Transumbilical Approach Research Articles

Contralateral Metachronous Hernia Following Negative Laparoscopic Evaluation for Contralateral Patent Processus Vaginalis: A Meta-analysis

To conduct a meta-analysis of contralateral metachronous inguinal hernia (CMIH) that originated from negative laparoscopic evaluation for contralateral patent processus vaginalis (CPPV) in children who presented with a unilateral inguinal hernia and to determine the incidence of and factors associated with such a CMIH. A PubMed search was performed for all studies concerning laparoscopic repair or evaluation of inguinal hernia in children. The search strategy was as follows: (laparoscop* OR coelioscop* OR peritoneoscop* OR laparoendoscop* OR minilaparoscop*) AND ("inguinal hernia" OR "metachronous hernia") AND child*. Inclusion criteria included unilateral inguinal hernia in children, negative laparoscopic evaluation of CPPV, without history of contralateral inguinal surgery previously, and clearly reporting CMIH development or not. Editorials, letters, review articles, case reports, animal studies, and duplicate patient series were excluded. Twenty-three studies comprising 6091 children with negative CPPV fulfilled the inclusion criteria and were included in the final analysis, of whom 80 (1.31%) subsequently presented with a CMIH. Subgroup analysis showed that CMIH incidence was lower through an umbilical approach than via an inguinal one (0.85% versus 1.78%, P=.009). As for the transinguinal approach, there was a CMIH incidence of 0.78% and 2.05%, respectively, for laparoscopy with a small angle (30° and 70°), whereas there was no CMIH development for that with a large angle (110°, 120°, and flexible). A high pneumoperitoneum pressure (>10 mm Hg, >12 mm Hg, and >14 mm Hg) was usually associated with a slightly higher CMIH incidence than a low one (≤10 mm Hg, ≤12 mm Hg, and ≤14 mm Hg), all without significant difference. CMIH incidence was slightly lower for using a broad CPPV definition than for using a narrow one (0.64% versus 1.35%, P=.183). CMIH following negative laparoscopic evaluation for CPPV was a rare but possible phenomenon. Choosing the transumbilical approach, transinguinal laparoscopy with a large angle, low-pressure pneumoperitoneum, and broad CPPV definition would probably reduce the occurrence of such CMIHs.

Prospective, randomized clinical trial comparing the use of a single-port device with that of a flexible endoscope with no other device for transumbilical cholecystectomy: LLATZER-FSIS pilot study

Natural orifice transumbilical endoscopic surgery (NOTES) is a technique still in experimental development that requires clinical trials to assess its safety and efficacy. We present a pilot prospective, randomized, three-arm clinical trial of 1-year duration that was conducted as a noninferiority trial comparing single-incision laparoscopic surgery (SILS) and flexible single-incision surgery (FSIS) with conventional laparoscopy for elective cholecystectomy (NCT01558414). Sixty patients between aged 18 and 65 years who were eligible for elective cholecystectomy were randomly assigned in a 1:1:1 ratio (n = 20 per group): group A (SILS), single-incision endoscopic surgery using a transumbilical SILS™ device; group B (FSIS), single-incision transumbilical surgery using a flexible endoscope; and group C (CL), conventional laparoscopy. The main outcome variable of the study was "parietal complications" (wound infection, bleeding, and ventral hernia). The analysis was by intention to treat and attritions were not replaced. Cholecystectomy was performed in 100 % of the cases; perioperative complications occurred in only 1.6 % of the cases, and umbilical surgical wound infection in 3.33 %, with no differences between groups. After a minimum follow-up of 1 year, no differences were noted in the frequency of parietal complications and no ventral hernias occurred. Postoperative pain, hospital length of stay, and downtime from work were similar in all three groups. Surgical time was longer in cases in which a single-incision transumbilical approach was used (58.95 min for SILS and 54.15 for FSIS vs. 49.21 for laparoscopy). Single-incision transumbilical approaches are not inferior for safety or effectiveness compared with conventional laparoscopy. The transumbilical approach using a flexible endoscope is just as effective and safe as the other two procedures and is a promising single-incision approach.

