Trocar Access Research Articles

Port-site hernia recurrence at previous 5-mm laparoscopic access: case report and review of literature.

Port-site hernia (PSH) of less than 10 mm is an exceptionally rare complication of minimally invasive surgery (MIS). To date, there have been no cases in the literature reporting recurrence of PSH from a 5 mm incision. We present the first case of PSH recurrence in a woman who underwent surgery for benign gynaecological pathology via a MIS approach. Her post-operative course was complicated by an episode of symptomatic hernia arising from a 5 mm accessory trocar which was surgically managed. A few months later she re-presented with the same symptoms and had a PSH recurrence of the same port-site. Two corrective surgeries employing different techniques were performed. The first episode was managed laparoscopically using interrupted stitches. On the other hand, the PSH recurrence was managed by placement of a mesh. Ultrasound played a crucial role in diagnostics, especially in the recurrent setting. Due to the complete absence of similar cases in the literature, the decision making around the management of a PSH recurrence from a 5 mm trocar site proved to be challenging. As MIS is the current standard of care, more cases are likely to occur, however despite the increasing number of surgical procedures performed via MIS, no established guidelines for managing such complications have been proposed. Trying to bridge this gap, we present the case report of the first case of PSH recurrence from a 5 mm accessory port and a review of the most significant literature available to date. We finally summarise the reported cases of PSH and the types of surgical repair conducted to highlight the absence of a standard of care.

Optical Trocar Access for Retroperitoneal Robotic-Assisted Pyeloplasty in Children with Ureteropelvic Junction Obstruction.

Purpose: Retroperitoneal robotic-assisted pyeloplasty (ret-RAP) for ureteropelvic junction obstruction (UPJO) requires a larger retroperitoneal space (RS) to maintain specified distances between robotic (da Vinci) trocars and between trocars and the region of interest. A modified closed technique (MOT) and conventional closed technique (COT) were compared for creating an adequate RS with optical trocars. Methods: RS access in children with UPJO who underwent ret-RAP (n = 30) was MOT (n = 15) and COT (n = 15). All patients were positioned laterally. For MOT, a 5 mm optical trocar was inserted at the angle formed between the 12th rib and the erector spinae muscles. As the trocar was advanced under direct vision, it pierced the superficial subcutaneous layer, Scarpa's fascia, lumbar fascia, internal/external oblique and transversus abdominalis muscles, and the posterior renal fascia. Once in the RS, the tip of the scope was used for blunt dissection of perirenal fat, the tip was withdrawn until it was outside the perirenal fascia, and used to dissect toward the anterior abdomen in the pararenal fat layer. Results: Ages and weights at ret-RAP were similar (MOT: 5.6 ± 1.8 years versus COT: 7.8 ± 4.6 years; MOT: 20.6 ± 10.1 kg versus COT: 27.6 ± 13.9 kg). Times for RS access were similar (MOT: 1.6 ± 0.5 minutes versus COT: 1.9 ± 0.7 minutes), but RS expansion was significantly quicker in MOT (32.3 ± 8.7 minutes versus 52.0 ± 15.1 minutes; P < .001). Peritoneal injury caused carbon dioxide leakage in 4 of 15 COT cases and 0 of 15 MOT cases. Conclusion: RS expansion with MOT was safer because there were no peritoneal injuries and MOT was quicker than COT.

Trocar Entry Site Hernias in Laparoscopic Sleeve Gastrectomy Patients: A Retrospective Cross-Sectional Study.

