Umbilical Wound Research Articles

Single-Incision Laparoscopic Surgery in Diagnosis and Treatment for Gastrointestinal Bleeding of Obscure Origin in Children

In this multimedia manuscript with video presentation, we reported our experience of performing single-incision laparoscopic surgery (SILS) on 3 children who presented with gastrointestinal bleeding from congenital small bowel lesions. Preoperative investigations including endoscopy and technetium scintigraphy were all negative in the 3 patients aged 4, 7, and 10 years, respectively. SILS was performed using reusable 3- and 5-mm ports and standard straight instruments. The small bowel lesions were located by SILS and the bowel segment with the pathology was exteriorized through the umbilical wound for extracorporeal resection. The diagnoses of the 3 children were Meckel's diverticulum, ileal duplication cyst, and multiple small bowel vascular malformations. All the 3 children recovered uneventfully from surgery without any complications and required minimal postoperative analgesia. Our experience suggested that SILS is an effective alternative to conventional laparoscopy in both diagnostic and therapeutic functions for children with gastrointestinal bleeding of obscure origin.

Laparoscopic Hemicolectomy in Ascending Colon Cancer with Situs Inversus Totalis

Introduction: Situs inversus totalis (SIT), occurring at a frequency of 1:5000–1:10,000 live births,1 is characterized by a complete right-to-left transposition of the thoracic and abdominal organs. Only five cases of laparoscopic colon surgery in an SIT patient have been reported. The present case describes a laparoscopic hemicolectomy necessitated by ascending colon cancer in a patient with SIT. Patient and Methods: A 54-year-old woman with ascending colon cancer was referred to our hospital. Preoperative chest radiography showed dextrocardia, and computed tomography showed complete transposition of the abdominal viscera, confirming a diagnosis of SIT. The patient, free of distant metastasis, underwent laparoscopic right hemicolectomy and radical lymphadenectomy, performed by a surgeon experienced in laparoscopic colectomies. After inducing general anesthesia, the patient was placed in a modified lithotomy position, with the operator and scopist situated on the patient's right and the first assistant on the patient's left, similar to the positioning used in laparoscopic anterior resections. A 10-mm umbilicus trocar was inserted for the camera, and 5-mm trocars were placed in the right and left iliac fossa and subcostal areas, as working ports. Trocars were inserted symmetrically, we usually use this trocar system in Rt. hemicolectomy. The ascending colon, located on left side of patient, was mobilized along with the tumor, and the ileocolic vessels and right colic artery were identified and ligated. Radical lymphadenectomy was performed after ligation of the root of the middle colic artery and the right branch of middle colic artery. The umbilical wound was extended by ∼5 cm to allow for extracorporeal anastomosis and removal of the tumor; colon reconstruction was performed using a double-stapling technique. Results and Conclusions: The operation time was 120 minutes, with minimal blood loss. The resected tumor was a 1.5×1.2-cm Bormann type II moderately differentiated adenocarcinoma. The depth of the tumor's invasion into the submucosa was classified as pT1; no lymph node metastasis or angiolymphatic invasion was observed. The patient, discharged 7 days after surgery, did not receive postoperative adjuvant chemotherapy, and was free of complications and evidence of recurrence at her 2-year follow-up examination. Previous reports on cases of laparoscopic surgery in SIT patients1–3,11–14 have described the technical difficulties associated with the abnormal anatomy. In the present case, the surgical team needed to understand the modified vessel anatomy and orientation to avoid confusing the right colic artery with the ileocolic artery. Meticulous preoperative planning, including the selection of proper locations for the trocars, positioning of surgical personnel, and selection of a well-experienced surgeon, was essential for the successful outcome. The authors did not receive any grant or financial support to perform this study. Runtime of video: 7 mins 13 secs

A Simple Postoperative Umbilical Negative-Pressure Dressing

Application of umbilical wound dressings is challenging because of the shape and depth of the navel. Dressing changes and umbilical wound cleaning as practiced by many surgeons are painful procedures. The authors describe a simple and durable postoperative umbilical vacuum dressing, providing the advantages of topical negative-pressure wound therapy.

