Trocar Insertion Sites Research Articles

P-313 Additional tubal flushing with ethiodized oil during transvaginal hydrolaparoscopy; feasibility and live birth rate, a pilot study in subfertile women

Abstract Study question Is tubal flushing with ethiodized oil during transvaginal hydrolaparoscopy (THL) feasible and what is the live birth rate within 6 months after THL? Summary answer Additional flushing with ethiodized oil during THL is feasible and safe with a live birth rate of 32.0% compared to 23.4% using solely water-based-contrast (p = 0.25). What is known already The use of ethiodized oil during hysterosalpingography (HSG), an alternative method to test tubal patency, has shown to have a positive effect on the live birth rate, compared to the use of water-based contrast (methylene blue). The benefit of THL over HSG as a tubal testing method is the possibility to also explore tubo-ovarian structures and the pouch of Douglas. Currently, only water-based media are used for tubal flushing during THL. Study design, size, duration A single-center cohort study at Máxima MC, the Netherlands, including 50 subfertile women who underwent THL and in whom there was at least unilateral tubal patency for methylene blue. Outcomes of interest included feasibility, safety and 6- months live birth rate. Our data were compared with a historical cohort of 111 subfertile women who underwent THL using solely water-based contrast (van Kessel MA. et al., 2021). Univariate – and multivariate logistic regression analysis were performed. Participants/materials, setting, methods Women with an iodine allergy and/or manifest thyroid dysfunction were excluded. Participants received additional tubal flushing with ethiodized oil (Lipiodol® Ultra Fluid). Main outcomes were appearance of oil and cell/mucus debris at the tubal fimbriae, pain scores (Visual Analogue Scale, VAS) and acceptability scores (0-10, completely unacceptable-acceptable). Secondary outcomes included; amount of ethiodized oil used, thyroid function four weeks afterwards, adverse events and live birth rate within 6 months after THL. Main results and the role of chance In 48 of the 50 THL procedures there was bilateral patency to methylene blue, ethiodized oil appeared from the tubal fimbriae bilateral in 77% (37/48), unilateral in 17% (8/48), while it did not appear in 6% (3/48). In two procedures there was unilateral patency to methylene blue. Ethiodized oil appeared unilateral in one and did not appear during the other THL. The amount of ethiodized oil used was 5 mL [3.4–6.3). The median reported pain scores on the VAS were 2.9 [IQR 1.0–5.0] after flushing with methylene blue and 3.0 [IQR 1.0–5.0] after ethiodized oil. The acceptability of the procedure was rated as 10 out of 10 [IQR 8–10]. Four weeks after the procedure 14% (6/42) had developed subclinical hypothyroidism, one woman had overt hypothyroidism (FT4 slightly decreased to 11.0 pmol/L, TSH 5.60 mU/L) and one woman had isolated hypothyroxinemia (FT4 11.0 pmol/L, TSH 3.40 mU/L). One adverse event, persistent bleeding at the trocar insertion site was reported, for which a diagnostic laparoscopy was performed. The live birth rate within 6 months after a THL was 32% (16/50), compared to 23% (26/111) in our historical cohort using solely water-based contrast (OR = 1.54, 95% CI 0.74–3.22, P = 0.25). Limitations, reasons for caution As this is a pilot study without a power analysis, the study is presumably underpowered to show an effect on the live birth rate. Also, the control group was historical. Wider implications of the findings By proving feasibility of using ethiodized oil during THL we encourage further research on its effect on pregnancy rates. Furthermore, the direct observation of tubal flushing with ethiodized oil during THL enables further investigation of the contrast characteristics, which are presumably responsible for its positive effect on live birth rate. Trial registration number NL8696

Insights Into Laparoscopic Port Site Complications: A Comprehensive Review.