Introduction There is insufficient data regarding trocar access site hernias (TSH) in laparoscopic sleeve gastrectomy (LSG). This retrospective study aimed to identify the incidence and risk factors for hernia development in patients who did not undergo fascia repair at trocar entry sites. Materials and methods We retrospectively reviewed the records of 284 patients with morbid obesity who underwent LSG between January 2016 and December 2021. The fascia of the trocar entry site was not closed in any of the patients. Weight, body mass index (BMI), percentage of excess weight loss (%EWL), percentage oftotal weight loss (%TWL), comorbidities, and the occurrence of complications were recorded at one, six, 12, 18, and 24 months after surgery. Ultrasonography (USG) was performed and supplemented with computed tomography (CT) when necessary. Results All patients underwent a 24-month follow-up, during which four patients developed trocar site hernias, resulting in an overall prevalence of 1.4%. Of the total hernias, two occurred within the first 30 days. A single patient required surgical intervention for an incarcerated hernia on the 18th day. Before undergoing laparoscopic sleeve gastrectomy (LSG), the mean weight and body mass index (BMI) of the participants were 124.2 ± 16.7 kg and 43.4 ± 5.7 kg/m², respectively. After one year, the participants experienced a mean percentage of excess weight loss (EWL) of 77.1 ± 12.2% and a mean total weight loss (TWL) of 33.2 ± 6.2%. Hernia formation has been found to be associated with both type 2 diabetes (T2D) and female gender. Conclusion In laparoscopic sleeve gastrectomy (LSG), repair of the trocar port closure is not always necessary. The rates of hernia at port entry sites were similar between cases with and without fascial repair.

Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study

IntroductionThe optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. MethodsThis is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1−10; 11−20; 21−30) for both trainee and expert and LC variables were compared. ResultsOverall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, P = .01). For cases 11−20 and 21−30, time advantage of the senior surgeon is less evident (P = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. ConclusionsOTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

Curva de aprendizaje para el acceso con trocar óptico en cirugía pélvica laparoscópica: estudio prospectivo

IntroductionThe optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n=30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. MethodsThis is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared. ResultsOverall, mean OTA insertion time was 56s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33s respectively, p=0.01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (p=0.05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. ConclusionsOTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

PROSPECTIVE OBSERVATIONAL STUDY COMPARING OUTCOMES AND COMPLICATIONS OF OPEN VS LAPAROSCOPIC NEPHRECTOMY

Introduction: Nephrectomy refers to surgical removal of the kidney and is further divided into simple, radical, partial and donor nephrectomy. Simple nephrectomy is conducted in irreversible kidney damage; radical nephrectomy in malignant or benign renal tumours while partial nephrectomy involves removal of part of kidney. Nephrectomy may be performed via open or laparoscopic approaches; although there is evidence favouring laparoscopy, supplementary evidence is necessary to establish it.2 This study aims to compare outcomes, complications and other parameters for laparoscopic and open surgical nephrectomy at a tertiary care centre in western India. To compare outcomes and Aim: complications for laparoscopic and open nephrectomy. Objectives: To compare: 1. Immediate and late complications. 2. A] Requirement of analgesia. B] Return of bowel functions. 3. Mean length of hospitalization and return to regular normal activity. Materials And Methods: A prospective observational single centre study was conducted at a tertiary care centre in western India. Total sample size was 49 of which 25 patients underwent laparoscopic nephrectomy while 24 patients underwent open nephrectomy. Intraoperative anaesthesia, trocar access, duration of surgery, blood loss, repeat haemoglobin and haematocrit value at post operative day 1, requirement of blood transfusion, duration of analgesics requirement, post-operative stay; histopathology report and time to resume normal activity at immediate follow up, follow up at 3 months and further follow up after surgery were noted down. Current study found statist Results: ically signicant relationship of higher intra-operative blood transfusion requirement and higher post-op requirement of Analgesia in case of open surgery. Moreover, among laparoscopy group there was signicantly lower blood loss during surgery, early time to oral diet, low pain VAS score, lower doses of Tramadol and early return to normal activity was found as compared to Open surgery group (p&lt;0.05). Laparoscopic nephrectom Conclusion: y results in less blood loss, less requirement of post operative analgesia and more rapid post operative recovery in comparison to open surgery

Single-Port Robotic Radical Prostatectomy: Short-Term Outcomes and Learning Curve.