Reduced Port Surgery for Laparoscopic Distal Pancreatectomy Using the Transumbilical Approach with Zigzag Incision

Introduction: Laparoscopic surgery in distal pancreatectomy (DP) is as an effective approach for patients with pancreatic disease because of the reduction in the blood loss, length of hospital stay, and risks of overall postoperative complications and wound infection, without a substantial increase in the operating time.1 Moreover, single-port laparoscopic surgery has become increasingly popular with a widened indication in more types of surgery. However, compared with the conventional laparoscopy, this approach may take longer to complete and requires advanced skills and dedicated instrumentations to compensate for the lack of triangulation.2 In particular, the Gelport laparoscopic system provides a flexible, airtight fulcrum to facilitate the triangulation of standard instrumentation while maintaining the pneumoperitoneum for a minimally invasive surgery. As it is easy to perform hand-assisted operation at the same time, the surgeon can cope with unexpected bleeding with safe quickly. The device has been used for various organ laparoscopic surgeries.3–5 The combination of the umbilical zigzag skin incision technique and the Gelport laparoscopic system was introduced as an effective procedure for laparoscopic surgery to various organs, reconciling the reduction of technical difficulties with the cosmetic outcomes in laparoscopic surgery.6 In this video (410 seconds), we demonstrate the technique as a safe procedure for reduced port surgery performed in laparoscopic DP, without adverse cosmetic effects. Materials and Methods: A 64-year-old woman underwent laparoscopic DP for pancreatic nonfunctional endocrine tumor. The procedure is described as follows: After marking the umbilical region for a zigzag skin incision, the skin was incised along the line. Then, a Gelport double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The Gelport was latched to the wound retractor ring, and the pneumoperitoneum was then inflated using CO2. Two additional 5-mm trocars were inserted into the upper middle and lower left hypochondria. If the operation field is not enough for continuing the procedure, the 5-mm flexible retractor is useful for lifting the organ through another 5-mm trocar. The pancreatic body and spleen were resected using the standard procedures. After dissection of the splenic artery and vein, the pancreatic parenchyma was dissected using the stapler technique. The dissected specimen was extracted smoothly through the umbilical incision, without any additional incision and destruction of the spleen. The operating time was 385 minutes, and the blood loss was 20 mL. During the postoperative period, the wound in the umbilical region shrank to the bottom of the umbilicus. Results and Conclusions: We introduced a transumbilical approach using the Gelport system with an umbilical zigzag incision for reduced port surgery in laparoscopic DP. Although this procedure took a longer operating time compared to the conventional method, this patient was still a second case for us after experiences of 15 conventional laparoscopic DP cases in our department. We consider that it is not difficult to shorten the operating time by repeating experience. Thus, we suggest that the creation of an umbilical incision using the zigzag technique allows for an easy and safe laparoscopic surgery for pancreatic diseases. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 6 mins 50 secs

Comment on “Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250)” (doi:10.1007/s00464-012-2359-4)

I read with the interest the article by Noguera et al. [1] in which they describe a randomized trial of conventional laparoscopy and two hybrid NOTES approaches for cholecystectomy. The authors found no significant differences in outcomes among the three treatment groups. The authors are to be commended for the performance of a randomized controlled trial (RCT) on this controversial topic. While one could quibble over the article’s minor nonadherence to the CONSORT Statement [2, 3], my primary criticism is that the authors made conclusions that have no basis. Here is a quote from the final paragraph of the Discussion section: ‘‘...it is safe to conclude that the transvaginal approach with the flexible endoscope is not inferior to conventional laparoscopy in either effectiveness or safety, and that the transumbilical approach with the flexible endoscope is as effective and safe as the transvaginal approach.’’ With 20 patients per group, this study was underpowered to make such a conclusion. Based on the authors’ own power analysis, the estimated sample size to see a difference of 1 versus 3 % in complication rates would have been 285 patients per group. Incidentally, these numbers would have been even higher if the authors wanted to rule out differences in bile duct injury. The authors stated that their study was done as a ‘‘pilot study,’’ since the calculated sample size was too high. While I would not accept such a statement as justification for an underpowered trial, my main objection is that the authors’ data do not support their conclusions. The only conclusion that can be drawn from this paper is simply this: in a trial of 60 women, no differences in outcome among three cholecystectomy techniques were observed. After this statement, the authors would have to make the concession that their study, by their own admission, was underpowered to make any conclusion that could be generalized beyond their 60-patient experience. To reiterate, it is not valid to extrapolate the data of this study and instruct the general readership that gallbladder technique A is not inferior to technique B, or that various techniques are safe and effective, and so forth. The other major concern that I have is why the data– conclusion incongruity was not corrected during the Surgical Endoscopy peer review process. This suggests an issue with the manuscript’s peer review. Unfortunately, we now have an article that has been vetted, published, and is searchable on the internet, a paper that contains the laudable ‘‘prospective randomized clinical trial’’ in its title, yet makes unfounded conclusions that could mislead surgeons and patients. The adequacy of planning, performing, and reporting surgical clinical trials has been under increasing scrutiny [4–6]. Unfortunately, it appears that this article is not helping this situation or surgical science in general.

