Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels

Safe introduction of ancillary trocars

The problem of laparoscopic entry is currently still unsolved, and despite the various techniques adopted by the surgical community, it has not yet been determined which is the correct access in all patients. Add to this the problem of safe ancillary port introduction; all surgeons must avoid vascular and visceral damage. The 2 most common problems with second port trocars are inferior and superior epigastric artery damage, and bowel loops and adhesions. Over the years, we have developed 2 steps that are very useful to avoid iatrogenic injuries to vessels and viscera. In this brief report, we explain the following 2 simple steps, called by the authors "yellow island" port entry and second trocar "tip entry guided" by a suction cannula. In our practice of more than 3400 conventional laparoscopies, with data from patients with different characteristics, surgeons who have introduced laparoscopic surgery into their daily practice might teach these steps to young fellows and trainees.

A review of minimally invasive single-port/incision laparoscopic appendectomy

INTRODUCTION

Single-port/incision laparoscopic appendectomy (SPILA) is a modern advancement toward stealth surgery, using a single point of entry. Despite the paucity of clinical data, it is increasingly being used to minimize scarring and, potentially, pain associated with the multiple entry points. We aimed to summarize and present available data on this new approach.

METHODOLOGY

All available databases until December 2010 including the Cochrane Controlled Trials Register, MEDLINE, and EMBASE were searched and cross-referenced for studies describing single-incision laparoscopic appendectomy. Case and experimental reports, series with fewer than 5 patients, and non-English articles were excluded. Outcome measures were operative time, postoperative hospital stay, pain scores, complications, conversion, and mortality, stratified according to type of SPILA approach. SPSS version 18.0.0 software was used for data collection.

RESULTS

Database query yielded 79 articles; 45 were included (1 randomized controlled trial, 44 case series). Total cases were 2806, with mean patient age for studies ranging from 7.0 to 37.5 years. No mortality was reported. The overall complication rate was 4.13%. The overall weighted mean operating time was 41.3 minutes (range, 15.0-95.9 minutes). The weighted mean hospital stay was 2.79 days (range, 1.0-6.6 days).

CONCLUSIONS

Although the incidence of complications with SPILA remains low and operating times between new and traditional approaches are comparable in case-based literature, adequately powered randomized trials are required to assess its effectiveness. Occurrence of long-term complication types remains unexplored.

Rupture of an inferior epigastric artery pseudo-aneurysm following laparoscopic port insertion

Laparoscopic port insertion is a potential cause of trauma to the inferior epigastric artery, resulting in pseudo-aneurysm formation. Treatment of pseudo-aneurysms includes thrombin injection, coil embolisation, embolisation with N-butyl cyanoacrylate, compression therapy or surgical excision and ligation. The authors present a case of pseudo-aneurysm caused by port insertion during laparoscopic sigmoid colectomy. The pseudo-aneurysm was identified using CT and Doppler ultrasound scans, but underwent spontaneous resolution with cessation of flow prior to intervention. The patient was therefore discharged, but he presented again as an emergency with rupture of a clinically infected pseudo-aneurysm and needed emergency surgical intervention.

Unusual complication after left-lobe liver biopsy for diffuse liver disease: severe bleeding from the superior epigastric artery

OBJECTIVE

Imaging-guided parenchymal liver biopsy for diffuse liver disease is increasingly performed via an epigastric route from the left lobe, as opposed to the more traditional intercostal right-sided approach.

MATERIALS AND METHODS

We conducted a retrospective analysis of all liver biopsies performed at our department for 3 years (July 2007 through June 2010). A total of 1028 liver biopsies were performed during this period. Of these, 776 biopsies were performed for diffuse medical liver disease. Electronic medical records were reviewed for any documented complications.

RESULTS

We identified six cases (0.8%) of documented significant bleeding after 776 biopsies. All bleeding complications were associated with the left-sided epigastric approach. No documented case of major bleeding from the right-sided approach was recorded during the same period. We describe four patients with severe bleeding complications in which classic imaging features were noted on CT, pointing to injury of the superior epigastric artery as the possible cause of the bleeding.

CONCLUSION

It is important to recognize the subtle CT signs of superior epigastric artery bleeding because the traditional femoral approach with angiography of the hepatic and portal vessels may not reveal active bleeding. The superior epigastric artery, rather than the hepatic arteries, should be evaluated. A brachial approach for the angiogram may be the more optimal technique.