Introduction and Objective: In 2018, the U.S. Food and Drug Administration approved the da Vinci single-port (SP) system, in which four instruments are still utilized, but enter through a single-site access trocar. Herein, we report the largest case series for SP robot-assisted radical prostatectomy (RARP) to date. Our primary aim is to analyze the perioperative and short-term outcomes of this procedure. Our secondary aim is an assessment of the learning curve with this new platform. Methods: A total of 157 patients underwent SP RARP by two surgeons who have completed >3000 multiport robotic surgeries collectively. Institutional Review Board-approved prospectively collected data were used. Basic demographic preoperative variables and perioperative outcomes were analyzed. Results: Median patient age and prostate-specific antigen was 63 years and 6.3 ng/mL before treatment (interquartile range [IQR] 4.7-8.2 ng/mL). Average prostate weight was 47 g. The median operating time was 195 minutes (IQR 165-221.25 minutes) with a median estimated blood loss of 100 mL (IQR 100-200 mL). Surgeon 1's operating time stabilized around case #56, and Surgeon 2 around case #26. Surgeon 2 used the transperitoneal approach for the first 7 cases. There were no intraoperative complications. There were six total postoperative complications (3.8%) and four (2.5%) were Clavien-Dindo scale ≥IIIa. One hundred ten patients went home same day, 45 stayed 1 night at the hospital, with only 2 patients requiring stay in the hospital for more than 1 night (70%, 29%, and 1% respectively). With the median follow-up period of 9 months, rates of biochemical recurrence, pad-free, and potency preservation were 8.3%, 82.5%, and 64.4%, respectively. Conclusions: This case series confirms the safety and efficacy of SP RARP with acceptable short-term outcomes. There is a significant learning curve for this new modality. Shorter hospital stay appears to be an early benefit of the SP platform.

SAFETY OF THE OPTICAL TROCAR AS A METHOD OF 1st LAPAROSCOPIC ACCESS VS DIRECT TROCAR, VERESS AND HASSON NEEDLE

Background: Laparoscopic surgery is a surgical procedure by which access to the abdomino-pelvic cavity is obtained through small incisions. The incidence of bowel injury is estimated at 0.5% and of injury to major blood vessels (iliac, aorta, cava) at the time of access at 1%. Theoretical benets of optical trocar access include immediate and/or early recognition of injury, as well as failed entry, on the assumption that the layers of the abdominal wall are observed with the optical trocar until access has been achieved. To determine whether the optical trocar is a saferObjective: laparoscopic access method compared to the other techniques with direct trocar, Veress needle and Hasson open technique. Material and Methods: Observational, analytical, prospective cohort study with four arms. The study included women over 18 years of age who attended the gynaecology and laparoscopic surgery department of the Hospital Ángeles del Pedregal. The number of attempts and access time, as well as the presence of complications were quantied. Results and Conclusions: Trocar access had an advantage over the other techniques, both in access time and lower incidence of complications. The number of attempts to enter the cavity was similar to the open technique. We can conclude that the optical trocar technique is safer than the other techniques even over the open technique (Hasson).

Effectiveness of local anesthetic application methods in postoperative pain control in laparoscopic cholecystectomies; a randomised controlled trial

BackgroundLaparoscopic cholecystectomy is a minimally invasive procedure that causes pain originating from parietal and visceral peritoneum. Many studies have been conducted to improve postoperative pain management and comfort of patients. Various methods such as local anesthetic injection (LAI) at trocar access points, intraperitoneal local anesthetic injection (IPLA), pneumoperitoneum pressure reduction, transversus abdominis plane block (TAPB), and reducing the number of trocars used during the operation were attempted to reduce postoperative pain. MethodsIn this study, we compared LAI, TAPB and IPLA methods with the control group in which no local anesthetic was applied to reduce postoperative pain after laparoscopic cholecystectomy. We also demonstrated the effect of these methods on postoperative pain, need for additional analgesics, length of hospitalization, and patient satisfaction. ResultsOverall, 160 patients aged 18–74 years who underwent laparoscopic cholecystectomy for cholelithiasis between October 2018 and August 2019 were included in the study and divided into four groups as follows: LAI group, TAPB group, IPLA group, and the control group without any intervention. Visual Analog Scale (VAS) values at 1, 2, 4, 6, 12, and 24 h in the control group were significantly higher than in the LAI, TAPB, and IPLA groups. Further, VAS values at 1, 2, 4, 6, 12, and 24 h in the IPLA group were significantly higher than in the LAI and TAPB groups. No significant difference was observed between the LAI and TAPB groups in terms of VAS values at 1, 2, 4, 6, and 24 h. VAS values at 12 h in the LAI group were significantly higher than in the TAPB group. ConclusionsPeroperative local anesthetic administration methods were more effective in preventing pain after laparoscopic cholecystectomy compared to the control group. In addition to reducing postoperative pain, these methods reduced the need for postoperative analgesics and increased patient satisfaction.