Feasibility of Transumbilical Surgical Lung Biopsy and Pericardial Window Creation

To date there are no practical platforms for performing natural orifice transluminal endoscopic surgery in the thoracic cavity. This study evaluates the feasibility of transumbilical thoracosopy for lung biopsy and pericardial window creation. Eleven dogs (6 in the nonsurvival group and 5 in the survival group) were used for this study. A homemade metallic tube was advanced into the abdominal cavity via a 12-mm umbilical incision. The metallic tube was advanced into the thoracic cavity through a subxyphoid diaphragmatic incision under video guidance. Access to the thoracic cavity was achieved by a flexible bronchoscope via the metallic tube. Surgical lung biopsy and pericardial window creation were performed using an electrocautery loop and needle knife. The animals were euthanized 20 minutes after the surgery was complete (nonsurvival group) or 14 days postsurgery (survival group) for necropsy evaluation. Eight pericardial window creations and 21 of 22 preplanned lung biopsies were completed in a median time of 72.18 minutes (range 50-105 minutes). One dog in the nonsurvival group died after tension pneumothorax due to postprocedure massive air leaks. In the survival group, the postoperative period was uneventful in all 5 dogs. Autopsies revealed no signs of vital organ injury and complete healing of the diaphragmatic incision occurred in all animals. The study demonstrated that transumbilical thoracoscopic surgical lung biopsy and pericardial window creation is feasible. The safety and efficacy of the transumbilical approach need to be verified by a more detailed survival study.

Trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife: A pilot animal study

To investigate the feasibility and safety of Natural orifice trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife in a non-survival porcine model. Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy was performed on three non-survival pigs, by transumbilical approach, using a water-jet hybrid-knife. Under general anesthesia, the following steps detailed the procedure: (1) incision of the umbilicus followed by the passage of a double-channel flexible endoscope through an overtube into the peritoneal cavity; (2) establishment of pneumoperitoneum; (3) abdominal exploration; (4) endoscopic cholecystectomy: dissection of the gallbladder performed using water jet equipment, ligation of the cystic artery and duct conducted using nylon loops; and (5) necropsy with macroscopic evaluation. Transumbilical endoscopic cholecystectomy was successfully completed in the first and third pig, with minor bleedings. The dissection times were 137 and 42 min, respectively. The total operation times were 167 and 69 min, respectively. And the lengths of resected specimen were 6.5 and 6.1 cm, respectively. Instillation of the fluid into the gallbladder bed produced edematous, distended tissue making separation safe and easy. Reliable ligation using double nylon loops insured the safety of cutting between the loops. There were no intraoperative complications or hemodynamic instability. Uncontrolled introperative bleeding occurred in the second case, leading to the operation failure. Pure NOTES trans-umbilical cholecystectomy with a water-jet hybrid-knife appears to be feasible and safe. Further investigation of this technique with long-term follow-up in animals is needed to confirm the preliminary observation.