Technical approaches to single port/incision laparoscopic appendicectomy: a literature review

INTRODUCTION

Single port/incision laparoscopic surgery (SPILS) is a modern advancement toward stealth surgery. Despite the paucity of high-quality scientific studies assessing its effectiveness, this procedure is being used increasingly. This review aims to describe commonly used techniques for SPILS appendicectomies (SPILA), to summarise complication rates in the literature and to provide discussion on indications and implementation.

METHODS

All available databases including the Cochrane Central Register of Controlled Trials, MEDLINE(®) and Embase™ were searched in February 2011 and cross-referenced for available English literature describing SPILA in patients of any age.

RESULTS

Three broad technical approaches are described: procedures using laparoscopic instruments through a single skin incision in the abdominal wall, regardless of the number of fascial incisions, with or without the additional use of percutaneous sutures or wires to 'assist' the operation, and hybrid procedures, in which the appendix is exteriorised using a single incision laparoscopically assisted operation but subsequently divided using a conventional 'open' appendicectomy technique. Complication rates seem to be highest in SPILA procedures unassisted by sutures or wires.

CONCLUSIONS

Future research assessing the efficacy of single incision laparoscopic procedures should consider variation in technique as a possible factor affecting outcome.

Single-incision versus standard laparoscopic cholecystectomy: comparison of surgical outcomes from a single institution

BACKGROUND

Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of mini-invasive surgery. We here described our 24-month experience SILS cholecystectomy.

METHODS

Between February 2009 and 2011, patients referred for cholecystectomy to the General and Endocrine Unit of our institution who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing SILS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period.

RESULTS

The SILS and standard cholecystectomy groups included 120 patients each. SILS was performed in all patients and none of them required conversion to an open procedure. The median operating time of 45 minutes in the SILS group was not significantly different from that in the standard laparoscopic cholecystectomy group. We suture fascial edge with simple stitches under direct vision, thus reducing the risk of incisional hernia in SILS group (P=.046).

CONCLUSIONS

SILS cholecystectomy was technically feasible and safe and represents a reproducible alternative to standard laparoscopic cholecystectomy in selected patients. The definitive clinical, esthetic, and functional advantages of this technique require further analysis.

Single-Incision Laparoscopic Placement of an Adjustable Gastric Band versus Conventional Multiport Laparoscopic Gastric Banding: A Comparative Study

Single-incision laparoscopic surgery (SILS™) is rapidly becoming the focal point of attraction for early adopters of minimally invasive surgery nationwide. Having achieved a rapid crossover to the realm of advanced surgical procedures, SILS™ has shown remarkable versatility and adaptability, making it no longer limited to basic laparoscopic procedures. We report our experience performing laparoscopic placement of gastric bands with an emphasis on comparison of the single-incision laparoscopic approach with the conventional multiport laparoscopic approach. From December 2008 to September 2009, 27 patients underwent laparoscopic placement of an adjustable gastric band at Michigan State University/Kalamazoo Center for Medical Studies. This included 15 patients who underwent single-incision laparoscopic gastric banding and 12 patients who underwent conventional multiport laparoscopic gastric banding procedures. The overall pain score was found to be significantly less in the SILS group than that for the conventional multiport laparoscopic gastric banding group with a statistically significant P value of 0.012. The operating time was found to be significantly less in the multiport group with a P value of 0.000. Differences in immediate postoperative pain scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant. Single-incision laparoscopic gastric banding is associated with significantly less overall postoperative pain than the conventional laparoscopic approach; in addition, it provides improved cosmetic outcome despite a modest increase in operative time.

Does transumbilical single incision laparoscopic adjustable gastric banding result in decreased pain medicine use? A case-matched study

BACKGROUND

We report on our initial experience of laparoscopic adjustable gastric banding performed through a single transumbilical incision of approximately 2.5 cm. All single incision bands were placed using the Covidien SILS Port™ and the Allergan Lap-Band(®). The purpose of the present study was to report on the analgesic use after single-incision laparoscopic surgery (SILS) adjustable gastric banding versus that after conventional laparoscopic gastric banding at a community hospital.

METHODS

A retrospective review of postoperative pain medication use and the time to return to work was conducted of 24 consecutive SILS adjustable gastric banding procedures compared with 24 traditional 5-incision laparoscopic adjustable gastric banding procedures.

RESULTS

The patients in both groups were evenly matched for age, body mass index, and co-morbidities. All patients were discharged home on postoperative day 1. No complications developed. The mean patient-controlled analgesia morphine use during hospitalization for the SILS group was 33 ± 19.22 mg versus 49 ± 23.78 mg in the traditional group (P <.05). The mean period of postoperative pain medication use for the SILS group was 2 days versus 5 days for the traditional group (P <.05). However, the mean period to return to work was 9.5 days for the SILS group versus 11 days for the traditional group (P = NS).