Single-Incision plus One Port Laparoscopic Anterior Resection for Rectal Cancer as a Reduced Port Surgery

Only limited data in the literature about single-incision laparoscopic rectal surgery, because the laparoscopic stapler does not allow low rectal transection without sufficient distal margins from the umbilicus port. We have developed single-incision plus one port laparoscopic anterior resection of the rectum (SILS+1-AR) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. A Lap protector (LP) mini was inserted through a 2.5 cm transumbilical incision, and an EZ-access was mounted to LP and three 5-mm ports were placed in EZ-access. A 12 mm port was inserted in right lower quadrant. Almost all the procedures were performed with usual laparoscopic instruments, and the operative procedures were much the same as in usual laparoscopic low anterior resection of the rectum using a flexible 5mm scope. The rectum was transected normally using only one endoscopic linear stapler inserted from the right lower quadrant port. We underwent modified SILS+1-AR in 16 patients with advanced rectal cancer. In all cases, there was no need to extend the skin incision. We transected the lower rectum with one laparoscopic stapler in all six cases. Postoperative follow-up did not reveal any umbilical wound complications or recurrences. The safety and feasibility of SILS+1-AR for advanced rectal cancer was established in this study. However, further studies are needed to prove the advantages of this procedure to conventional laparoscopic law anterior resection.

Treatment of super obesity by laparoscopic Roux-en-Y gastric bypass: experience of 42 cases

To investigate the feasibility and efficacy of laparoscopic Roux-en-Y gastric bypass(LRYGB) for super obesity(BMI≥50 kg/m(2)). Clinical data of 42 patients undergoing LRYGB in the First Affiliated Hospital of Jinan University between 2004 and 2008 were analyzed retrospectively. All the LRYGB procedures were successfully performed with no conversion to open surgery. Average operation time was 145.1 minutes, volume of blood loss during the surgery was 25.0 ml, and length of postoperative hospital stay was 9.9 days. The cases were followed up for 1 month to 30 months. Body weight and BMI decreased significantly 1 month after the operation and reached a minimum level after 2 years then became stable while excess body weight loss rate(EWL) increased(P<0.05). All the obese-related symptoms were relieved significantly. Four cases(9.5%) showed complications during perioperative period including 1 case of respiratory failure, 2 cases of gastrojejunal anastomotic bleeding, 1 case of umbilical wound infection, and 11 developed long-term complications. All of them were cured by conservative treatment. Treatment of super obesity by LRYGB is feasible with significant short-term results. But due to the difficulty of the operation and postoperative complications, comprehensive treatment from experienced bariatric surgical team is needed. The long-term outcome needs for further observation.

Single‐incision laparoscopic distal pancreatectomy with or without splenic preservation: How we do it

Recent interest in improving cosmetic outcomes has led to single-incision laparoscopic surgery (SILS) being performed in a variety of organs. However, this innovative technique has rarely been introduced in pancreatic surgery, as it is considered to be a challenging procedure. We report herein our technique of single-incision laparoscopic distal pancreatectomy with or without splenic preservation. A 2.5-cm intraumbilical mini-laparotomy was made for the placement of a SILS Port as a single access site. The overall procedures were similar to those performed in the standard laparoscopic distal pancreatectomy with multiple trocars. To obtain better exposure of the operative field, we made technical refinements by employing gastric suspension with sutures, the tug-exposure technique, a balloon retractor, and gravity by changing the patient's position. The pancreas was transected with a linear stapler, and the specimen was extracted through the umbilical wound. Patients were discharged without any complications. The umbilical wounds were almost invisible 1 month after surgery. We believe that SILS, with some technical refinements, can be safely applied for distal pancreatectomy. Although the cosmetic benefits of single-incision laparoscopic distal pancreatectomy are obvious, several issues such as the extent of invasiveness, cost, indications, and learning curve need to be investigated.

