Complications of laparoscopic surgery

Botulinum Toxin A as an Adjunct for the Repair Giant Inguinal Hernias: Case Reports and a Review of the Literature

The management of giant inguinoscrotal hernias remains a challenge as a result of the loss of the intra-abdominal domain from long-standing hernia contents within the scrotum. Multiple techniques have been described for abdominal wall relaxation and augmentation to allow the safe return of viscera from the scrotum to the intraperitoneal cavity without adversely affecting cardiorespiratory physiology. Preoperative progressive pneumoperitoneum, phrenectomy, and component separation are but a few common techniques previously described as adjuncts to the management of these massively large hernias. However, these strategies require an additional invasive stage, and reproducibility remains challenging. Botulinum toxin A (BTA) has been successfully used for the management of complex ventral hernias. Its use for these hernias has shown reproducibility and a low side effect profile. In the present report, we describe our institutional experience with BTA for giant inguinal hernias in two patients and present a review of the literature. In one case, a 77-year-old man with a substantial cardiac history presented with a giant left inguinal hernia that was interfering with his activities of daily living. He had BTA six weeks prior to inguinal hernia repair. Repair was performed via an inguinal incision with a favorable return of the viscera into the peritoneum. He was discharged on the same day of the operation. A second patient, 78 years of age, had a giant right inguinoscrotal hernia. He had a significant cardiac history and was treated with BTA six weeks prior to inguinal hernia repair via a groin incision. Neither patient had complaints nor recurrence at 7- and 3-month follow-ups. While the literature on this topic is scarce, we found 13 cases of inguinal hernias treated with BTA as an adjunct. BTA might be a promising adjunct for the management of giant inguinoscrotal hernias in addition to or in place of current strategies.

A rare case of multiple port site incisional hernias repaired by laparoscopy-assisted intraperitoneal onlay mesh: A case report

INTRODUCTION

Port site herniation is a frequent complication of abdominal surgery, yet treatment strategies for multiple port site hernias are often difficult and case reports are rare.

PRESENTATION OF CASE

A 72-year-old woman, with a history of multiple abdominal surgeries, underwent laparoscopic surgery for rectal prolapse four years prior. Three 12 mm ports were inserted into the umbilical region, right upper quadrant and right lower abdomen, subsequently, incisional hernias developed at all three sites. In addition, an incisional hernia developed in the lower abdomen, for a total of four incisional hernias. She was taking apixaban for atrial fibrillation, and since the standard surgical method of placing the mesh in the extraperitoneal space was judged to be high risk for postoperative bleeding and hematoma formation, we performed a laparoscopy-assisted intraperitoneal onlay mesh repair (IPOM).

DISCUSSION

The key points of the surgery performed are: Laparoscopic surgery was initiated with a small incision in the umbilical region, using two 5 mm ports because we reasoned that using a 12 mm port could cause a new hernia. In the lateral hernia repair, a mesh was placed in the preperitoneal space on the dorsal side of the hernia, the mesh was sutured to the peritoneum because tucking cannot be performed if nerves are present on the dorsal aspect. The medial hernia was repaired by IPOM via a small laparotomy incision.

CONCLUSION

For multiple incisional hernias, it is necessary to consider appropriate repair methods for each site.

Implementation of robotic surgery in Dubai: a focus on outcomes

The rapid acceptance of robotic surgery in gallbladder, inguinal, and ventral hernia surgery has led to the growth of robotic surgery programs around the world. As this is new technology, implementation of such programs needs to be done safely, with a focus on patient outcomes. We herein describe the implementation of a new robotic surgery program in a major hospital in the Middle East. A laparoendoscopic surgeon led the program after training and proctoring. Competency based credentialing were created and put in place. To confirm safety of the program, all laparoscopic and robotic cholecystectomy and hernia operations were followed, and perioperative data analyzed. Out of the 304 patients included in this study, 157 were performed using the robotic approach. In the cholecystectomy group (n = 103) the single site approach offered shorter operative times (P < 0.05). Both the single site robotic and the robotic assisted approaches resulted in less pain (P < 0.05). In the inguinal hernia group (n = 146) the laparoscopic approach offered shorter operative times (P < 0.05), but the robotic approach was associated with less pain (P < 0.05). In the ventral hernia group (n = 55), the open approach offered the best operative times, but the robotic approach was associated with the least amount of pain (P < 0.05). This is the first report of the implementation of a robotic program in the MENA region where the primary measure of success is outcomes. We show that monitoring cholecystectomy, inguinal or ventral hernia data can confirm the quality of the program before expansion and moving forward to more complex procedures.

The "Flip-Flap" Technique for Laparoscopic Port-Site Closure-Description of a Novel, Cost-Effective Technique with Review of Literature

Overview  Laparoscopic approach has changed the face of surgical care offered to patients. Almost all surgical procedures across specialties are now undertaken by the laparoscopic approach. Closure of port sites to prevent trocar-site hernias (TSHs) forms an integral part of the laparoscopic procedure. TSH is an area of preventable surgical morbidity. We hereby report our technique that is easily applicable, simple, safe, and highly cost-effective. It requires no additional instruments or retractors, is easy to learn, and has a very favorable safety profile.