CONCLUSION

Transumbilical single-incision laparoscopic adjustable gastric banding with mechanical port fixation resulted in significantly decreased postoperative pain medication use compared with traditional laparoscopic gastric banding with suture fixation of the band port. Also, the patients tended to return to work earlier after SILS gastric banding.

Single-Incision Transumbilical Laparoscopic Splenic Cyst Unroofing: First Reported Case

Single-incision laparoscopic surgery is an emerging minimally invasive approach. When using the single-incision laparoscopic surgery approach, the surgeon operates almost exclusively through a single point of entry, usually the patient's umbilicus. This approach is steadily gaining popularity among minimally invasive surgeons, as it combines the cosmetic advantage of Natural Orifice Translumenal Surgery with the technical familiarity of conventional laparoscopic surgery. In this report, we describe our implementation of the single-incision laparoscopic approach to perform an unroofing of a posttraumatic splenic cyst; in this case, the entire procedure is performed through a 2-cm intraumbilical incision.

Single-incision transumbilical laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy has been gaining popularity due to its simplicity and outstanding results. This procedure is no exception to attempts aimed at minimizing abdominal port access. In this article, the senior author (AAS) presents his technique for an entirely transumbilical single-incision approach where no extraumbilical incisions are necessary.

MATERIALS AND METHODS

Seven patients underwent laparoscopic sleeve gastrectomies using this single-incision, totally transumbilical technique. The same surgeon (AAS) performed all surgical interventions. The same perioperative protocol and operative techniques were implemented for all the patients.

RESULTS

A total of 7 single-incision transumbilical laparoscopic sleeve gastrectomies were successfully performed using this technique. Two patients required lysis of adhesions, and 1 patient underwent an umbilical hernia repair during the procedure. Mean operating time was 143 minutes. One of the patients required the insertion of an additional trocar. There were no mortalities or postoperative complications noted during the mean follow-up period of 1.5 months.

CONCLUSIONS

Single-incision laparoscopic sleeve gastrectomy performed entirely through the umbilicus is safe, technically feasible, and reproducible.

Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery

OBJECTIVE

We sought to describe relationships of clinically relevant nerves and vessels of the anterior abdominal wall.

STUDY DESIGN

The ilioinguinal and iliohypogastric nerves and inferior epigastric vessels were dissected in 11 unembalmed female cadavers. Distances from surface landmarks and common incision sites were recorded. Additional surface measurements were taken in 7 other specimens with and without insufflation.

RESULTS

The ilioinguinal nerve emerged through the internal oblique: mean (range), 2.5 (1.1-5.1) cm medial and 2.4 (0-5.3) cm inferior to the anterior superior iliac spine (ASIS). The iliohypogastric emerged 2.5 (0-4.6) cm medial and 2.0 (0-4.6) cm inferior. Inferior epigastric vessels were 3.7 (2.6-5.5) cm from midline at the level of the ASIS and always lateral to the rectus muscles at a level 2 cm superior to the pubic symphysis.

CONCLUSION

Risk of anterior abdominal wall nerve and vessel injury is minimized when lateral trocars are placed superior to the ASISs and >6 cm from midline and low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscles.

Laparoendoscopic single-site cholecystectomy: a safe and reproducible alternative

BACKGROUND

Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. In this article, we describe the initial experience with laparoendoscopic single-site surgery (LESS) cholecystectomy.

PATIENTS AND METHODS

Between February and April 2009, patients referred for cholecystectomy to the General Surgery Unit of our institution who agreed to undergo LESS were included in a prospective study. All operations were performed by the same surgical team that was specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing LESS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period.

RESULTS

The LESS and standard cholecystectomy groups included 19 patients each. LESS was successfully performed in all patients and none required conversion to an open procedure or a conventional laparoscopic cholecystectomy by adding more entry ports. The median operating time of 62 minutes in the LESS group was not significantly different than that in the standard laparoscopic cholecystectomy group.

CONCLUSIONS

LESS cholecystectomy was technically feasible, safe, and represents a reproducible alternative to standard laparoscopic cholecystectomy.

Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS Port: first reported case

The emergence of natural orifice translumenal endoscopic surgery (NOTES) has brought significantly more attention to the single-incision transumbilical laparoscopic approach (SILS) for minimally invasive surgery. SILS combines the cosmetic advantage of NOTES with the technical familiarity of the conventional multiport laparoscopic approach. Additionally, SILS does not involve penetration of an organ, nor does it involve the steep learning curve and costly instruments associated with NOTES. Given these advantages, the authors believe that the single-incision transumbilical approach highlights the future direction of minimally invasive surgery. However, because of the associated technical challenges, the single-incision approach has not quite yet achieved the crossover to advanced surgical procedures that conventional multiport laparoscopy achieved in its early years. In this report, the authors present what is, to the best of their knowledge, the first reported case of a single-port access laparoscopic Roux-en-Y gastric bypass using the SILS Port placed through a single intraumbilical skin incision.

Laparoendoscopic single-site surgery appendectomy

BACKGROUND

Laparoscopic appendectomy via the three-trocar technique is widely used for appendectomy. This report describes the initial experience with laparoendoscopic single-site surgery (LESS) appendectomy.

METHODS

Between December 2008 and March 2009, patients with acute appendicitis admitted to the General Surgery and Emergency Unit of the authors' institution who agreed to undergo LESS appendectomy were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of emergency surgery. The umbilicus was the sole point of entry for all patients, and the same operative technique was used in all cases. The data for patients undergoing LESS appendectomy were compared with the data from an uncontrolled group of patients undergoing standard laparoscopic appendectomy during the same study period.

RESULTS

The LESS and standard appendectomy groups included 15 patients each. The LESS procedure was performed successfully for all the patients, and none required conversion to an open procedure or a conventional laparoscopic appendectomy by the addition of more entry ports. The mean operating time of 51 min in the LESS group was not significantly different from the 46 min in the standard laparoscopic appendectomy group.

CONCLUSIONS

In this study, LESS appendectomy was technically feasible and safe, representing a reproducible alternative to standard laparoscopic appendectomy.

Early experience with single incision transumbilical laparoscopic adjustable gastric banding using the SILS Port

BACKGROUND

The rapid progression of single-incision laparoscopic surgery (SILS) into the realm of advanced surgical procedures has been fueled in recent years by the development of flexible instrumentation necessary to restore triangulation lost in the divergent nature of this approach, and multichannel ports that addressed the challenges regarding the limited range of movement of trocars in close proximity. We herein are reporting our early experience using the SILS Port to perform single incision transumbilical laparoscopic gastric banding in five of our patients.

METHODS

Five carefully selected female patients (body mass indices between 35 and 45kg/m(2) with peripheral obesity) underwent laparoscopic gastric banding using this single incision transumbilical technique. The same surgeon performed all surgical interventions. For all five patients, the same perioperative protocol and operative techniques were implemented.

RESULTS

A total of five single incision transumbilical laparoscopic gastric banding procedures were successfully performed using this technique. Mean operative time was 111min. There were no mortalities or postoperative complications noted during the mean follow-up period of 1.5 months.

CONCLUSION

Single incision transumbilical laparoscopic adjustable gastric banding using SILS Port is a safe and feasible evolving approach. The intraumbilical location of the implanted port facilitates access for subsequent adjustments and provides patients with an improved cosmetic outcome.

Prevention and treatment of abdominal wall bleeding complications at trocar sites: review of the literature

Abdominal wall bleeding may complicate any laparoscopic procedure. Piercing or laceration of vessels transversing the abdominal wall during trocar placement is generally the cause. Bleeding may occur at the very beginning of the surgery but, in some cases, it may go unrecognized for a while complicating the operation and the postoperative course. Planned and careful trocar placement can prevent most of these instances that otherwise can be readily managed avoiding severe morbidity.

Single incision laparoscopic sleeve gastrectomy (SILS): a novel technique

BACKGROUND

Laparoscopic sleeve gastrectomy is an emerging bariatric procedure that typically necessitates five to seven small skin incisions to place five to seven trocars. The senior author (Saber) has developed a single umbilical incision approach to laparoscopic sleeve gastrectomy.

METHODS

Seven patients underwent single access transumbilical laparoscopic sleeve gastrectomy between March 2008 and July 2008. The same surgeon performed all surgical interventions. The umbilicus was the sole point of entry for all patients, and the same operative technique and perioperative protocol were used in all patients.

RESULTS

A total of seven single-incision laparoscopic sleeve gastrectomies were performed. The procedure was successfully performed in all patients. Mean operating time was 125 min. None of the patients required conversion to an open procedure. There were no mortalities or postoperative complications noted during the mean follow-up period of 3.4 months.

CONCLUSION

Single-incision transumbilical laparoscopic sleeve gastrectomy is safe, technically feasible, and reproducible.