Laparoscopic repair of perforated peptic ulcer: A prospective study

Background: Perforated peptic ulcer is a common surgical emergency. Its classic treatment is the mid-line laparotomy. However, laparoscopic treatment has been shown to be reliable. Few studies have evaluated its overall utility. The aim of this study is to assess the efficacy of laparoscopy in perforated peptic ulcer repair. Patients and methods: The study included 18 patients presented by perforated peptic ulcer between July 2009 and December 2011. They were submitted to laparoscopic omental patch repair with thorough peritoneal wash. Patients' demographics, diagnostic techniques, management, and outcome were evaluated. Results: The mean age was 35.6 years. Male to female ratio was 14:4. The mean duration of symptoms was 18 hours. The perforation was diagnosed by plain X-ray of the abdomen in erect position in 15 patients and by abdominal CT scan in 3 patients.The laparoscopic repair of the perforation was successful in 16 patients while in 2 patients mid-line laparotomy was needed for proper control of the severe intra-abdominal sepsis. The mean operative time was 90 minutes. Post-operatively, the VAS score ranged between 3 and 6 with a mean of 3.5 in the first post-operative day. Narcotics were needed for a mean of 1.5 days. All the patients tolerated soft diet on the 3rd post-operative day and full diet on the 4th post-operative day. The mean duration of hospital stay was 4.5 days. One patient developed post-operative intra-abdominal collection that was treated by ultrasound guided drainage. One patient developed umbilical port site wound infection. No chest infection, prolonged ileus, leakage, or mortality was encountered in the study. Conclusion: Laparoscopic repair of perforated peptic ulcer is a safe and reliable technique with accepted morbidity and mortality rates and all the advantages of the minimally invasive surgery.

Temporary umbilical loop colostomy for anorectal malformations

Transumbilical surgical procedures have been reported to be a feasible, safe, and cosmetically excellent procedure for various pediatric surgical diseases. Umbilical loop colostomies have previously been created in patients with Hirschsprung's disease, but not in patients with anorectal malformations (ARMs). We assessed the feasibility and cosmetic results of temporal umbilical loop colostomy (TULC) in patients with ARMs. A circumferential skin incision was made at the base of the umbilical cord under general anesthesia. The skin, subcutaneous tissue, and fascia were cored out vertically, and the umbilical vessels and urachal remnant were individually ligated apart from the opening in the fascia. A loop colostomy was created in double-barreled fashion with a high chimney more than 2 cm above the level of the skin. The final size of the opening in the skin and fascia was modified according to the size of the bowel. The bowel wall was fixed separately to the peritoneum and fascia with interrupted 5-0 absorbable sutures. The bowel was opened longitudinally and everted without suturing to the skin. The loop was divided 7 days postoperatively, and diversion of the oral bowel was completed. The colostomy was closed 2-3 months after posterior saggital anorectoplasty through a peristomal skin incision followed by end-to-end anastomosis. Final wound closure was performed in a semi-opened fashion to create a deep umbilicus. TULCs were successfully created in seven infants with rectourethral bulbar fistula or rectovestibular fistula. Postoperative complications included mucosal prolapse in one case. No wound infection or spontaneous umbilical ring narrowing was observed. Skin problems were minimal, and stoma care could easily be performed by attaching stoma bag. Healing of umbilical wounds after TULC closure was excellent. The umbilicus may be an alternative stoma site for temporary loop colostomy in infants with intermediate-type anorectal malformations, who undergo radical anorectoplasty via a non-abdominal approach.