Materials and Methods  This prospective case series enrolled a total of 454 port-site closures in 255 patients undergoing different laparoscopic procedures over a period of 2 years. The intraperitoneal tissue forceps were used in the reverse direction to lift the fascia up and a right-angled retractor was used to retract back the skin and subcutaneous tissue. The port-site closure is done under vision and no adverse events were reported.

Results  This technique was used in 454 port sites in 255 patients. No intraoperative incidents were noted. There is no requirement of any specialized instruments or retractors. No additional tissue trauma or dissection is required. There is no extension of operative time. The technique is simple to learn and easy to teach. No bowel injuries or TSHs were reported during a follow-up of 26 months.

Conclusion  The described technique is easy, simple, cost-effective, and has a good safety profile.

Effects of Leaving Amputated Ovaries Intra-Abdominally during Elective Bilateral Standing Laparoscopic Ovariectomy in Equids

Simple Summary

When removing the ovaries of a mare via laparoscopic technique, there is potential to drop the ovary in the abdomen when trying to exteriorize it through the abdominal wall. If the ovary can no longer be seen with the laparoscope, then the procedure is converted to a flank incision and the ovary is identified and removed by hand. Having to convert the procedure negates the benefits of the minimal invasive laparoscopic procedure and increases the risk of post-operative complications. The objective of this study was to identify if amputated ovaries left in the abdomen during surgery would atrophy or if they would regain a blood supply and produce hormones. After surgery, the mare’s hormone values were at low levels and an improvement in all mare’s behavior and general herd dynamics was observed. While this study does not encourage to leave ovaries in the abdomen after amputation, we report no complications related to their voluntary release into the abdomen.

Abstract

There is risk of dropping an amputated ovary within the abdomen during standing laparoscopic ovariectomies in mares. If the ovary can no longer be directly visualized with the laparoscope, the procedure is then converted to a flank laparotomy for manual retrieval of the ovary which negates the minimally invasive nature of the laparoscopic procedure. The objective was to identify if ovaries left in the abdomen after amputation would atrophy or if they re-vascularize. Standing bilateral ovariectomies were performed in mature mares, but after transection of the ovarian pedicle, the ovaries were intentionally dropped and left within the abdomen. Post-operative endocrine values were at basal levels and an improvement in all mare’s behavior and general herd dynamics was observed. While this study does not encourage to leave ovaries in the abdomen after amputation, we report no complication related to their voluntary release into the abdomen.

Mediterranean diet and breastfeeding reduce the risk of gallstone in women

OBJECTIVE: This study aimed to determine the effect of nutrition style and breastfeeding on the formation of gallstone in women. METHODS: 50 women age from 40 to 69 included in the study. A questionnaire in which the participant’s general information questioned, their anthropometric values recorded, and the Mediterranean diet (MD) adherence scale included, was filled in by the face-to-face interview method. RESULTS: Body mass index (BMI), waist circumference (WC), diastolic blood pressure (DBP), fasting blood glucose (FBG), and serum C-reactive protein (CRP) values were higher in those with gallstones than in the control group. The total breastfeeding time and MD adherence scores were higher in the control group. It determined that there was a negative relationship between breastfeeding time with DBP and CRP. It found that an increase in BMI and WC increases the probability of gallstones. It found that an increase in the duration of breastfeeding and MD adherence score decreases the probability of the gallstones. CONCLUSION: Breastfeeding and Mediterranean diet reduce the risk of gallstones in women.

Major Bleed Post Minimally Invasive Surgical Repair of Inguinal Hernia

At our center, over 200 patients undergo minimally invasive repairs of inguinal hernias every year using a laparoscope and a robotic-assisted technique. In three patients who underwent a minimally invasive procedure for uncomplicated indirect inguinal hernia, the postoperative course was complicated with bleeding and required an exploratory laparotomy. Post-procedure, the patients developed tachycardia and hypotension with a drop in hemoglobin, for which the patients required surgical re-exploration in an emergent fashion. The factors leading to bleeding were analyzed and are reported herein to increase awareness and prevent the occurrence of these complications during inguinal hernia surgery.

Incidence of acute postoperative robotic port-site hernias: results from a high-volume multispecialty center

Fascial closure at 8-mm robotic port sites continues to be controversial. As the use of the robotic platform increases across multiple abdominal specialties, there are more case reports describing reoperation and small bowel resection for acute port-site hernias. A retrospective review of all robotic abdominal surgeries performed from 2012 to 2019 at NYU Langone Medical Center was conducted. Patients who had a reoperation in our facility within 30 days were identified, and medical records reviewed for indications for reoperation and findings. The study included 11,566 patients, of which 82 patients (0.71%) underwent a reoperation related to the index robotic surgery within 30 days. Fifteen of 11,566 patients (0.13%) had acute port-site hernias, and 3 of these 15 patients required small bowel resection. Eleven of 15 acute port-site hernias (73%) were at 8-mm robotic port site, 2 of which required a small bowel resection. More than a third of the patients had a hernia at an 8-mm port site where a surgical drain had been placed. Considering that each robotic case, regardless of specialty, has three ports at a minimum, the true incidence of acute postoperative robotic port-site hernia is 0.032% (11/34,698), with the incidence of concomitant small bowel resection being 0.006% (2/34,698). The incidence of acute port-site hernias from 8-mm robotic ports is exceedingly low across specialties. Our results do not support routine fascial closure at 8-mm robotic port sites due to an extremely low incidence. However, drain sites require special consideration.