Transumbilical single-incision laparoscopic sleeve gastrectomy: Short-term results and technical considerations

BACKGROUND:Laparoscopic sleeve gastrectomy (SG) has gained popularity and acceptance among bariatric surgeons, mainly due its low morbidity and mortality. Single-incision laparoscopic surgery has emerged as another modality of carrying out the bariatric procedures. While the single-incision transumbilical (SITU) approach represents an advance, especially for cosmetic reasons, its application in morbid obesity at present is limited. We describe our short-term surgical results and technical considerations with SITU-SG.MATERIALS AND METHODS:SITU-SG was performed in 10 patients between June 2010 and June 2011. SG was performed in a standard fashion and was started 6 cm from the pylorus using a 36 French bougie.RESULTS:They were all females with a mean age of 45 years. Preoperative BMI was 40 kg/m2 (range, 35–45). The mean operative time was 98 min. No peri- or postoperative complications or deaths occurred. All patients were very satisfied with the cosmetic outcomes and excess weight loss.CONCLUSION:True SITU laparoscopic SG is safe and feasible and can be performed without changing the existing principles of the procedure.

Conventional laparoscopy vs. single port surgery from a patient’s point of view: influence of demographics and body mass index

Single port surgery (SP) using a transumbilical approach is gaining more popularity, but who is the driving force behind this development: surgeons, industry, or patients? We evaluated patient's perception in conjunction with demographic data and body mass index (BMI) concerning conventional (multiport) and single port laparoscopy. Surgical patients were surveyed preoperatively and demographic data was recorded. Using the example of cholecystectomy, open surgery (OP), conventional laparoscopy (CL), and SP was explained. Participants were asked to rate importance of abstract items using a 5-point Likert scale (1: extremely important; 5: not important at all), decide between CL and SP and give reasons for their decision. One hundred and fifty (79 females, 52.7%) patients were surveyed. One hundred and six (70.7%) would prefer SP. Abstract items such as complications (1.29 ± 0.835) and surgeon's experience (1.23 ± 0.673) were rated higher than cosmesis (2.64 ± 1.398), length of hospital stay (2.13 ± 1.190), or cost of hospitalization (3.06 ± 1.428). Educational status and experience with prior surgery had no influence on decision making but especially younger patients more often decide in favor of SP (p = 0.007). In addition, more females (p = 0.254) and obese (p = 0.214) patients would opt for SP without reaching statistical significance. Superior cosmesis and reduced postoperative pain were the main arguments. However, only 11.1% of obese patients stated that cosmesis is a reasonable argument to favor SP whereas 56.4% of patients with a normal weight did (p < 0.001). The majority of patients surveyed would prefer SP because of potential benefits such as superior cosmesis and reduced postoperative pain. Prior surgery and educational status had no influence on decision making whereas slightly more female and obese and especially younger patients are prone to SP.

Transumbilical Sleeve Gastrectomy with an Accessory Lateral Port: Surgical Results in 237 Patients and 1-Year Follow-up

The transumbilical approach has recently been shown to be safe for several surgical procedures. Case series of sleeve gastrectomy (SG) with a transumbilical approach (TUSG) has been reported with various techniques. The objective of this report is to present the technique, surgical results, and 1-year follow-up results of simplified TUSG using rigid instruments. All of the patients who had undergone SG since July 2010 were offered a transumbilical approach. The operative technique involves a transumbilical incision and the introduction of a SILS® or GelPoint® multiport and a 5-mm metallic accessory trocar laterally in the left flank. Rigid instruments were used in all patients. Gastric transection was made 4-5 cm proximal to the pylorus, calibrated with a 36-Fr bougie. Selected hemostasis to the staple line was achieved with metallic clips. A total of 237 patients underwent TUSG. Patient body mass index ranged from 30 to 46 kg/m(2). The mean operative time was 49.5 ± 14.9 min. Six patients presented with early complications, including hemoperitoneum in three cases, antral leak in one case, intestinal perforation in one case, and portal vein thrombosis in one case. Conversion to the multitrocar technique was required in one patient. There were no mortalities. The mean length of hospital stay was 2.2 ± 1 days. The cosmetic result was satisfactory for all of the patients. TUSG is a safe and feasible procedure using the described technique. The insertion of a 5-mm assistance trocar simplifies the procedure, allowing the use of rigid instruments.