Laparoscopic surgery has become a widely accepted standard of care for numerous procedures in the modern world. Nearly every major surgical procedure previously only possible by employing open techniques may now be completed laparoscopically, attributable to the quick advancement of technology and surgeons' abilities. There are several complications associated with the laparoscopic port site, either infective, non-infective, or neoplastic. This study aims to explore the morbidity associated with the port site following laparoscopic surgery and discuss the risk factors for complications. The umbilical port was most frequently associated with port-site hernia (PSH), followed by the epigastrium and the left and right hypochondrium. Prolonged port manipulation and reinsertion, longer surgical times, failure to effectively close the fascial defect, and wound infection are responsible for the development of PSH. Port-site infection (PSI) is one avoidable adverse effect of laparoscopic surgery. Patients who have a history of diabetes, malnourishment, prolonged preoperative hospital stays, preoperative Staphylococcus aureus colonization of the nares, perioperative blood transfusions, and tobacco or steroid use are more likely to have PSI. Port-site hydatid cyst (PSHC) and port-site tuberculosis (PST) are rare but possible. While uncommon, a doctor should rule out endometriosis if a painful mass in the surgical scar, such as the trocar site, is discovered in a reproductive-age woman who has had pelvic or obstetric surgery in the past. Port-site metastasis (PSM) is the term for tumor-cell implantation at the trocar insertion site after a malignant tumor is removed laparoscopically. PSM has been reported in 1-2% of laparoscopic gynecologic surgical procedures. A few potential mechanisms for cell implantation at the port site include embolization of exfoliated cells during tumor dissection or hematogenous spread, air turbulence during long laparoscopic operations, and direct implantation onto the wound during forced, unprotected organ/tissue retrieval or from contaminated surgical instruments during tumor dissection. Nonetheless, the triggering mechanism is likely essentially multifaceted.Prevention is better than cure. Port-site hernia can be prevented using smaller trocars and meticulous rectus sheath defect closure at the end of surgery. The rest of the port site complications can be prevented by employing autoclavable laparoscopic hand instruments, utilizing autoclaved water to clean the instruments following disassembly, adhering to the recommended concentration, contact duration, and usage cycles when sterilizing instruments with liquid sterilizers, preventing bile or gut content from spilling into the operating room or the port site, using non-porous specimen retrieval bags for recovering the specimen, and thoroughly cleaning and irrigating the port site before closing the wound.

Long-term outcome of retroperitoneoscopic one-trocar-assisted pyeloplasty: a single-center and single-surgeon experience.

The aim of this study was to assess the long-term outcomes of retroperitoneoscopic one-trocar-assisted pyeloplasty (OTAP) for ureteropelvic junction obstruction (UPJO) in children. This retrospective analysis included 70 pediatric cases, all under the age of 5, diagnosed with UPJO and treated with the OTAP technique between May 2011 and June 2013 by a single surgeon. A single 10mm operative scope with a 5mm working channel was utilized to mobilize the ureteropelvic junction (UPJ) and exteriorize it through the trocar insertion site. Subsequently, conventional Anderson-Hynes dismembered pyeloplasty was conducted extracorporeally. Patient's demographics, operative time, hospital stay, complications, and success rate were evaluated. Seventy pediatric patients (65 males and 5 females) underwent OTAP, with ages at the time of operation ranging from 1month to 5years (mean = 22.6 ± 18.6months). The mean operative time was 74.8 ± 15.2min. There was a significant reduction in the mean renal pelvis size from 34.3 ± 8.1mm preoperatively to 13.8 ± 4.7mm postoperatively (p < 0.05). Moreover, the mean differential renal function (DRF) increased from 47.9 ± 9.8% preoperatively to 51.2 ± 5.9% postoperatively (p < 0.05). All patients experienced an uneventful postoperative recovery, with a median hospital stay of 3.4days. The success rate was 95.7%, with a median follow-up time of 75months (range: 6-125months). OTAP is a safe and feasible minimally invasive technique to correct ureteropelvic junction obstruction in children. It could be considered as a treatment of choice for children under the age of 5 as it combines the advantages of open and retroperitoneoscopic pyeloplasty and presents excellent long-term outcomes. NCT06349161 April 4th, 2024, retrospectively registered.