Randomized control trial on effectiveness and safety of direct trocar versus Veress needle entry techniques in obese women during diagnostic laparoscopy.

To determine the benefits and safety of direct trocar insertion versus Veress needle technique in obese women undertaking diagnostic laparoscopy procedures. Randomized-controlled trial on 135 obese women undergoing diagnostic laparoscopy and dye test for infertility was conducted. Women were randomly assigned to either direct trocar access (n = 68) or Veress needle access (n = 67) before achieving pneumoperitoneum. The same surgeon executed thelaparoscopictechniques with a single-puncture technique. The primary outcome measures included total length of the procedure and incidence of any complications, while the mean laparoscopic entry time, volume of CO2 required, and total of tries needed to attain successful entry were secondary outcomes. Intention-to-treat principle was applied to analysis. Women in both groups had similar socio-demographic and clinical characteristics and none were lost to follow-up. The overall length of the procedure was significantly lesser in the direct trocar group compared to the Veress needle group (9.9 ± 6.0 vs 16.7 ± 4.7min; p < 0.001). No significant differences occurred in other outcomes including mean entry time, volume of CO2 used, number of attempts for successful entry, and major/minor complications (p > 0.05). Direct trocar technique may be an effective alternative to Veress needle for pneumoperitoneum in obese women for diagnostic laparoscopy. It has a comparable rapid laparoscopic entry time but a significantly lower duration of the procedure and shorter exposure to anesthesia. Both methods are equally effective as there was no significant difference in the complications recorded. A greater sample trial may be essential for more corroborative substantiation. PACTR201510000999192.

Optimizing first trocar access for robot-assisted radical prostatectomy: Optical trocar access through the upper abdominal quadrant using the Kii Fios First Entry trocar.

A pre-equipped metal trocar is required to use as a camera trocar due to a specification change in the da Vinci X/Xi system (Intuitive Surgical). We observed slight slippage of a trocar placed by the open method. With optical trocar access (OTA), the initial trocar is viewed directly with a laparoscope during placement. Reports regarding OTA for robotic surgery are limited, particularly for robot-assisted radical prostatectomy (RARP). We modified the OTA procedure such that it was appropriate for RARP. A total of 158 patients were enrolled in this study. The first trocar placement time (FTPT) was compared between the open and OTA groups. In the OTA group, the trocar was mainly placed through the upper abdominal quadrant. We also analyzed the differences between the conventional and modified OTA procedures using the Kii Fios First Entry trocar (Applied Medical). We examined the factors affecting the FTPT using linear regression models. A P value <.05 was considered significant. The FTPT was significantly shorter in the OTA group than the open group (P < .0001). The modified method was associated with a shorter FTPT (P=.0001). None of the patient characteristics affected the FTPT in either group. No major complications were observed. OTA was applied successfully during RARP. Use of the Kii Fios First Entry trocar with upper abdominal quadrant placement was suitable for RARP.

Optically guided peritoneal access in pediatric laparoscopy: is it a good alternative for open access? A prospective comparative study

Background A minimally invasive approach has become the method of choice for treating many surgical cases. The superiority of open peritoneal access is owing to the low probability of visceral injury. Optically guided trocars were designed to decrease the injury risk to intra-abdominal contents by permitting the surgeon to see abdominal wall layers while traversing it and abdominal contents once access is complete. Materials and methods A prospective comparative study was done between optical trocar access using Fengh optical port, trocar model FLTC5 (Fengh medical Co. Ltd, Jiangsu, China), and open access using Hasson technique in pediatric patients. The study included 187 patients from the age of 1 year to the age of 16 years. Patients with previous open abdominal surgery, abdominal masses in the periumbilical region, and/or traumatic abdominal injury were excluded from the study. Access time and initial port insertion complications were reported to clarify safety and time for optical access. Results Optical access was done in 92 patients and open access in 95 patients. No visceral or major vascular complications were reported in both types of access. Access time in group IA (optical) was 58.06±16.1 s. in comparison with 175.7±54.7 s. in group IB (open) (P=0.0001*), and it was 49.7±9.4 s. in group IIA (optical) in comparison with 169.3±38.3 s. in group IIB (open) (P=0.0001*). Conclusions In selected cases, optical access is feasible, safe, and time-saving and avoids many problems in initial port insertion in pediatric laparoscopy.

