American Society of Anesthesiologists score, history of abdominal operations, intraoperative data about operating time and conversion to open surgery, and postoperative data about length of hospital stay and postoperative complications were recorded prospectively. We concluded that our new three-port technique with different port sites is as feasible and safe as traditional four-port technique.

LAPAROSCOPIC OVARIECTOMY IN THE ASIATIC BLACK BEAR (URSUS THIBETANUS) WITH THE USE OF THE SONICISION™ DEVICE.

Laparoscopic ovariectomy was performed in two Asiatic black bears ( Ursus thibetanus ). Bears were placed in a 20° Trendelenburg position on a surgical table. A three-portal technique was used. A camera port was established 10 cm caudal to the umbilicus with a 5-mm cannula. Two instrument ports were made 1 cm caudal to the umbilicus with a 5-mm cannula and 8 cm caudal to the camera port with a 12-mm cannula, respectively. The suspensory ligament, ovarian vasculature, and uterine horn tip were progressively dissected following coagulation with the Sonicision™ cordless ultrasonic dissection device. The resected ovary was exteriorized through the 12-mm instrument portal site but enlarged to a 2-cm incision length. The abdominal musculature, subcutaneous tissue, and skin of the portal sites were closed separately. Total surgical time was 113 min (Bear A) and 49 min (Bear B), and no postoperative complications were encountered. This is the first report of laparoscopic ovariectomy in the Asiatic black bear.

An investigation of bedside laparoscopy in the ICU for cases of non-occlusive mesenteric ischemia

BackgroundAcute mesenteric ischemia is a rare affection with high related mortality. NOMI presents the most important diagnostic problems and is related with the higher risk of white laparotomy. This study wants to give a contribution for the validation of laparoscopic approach in case of NOMI.MethodsThirty-two consecutive patients were admitted in last 10 years in ICU of Paolo Giaccone University Hospital of Palermo for AMI. Diagnosis was obtained by multislice CT and selective angiography was done if clinical conditions were permissive. If necrosis was already present or suspected, surgical approach was done. Endovascular or surgical embolectomy was performed when necessary. Twenty NOMI patients underwent medical treatment performing laparoscopy 24 h later to verify the evolution of AMI. A three-port technique was used. In all patients we performed a bed side procedure 48–72 h later in both non-resected and resected group.ResultsIn 14 up 20 case of NOMI the disease was extended throughout the splanchnic district, in 6 patients it involved the ileum and the colon; after a first look, only 6 patients underwent resection. One patient died 35 h after diagnosis of NOMI. The second look, 48 h later, demonstrated 4 infarction recurrences in the group of resected patients and onset signs of necrosis in 5 patients of non-resected group. A total of 15 resections were performed on 11 patients. Mortality rate was 6/20–30% but it was much higher in resected group (5/11–45,5%). Non-therapeutic laparotomy was avoided in 9/20 patients and in this group mortality rate was 1/9–11%. No morbidity was recorded related to laparoscopic procedure.ConclusionsLaparoscopy could be a feasible and safety surgical approach for management of patient with NOMI. Our retrospective study demonstrates that laparoscopy don’t increase morbidity, reduce mortality avoiding non-therapeutic laparotomy.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease: a comparison of surgical results with open thyroidectomy.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) provides excellent cosmetic results from its potential for scar-free operation. The procedure has been applied successfully for Graves' disease by the authors of this work and compared with the standard open cervical approach to evaluate its safety and outcomes. From January 2014 to November 2016, a total of 97 patients with Graves' disease were reviewed retrospectively. Open thyroidectomy (OT) and TOETVA were performed in 49 patients and 46 patients, respectively. For TOETVA, a three-port technique through the oral vestibule was utilized. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device. Patient demographics and surgical variables, including operative time, blood loss, and complications, were investigated and compared. TOETVA was performed successfully in all 45 patients, although conversion to open surgery was deemed necessary in one patient. All patient characteristics for both groups were similar. Operative time was shorter for the OT group compared to the TOETVA group, which totaled 101.97±24.618 and 134.11±31.48 minutes, respectively (P<<0.5). Blood loss was comparable for both groups. The visual analog scale (VAS) pain score for the TOETVA group was significantly lower than for the OT group on day 1 (2.08±1.53 vs. 4.57±1.35), day 2 (0.84±1.12 vs. 2.57±1.08) and day 3 (0.33±0.71 vs. 1.08±1.01) (P<<0.05). Transient recurrent laryngeal nerve (RLN) palsy was found in four and two cases of TOETVA and OT group, respectively. Transient hypocalcemia was found in ten and seven cases of TOETVA and OT group, respectively. No other complications were observed. TOETVA is a feasible and safe treatment for Graves' disease in comparison to the standard open cervical approach. It is considered a viable alternative for patients who have been indicated for surgery with excellent cosmetic results.