Concurrent Single-Incision Laparoscopic Right Hemicolectomy and Sigmoidectomy for Synchronous Carcinoma: Report of a Case

Synchronous colorectal tumors that require surgical treatments are rare. Preliminary experience with concurrent single-incision laparoscopic right hemicolectomy and sigmoidectomy for synchronous carcinoma is reported. A 61-year-old woman presented to our department for the close examination of a bloody stool. Colonoscopy revealed two masses in the right-sided transverse colon and sigmoid colon and another slightly elevated lesion in the transverse colon, and all biopsies from these three lesions demonstrated adenocarcinoma. Under the diagnosis of transverse colon cancers and sigmoid colon cancer, we performed simultaneous single-incision laparoscopic sigmoidectomy and right hemicolectomy. First, a lap protector was inserted through a 2.5cm transumbilical incision. Three 5mm ports were placed in the lap protector. We successfully performed sigmoidectomy and right hemicolectomy with lymph node dissection. The patient was discharged on the thirteenth postoperative day. Postoperative follow-up did not reveal any umbilical wound complications. SILS should be the treatment of choice for concurrent laparoscopic surgery for also the other diseases.

Single Incision Laparoscopic Right Colectomy Using the Techniques of Open Surgery Through the Small Incision

To perform single-incision laparoscopic colectomy (SILC) safely while maintaining the minimal invasiveness of SILC and the quality of the lymph node dissection, we have used hybrid single-incision laparoscopic colectomy (H-SILC). Preliminary experience with H-SILC in advanced colon cancer is reported. First, a multi-flap gate was inserted through a 4.0cm transumbilical incision, and three 5mm ports were placed in the converter sheet. The procedures were much the same as in usual laparoscopic colectomy excluding a lateral to medial approach. The initial identification or exposure of the ileocolic vessels was performed through a small incision, and lymphadenectomy was mainly achieved using laparoscopic technique. In the course of laparoscopic procedures, whenever we felt stress, we used the techniques of open surgery through the small incision. The procedure was completed successfully without any perioperative complication and no need to extend the skin incision. The operative time was 191min. Postoperative follow-up did not reveal any umbilical wound complication or any recurrence. Our experience indicates H-SILC is safe and feasible for selected patients with colon cancer with improved cosmesis.

Transumbilical 1-port laparoscopic resection of benign ovarian tumor

Background/PurposeWe evaluated the effectiveness of transumbilical 1-port laparoscopic resection of benign ovarian tumors in children with limited working space. MethodsThis study involved 15 children and adolescents with benign ovarian tumors treated from January 2006 to December 2010. Preoperative evaluation included physical findings, tumor markers, and imaging studies. A single surgeon performed the procedure using a 10-mm 0° operative laparoscope with a 5-mm working channel. The fallopian tube was suspended with transabdominal suspensory sutures passing through the mesosalpinx to expose the tumor and remove it after aspiration of the contents. The tumor was contained in the endobag and chopped into pieces before removal through the small umbilical wound. ResultsThe patients' age ranged from 2 to 17 years (mean, 9.7 years). Tumor size ranged from 3.6 to 23 cm. Tumor markers including α-fetoprotein, β-human chorionic gonadotropin, cancer antigen 125, and carcinoembryonic antigen were negative. The average operating time was 134 minutes. Except for 1 patient with associated encephalomyelitis, all patients were discharged within 3 days after surgery. Pathologic examination and follow-up studies revealed benign tumors, with no residual lesions in the abdomen or recurrence. ConclusionsTransumbilical 1-port laparoscopic resection is effective for resection of benign ovarian tumors in children, with a satisfactory cosmetic outcome. However, to prevent inadequate resection of a potential malignant lesion, thorough preoperative evaluation with physical signs, tumor markers, and imaging studies, as well as flexible intraoperative tactics, should be adopted.