Midline incision as specimen extraction site: always to avoid? Single center experience about the use of enlarged umbilical trocar access

By the years several locations for specimen extraction site (SES) during laparoscopic surgery for colorectal disease have been proposed and many studies have focused their attention on outcomes and complications, but the 'best' SES has not yet been found. In this paper we describe our experience using the enlargement of umbilical trocar access as SES during laparoscopic colorectal surgery: at the end of the intracorporal phase we remove Hasson's trocar from the umbilicus, therefore the skin and fascial incision is enlarged up to 5-6 cm. In our work we considered 36 patients extracted from our database from 2017 with at least one year follow up. We don't report any skin closure dehiscence or surgical site infection (SSI) and in only one patient (2.7%) occurred incisional hernia (IH). The results of our study are good and an accurate wound closure at the end of the surgery and an optimal perioperative management are important to reach this goal. The enlargement of umbilical access could enable several post-operative advantages such as a fewer painful areas and a reduced number of incisions with a potential risk of SSI and incisional hernia compared to traditional SES options but further studies investigating that are needed. In the future other incisions will not be necessary except the normal trocar site ones.

Midline incision as specimen extraction site: always to avoid? Single center experience about the use of enlarged umbilical trocar access.

By the years several locations for specimen extraction site (SES) during laparoscopic surgery for colorectal disease have been proposed and many studies have focused their attention on outcomes and complications, but the "best" SES has not yet been found. In this paper we describe our experience using the enlargement of umbilical trocar access as SES during laparoscopic colorectal surgery: at the end of the intracorporal phase we removed Hasson's trocar from the umbilicus, therefore the skin and fascial incision is enlarged up to 5-6 cm. In our work we considered 36 patients extracted from our database from 2017 with at least one year follow-up. We do not report any skin closure dehiscence or surgical site infection (SSI) and in only one patient (2.7%) occurred incisional hernia (IH). The results of our study are good. Important to reach this goal are an accurate wound closure at the end of the surgery, and an optimal perioperative management. The enlargement of umbilical access could enable several postoperative advantages such as a fewer painful area, a reduced number of incisions with a potential risk of SSI, and incisional hernia compared to traditional SES options. However, further studies investigating that are needed. In the future, other incisions will not be necessary except the normal trocar site ones.

Preoperative Computer-Assisted Laparoscopy Planning for the Minimally Invasive Surgical Repair of Hiatal Hernia.

Minimal invasive surgical procedures such as laparoscopy are preferred over open surgery due to faster postoperative recovery, less trauma and inflammatory response, and less scarring. Laparoscopic repairs of hiatal hernias require pre-procedure planning to ensure appropriate exposure and positioning of the surgical ports for triangulation, ergonomics, instrument length and operational angles to avoid the fulcrum effect of the long and rigid instruments. We developed a novel surgical planning and navigation software, iMTECH to determine the optimal location of the skin incision and surgical instrument placement depth and angles during laparoscopic surgery. We tested the software on five cases of human hiatal hernia to assess the feasibility of the stereotactic reconstruction of anatomy and surgical planning. A whole-body CT investigation was performed for each patient, and abdominal 3D virtual models were reconstructed from the CT scans. The optical trocar access point was placed on the xipho-umbilical line. The distance on the skin between the insertion point of the optical trocar and the xiphoid process was 159.6, 155.7, 143.1, 158.3, and 149.1 mm, respectively, at a 40° elevation angle. Following the pre-procedure planning, all patients underwent successful surgical laparoscopic procedures. The user feedback was that planning software significantly improved the ergonomics, was easy to use, and particularly useful in obese patients with large hiatal defects where the insertion points could not be placed in the traditional positions. Future studies will assess the benefits of the planning system over the conventional, empirical trocar positioning method in more patients with other surgical challenges.