The iArmS Robotic Armrest Prolongs Endoscope Lens–Wiping Intervals in Endoscopic Sinus Surgery

Objective. Fouling of the endoscope lens is a major problem in endoscopic sinus surgery (ESS). We examined whether the use of the intelligent arm support system (iArmS), a robotic armrest, could prolong endoscope lens–wiping intervals in ESS and thus allow for continuously clear endoscopic images. Study Design. This study is a prospective, nonrandomized crossover study. Methods. Three surgeons who performed ESS at 2 centers each conducted 3 operations with the iArmS and 3 operations without the iArmS; thus, 18 operations were assessed. To blind the assessments, we performed them prospectively without informing subjects of the endpoints. We recorded the operations and observed the recordings at a later date; endoscope lens–wiping times were noted in seconds to determine the endoscope lens–wiping intervals. Our examination was based on the null hypothesis that endoscope lens–wiping intervals would not differ according to the use or nonuse of the iArmS. Results. The median endoscope lens–wiping intervals with and without using the iArmS were 361 seconds and 135 seconds, respectively. Based on the Wilcoxon rank-sum test, this difference was significant ( P = 0.001); thus, the null hypothesis was rejected. This result indicated that endoscope lens–wiping intervals are greatly prolonged by the use of the iArmS. Conclusion. The iArmS robotic armrest is suitable for ESS, prolongs endoscope lens–wiping intervals, and facilitates obtaining continuous clear endoscopic images.

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.

Application of failure mode and effect analysis in total laparoscopic hysterectomy in benign conditions

BACKGROUND

Hysterectomy is the most common major gynecological operation in developed countries. The rate of intraoperative complications related to the laparoscopic approach during hysterectomy is a relevant issue. The failure mode and effect analysis (FMEA) method is a prospective approach, which tries to identify possible errors before they occur.

METHODS

In this study we applied the FMEA method to laparoscopic approach to hysterectomy in order to reduce the theorized risk of intraoperative complications. We selected a team who analyzed and deconstructed the total laparoscopic hysterectomy (TLH) process recording on the FMEA worksheet phases and activities of the entire procedure. Each activity-related failure mode and their potential effects were developed. The team also described actions to eliminate or decrease the likelihood of mistakes.

RESULTS

A numerical value reflecting the risk was assigned to each activity. Five activities were identified as high priority risk, and for each activity actions were then taken to mitigate the identified risk. After introduction of these actions, the risk scores for each activity were recalculated, and we obtained a total risk reduction of 55%.

CONCLUSIONS

It is our opinion that the systematic implementation of the FMEA model can reduce the risk of human error during laparoscopic surgery, improving patient safety.

Single-port laparoscopy in gynecologic oncology: seven years of experience at a single institution

BACKGROUND

Single-port laparoscopy has gained popularity within minimally invasive gynecologic surgery for its feasibility, cosmetic outcomes, and safety. However, within gynecologic oncology, there are limited data regarding short-term adverse outcomes and long-term hernia risk in patients undergoing single-port laparoscopic surgery.

OBJECTIVE

The objective of the study was to describe short-term outcomes and hernia rates in patients after single-port laparoscopy in a gynecologic oncology practice.

STUDY DESIGN

A retrospective, single-institution study was performed for patients who underwent single-port laparoscopy from 2009 to 2015. A univariate analysis was performed with χ² tests and Student t tests; Kaplan-Meier and Cox proportional hazards determined time to hernia development.

RESULTS

A total of 898 patients underwent 908 surgeries with a median follow-up of 37.2 months. The mean age and body mass index were 55.7 years and 29.6 kg/m², respectively. The majority were white (87.9%) and American Society of Anesthesiologists class II/III (95.5%). The majority of patients underwent surgery for adnexal masses (36.9%) and endometrial hyperplasia/cancer (37.3%). Most women underwent hysterectomy (62.7%) and removal of 1 or both fallopian tubes and/or ovaries (86%). Rate of adverse outcomes within 30 days, including reoperation (0.1%), intraoperative injury (1.4%), intensive care unit admission (0.4%), venous thromboembolism (0.3%), and blood transfusion, were low (0.8%). The rate of urinary tract infection was 2.8%; higher body mass index (P = .02), longer operative time (P = .02), smoking (P = .01), hysterectomy (P = .01), and cystoscopy (P = .02) increased the risk. The rate of incisional cellulitis was 3.5%. Increased estimated blood loss (P = .03) and endometrial cancer (P = .02) were independent predictors of incisional cellulitis. The rate for surgical readmissions was 3.4%; higher estimated blood loss (P = .03), longer operative time (P = .02), chemotherapy alone (P = .03), and combined chemotherapy and radiation (P < .05) increased risk. The rate of incisional hernia rate was 5.5% (n = 50) with a mean occurrence at 570.2 ± 553.3 days. Higher American Society of Anesthesiologists class (P = .04), diabetes (P < .001), hypertension (P = .043), increasing age (P = .017; hazard ratio [HR], 1.03), and body mass index (P < .001; HR, 1.08) were independent predictors for incisional hernia development. Previous abdominal surgeries (P = .24) and hand assist (P = .64) were not associated with increased risk for incisional hernia. Patients with American Society of Anesthesiologists class III/IV had a 3 year hernia rate of 12.8% (HR, 1.81). Patients with diabetes mellitus had a 3 year hernia rate of 23.0% (HR, 3.60).