Bupivacaine Local Infiltration at Trocar Insertion Sites after Gynecologic Laparoscopic Surgery: A Randomized, Double-blind, Placebo-Controlled Trial

Objective: To compare local infiltration of bupivacaine with placebo for reducing pain at trocar insertion sites after gynecologic laparoscopic surgery (GLS). Materials and Methods: A prospective, randomized, double-blind, placebo-controlled trial was conducted on women who underwent GLS at Buddhachinaraj Phitsanulok Hospital, Thailand between September 2021 and March 2022. Eighty subjects were included for this trial. Bupivacaine 0.5% 10-mL was infiltrated at each port site after removing the trocars compared with placebo. Pain intensity was evaluated by visual analog scale (VAS) for four pain points including abdominal parietal pain (APP), abdominal visceral pain (AVP), and right and left shoulder pain at 2, 4, 8, 12, and 24 hours postoperatively. Results: There were no significant differences in baseline characteristics between the two groups except for parity. APP and AVP had no significant difference in postoperative pain (mean difference –0.23, 95% CI –0.58 to 0.10, p=0.169 and –0.35, 95% CI -0.72 to 0.02, p=0.063, respectively). Only mild pain, with a VAS of 0 to 2, on both sides of shoulder were found in most participants, which had no significant difference between the two groups. Opioid consumption and adverse events were also not a significant difference. Multivariate analysis showed the APP had no significant difference between the two groups after adjusting confounding factors. However, gynecologic cancer and increased age were the significant factors associated with postoperative pain (mean difference 0.60, 95% CI 0.12 to 1.08, p=0.014 and –0.02, 95% CI –0.04 to –0.01, p=0.010, respectively). Conclusion: Locally infiltrated bupivacaine at trocar insertion sites after GLS did not significantly improve postoperative analgesia. Keywords: Gynecologic laparoscopic surgery; Postoperative analgesia; Bupivacaine

Robotic-assisted approaches to urachal carcinoma: A comprehensive systematic review of the safety and efficacy outcomes.

Surgical intervention is the treatment of choice in patients with urachal carcinoma. Due to complications and to reduce hospital stay from open surgery, minimally invasive approaches are desirable. Nowadays, robotic-assisted surgery has become increasingly popular, and robot-assisted cystectomy can be performed in patients with urachal carcinoma with low complication rates. We performed a systematic review to search for studies that evaluated patients who underwent robotic-assisted surgery for urachal carcinoma. The outcomes of interest were the type of cystectomy performed, whether there was umbilicus resection, total operative time, console time, intraoperative complications, estimated blood loss, postoperative complications, time of hospitalisation, positive surgical margins and the presence of documented tumour recurrence. In this study, we evaluated three cohorts comprising a total of 21 patients. The median follow-up period ranged from 8 to 40 months. Medium age was between 51 and 54 years, with a majority (63.1%) being male. One patient (5.2%) underwent a radical cystectomy, and 19 patients (94.7%) underwent to partial cystectomy. Umbilical resections were performed in all cases, and pelvic lymphadenectomy in 14 cases (73.6%). Recurrence occurred in three patients at a median of 17 months postoperation, two cases in the trocar insertion site. Additionally, there was one death, which was attributed to postoperative cardiovascular complications. Robotic-assisted partial cystectomy has a low incidence of adverse outcomes in patients with urachal carcinoma. Controlled studies, ideally randomised, are warranted to establish the comparative efficacy and safety of the robotic-assisted cystectomy approach relative to open surgery.

Patent umbilical artery in medial umbilical fold: Cadaveric study and clinical implications