Jinekolojik Laparoskopik Cerrahi Sırasında Masif Cilt Altı Amfizem

Massive subcutaneous emphysema is a rare complication in laparoscopic surgery. Complications such as insufflation, pneumothorax, pneumomediastinum to the preperitoneal area during pneumoperitoneum have also been reported in laparoscopic surgery. A 32-year-old, Body Mass Index (BMI) 26.2 kg/m2, woman was admitted for laparoscopic cystectomy because of right ovarian cyst. The end-tidal carbon dioxide values of the patient started to increase (end-tidalCO2:49mmHg) 20 minutes after starting CO2 insufflation (P:15mmHg). Subcutaneous emphysema was detected in face and neck, eyelids and PaCO2 was measured 59mmHg. Patient was extubated after positive pressure ventilation. Emphysemia in the face area including the eyelid continued in the 12th hour of the patient's emphysema completely regressed. Prolonged surgery, CO2 gas insufflation pressure ≥15mmHg, 6 or more trocar access, older age may reduce subcutaneous resistance and causes emphysema. In this case, we would like to highlight to massive subcutaneous emphysema in laparoscopic surgeries.

Interventional Radiology Image-Guided Suprapubic Cystostomy Using Trocar versus Seldinger Technique: A Comparative Analysis of Outcomes and Complications

ObjectiveTo compare two techniques—trocar and Seldinger—for performing percutaneous suprapubic cystostomy. Materials And Methods125 patients, mean age 71.8 ± 16.5 years (range, 15-102 years), underwent primary suprapubic cystostomy from January 2013 to December 2018. Trocar access (N = 60) was performed as a single step using a puncture cannula without guidewire access. Seldinger access (N = 65) involved needle puncture, guidewire placement, and serial dilation. A retrospective review of patient records was conducted. ResultsAll procedures were technically successful. Mean catheter size was 13.1 ± 2.0 and 13.9 ± 2.0 French for trocar and Seldinger, respectively (P = .044). Mean procedure time was significantly reduced using trocar technique, 12.4 ± 7.7 versus 25.7 ± 12.1 minutes (P <.001), and was associated with lower anxiolytic dose, 1.2 ± 0.8 versus 1.9 ± 1.1 mg midazolam (P = .003), and less radiation exposure, 20.2 ± 59.5 versus 100.7 ± 98.5 mGy (P <.001). Catheter occlusion was the most common complication (28.8%), followed by UTI (13.6%) and bladder spasm (8.0%). All but 2 complications were classified as Clavien-Dindo grade I or II. Catheter occlusion was more frequent in the trocar group (41.7% vs 16.9%, P = .003), while bladder spasms were more frequent in the Seldinger group (13.8% vs 1.7%, P = .018). ConclusionSuprapubic cystostomy via trocar is associated with faster procedure time, lower anxiolytic dose, and less radiation. While major complications are rare, catheter occlusion is a common occurrence that may be overlooked. Although we detected more occlusions with trocar technique, this may be confounded by a catheter-tract size discrepancy.

Nefrectomia simple laparoscópica robot asistida con extracción de pieza transvaginal. Reporte de caso

Objetivo: Minimizar la morbilidad en la nefrectomía laparoscópica robot asistida con la extracción de la pieza por orificios naturales, asi como estandarizar la técnica quirúrgica laparoscópica robot asistida con extracción de pieza transvaginal a fin de identificar los pasos críticos y posibles complicaciones de este abordaje.&#x0D; Materiales y métodos: Se trata de una paciente femenina de la cuarta década de la vida, multípara, con antecedente de infección de vías urinarias recurrentes, secundaria a hipoplasia renal derecha, documentando la exclusión renal funcional mediante gamagrama renal, se propuso el manejo mediante técnica quirúrgica tradicional, realizando abordaje transperitoneal laparoscópico robot asistido, con el uso de 2 trocares robóticos, un trocar accesorio abdominal y un trocar transvaginal.&#x0D; Resultados: Se utilizaron 2 trocares robóticos, un trocar accesorio en el fondo de saco de Douglas y uno abdominal, con un tiempo operatorio de 45 minutos posterior al acoplamiento robot-paciente, con un sangrado transoperatorio cuantificado en 30 ml. El tiempo de estancia hospitalaria fue de 2 días, con un tiempo promedio de uso de analgésicos de 5 días; en el post operatorio mediato la paciente presentó como complicación la presencia de infección de vías urinarias que ameritó tratamiento mediante antibioticoterapia, sin otras complicaciones.&#x0D; Conclusiones: El abordaje laparoscópico robot asistido con la utilización de orificios naturales para la extracción de la pieza quirúrgica, reduce el costo y la morbilidad trans y post operatoria de las pacientes sometidas a este tipo de abordaje, así mismo reduce el tiempo quirúrgico, el sangrado transoperatorio, la estancia hospitalaria y el uso de analgésicos.