Transumbilical Laparoscopic Roux-en-Y Gastric Bypass with Hand-Sewn Gastrojejunal Anastomosis

Single-port laparoscopic surgery has undergone significant development over the past 5 years. Single port is used in various procedures, including bariatric surgery. The aim of this paper is to describe a surgical technique for gastric bypass with a transumbilical approach (transumbilical gastric bypass-TUGB) with hand-sewn gastrojejunostomy, in selected patients who may be benefited by a better cosmetic result. The procedure begins with a transumbilical vertical incision. We use the GelPOINT single-port device and a 5-mm assistant trocar in the left flank (in the first two cases, a 2-mm subxiphoid liver retractor was used). A gastric pouch is made and calibrated with a 36-Fr bougie. The gastrojejunal anastomosis is performed by hand-sewing in two layers. A Roux-en-Y with a biliary limb of 50 cm and an alimentary limb of 120 cm is performed with a stapler. Three women were subjected to TUGB. The women were aged 28, 31, and 42 years; they had body mass indexes of 40.3, 33, and 38.2; and the operating times were 150, 200, and 150 min, respectively. The first two women underwent a Roux-en-Y gastric bypass (RYGB), and the last woman underwent a RYGB with a resection of the stomach remnant. There were no conversions to open or multitrocar techniques. No complications or deaths occurred. The three patients were satisfied with the cosmetic result. The technique described for TUGB is a feasible procedure for surgeons who have previous experience with the transumbilical approach.

Single-Incision Laparoscopic Cholecystectomy Versus Traditional Four-Port Cholecystectomy

Laparoscopic cholecystectomy has traditionally been performed using multiple small sites. Single-incision laparoscopic surgery has emerged as an alternative technique to improve cosmesis and minimize complications associated with multiple incisions. A retrospective study was performed of all patients who underwent laparoscopic cholecystectomy by a single surgeon (DTA) from April 2008 to August 2011. Charts were reviewed for surgical indication, operative technique (multiple vs. single transumbilical incision), operative time, length of stay, and surgical complications. Sixty-three patients underwent laparoscopic cholecystectomy using a traditional approach of four skin incisions, while 62 patients underwent a single-incision transumbilical approach. Average age and sex were comparable between the two groups. Indications for surgery included cholelithiasis, cholecystitis, biliary dyskinesia, biliary pancreatitis, and porcelain gallbladder. Of those undergoing single-incision cholecystectomy, 85% (53/62) went home the same day, compared with 70% (44/63) of those undergoing four-incision cholecystectomy (P = 0.03). Among those not discharged on the same day of surgery, the average length of stay trended shorter in the single-incision group (2.8 days, range 1–6) compared with the four-incision group (3.3 days, range 1–12; P = NS). Operative time was slightly longer for those undergoing single-incision surgery (65 minutes, range 35–141) versus traditional four-incision surgery (51 minutes, range 41–109) (P < 0.001). With this single surgeon's single-incision transumbilical technique, costs were comparable between the two groups. One patient who underwent traditional four-incision cholecystectomy was readmitted for biliary pancreatitis and bacteremia on postoperative day 3. In the single-incision group, one patient was readmitted 1 month later with pancreatitis. In conclusion, single-incision transumbilical laparoscopic cholecystectomy can be an effective alternative to traditional four-incision cholecystectomy, with the added benefit of minimized scarring and a shorter length of stay. A longer operative time may be needed initially to adjust for a learning curve. This technique can be performed safely for patients with a multitude of gallbladder diseases without resulting in additional complications.

Gastrectomía en manga transumbilical con técnica simplificada: técnica y resultados quirúrgicos en 100 pacientes