CONCLUSION

In this large cohort of patients undergoing single-port laparoscopy, the incidence of short-term adverse outcomes is low. While the rate of incisional hernia was 5.5%, incidence reached 23.0% at 3 years in high-risk groups. Previous studies with short follow-up duration may underestimate the risk of hernia, especially in patients with significant comorbidities.

Trocar site hernia following laparoscopic cholecystectomy: a 10-year single center experience

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard of treatment for patients with symptomatic cholelithiasis. Compared to open cholecystectomy, LC is associated with significantly lower postoperative complications. Trocar site hernia (TSH) is an uncommon, but potentially dangerous, complication of LC. The aim of this study was to evaluate the incidence of TSH following LC.

METHODS

The records of all patients who underwent elective LC between January 2004 and December 2013 were retrospectively reviewed. The open technique with a vertical incision infraumbilically was used to establish pneumoperitoneum. Two or three other skin incisions were made and trocars were inserted. In all cases, only the fascia at the site of infra-umbilical incision was closed. Following hospital discharge, all patients were regularly re-examined 1, 4 and 52 weeks postoperatively and were contacted by phone during November-December 2015. Based on the findings from clinical and telephone follow-ups, the incidence of TSH was recorded. Using univariate/multivariate analysis, we investigated several variables to identify risk factors for TSH development.

RESULTS

During the study period, 1172 patients were eligible and included in the final analysis. Seven patients (0.6%) presented TSH at 1-year follow-up. At the end of the study and with a mean follow-up of 65.86 ± 25.19 months, 11 patients (0.94%) presented TSH. Interestingly, all TSHs were developed at the infra-umbilical site. Multivariate analysis identified obesity as an independent risk factor for TSH.

CONCLUSION

The incidence of TSH following LC is considerably low. Obesity is an independent risk factor for TSH development, while closure of fascial incision of 10 mm below the xiphoid is not justified.

The assessment of portal-tract healing after knee arthroscopy

Objective

The aim of this study was to analyse the pattern of portal-tract healing, to compare the healing time of anteromedial and anterolateral portal tracts and to assess the impact of portal-tract delayed healing on the post-operative sub-acute and chronic anterior knee tenderness.

Methods

The study included 104 patients (68 males and 36 females; mean age: 49 ± 3.16 years (range; 17–66)) who have undergone knee arthroscopy. Puncture wounds were divided into two groups, (1) anteromedial and (2) anterolateral groups. Each group contained 104 portal-tracts. Healing of portal tracts was evaluated using sequential superficial ultrasonographic examinaitons. Visual analogue scale (VAS) was used to measure pain related to delayed tract healing and its association with the post-operative sub-acute and chronic anterior knee tenderness.

Results

Anteromedial and anterolateral tracts total healing time average values were 47 days and 28 days respectively. The VAS average values of anteromedial tracts after 2 weeks, one month, three months, six months and one year were 8.2, 6.3, 4, 1.9 and 0.6 respectively, and for the anterolateral tracts 7.4, 5.5, 2.8, 1.2 and 0.2 respectively. A statistical significance was detected between the two groups at the first and third months with P values 0.042 and 0.0035 respectively.

Conclusions

Anteromedial tracts closed later than anterolateral tracts. Both portal-tracts delayed closure is a potential for post-operative sub-acute and chronic anterior knee tenderness after arthroscopic surgery. Four grades of tract healing were recognized. Portal-tract ultrasonography is advised in persistent post-operative sub-acute and chronic anterior knee tenderness.

Level of evidence

Level III, Therapeutic study.

Anomalous biliary and vascular anatomy-Potential pitfalls during cholecystectomy

Laparoscopic cholecystectomy is usually a low-risk procedure associated with a short stay and a low rate of conversion to open surgery. Complications are sometimes associated with anomalous vascular or biliary anatomy. Outlined below are the variations in vascular and biliary anatomy which may result in complications either due to involvement in the inflammatory process or inadvertent division during dissection. Clin. Anat. 30:1103-1106, 2017. © 2017 Wiley Periodicals, Inc.