Minimally invasive surgery has become one of the most accepted surgical options across the globe. In most laparoscopic surgeries, medial umbilical fold (MUF) containing the umbilical artery (UA) serves as an important landmark for creation of peritoneal flap. 50% of gynaecological laparoscopic injuries occur at the time of entry into the anterior abdominal wall, as it involves blind insertion of the trochar or veress needle in the peritoneal cavity. Any variation in the structures of the anterior abdominal wall may affect the placement location of the trocar, which is a crucial aspect to ease the surgeon’s ability to manoeuvre the abdominal cavity. The presence of cords and/or dense ligamentous structures in the anterior abdominal wall may complicate trocar insertion and restrict the probe movement during laparoscopic procedures. Hence, the aim of the present study was to classify and observe the variations in the MUF in the anterior abdominal wall.The cadavers in the study were formalin fixed through femoral artery perfusion method. Out of the 35 (23 males; 12 female) cadavers (70 MUF), studied, 34 cadavers (69 MUF) followed the pattern of the existing classification proposed by Tokar and Yucel, (2009). However, the right MUF of one male cadaver presented, patent umbilical artery (PUA) associated with a long mesentery. Based on safe presentations for laparoscopic exploration, MUF was given grades. Grades 0 and 1 were categorised as safe as compared to grade 2 and the novel variant observed, based on the morphology of MUF. No significant difference was noted in the occurrence of safe presentations of MUF amongst males and females.MUF with a patent vessel and a mesentery may cause technical difficulties to the surgeon by decreasing the laparoscopic port work space and obscuring the view of lateral pelvic wall during surgeries. Furthermore, persistent UA can compress the ureter and vas deferens resulting in myriad of symptoms ranging from unexplainable flank pain, hydronephrosis to male infertility. Awareness of such variants is of relevance to urologists in determining the cause of these unexplained symptoms and to surgeons in determining the site of safe trocar insertion. The findings also, highlight the fact that anterior abdominal wall anatomy is not mirror image on both the sides.

Comparison of Abdominal Initial Entry Techniques in Gynecological Laparoscopy

Objective: The aim of this study is to assess the safety of laparoscopic entry techniques.&#x0D; Materials and Methods: Within the scope of the study, medical records of patients who underwent laparoscopy due to various gynecological indications at our clinic between January 1, 2011, and July 1, 2015, were examined. Evaluation was conducted using our hospital’s electronic database.&#x0D; Results: In the patient cohort, direct trocar placement was preferred in 91.8% (1025 patients), Veress needle placement was used in 7.4% (82 patients), and an open technique was used in 0.8% (9 patients). In terms of entry sites, umbilicus was the most commonly chosen option, being preferred in 97.2% (1085 patients) of cases. In 2.4% of patients (27 patients), the midline abdominal trocar was preferred as the initial trocar insertion site. Among these patients, suprapubic incision was preferred in 62% (17 patients), while Lee-Huang point was chosen as the entry site in 38% (10 patients).Looking at the history of previous surgeries, 18.5% (206 patients) had a history of prior abdominal surgery, and 3.5% (39 patients) had undergone two previous surgical procedures. Only 0.1% (1 patient) had undergone three or more abdominal surgeries.&#x0D; Discussion: In conclusion, no clear superiority of one initial entry technique over another has been proven. Despite the extensive literature on laparoscopic entry, debates regarding the most effective method to prevent significant complications continue.

7737 Assessment of Interoperative Transverse Abdominis Plane (TAP) Block in Minimally Invasive Gynecologic Surgery

<h3>Study Objective</h3> To assess whether an inter-operative transverse abdominis plane (TAP) block to provide analgesia is more effective than local anesthetic injection into trocar insertion sites during robotic gynecologic surgery. <h3>Design</h3> Retrospective chart review of patients undergoing robotic surgery (myomectomy, hysterectomy, and removal of endometriosis) with one surgeon between January and July 2021. <h3>Setting</h3> Academic hospital OR. <h3>Patients or Participants</h3> 109 patients underwent robotic surgery with median age (interquartile range, IQR) of 39 years (11.8) for the following indications: endometriosis (45.9%), fibroid uterus (50.5%), and other (3.6%). <h3>Interventions</h3> Patients undergoing robotic surgery received local injection of anesthetic into trocar insertion sites (control group) or a TAP block. <h3>Measurements and Main Results</h3> Of 109 patients, 54 (49.5%) were in the control and 55 (50.5%) were in the TAP block group. No significant differences in age, BMI, diagnosis, chronic pain status or ASA classification were found between groups. Incision time and length of PACU stay were not statistically different between groups (Table 1). In terms of pain management, the first and maximum pain scores in the PACU were the same in both groups. However, the median (IQR) morphine milligram equivalents used in the PACU for the TAP block group was 17.0 (11.5) compared with 12.5 (8.9) in the control group (p=0.04). <h3>Conclusion</h3> Our analysis demonstrates that performing TAP block in robotic gynecologic surgery cases did not significantly lengthen surgery time or affect patient reported pain scores, however it was associated with greater use of pain medication in the acute postoperative setting.