The Transverse Colon Cancer with the Reversed Rotation of the Midgut Treated with Single Incision Laparoscopic Colectomy

Reversed rotation of the midgut is a rare type of intestinal malrotation. Moreover, synchronous colon cancer has rarely been reported. Preliminary experience with single-incision laparoscopic colectomy (SILC) for colon cancer with reversed rotation of the midgut is reported. An 82-year-old woman was admitted because of a fecal occult blood. A colonoscopy revealed transverse colon cancer. An air-barium contrast enema showed the right-sided sigmoid colon and the left-sided cecum. A computed tomography revealed that the duodenum and the transverse colon were situated at the ventral side of the superior mesenteric artery, and a preoperative diagnosis of suspicion of reversed rotation of the midgut was made. First, a lap protector was inserted through a 4.0cm transumbilical incision. Four 5mm ports were placed in the lap protector. On the observation of laparoscopy, the cecum and the ascending colon were not fixed with the retroperitoneum and situated on the left, and the sigmoid colon was situated on the right. We successfully mobilized the transverse colon using a single-incision laparoscopic approach. Resection was achieved following extracorporealization, and the anastomosis was performed extracorporeally using staplers. The patient was discharged on the thirteenth postoperative day. Postoperative follow-up did not reveal any umbilical wound complications. SILC for colon cancer associated with malrotation of the midgut is feasible and a promising alternative method because of its less invasiveness and its adaptability to the malrotation without extending the skin incision.

Feasibility of Single-Incision Pediatric Endosurgery for Treatment of Appendicitis in 415 Children

Single-incision pediatric endosurgery (SIPES) has gained popularity for ablative procedures such as appendectomy in many pediatric surgical centers. This study evaluates the outcome of SIPES for treatment of appendicitis in our institution. After Institutional Review Board approval was obtained, data were prospectively collected on all patients undergoing SIPES appendectomy in our hospital from March 2009 through October 2011. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded. SIPES appendectomy was attempted in 415 children (mean age, 10.9 years; age range, 1.4-17.9 years; 266 males, 149 females; median weight, 43 kg; weight range, 9.8-146 kg). Intraoperatively, acute appendicitis was found in 298 cases and perforated appendicitis in 79 cases. Thirty-eight patients underwent interval appendectomy. Appendectomy was carried out solely as SIPES in 397 cases (96%). Median operative time was 40±16 minutes (37±16 minutes for fellows [n=284] and 46±15 minutes for residents [n=131]). There were three intraoperative complications, which could be handled during the procedure. Pathologic reports revealed inflammatory changes of the appendix (n=386), other pathology (n=11), and no pathologic change (n=18). Overall, 24 patients (5.8%) were readmitted for intra-abdominal abscess (n=14), umbilical wound infection (n=3), and other reasons (n=7). Twelve patients (2.9%) underwent reoperation: drainage of intra-abdominal abscess (n=8) (3 by the surgeon, 5 by the interventional radiologist), wound drainage (n=3), and right hemicolectomy for carcinoid (n=1). In perforated appendicitis the postoperative intra-abdominal abscess rate was 10 of 79 cases (12.7%), which is similar to the previous report with conventional laparoscopic appendectomy from our institution (13.6%). The wound infection rate (5 of 79 cases [6.3%]) was also similar to the previously report (6.8%) with conventional laparoscopic appendectomy for perforated appendicitis. Appendectomy can be accomplished successfully and safely using single-incision endosurgery in children with acceptable operative times without leaving any appreciable scar. Additional trocars are infrequently necessary. So far, the intraoperative and postoperative complication rates are comparable to those of triangulated laparoscopic appendectomy.