Complications of gynecologic surgery

Complications during gynecologic surgery result from the proximity of the uterus and ovaries to other critical pelvic structures. These structures include the urinary tract, bowel, nerves, and vasculature. Knowledge of pelvic anatomy is important when performing these procedures and is critical in cases of altered anatomy from adhesive disease and during intraoperative hemorrhage. Recognition and repair of an unintended injury gives the best chance for minimizing sequelae from these complications.

Ultrasound-guided interventional radiology in critical care

Ultrasound-guided intervention is becoming an increasingly popular and valuable tool in the critical care setting. In general, image-guided procedures can expedite wait times and increase the accuracy, safety, and efficacy of many procedures commonly performed within intensive care units. In the intensive care unit setting, ultrasound has particular advantages over other imaging modalities such as computed tomography and fluoroscopy, including real-time visualization, portability permitting bedside procedures, and reduced exposure to nephrotoxic contrast agents. We review the technical and procedural aspects of a number of ultrasound-guided interventions appropriate for critical care patients. These include central venous catheter deployment, thoracentesis, paracentesis, and drainage of a wide variety of abscesses, and percutaneous nephrostomy, percutaneous cholecystectomy, and inferior vena cava filter placement. Although we believe ultrasound is significantly underutilized in critical care today, we anticipate that with the improvement of ultrasound technology and the innovation of new ultrasound-guided procedures, the role of ultrasound in the intensive care unit will continue to expand, with bedside ultrasound-guided interventions increasingly becoming the norm.

Rectus sheath abscess after laparoscopic appendicectomy

Port site wound infection, abdominal wall hematoma and intraabdominal abscess formation has been reported after laparoscopic appendicectomy. We describe here a rectus sheath abscess which occurred three weeks after the laparoscopic appendicectomy. It was most likely the result of secondary infection of the rectus sheath hematoma due to bleeding into the rectus sheath from damage to the inferior epigastric arteries or a direct tear of the rectus muscle. As far as we are aware this complication has not been reported after laparoscopic appendicectomy.

Inferior epigastric artery false aneurysms: review of the literature and case report

A case report is presented of a IEA false aneurysm successfully embolized in a 50-year old man following a blunt abdominal injury. A literature review revealed another 15 cases. Most cases were iatrogenic (13/16) complicating abdominal wall procedures. Treatment options included open surgery (8 cases), percutaneous coil embolization (6), ultrasound guided thrombin injection or ultrasound guided compression (2). The selected treatment (surgical or non-surgical) was not affected by the size of the aneurysm (p=0.6) and was successful in all patients. However two of the non-surgically removed lesions (25%) remained unchanged in size for a long time causing discomfort. IEA false aneurysms represent an uncommon entity. Open surgery for IEA false aneurysms is easy and cheap. Endovascular approaches can lead to a long delay in resolution of the problem.

Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience

BACKGROUND

Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. Reconstruction with deep inferior epigastric perforator (DIEAP) flaps requires a precise location and preoperative evaluation of perforating vessels. The objective of this report is to demonstrate the usefulness of multislice-CT (MSCT) angiography for preoperative planning in patients undergoing DIEAP flap reconstruction.

METHODS

Six consecutive women were considered for breast reconstruction with DIEAP flaps after previous mastectomy for breast cancer. Preoperative MSCT angiography was performed to localise the arterial perforators. Axial images, multiplanar reconstructions (MPR) and 3D volume-rendered images were analysed. Findings were correlated with surgery. Initial experience and imaging findings will be described.

RESULTS

Accurate identification of the main perforators was achieved in all six patients with a very satisfactory concordance between MSCT angiography and surgical findings. No unreported vessels were found. Location, course, anatomical variations and relations of the superficial inferior epigastric artery were reported. The very small perforators, were equally evaluated and described.

CONCLUSIONS

Preoperative evaluation of perforator arteries with MSCT angiography is feasible in patients undergoing breast reconstruction. This technique provides a noninvasive global approach of the vascular anatomy and the entire anterior abdominal wall. However, more patients need to be evaluated in order to clarify the potential aspects pointed in this report.

Conservative Treatment of a Huge Abdominal Wall Hematoma After Laparoscopic Appendectomy

We report a case of a 30-year-old male patient who presented with a huge abdominal wall hematoma 60 minutes after laparoscopic appendectomy. During surgery there had been no sign of abdominal wall bleeding. We found a lateral abdominal wall hematoma caused by rupture of the abdominal epigastric artery after trocar insertion. We conclude that trocar injury is a potentially preventable complication in laparoscopic surgery if certain precautions are taken. Abdominal wall hematoma secondary to injury of an epigastric vessel can be successfully treated with conservative management.