8842 Optimizing Trocar Placement in Gynecologic Surgery for the Obese Patient: A Systematic Review and Meta-Analysis

<h3>Study Objective</h3> Obesity, as defined as a BMI of greater than 30 kg/m2, has been associated with increased surgical risk and increased technical difficulty. Many studies have evaluated ways of combating these challenges, including patient positioning and abdominal entry, however little has been reported in regard to ancillary trocar insertion site and techniques. This systematic review and meta-analysis aim to answer the question, what is the optimal trocar placement in the obese patient? <h3>Design</h3> A systematic review will be conducted using the following databases: Embase, Cochrane, Medline and Pubmed. <h3>Setting</h3> Clinical trials, randomized control trials, retrospective cohort studies and systematic reviews will be analyzed. <h3>Patients or Participants</h3> Women who have undergone laparoscopic surgery with a BMI of 30 kg/m2 or greater. <h3>Interventions</h3> Outcomes following laparoscopic gynecologic surgery related to trocar placement in the obese patient will be evaluated. <h3>Measurements and Main Results</h3> Statistical analysis will be performed using comprehensive meta-analysis software. Outcomes to be compared and evaluated will include successful surgery, complications such as vascular or bowel injury, unsuccessful trocar placement, conversion to open, wound infection, and operative time. Complete review and meta-analysis to be completed by August 2022. <h3>Conclusion</h3> Laparoscopic surgery in the obese patient has been known to have increased surgical risks and technical challenges. By determining the optimal trocar placement in the obese patient, we can improve surgical ergonomics, as well as the laparoscopic safety profile for this population.

Utilizing the chest tube insertion site as the site of initial trocar insertion with an optical-access trocar in video-assisted thoracoscopic surgery for spontaneous pneumothorax.

BackgroundIn video-assisted thoracoscopic surgery for spontaneous pneumothorax, the initial trocar can be inserted into the pleurocutaneous fistula formed during preoperative chest drain placement. The use of an optical-access trocar to replace the initial trocar and chest tube may have a greater success rate than blind trocar insertion. Therefore, the present study aimed to evaluate the safety and feasibility of the use of an optical-access trocar to replace the initial trocar and chest tube during surgery for spontaneous pneumothorax.MethodsThe present study included 28 patients who underwent video-assisted thoracoscopic surgery for spontaneous pneumothorax following preoperative chest drain placement between April, 2017 and December, 2019. At the start of surgery, the chest drain was removed and the initial trocar was inserted into the pleural cavity. An optical-access trocar with an inner diameter of 5 mm was used as the initial trocar. To use a 0-degree endoscope for the optical-access trocar, this procedure requires the preparation of both, a 0-degree endoscope and a 30-degree endoscope. To evaluate the safety of the optical view method, the lungs and chest wall adjacent to the initial trocar insertion site were observed from the second trocar.ResultsThe initial trocar could be inserted through the chest tube insertion site in 26 out of 28 cases (92.9%). No instances of lung injury or pulsatile bleeding around the initial trocar were observed. No cases of postoperative wound infection or wound dehiscence were observed.ConclusionsThe use an optical-access trocar as the initial trocar when replacing a preoperatively placed chest tube is safe and feasible during video-assisted thoracoscopic surgery for spontaneous pneumothorax.