Simplifi ed transumbilical sleeve gastrectomy. Technique and surgical results in 100 patients Background: The use of transumbilical approach for sleeve gastrectomy has been recently reported, using different technique variations. Aim: To report the technique and surgical results of a transumbilical approach simplifi ed sleeve gastrectomy, using rigid instruments. Material and Methods: Ninety four women and six men, selected by a multidisciplinary team, underwent transumbilical sleeve gastrectomy. The opera- tive technique involved a transumbilical incision, introduction of a SILS ® or GelPoint ® multiport, and a 5mm metallic accessory trocar laterally in the left fl ank. Rigid instruments were used in all patients. The greater curvature was dissected from 4-5 cm above the pylorus to the angle of His. Gastric transection was completed with a stapler, and calibrated with a 36 French tube advanced through the pylorus. Hemostasis of the staple line was carried out with metallic clips. A barium swallow was performed in ten randomly chosen patients, confi rming the correct tubular shape of the stomach. Results: Body mass index of operated patients ranged from 30 to 43 kg/m 2 . Mean operative time was 56.4 ± 16.7 minutes. During the early postoperative period, two patients had a hemoperitoneum, one had an antral leak and one had an intestinal perforation. No conversion to conventional laparoscopy or open technique was required. No patient died. The mean length of hospital stay was 2.3 ± 0.5 days. The cosmetic result was satisfactory for all patients. Conclusions: Transumbilical sleeve gastrectomy is a safe and feasible procedure with the reported technique. The insertion of an accessory 5mm trocar in the left fl ank simplifi es the procedure, allowing the use of rigid instruments.

Laparoendoscopic Single-Site Surgery for Partial Nephrectomy Without Ischemia Using a Microwave Tissue Coagulator

Herein, we report our initial experience with laparoendoscopic single-site surgery for partial nephrectomy (LESSPN) using a microwave tissue coagulator (MTC). Two patients with small and exophytic renal tumors underwent LESSPN. A multichannel port was inserted into the peritoneal or retroperitoneal space through a 3-cm skin incision. After tumor exposure, the surgeon introduced a laparoscopic MTC instrument through a 5-mm port and the tumor margin was coagulated circumferentially. After coagulation, the tumor was resected without renal pedicle clamping. These procedures were successfully performed without any conversions to standard laparoscopy or need for placement of additional trocars. The operative times were 183 and 160 minutes, respectively. The estimated blood loss was <150 mL in both cases. The final length of the LESS wound was 3 cm. Using the transumbilical approach, the operative scar receded into the umbilicus and was hardly visible. This novel surgical technique is feasible and enables the bloodless resection of a renal tumor without renal pedicle clamping. Further clinical experience and longer follow-up are needed to define the benefits of this new technique.

Single-incision transumbilical levels 1 and 2 axillary lymph node dissection using a flexible endoscope in human cadaveric models

The use of the flexible endoscope as a surgical platform potentially exposes a range of new surgical approaches and benefits yet to be fully defined. A new method using the flexible endoscope to undertake axillary dissection for breast cancer treatment is explored together with an investigation into its acceptability to the general public. Endoscopic axillary dissection via a transumbilical approach using the flexible endoscope passed subcutaneously from the umbilicus is described for four human cadaveric axillas. A questionnaire, validated by clinicians, explored the general public's reaction to the approach and how it might be influenced by potentially serious morbidity such as an increased rate of cancer recurrence. All axillas were accessed successfully via the transumbilical approach. Levels 1 and 2 axillary dissection was attempted on four axillas. Scarring from previous axillary surgery prevented dissection in one case. In the remaining three cases, respectively 12, 11, and 14 lymph nodes were harvested. The operative times improved with each case, from 1080 to 390 min. A total of 127 people responded to the questionnaire, with 73 % preferring the described approach over the open and periareolar alternatives when morbidities were considered equivalent. When a hypothetical elevated risk of cancer recurrence was included with the transumbilical approach, one-fifth of the public still accepted the approach due to the likelihood of a superior cosmesis. The use of the flexible endoscope for oncologically safe levels 1 and 2 axillary dissection is possible and would be acceptable to the general public if it were clinically approved. However, significant challenges with the current endoscopic equipment and relevant instrumentation limit the potential of the technique. Technical innovation in terms of new instrument design with improved ergonomics will reduce long operating times and fatigue, thus ensuring surgical acceptance of the flexible endoscope.