Late Umbilical Port-site Recurrence of a Gastrointestinal Stromal Tumor With an Acquired PDGFRα Mutation After Laparoscopic Resection

A 71-year-old man underwent laparoscopic partial gastrectomy for a gastric submucosal tumor in 1997; subsequently, he underwent follow-up without therapy. In December 2008, he noticed a mass at the umbilical wound. Computed tomography and physical examination of the umbilical mass indicated suspected recurrence of the gastric submucosal tumor at the port site. Because the lesion was locally confined, surgery was performed, including resection of the greater omentum; peritoneum; rectus abdominis; and the navel, including the skin. Histologic analysis of the tumor yielded positive results for c-kit, thereby indicating a gastrointestinal stromal tumor (GIST). Mutation analysis of c-kit and platelet-derived growth factor receptor α (PDGFRα) revealed an acquired mutation in exon 18 of PDGFRα in the recurrent tumor. To date, only 4 cases of port-site recurrence after laparoscopic resection of GIST have been reported. This is the first study to report an acquired PDGFRα mutation in port-site recurrence after laparoscopic resection of a GIST.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis

Background/PurposeThis study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. MethodsAfter institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. ResultsLaparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). ConclusionRoutine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Single Port Laparoscopic Appendectomy in Pediatric Patients: A Preliminary Experience

Purpose: The authors retrospectively compared single-port laparoscopic appendectomy (SPLA) with conventional laparoscopic appendectomy (CLA) in terms of the perioperative outcomes in pediatric patients. Methods: Cases of laparoscopic appendectomy between December 2009 and July 2010 were retrospectively reviewed. The demographic data, operating time, pathology of the appendix, hospital stay and surgical morbidities were compared. Results: Ten patients underwent SPLA and 57 underwent CLA. The mean age of the CLA and SPLA groups were 11.2 and 10.6 years, respectively. The pathology of the appendix showed that relatively more severe cases were included in the CLA group. There were 2 cases of a post operative intra-abdominal abscess and 2 cases of an umbilical wound infection in the SPLA group. Therefore, the SPLA group showed a significantly higher surgical morbidity rate (p=0.003) and hospital stay (p=0.05). The mean operation time of the SPLA and CLA group was 88.1±30.1 and 71.6±26.3 minutes, respectively; the mean operation time of the SPLA group was slightly longer (p=0.054). On the other hand, surgical morbidity and the mean operation time showed a decreasing tendency in the latter half of 10 Cases. Conclusion: The initial experience of SPLA in pediatric patients shows a higher complication rate and longer hospital stay than CLA. On the other hand, the complication rates and operation time have been decreasing. The clinical outcomes are expected to improve after going through a learning curve.

Single-port laparoscopic appendectomy: Prospective study of 30 cases

Background: Since the introduction of the laparoscopic appendectomy, it has become an alternative method of treatment to an open appendectomy because of less pain, less abdominal scarring, and quick recovery to daily life. Looking for ways to take advantage of the benefits of laparoscopic surgery has led some surgeons to start performing appendectomy utilizing the single incision laparoscopic surgery. Methods: 30 patients (12 males, 18 females) underwent single port laparoscopic appendectomy using the Covidien port through an incision of 2cm made just infraumbilical. With the use of ligasure for dissection and extracorporeal knot for the stump the appendix was removed. Results: All the 30 patients with age rangingfrom 18 to 50 years were successfully operated upon. The operative time range was 50 to 80 minutes. All were discharged 24 hours after operation. 2 patients (6, 66%) presented with postoperative complications, one case with umbilical wound infection and the other with postoperative pelvic collection. Conclusion: Single port laparoscopic appendectomy is feasible and safe in acute appendicitis without mass or abcess formation.

The enhanced view–totally extraperitoneal technique for repair of inguinal hernia