Comparative evaluation of intraperitoneal instillation of 0.25% ropivacine alone or with dexmedetomidine for postoperative analgesia following laparoscopic cholecystectomy

Intraperitoneal instillation of local anesthetic agent with or without adjuvant in laparoscopic surgeries is a common practice now a days. This study aimed to assess the efficacy and safety of addition of dexmedetomidine (1µg/kg) to 0.25% ropivacaine by intraperitoneal instillation for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. This prospective, randomized, double blind study was conducted on 80 patients of American society of Anaesthesiologists (ASA) grade I and II, either sex, aged 18 to 60 years enrolled for laparoscopic cholecystectomy to receive either Ropivacaine (0.25%) 30ml + 5 ml Normal saline (NS) in group R (n=40) or Ropivacaine (0.25%) 30ml + Dexmedetomidine (1µg/kg) + 5ml with NS in group RD (n=40) by intraperitoneal instillation, before removing trocar. All patients received infiltration of 20mL of (0.25%) ropivacaine at trocar insertion site, being 6 ml in umbilical incision, 6 ml in epigastric incision and 4 ml in both working portals after gall bladder removal. Duration of analgesia using Visual analog scale (VAS) score, total amount of rescue analgesic in 24 hrs, hemodynamic parameters, and any adverse effects were monitored. Student t test was used to analyze the metric parameters and chi square test was used to compare the categorical variables.

The Effect of Intraoperative Transversus Abdominis Plane Blocking on Postoperative Pain After Laparoscopic Transabdominal Pre-peritoneal (TAPP) Groin Hernia Repair.

BackgroundManaging postoperative pain even after laparoscopic groin hernia repair still remains an interesting challenge for clinicians especially for patients of high risk. Plenty of operative techniques and analgesic methods have been proposed in order to minimize postoperative pain after laparoscopic groin hernia repair. The aim of the present study is to compare transverse abdominis plane (TAP)-block with local analgesic infiltration at trocar entry sites in the terms of reducing postoperative pain.MethodsPatients that underwent laparoscopic trans-abdominal pre-peritoneal (TAPP) groin hernia repair in a high-volume university hospital were included. Patients were divided in two groups depending on the analgesic method used. Pain was assessed using Visual Numerical Scale (VNS) score.ResultsThirty patients were included. Intraoperative TAP-block seemed to be superior in terms of decreasing pain at the hernia area and at the trocar insertion site (p < 0.05) compared to local analgesic infiltration at the trocar insertion site at 6, 12 and 24 h after surgery (p < 0.05). In addition, pain reduction was more effective in rest rather than in motion for both analgesic methods.ConclusionIntraoperative TAP-block under direct vision seems to be an effective, fast and easy technique in order to reduce postoperative pain after laparoscopic groin hernia repair, but more studies are required to validate these results in a prospective and randomized context.

Postoperative Analgesia after Laparoscopic Cholecystectomy - Prospective, Randomized, Double Blind, Control Trial

In this prospective, randomized, double blind control trial we aim to investigate which of the most used analgesic techniques after laparoscopic cholecystectomy is the most efficient. Methods: This study included 81 patients that were randomly distributed into 3 groups using a computer-generated random number which was enclosed in a sealed envelope: group A (control) received classic multimodal iv opioid analgesia, group B received Tap block in oblique subcostal approach (OSTAP) and group C received local anesthetic infiltration of the trocar insertion sites (LAI). The primary outcome of this trial was to evaluate the efficacy of each analgetic technique by measuring VAS pain scores. Secondary outcome included intraoperative opioid requirement and the opioid consumption in the first 24h postoperatively. Intraoperative parameters and outcome data were recorded by an anesthesiologist who was blinded to the study groups. Results: We analyzed a total of 75 patients. For the primary outcome variable, VAS pain scores at rest were significantly reduced in OSTAP group at each time point assessed in the first 24 hours after surgery compared with LAI group and IV opioid analgesia group (p 0.001). Intraoperative fentanyl consumption and 24h pethidine consumption were also significantly reduced in TAP block group compared with LAI group and IV opioid analgesia group (p 0.001). Conclusions: Our study showed that OSTAP block is a more efficient analgesia technique compared with IV opioid analgesia and with local anesthetic infiltration of trocar sites after laparoscopic cholecystectomy surgery. This trial was registered at www.clinicaltrials.gov (NCT02707250).