Transvaginal Sigmoid Cancer Resection: First Case with 12 Months of Follow-Up—Technique Description

Several minimally invasive techniques using natural orifices as an entrance site to the peritoneal cavity have been described recently. Pure natural orifice translumenal endoscopic surgery (NOTES) techniques have been mainly implemented to perform cholecystectomies and appendectomies, while more complex operations like colon resections have been described in a hybrid setting and with the use of the transumbilical approach. Here we describe the technique of transvaginal sigmoid colon resection for cancer with standard laparoscopy equipment. After developing the transvaginal technique of sigmoid colon resection in an experimental sheep model, we have performed this operation in a human patient for cancer. Twelve months of follow-up is reported. A totally transvaginal R0 resection of the sigmoid colon for adenocarcinoma has been successfully performed in a female patient with laparoscopy equipment. The specimen included 13 lymph nodes, all of which were free of metastasis. Twelve months after surgery the patient is alive with no evidence of disease. A pure transvaginal NOTES approach to sigmoid colon cancer is feasible in human patients.

Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250)

Natural orifice transluminal endoscopic surgery (NOTES) is a technique still in experimental development whose safety and effectiveness call for assessment through clinical trials. In this paper we present a three-arm, noninferiority, prospective randomized clinical trial of 1 year duration comparing the vaginal and transumbilical approaches for transluminal endoscopic surgery with the conventional laparoscopic approach for elective cholecystectomy. Sixty female patients between the ages of 18 and 65 years who were eligible for elective cholecystectomy were randomized in a ratio of 1:1:1 to receive hybrid transvaginal NOTES (TV group), hybrid transumbilical NOTES (TU group) or conventional laparoscopy (CL group). The main study variable was parietal complications (wound infection, bleeding, and eventration). The analysis was by intention to treat, and losses were not replaced. Cholecystectomy was successfully performed on 94% of the patients. One patient in the TU group was reconverted to CL owing to difficulty in maneuvering the endoscope. After a minimum follow-up period of 1 year, no differences were noted in the rate of parietal complications. Postoperative pain, length of hospital stay, and time off from work were similar in the three groups. No patient developed dyspareunia. Surgical time was longer among cases in which a flexible endoscope was used (CL, 47.04 min; TV, 64.85 min; TU, 59.80 min). NOTES approaches using the flexible endoscope are not inferior in safety or effectiveness to conventional laparoscopy. The transumbilical approach with flexible endoscope is as effective and safe as the transvaginal approach and is a promising, single-incision approach.

Instruments Interaction in Laparoendoscopic Single-Site Nephrectomy: An Endoscopic Perspective

Introduction and Objectives: Reduced triangulation and instrument collision remain obstacles to widespread clinical adoption of laparoendoscopic single-site (LESS) surgery.1 Our aim was to study interaction of instruments in a LESS radical nephrectomy (LESS RN) by placing an additional endoscope to monitor instrument movements during the procedure and develop methods to bypass observed difficulties. Materials and Methods: Our patient was a 62-year-old woman with a 6-cm right renal tumor and multiple abnormal cysts. Through a 3-cm omega-shaped incision, a transperitoneal transumbilical approach was employed with a Gelpoint® platform (Applied Medical, Inc., Rancho Santa Margarita, CA) for access. Four 5-mm reusable trocars were positioned. One was exchanged with a 10-mm trocar for Hem-o-lok® (Teleflex, Inc., Limerick, PA) clip delivery. Surgery was performed with a 5-mm 30° endoscope and standard laparoscopic instruments. A 5-mm trocar was inserted in the right flank to observe and record the procedure through another 5-mm 30° endoscope in its entirety. The surgeon did not have access to this extra camera view during the procedure. Conventional laparoscopic radical nephrectomy (LRN) steps were utilized (colon/liver mobilization, vena cava and pedicle dissection/control, ureteral sectioning, and final specimen dissection). The specimen was extracted through the umbilical incision. Operative time was under 2 hours. The patient had a normal postoperative course without complications. Results: The procedure was completed in comparable time to LRN with standard laparoscopic instruments. Video observations of all surgical steps were reviewed. From the endoscopic perspective, clashing of the endoscope and the main instrument occurred most frequently during the upper-pole dissection when the instruments entered in the same axis. This prevented triangulation and reduced mobility. Avoiding collisions required surgeon/assistant coordination and minor adjustments to trocars placed within the Gelpoint. The remainder of the procedure had minimal instrument-related difficulties as shown in the video. The multifunctionality of the ultrasonic shears facilitated the procedure by reducing instrument switching. Conclusions: LESS RN can be performed with standard laparoscopic instruments in a comparable amount of time to standard LRN with excellent cosmesis and no significant change in cost or morbidity.1 The observation endoscope in the flank clearly demonstrated that although some instrument clashing and decreased triangulation were seen, the use of the Gelpoint access system and low-profile trocars allowed the operation to progress smoothly. We believe that these observations further support the use of LESS RN as a feasible alternative to LRN in appropriately selected patients.1,2 The authors have nothing to disclose Runtime of video: 09 mins 49 secs This video was presented in part at the 2011 European Association of Urology Congress in Vienna.