Long-Term Surgical Outcome of Trocar Site Hernia Repair

Port site hernias are emerging as a problematic complication of laparoscopic surgery. The aim of this study was to elucidate the characteristics of port site hernias and determine the long-term outcomes based on the interval between primary surgery and hernia occurrence. Twenty-four patients were surgically treated for trocar site hernia between 1997 and 2013. The patients were grouped into early-onset group (EOG; less than one month) and late-onset group (LOG; more than one month) based on the interval between laparoscopic surgery and hernia onset. A retrospective analysis was performed. There were seven patients in the EOG and 17 patients in the LOG. The body mass index was significantly higher (P = 0.033) in the LOG. In the EOG, primary closure was performed, and there were no recurrences. In the LOG, mesh reinforcement was applied in 58.8 per cent of patients, and 29.4 per cent of patients had recurrences. This recurrence rate was higher than the recurrence rate after primary repair of incisional hernia after open laparotomy (P = 0.088). In conclusion, In the EOG, small bowel resection was more frequent, but once repaired, there were no recurrences. Although mesh reinforcement was applied in the LOG, the recurrence rate was not less than the EOG.

How to Prevent Trocar-site Hernia? A Totally Atraumatic Endoscopic Mini-IPOM-Plug Technique (With Extra-Lightweight Titanium-coated Mesh and Glue)

BACKGROUND

The trocar-site hernia is a new complication in laparoscopic surgery, which is becoming increasingly prevalent. Thus, the search for an efficient method of prophylaxis should be prioritized.

MATERIALS AND METHODS

We describe a new, totally endoscopic technique based on 2 steps, intra-abdominal and parietal: (1) a mini-IPOM with an extra-lightweight titanium-coated mesh, fixed atraumatically using glue and (2) occlusion of the parietal opening using a small plug.

RESULTS

In 15 cases, we have not needed to expand the initial aperture, performance time was always less than a minute, and we did not encounter any added morbidity, pain, local infection, or hernia, over a minimum postoperative follow-up period of 6 months.

CONCLUSIONS

Our technique for trocar-site closure is easy to perform, safe, and not time-consuming. A complete reconstruction is achieved of the peritoneal injury (intra-abdominal) and of the parietal route created by the trocar (intraparietal). The mesh design and fixation with glue are essential for good results.

Coming to terms with the fact that the evidence for laparoscopic entry is as good as it gets

Entry to the peritoneal cavity for laparoscopic surgery is associated with defined morbidity, with all entry techniques associated with substantial complications. Debate over the safest entry technique has raged over the last 2 decades, and yet, we are no closer to arriving at a scientifically valid conclusion regarding technique superiority. With hundreds of thousands of patients required to perform adequately powered studies, it is unlikely that appropriately powered comparative studies could be undertaken. This review examines the risk of complications related to laparoscopic entry, current statements from examining bodies around the world, and the medicolegal ramifications of laparoscopic entry complications. Because of the numbers required for any complications study, with regard to arriving at an evidence-based decision for laparoscopic entry, we ask: is the current literature perhaps as good as it gets?

Novel port placement and 5-mm instrumentation for robotic-assisted hysterectomy

Background and Objectives:

The value of robotic surgery for gynecologic procedures has been critically evaluated over the past few years. Its drawbacks have been noted as larger port size, location of port placement, limited instrumentation, and cost. In this study, we describe a novel technique for robotic-assisted laparoscopic hysterectomy (RALH) with 3 important improvements: (1) more aesthetic triangular laparoscopic port configuration, (2) use of 5-mm robotic cannulas and instruments, and (3) improved access around the robotic arms for the bedside assistant with the use of pediatric-length laparoscopic instruments.

Methods:

We reviewed a series of 44 women who underwent a novel RALH technique and concomitant procedures for benign hysterectomy between January 2008 and September 2011.

Results:

The novel RALH technique and concomitant procedures were completed in all of the cases without conversion to larger ports, laparotomy, or video-assisted laparoscopy. Mean age was 49.9 years (SD 8.8, range 33–70), mean body mass index was 26.1 (SD 5.1, range 18.9–40.3), mean uterine weight was 168.2 g (SD 212.7, range 60–1405), mean estimated blood loss was 69.7 mL (SD 146.9, range 20–1000), and median length of stay was <1 day (SD 0.6, range 0–2.5). There were no major and 3 minor peri- and postoperative complications, including 2 urinary tract infections and 1 case of intravenous site thrombophlebitis. Mean follow-up time was 40.0 months (SD 13.6, range 15–59).

Conclusion:

Use of the triangular gynecology laparoscopic port placement and 5-mm robotic instruments for RALH is safe and feasible and does not impede the surgeon's ability to perform the procedures or affect patient outcomes.

Trocar-site hernia at the 8-mm robotic port after robot-assisted laparoscopic prostatectomy: a case report and review of the literature

Trocar-site hernia is an uncommon but serious complication after laparoscopic surgery as it frequently requires surgical intervention. We describe a 75-year-old man with Gleason score 4 + 3, clinical stage T1c prostate adenocarcinoma who underwent an uneventful robot-assisted transperitoneal laparoscopic radical prostatectomy. On post-operative day four, he developed symptoms of small bowel obstruction due to herniation and incarceration of the small bowels in a Spigelian-type hernia at the left lower quadrant 8-mm trocar site. Surgical exploration was performed via a mini-laparotomy to reduce the bowel and repair the fascial layers. A literature search was performed to review other cases of trocar-site hernia through the 8-mm robotic port after robot-assisted surgery and the suggested methods of prevention.

Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study

BACKGROUND

Trocar site incisional hernia (TSIH) is a common complication after laparoscopic cholecystectomy. The aim of this study was to evaluate the prevalence of TSIH and analyze the influence of several risk factors for this complication in a prospective series.

METHODS

From 2007 to 2008, a prospective observational study with 3 years of follow-up was performed including all consecutive patients with cholelithiasis who underwent elective laparoscopic cholecystectomy. A multivariate analysis was performed to identify risk factors for TSIH.

RESULTS

Overall, 241 patients were included. During a median follow-up period of 46.8 months, 57 patients (25.9%) were diagnosed with umbilical TSIH by physical exam or ultrasound. The multivariate analysis revealed that incision enlargement (odds ratio [OR], 14.17; 95% confidence interval [CI], 3.61 to 55.51; P < .001), wound infection (OR, 5.62; 95% CI, 2.35 to 13.42; P < .001), diabetes mellitus (OR, 2.79; 95% CI, 1.05 to 7.37; P = .0038), and obesity (OR, 2.71; 95% CI, 1.28 to 5.75; P = .009) contributed to the risk for developing a TSIH.

CONCLUSIONS

Umbilical TSIH is highly prevalent. This study identified several factors that could be useful to introduce preventive measures in high-risk patients.

A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial

OBJECTIVE

Laparoscopic entry techniques vary and still remain debated. We conducted a randomized control trial to compare three entry techniques.

STUDY DESIGN

Women aged 18-70 years, nominated for laparoscopic surgery at University of Rome Campus Bio-Medico, were randomized into three different groups: Veress needle (VER), Direct trocar insertion (DIR) and Open technique (OP). For each group, minor complications (extra-peritoneal insufflation, trocar site bleeding, omental injury and surgical site infection), failed entry and time of entry of the main trocar were evaluated. Major complications were also considered. Between-group comparisons were performed using chi-square test. Significance P value was <0.05.

RESULTS

A series of 595 consecutive procedures were included: 193 in the VER group, 187 in the DIR group and 215 in the OP group. Minor complications occurred in 36 cases: extraperitoneal insufflation (n=6) in the VER group only, site bleeding (n=2 in the VER group, n=2 in the DIR group and n=1 in the OP group), site infection (n=5 in the VER and n=6 in OP group), and omental injury (n=6 in the VER group and n=3 in the DIR group). Failed entry occurred in 4 cases of the VER group and 1 case of the DIR group. Mean time of entry was 212.4, 71.4 and 161.7s for the VER, DIR and OP groups respectively. Among major complications, one bowel injury resulted following the Veress technique.

CONCLUSIONS

In our series, DIR and OP entry presented a lower risk of minor complications compared with VER. In addition, time of entry was shorter in DIR than with OP entry.

Conventional box model training improves laparoscopic skills during salpingectomy on LapSim: a randomized trial

OBJECTIVE

Box model trainers have been used for many years to facilitate the improvement of laparoscopic skills. However, there are limited data available on box trainers and their impact on skill acquisition, assessed by virtual reality systems.

MATERIAL AND METHODS

Twenty-two Postgraduate Year 1 gynecology residents with no laparoscopic experience were randomly divided into one group that received structured box model training and a control group. All residents performed a salpingectomy on LapSim before and after the training. Performances before and after the training were assessed using LapSim and were recorded using objective parameters, registered by a computer system (time, damage, and economy of motion scores).

RESULTS

There were initially no differences between the two groups. The box trainer group showed significantly greater improvement in time (p=0.01) and economy of motion scores (p=0.001) compared with the control group post-training.

CONCLUSION

The present study confirmed the positive effect of low cost box model training on laparoscopic skill acquisition as assessed using LapSim. Novice surgeons should obtain practice on box trainers and teaching centers should make efforts to establish training laboratories.

Incarcerated Trocar Site Herniation of the Small Bowel following Laparoscopic Myomectomy

Small bowel herniation through the fascial defect created by the entry of trocars is one of the major complications of the laparoscopic surgery. In this paper, we describe a 42-year-old woman developing an incarcerated trocar site herniation of the small bowel following laparoscopic myomectomy and treated by laparoscopic approach.

5-millimeter trocar-site bowel herniation following laparoscopic surgery

BACKGROUND AND OBJECTIVES

This is a case report of a 5-mm trocar-site large bowel herniation following laparoscopic tubal sterilization. During laparoscopic sterilization, the 5-mm port site was closed initially. Large bowel herniation was recognized at the end of the case and managed immediately by laparoscopically reducing the hernia and closing the port site without any short- or long-term complications. Trocar-site bowel hernia is a rare complication after laparoscopic surgery. It is usually associated with trocar size > 10 mm. We describe a case of bowel herniation through a 5-mm trocar site, which was managed after laparoscopic surgery.

CASE REPORT

A 36-year-old multigravid patient underwent a laparoscopic tubal fulguration. Two 5-mm ports were used for the procedure. At the end of the procedure, the lateral trocar site was found to have fat protrusion that looked like appendices epiploicae. A laparoscopic camera was reintroduced into the abdominal cavity that showed a large bowel herniation through the 5-mm lateral port site. The hernia was reduced laparoscopically, and the fascial defect was repaired.