Prevention of transoral thyroidectomy complications: An analysis of surgical outcomes in 423 consecutive series

BackgroundAlthough there are several publications on the new transoral robotic thyroidectomy technique, few have thoroughly reviewed its associated complications. This study analyzed the causes and prevention of transoral robotic thyroidectomy–specific complications and presented preventive measures. MethodsThe medical records of patients who underwent transoral robotic thyroidectomy performed by a single surgeon between March 1, 2009 and April 30, 2019 were retrospectively analyzed. Patient demographic, clinical, and operative data were analyzed using descriptive statistics. We describe the transoral robotic thyroidectomy–related complications experienced at our institution and how to overcome them. ResultsThis study included a total of 423 patients who underwent transoral robotic thyroidectomy. The general surgical complications included immediate postoperative bleeding (2 cases) and delayed hematoma (3 cases). Chyle leakage and localized wound infection were found in 1 case each. Transient vocal cord palsy occurred in 4 cases, and 1 case developed transient hypoparathyroidism. The transoral robotic thyroidectomy–specific complications included zygoma bruise (2 cases), flap bruise (3 cases), chin flap perforation (2 cases), and oral commissure tearing (2 cases). The complications occurring when creating the flap included flap burns (4 cases), skin dimpling in the midline of the lower chin (2 cases), and hematomas in the intraoral trocar insertion sites (3 cases). ConclusionSurgeons familiar with thyroid surgery and experienced in robotic surgery can perform transoral robotic thyroidectomy without causing more complications than those seen with traditional surgery.

A Stepwise Approach to the Surgical Management of Hemorrhagic Choroidal Detachments.

This work describes a stepwise surgical approach to draining choroidal detachments and 2 cases for which this approach was used. The first step involves insertion of an anterior chamber maintainer and a nonvalved 23- or 25-gauge trocar cannula at the highest peak of hemorrhagic choroidal detachment (as determined using B-scan ultrasonography), 6 to 8 mm from and angled 20° to 30° toward the limbus. The second step involves removal of the trocar to expose the sclerotomy. Alternatively, the second step can be insertion of a second trocar. The third step involves the creation of a small focal peritomy around the preexisting sclerotomy and enlargement of the preexisting sclerotomy into a radial sclerotomy. Progression between steps only occurs if prior steps did not provide adequate drainage. Two cases of appositional hemorrhagic choroidal detachments in hypotonic eyes were successfully resolved by this stepwise approach. In case 1, a choroidal detachment developed after a corneal ulcer perforation. The hemorrhagic choroidal detachment in case 1 was resolved with steps 1 and 2, and an unnecessary scleral cutdown was avoided. In case 2, a choroidal detachment developed after a trabeculectomy. The detachment in case 2 required progression to step 3, extension of the trocar insertion site into a radial sclerotomy. This stepwise approach should be considered to reduce excessive manipulation of the globe and conjunctiva in hemorrhagic and serous choroidal detachments that warrant surgical intervention.

Port site implantation of clear cell carcinoma after laparoscopic ovarian cystectomy

Despite the fact that laparoscopic surgery has clearly shown benefits in patients with benign ovarian tumor, concerns remain regarding port site metastasis especially when final pathology reveals malignancy. Port site metastasis has been reported in early stages of malignant diseases. However, to our knowledge, there are no reports of port site implantation of malignant cells after laparoscopic surgery for benign disease. We present a 39-year-old woman who had undergone laparoscopic ovarian cystectomy for benign disease, and developed clear cell carcinoma at the site of trocar insertion 11 months after the initial operation. It is possible that the cancer was missed at the time of the initial surgery. Numerous factors have been suggested in the development of port site metastasis including aerosolization of tumor cells, lack of local immune response by the host and unskilled surgical techniques. A careful preoperative evaluation and meticulous laparoscopic maneuvers are the best way to prevent such occurrence.