Laparoscopic-assisted resection of juvenile polyp of the jejunum in a 3-year-old girl

Sporadic juvenile polyp of the jejunum is exceedingly rare, reported only once in the English literature. We describe a 3-year-old girl with a long-lasting history of chronic iron deficiency anemia and a delayed diagnosis of jejunal polyp. The lesion was eventually discovered by ultrasonography and successfully resected using a laparoscopic-assisted transumbilical approach.

Improving the Advantages of Single Port in Right Hemicolectomy: Analysis of the Results of Pure Transumbilical Approach with Intracorporeal Anastomosis

Background. Single-port laparoscopic surgery has recently emerged as a method to improve patient recovery and cosmetic benefits of laparoscopic surgery. The evolution of our technique has led us to move from a periumbilical incision to a transumbilical one, avoiding the use of drain and maintaining a pure single-port approach with intracorporeal anastomosis in order to maintain the incision as smaller as possible. Method. We report a prospective clinical analysis of our first 38 patients. Oncological surgical steps were followed as during the standard laparoscopic approach, performing the anastomosis intracorporeally in all cases. Results. Mean age of 68,39 years old and an average BMI of 27,88%. (range 19,81–41,5). Most lesions were adenocarcinoma (65,8%), while the remaining were polyps (31,5%) and one a mucocele of the appendix. We moved from a periumbilical incision, initial 14 cases, into a transumbilical one, (medium size of the incision 3,25 cm). Average surgical time was 117,42 minutes. Drains was only used in our first 3 cases. Mean hospital stay was 5,2 days, (86,5% stayed less than 5 days). Total morbidity was 13%. Histological exams of the specimens showed that the oncological criteria were preserved. Conclusions. Single-port right hemicolectomy with intracorporeal anastomosis is feasible and safe. The advantages of a total intracorporeal anastomosis include that there is no need to enlarge the umbilical incision and avoid traction of the pedicle of the mesenterium of the transverse colon during the extracorporeal anastomosis. A transumbilical incision offers better cosmetic results, and the use of drains can be avoided, which increase, patient's satisfaction.

Transumbilical approach for laparo‐endoscopic single‐site adrenalectomy: Initial experience and short‐term outcome

To report our initial experience with transumbilical laparo-endoscopic single-site adrenalectomy for adrenal tumors by using a single port with a multichannel cannula and bent laparoscopic instrumentation. Between December 2009 and December 2010, 30 patients underwent transumbilical laparo-endoscopic single-site adrenalectomy at our hospital. The procedure was carried out for adrenal cortical adenoma in 17 patients, adrenal pheochromocytoma in seven patients and other types of tumors in six patients. A multichannel port, bent laparoscopic instruments and Opti4 laparoscopic electrodes were used in all patients. The intraperitoneal space was approached through the umbilicus. The multichannel port was placed through a 2-cm incision at the inner edge of the umbilicus. A 5-mm flexible laparoscope was introduced to maintain an adequate laparoscopic view, and surgical specimens were extracted using an Endocatch bag. All procedures were successfully completed, with only one incision through the umbilicus, and without conversion to a standard laparoscopic approach. Mean operative time was 120.1 ± 34.7 min. Tumor laterality and patient body mass index did not affect surgical morbidity. The initial 15 patients had a significantly longer mean pneumoperitoneum time (95.8 ± 37.5 min) than the last 15 patients (70.5 ± 18.7 min). Only one postoperative complication was observed (postoperative hematoma). A transumbilical approach for laparo-endoscopic single-site adrenalectomy is safe and feasible, and it results in superior cosmesis. Improvements in surgical devices might facilitate further development of this approach.