CONCLUSION

Bowel herniation can occur through a 5-mm port. All port sites should be closed to avoid such complications.

Reasons and risk factors for intraoperative conversion from laparoscopic to open cholecystectomy

PURPOSE

The aim of this study was to analyze the reasons and risk factors for intraoperative conversion from laparoscopic cholecystectomy to open cholecystectomy.

METHODS

The study involved 407 patients in whom laparoscopic cholecystectomy was planned between January 1998 and July 2006. The patients were divided into two groups (the LC completed group and the conversion group), and the two groups were compared.

RESULTS

Laparoscopic surgery was intraoperatively converted to open surgery in 47 cases (11.6 %). The reasons for the conversion consisted of adhesions (15 cases), inflammation (8 cases), adhesion plus inflammation (9 cases), bleeding (8 cases), common bile duct injury (4 cases), suspected common bile duct injury (1 case), injury of the duodenal bulb (1 case) and respiratory disorder (1 case). The group of patients who required conversion to open surgery had a significantly higher percentage of males (P = 0.042) and prevalence of acute cholecystitis (P < 0.001) than the group of patients for whom laparoscopic surgery could be completed. A multivariate logistic regression analysis of these significant predictors showed that male sex [odds ratio (OR) 1.95] and acute cholecystitis (OR 8.45) were significant.

CONCLUSION

Particular attention is needed when laparoscopic surgery is considered for male patients with acute cholecystitis.

The incidence of trocar-site hernia in minimally invasive bariatric surgery: a comparison of multi versus single-port laparoscopy

INTRODUCTION

Single-port laparoscopy (SPL) employs a 1.5- to 2.5-cm incision at the umbilicus for the placement of a single working port. We hypothesized that the longer incision created by SPL compared with multiport laparoscopy may increase the incidence of trocar-site hernias. We examined our experience with SPL in bariatric operations.

METHODS

There were 734 laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding procedures performed at our institution between 2001 and 2011. Fifty-eight patients were lost to follow-up or had a short duration of follow-up (<1 month). Of the remaining 676 cases, 163 were performed via SPL. All laparoscopic wounds created by trocar size greater than 12 mm were closed with absorbable suture.

RESULTS

Patient demographics of the SPL group and the multiport group were similar in terms of age, gender, and comorbidities. The average body mass index (BMI) of the SPL group was lower than the multiport group (43.5 ± 5.3 vs. 45.8 ± 7.7, p < 0.01). The mean follow-up for the SPL group was 11 months versus 24 months for the multiport group. There were three trocar-site hernias out of 513 cases in the multiport compared to one hernia out of 163 cases in the SPL group (0.6 vs. 0.6 %, p = 0.967). All trocar-site hernias occurred at the 15-mm port site. The median time to hernia occurrence for the multiport group was 13 months (range, 1-18). In the SPL group, the hernia occurred at 8 months. On multivariate analysis, age, BMI, SPL, procedure type, and the postoperative weight loss were not associated with the development of trocar-site hernias.

CONCLUSIONS

SPL did not increase the rate of trocar-site hernia in this series. A low rate of trocar-site hernia can be achieved with the use of SPL in bariatric surgery.

Prophylactic surgery prior to extended-duration space flight: is the benefit worth the risk?

This article explores the potential benefits and defined risks associated with prophylactic surgical procedures for astronauts before extended-duration space flight. This includes, but is not limited to, appendectomy and cholecystesctomy. Furthermore, discussion of treatment during space flight, potential impact of an acute illness on a defined mission and the ethical issues surrounding this concept are debated in detail.

Laparoscopic entry techniques

BACKGROUND

Laparoscopy is a common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. Life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and an anterior abdominal-wall vessel. Other less serious complications can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To evaluate the benefits and risks of different laparoscopic techniques in gynaecological and non-gynaecological surgery.

SEARCH METHODS

This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. In addition, MEDLINE, EMBASE, CENTRAL and PsycINFO were searched through to February 2011.

SELECTION CRITERIA

Randomised controlled trials were included when one laparoscopic entry technique was compared with another.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the first three authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto OR) with 95% confidence interval (CI).

MAIN RESULTS

The review included 28 randomised controlled trials with 4860 individuals undergoing laparoscopy and evaluated 14 comparisons. Overall there was no evidence of advantage using any single technique in terms of preventing major vascular or visceral complications. Using an open-entry technique compared to a Veress Needle demonstrated a reduction in the incidence of failed entry, Peto OR 0.12 (95% CI 0.02 to 0.92). There were three advantages with direct-trocar entry when compared with Veress Needle entry, in terms of lower rates of failed entry (Peto OR 0.21, 95% Cl 0.14 to 0.31), extraperitoneal insufflation (Peto OR 0.18, 95% Cl 0.13 to 0.26), and omental injury (Peto OR 0.28, 95% CI 0.14 to 0.55).There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (Peto OR 0.31, 95% Cl 0.15 to 0.62). Finally, there was an advantage of not lifting the abdominal wall before Veress Needle insertion when compared to lifting in terms of failed entry, without an increase in the complication rate (Peto OR 4.44, 95% CI 2.16 to 9.13). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery and women with a raised body mass index who may have unusually high complication rates.