Çocuklarda Tek Kesi Laparoskopik ve Açık Yaklaşım Gastrostomi Yöntemlerinin Karşılaştırılması

Aim: The aim of this study was to compare single incision laparoscopic gastrostomy (SILG) with open surgery in children.&#x0D; Material and Methods: Children who underwent laparoscopic and open gastrostomy surgeries between January 2016 and March 2020 were retrospectively evaluated. The data were arranged according to the patient's demographics, duration of surgery and anesthesia, time to start enteral feeding, and complications. For Stamm procedure, the abdomen was explored with an upper midline incision and a gastric tube was passed through a second incision. In the SILG method, only one incision was made. After inserting a camera was placed into a trocar, then a grasper was placed just next to the trocar. A part of stomach was removed through the incision. A foley catheter was placed visually into the lumen.&#x0D; Results: There was no statistically significant difference between operation times for both surgical groups (p=0.844); the same was true for anesthesia times (p=0.919). The time taken to initiate and reach full enteral nutrition differed significantly between two groups (p=0.005). In general, when all complications were evaluated, more complications were found in the open surgery group (p=0.077). A remarkable number of maintenance problems (65.6%) were observed in both groups.&#x0D; Conclusion: SILG is a technique that is not technically demanding and can be performed by any pediatric surgeon with experience in laparoscopy. Primary laparoscopic gastrostomy at the trocar insertion site can be performed easily and safely in all children with malnutrition due to low postoperative complication rates and applicable for all ages of children.

Characteristics of Trocar Site Hernia after Laparoscopic Cholecystectomy

Trocar site hernia (TSH) is an incisional hernia occurring at the trocar insertion sites after different types of laparoscopic surgeries. The aim of this study is to present characteristics of patient and surgery series with trocar site hernia after laparoscopic cholecystectomy. A 2930 consecutive patients underwent laparoscopic cholecystectomy in two major university- affiliated hospitals from April 2014 to March 2018 and the patient followed up for variable periods of time. Retrospective medical chart review to study trocar site hernia including patient, operation, instruments, and pathologic characteristics described. Six patients had trocar site hernia (incidence 0.20%), the hernias occurred mostly at the umbilical port site after using 10 mm trocar. Risk factors included mainly obesity, female gender and use of 10 mm trocars at midline sites. TSH is more described. It occurs mostly at the umbilical port site. Major risk factors include obesity, diabetes mellitus, lengthy procedure, extension of entry site, and wound infection. Closure of fascial defect is supposed to reduce the incidence despite weak evidence.

Risk of port site hernia after laparoscopic sleeve gastrectomy

Aim: Recently, one of the most preferred options in the surgical treatment of obesity is laparoscopic sleeve gastrectomy The purpose of this study is to investigate the incidence of port site hernia formation and the factors affecting the fascia defect in the group with and without closure after LSG.Material and Methods: The data of patients who were operated due to morbid obesity in a single center between March 2014 and June 2018 was reviewed and analyzed retrospectively. The patients were divided into two groups, being those in whom the fascial defect at the 12-mm trocar insertion site from which the gastric remnant was removed during surgery was closed, and those in whom the fascial defect was not closed. The incidence of port site hernia and the factors affecting the development of port site hernia were evaluated with physical and ultrasound examinations 1year after surgery.Results: The study was completed with a total of 207 patients, of which 112 fascias was not closed and 95 fascia was closed. The rate of hernia formation was significantly lower in the fascial closure group than in the non-fascial closure group (p:0,036). Aside from this parameter, no significant difference was identified in the other parameters of the two groups. Age was significantly higher in patients that developed hernias following surgery than in those who did not develop hernias.Conclusion: This study determined that the closure of the fascial defect is a protective factor against the development of port site hernia when compared to non-fascial closure.

New insights in the use of pleural ultrasonography for diagnosis and treatment of pleural disease.

The use of transthoracic ultrasound (US) has acquired a wide consensus among respiratory physicians during the last few years. The development of portable devices promotes patient's bedside evaluation providing rapid, real-time and low-cost diagnostic information. The different acoustic impedance between different tissues and organs produces artifacts known as A lines, B lines, sliding sign, lung point, etc. The identification of such artifacts is essential to discriminate normal pleural appearance from the presence of pleural effusion, pneumothorax, thickenings and tumors. Ultrasounds are also a valuable tool during interventional procedures, such as thoracentesis, chest tube insertion and transcutaneous biopsy. Its use is recommended before medical thoracoscopy in order to assess the best site of trocar insertion according to presence, quantity and characteristics of pleural effusion. The aim of this review is to provide practical tips on chest ultrasound in clinical and interventional respiratory practice.