Robotic Control of Heavy Bleeding in Para-Aortic Lymph Node Dissection Without Conversion to Laparotomy - A Video Report

Video Objective Minimal invasive approach for endometrial cancer has gained popularity. However, when facing vessel injury, the control of bleeding is still a challenge without conversion to laparotomy. Robotic 3D vision and endo-wrist function do good for pelvic and para-aortic lymph node dissection. When facing vessel injuries with active bleeding, the robotic arm could also control the bleeder trustworthy and a logic plan to stop bleeding could take action. Setting Here we present a 37-year-old obese lady with endometrial cancer, cT1b. Robotic staging was arranged for the patient. During operation, hysterectomy and pelvic lymph node dissection went smoothly. When we started to approach the para-aortic lymph node, a spurting bleeder from IMA was noted. Due to deteriorated vision drowning by the heavy bleeding and collapsing abdominal wall, we grasped and compressed the bleeder immediately by the robotic arm. The fixed and stable robotic arm could buy more time for a hemostatic plan. Interventions After several initial tries failed, a cardiac vascular surgeon was consulted for help. Dual pneumoperitoneum system was set and one more 10 mm accessory trocar was inserted for the assistant. A 3.0 prolene was used for suturing the peri-bleeder area which could help to elevate the injury site and make the bleeder more clearly. Then a hemoclip was used for clamping the bleeder. Conclusion The blood loss was about 2500 c.c. The patient was sent to intensive care unit after operation and transferred to ordinary ward two days later. She recovered well without sequela. It's important for robotic surgeons to know how to control heavy bleeding with fixed arm and suture without panic before convert to laparotomy.

Mechanical Cavity Creation with Curettage and Vacuum Suction (Q-VAC) in Lytic Vertebral Body Lesions with Posterior Wall Dehiscence and Epidural Mass before Cement Augmentation.

Background and Objectives: We describe a novel technique for percutaneous tumor debulking and cavity creation in patients with extensive lytic lesions of the vertebral body including posterior wall dehiscence prior to vertebral augmentation (VA) procedures. The mechanical cavity is created with a combination of curettage and vacuum suction (Q-VAC). Balloon kyphoplasty and vertebral body stenting are used to treat neoplastic vertebral lesions and might reduce the rate of cement leakage, especially in presence of posterior wall dehiscence. However, these techniques could theoretically lead to increased intravertebral pressure during balloon inflation with possible mobilization of soft tissue tumor through the posterior wall, aggravation of spinal stenosis, and resultant complications. Creation of a void or cavity prior to balloon expansion and/or cement injection would potentially reduce these risks. Materials and Methods: A curette is coaxially inserted in the vertebral body via transpedicular access trocars. The intravertebral neoplastic soft tissue is fragmented by multiple rotational and translational movements. Subsequently, vacuum aspiration is applied via one of two 10 G cannulas that had been introduced directly into the fragmented lesion, while saline is passively flushed via the contralateral cannula, with lavage of the fragmented solid and fluid-necrotic tumor parts. Results: We applied the Q-VAC technique to 35 cases of thoracic and lumbar extreme osteolysis with epidural mass before vertebral body stenting (VBS) cement augmentation. We observed extravertebral cement leakage on postoperative CT in 34% of cases, but with no clinical consequences. No patients experienced periprocedural respiratory problems or new or worsening neurological deficit. Conclusion: The Q-VAC technique, combining mechanical curettage and vacuum suction, is a safe, inexpensive, and reliable method for percutaneous intravertebral tumor debulking and cavitation prior to VA. We propose the Q-VAC technique for cases with extensive neoplastic osteolysis, especially if cortical boundaries of the posterior wall are dehiscent and an epidural soft tissue mass is present.