The totally extraperitoneal (TEP) approach for repair of inguinal hernia is the preferred technique since it does not penetrate the peritoneal cavity, thus avoiding potential intraperitoneal complications. The TEP technique allows for regional or even local plus sedative anesthesia, and it gives us an incomparable view of the inguinal region and hernias exactly where they originate. Part of the difficulty with the TEP technique is the limited space it provides for dissection. We describe a modification of the classical TEP approach which overcomes this limitation: the e-TEP technique. Since October 2010 we have performed 36 e-TEP procedures. Many of these were in difficult cases such as inguinoscrotal and incarcerated hernias and patients with previous radical prostatectomy. We present an initial evaluation of this group of patients. Results in terms of pain and time off work were the same as with the classical technique. The average operating time was 38 min. This is longer than usual, probably due to the complexity of the cases performed and the time spent in documenting the technique for educational purposes. The peritoneum was often accidentally opened and air leaked into the peritoneal cavity without interfering with the completion of the surgery. We had two small seromas and one case of skin sloughing at the umbilical wound in a case of umbilical and bilateral inguinal hernias. We have had no recurrences, but follow-up has been short. Our initial experience with the e-TEP technique has been satisfactory. We have had no conversions in spite of the difficult cases selected. There were no major complications, and functional results were excellent. We believe this modification has a place in the armamentarium for hernia repair.

Left upper quadrant approach in gynecologic laparoscopic surgery

To review the use of the left upper quadrant approach in benign gynecologic laparoscopic surgery over a nine-year period. Retrospective review. Setting. University-affiliated hospital. Women who underwent laparoscopic gynecologic surgery the upper quadrant approach between January 2002 and December 2010. Medical records were reviewed. Demographic data, past surgical histories, indications for surgery and the use of the left upper quadrant approach, intraoperative findings, diagnosis and any complications. 143 patients were identified, accounting for 4.9% of all gynecologic laparoscopic surgery. The indications for using the left upper quadrant approach were: previous open abdominal surgery (113, 79.0%), surgery in the second trimester of pregnancy (16, 11.1%), presence of large pelvic mass (9, 6.2%), previous transverse rectus abdominis myocutaneous flap for breast reconstruction (3, 2.0%), previous periumbilical hernia repair (1, 0.6%) and previous laparoscopic umbilical wound dehiscence (1, 0.6%). In women with previous abdominal surgery, the overall incidence of adhesions between omentum and/or bowel to the anterior abdominal wall in the umbilical region was 58.4%. Twelve (8.3%) patients required conversion to laparotomy. One patient had subcutaneous surgical emphysema over the left upper quadrant entry site. The left upper quadrant approach is an effective, safe and easy technique for peritoneal cavity access in women undergoing laparoscopic gynecologic surgery and should be considered in women with risk factors of periumbilical adhesions and in the presence of a large pelvic mass.

An outbreak of methicillin resistant Staphylococcus epidermidis among neonates in a hospital in Saudi Arabia

Staphylococcus epidermidis is a pathogen associated with nosocomial infection in neonatal intensive care units (NICU). This study investigates an outbreak of methicillin resistant S. epidermidis in an NICU in a hospital in Saudi Arabia. A total of 41 isolates identified as Gram-positive cocci were obtained from blood culture, umbilical wound swabs and endotracheal aspirate specimens of neonates, of which 29 were identified as S. epidermidis. Bacterial identification at the species level and determination of antibiotic resistance were performed by MicroScan (Dade Behring, USA). Genotyping was completed using randomly amplified polymorphic DNA (RAPD) and the mecA gene was detected by PCR. All 29 S. epidermidis isolates were found to be resistant to oxacillin and were positive for the mecA gene. The isolates showed several multidrug-resistance patterns; the resistance rates to gentamicin, erythromycin, clindamycin, and trimethoprim/sulfamethoxazole were 89.7%, 86.2%, 75.9% and 72.4%, respectively. All isolates were susceptible to vancomycin, teicoplanin, rifampin, synercid, and ciprofloxacin. Several genotypic and phenotypic patterns were detected among the S. epidermidis isolates: antibiogram typing showed seven different patterns, one of which was shared by 65% of the isolates, whereas the most prevalent RAPD genotype was shared by only five S. epidermidis isolates, and did not correlate with antibiotic resistance phenotype. The diverse clonal origin of tested isolates indicates the presence of multiple S. epidermidis strains among neonates in the NICU setting.