AUTHORS' CONCLUSIONS

An open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, with no difference in the incidence of visceral or vascular injury.Significant benefits were noted with the use of a direct-entry technique when compared to the Veress Needle. The use of the Veress Needle was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury; direct-trocar entry is therefore a safer closed-entry technique.The low rate of reported complications associated with laparoscopic entry and the small number of participants within the included studies may account for the lack of significant difference in terms of major vascular and visceral injury between entry techniques. Results should be interpreted with caution for outcomes where only single studies were included.

The risk of umbilical hernia and other complications with laparoendoscopic single-site surgery

STUDY OBJECTIVE

To estimate the risk of umbilical hernia and other latent complications in women who underwent laparoendoscopic single-site surgery (LESS) for a gynecologic indication.

DESIGN

Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2).

SETTING

Four tertiary care academic medical centers.

PATIENTS

Women undergoing LESS for a benign or malignant gynecologic indication from 2009 to 2011.

INTERVENTIONS

A total of 211 women underwent LESS via a single 1.5- to 2.0-cm umbilical incision. All surgeries were performed by advanced gynecologic laparoscopists. Incisions were repaired with a running, delayed absorbable suture. Subject demographics and clinical variables were collected and surgical outcomes analyzed.

MEASUREMENTS AND MAIN RESULTS

Median age and body mass index were 45 years and 30 kg/m(2), respectively. Approximately half of study subjects underwent a hysterectomy with or without salpingo-oophorectomy, and 15% had a diagnosis of cancer. Overall, 0.9% of women were diagnosed with a preoperative umbilical hernia, and 2.4% of women experienced a major perioperative complication. After a median postoperative follow-up time of 16 months, 2.4% had development of an umbilical hernia. However, 4/5 of these women had significant risk factors for fascial weakening independent of LESS, including requirement for a second abdominal surgery in 1 subject and a cancer diagnosis with postoperative chemotherapy administration in 2 subjects. When these subjects deemed "high risk" for incisional disruption were excluded from the analysis, the umbilical hernia rate was 0.5% (1/207). On univariable analysis, obesity was the only factor associated with complications (p = .04).

CONCLUSION

When performed by advanced laparoscopic surgeons, laparoendoscopic single-site gynecologic surgery is associated with a low risk of major adverse events. Additionally, the overall umbilical hernia rate was 2.4% and was lower (0.5%) in subjects without significant comorbidities.

Trocar site hernia after laparoscopic colectomy: a case report and literature review

Background. Trocar Site Hernia (TSH) is defined as an incisional hernia which occurs after minimally invasive surgery on the trocar incision site.In 2004 Tonouchi classified trocar site hernias into 3 types: Early onset type; Late onset type; Special type. Case Report. We report the case of a 76-year old woman that underwent an emergency explorative laparotomy on the 10th p.o. day after a laparoscopic left hemicolectomy. Surgery showed a small bowel herniation through the 12 mm trocar incision site; the intestinal loop appeared necrotic and had to be resected, and the hernia orifice was repaired. We carried out a review of literature about this topic. Discussion. The clinical onset of a trocar site hernia is usually early, occurring within the 30th post operative day and it is caused by the omentum or small bowel entrapment into the trocar orifice. The clinical presentation is insidious, with progression to an acute abdomen, and an emergency surgical approach is often required. Conclusions. TSH is a severe complication of operative laparoscopy especially with large-bore trocar ports. The incidence of TSH resulting from our review ranges from 0.007% to 22% with an average of 1.85%. Prevention of TSH appears to be more effective when trocar insertion through the abdominal wall is tangential, the closure of both the fascia and the peritoneum is performed if the incision is greater than 7 mm, the suture of extra umbilical port site is performed under laparoscopic vision.

[Trocar site incisional hernia in laparoscopic surgery]

Trocar site incisional hernias (TSIH) are the most common complications in laparoscopic surgery. We have carried out a review of the literature with the aim of establishing their incidence, the reasons for them happening, and their prevention. After a search in the MEDLINE PubMed and PubMed CENTRAL data bases from 1991 to 2009, combining the words: "hernia", "laparoscopy" and "trocar", we obtained 545 articles, of which we analysed 60 of them. The incidence of TSIH varies between 0.18% and 2.8%. The diameter of the trocar, obesity and age play a fundamental role when proceeding to close the fascia, a closure which is the most important factor to prevent these incisional hernias appearing. The appearance of new laparoscopic material and the increasing more common closure of defects of the fascia means that new and more extensive prospective studies should be performed.

Principles and strategies for dealing with complications in laparoscopy

PURPOSE OF REVIEW

To help surgeons and to make patients become fully aware of the risks of laparoscopic surgery. As complications are an inevitable reality of surgery, we need to be aware of the types of complications in a systematic way, train to respond in an appropriate way, and learn to communicate in a transparent and honest way to deal with complications in laparoscopic surgery.

RECENT FINDINGS

This article aims to classify complications associated with laparoscopy according to the different phases in surgery and to promote a comprehensive strategy for dealing with them.

SUMMARY

To promote a culture of risk management which delivers the benefits and minimizes the risks associated with laparoscopic surgery.