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

Prevalence of Umbilical Hernias by Computed Tomography

INTRODUCTION

Umbilical hernias (UHs) are commonly underdiagnosed due to their asymptomatic presentation. The aim was to determine the prevalence of UHs by computed tomography (CT) in a trauma center, to assess the magnitude of their underdiagnosis.

METHODS

A cross-sectional study was designed, using CT studies to evaluate the integrity of the abdominal wall. The images were obtained from consecutive cases of adult patients (≥18 y) from the database of the radiology and imaging service during a 4-mo period. The sociodemographic features, type of CT scan, and description of the abdominal wall were obtained and compared with the radiology report. In the case of UH presence, the transversal, cephalocaudal, and anteroposterior lengths, as well as its content, were registered.

RESULTS

A total of 472 CT scans were included with a 67.6% (n = 319) prevalence of UH. These were most common in men (58.9%, n = 188/319), but women were more likely to have UH ≥ 10 mm (55%, n = 72/131). Of those with UH, 63.6% were unreported by radiology. The most common content was peritoneal fat (87.5%). UH had medians (interquartile range) of 9.1 mm (6.8, 12.5), 8.3 mm (6, 11.5), and 12.8 mm (8.6, 18.2) in its transversal, cephalocaudal, and anteroposterior lengths, respectively. Transversal length had a high positive correlation with cephalocaudal length (r = 0.877). This datum relationship can be explained by at least 76% due to this factor. Interobserver reliability analyses resulted in substantial reliability (ICC>0.85 and k > 0.85).

CONCLUSIONS

CT is an effective imaging tool for diagnosing UH. There is a high prevalence among the general adult population, with a high radiologic underreporting.

Anatomical characteristics of the inferior epigastric artery in Uygur and it's implication in the management of bleeding

OBJECTIVES

This study aimed to determine the locations of the inferior epigastric arteries in a group of Uygur by ultrasound and explore the anatomical characteristics of vessels in the management of inferior epigastric bleeding.

METHODS

The study included 61 patients. The locations of inferior epigastric arteries through ultrasound were determined at three levels, and the distance from the midline was correlated with patients' demographics by Pearson correlation coefficient.

RESULTS

This study included 52 males and nine females, with a mean age of 37.56 years (± SD 3.16) and a mean BMI of 24.34 kg/m2 (± SD 3.71). At the symphysis pubis level, the average distance from the inferior epigastric artery to the midline was 5.98 ± 0.13 cm on the right and 7.32 ± 0.15 cm on the left. At the anterior superior iliac spine level, the average distance of the inferior epigastric artery on the right was 4.12 ± 0.15 cm and 5.2 ± 0.15 cm on the left. The inferior epigastric arteries were 3.86 ± 0.17 cm on the right and 5.06 ± 0.16 cm on the left of the midline at the level midway between the umbilicus and anterior superior iliac spine.

CONCLUSION

Inferior epigastric arteries were located between 3.5 and 8 cm from the midline, with the right vessel being closer to the midline than the left. The invasive operations through the abdominal wall should avoid these areas to reduce vascular injury. The anatomical characteristics of inferior epigastric arteries may potentially manage inferior epigastric bleeding.

Inferior Epigastric Artery Pseudoaneurysm Following Laparoscopic Appendectomy

An inferior epigastric artery pseudoaneurysm is an exceptionally rare occurrence. Formation of an inferior epigastric artery pseudoaneurysm can be seen following surgical intervention and is more common after laparoscopy. A sixty-eight-year-old male presented with a right upper quadrant bulge at his incision site two months following laparoscopic appendectomy. The patient reported sudden onset of a non-reducible bulge at a 5 mm trocar incision site with minimal pain and without obstructive symptoms. Computed tomography of his abdomen and pelvis with intravenous contrast revealed a 4.2 cm pseudoaneurysm with peripheral thrombosis within the right inferior epigastric artery. The patient subsequently underwent open exploration with the evacuation of pseudoaneurysm thrombus and ligation of arteriovenous fistula. The patient recovered well without complication from pseudoaneurysm. Inferior epigastric artery pseudoaneurysm following any laparoscopic procedure is rare. This case highlights the importance of understanding the abdominal wall anatomy and its vascular supply to avoid such injury. We present this case to bring light to this rare occurrence and to highlight the importance of proper trocar placement during any laparoscopic procedure.

A Spontaneous Groin Collection Masquerading as an Irreducible Inguinoscrotal Hernia

This case report details a clinically rare presentation in which a middle-aged man was diagnosed clinically with a large irreducible inguinoscrotal hernia. However, intraoperatively, a large volume of old blood/clots was seen and aspirated, without a definite hernia being identified. Inguinal hernias remain a clinical diagnosis, and imaging is used only in equivocal cases. Owing to the number of differential diagnoses associated with groin swelling, careful clinical assessment is critical in differentiating between the various causes. Rupture of the inferior epigastric vessels was suspected, and although rare, it should be considered as a differential diagnosis as this may alter ongoing management.

S, T.S. S, Chordia DA. Pseudoaneurysm of the Inferior Epigastric Artery Following Laparoscopic Extended Totally Extraperitoneal Repair for Inguinal Hernia

We hereby report a rare case of pseudoaneurysm of the left Inferior epigastric artery following extended totally extraperitoneal (e-TEP) repair for bilateral inguinal hernia. The patient developed swelling and pain in the lower abdomen one month following surgery. He was diagnosed to have a pseudoaneurysm of the left inferior epigastric artery with significant collection in the retro rectus plane. The pseudoaneurysm was thrombosed using Thrombin injection under ultrasound guidance. He was subsequently taken up for laparoscopic pseudo aneurysm excision with hematoma evacuation and ultrasound-guided transfascial ligation of the inferior epigastric artery with mesh explantation. The pseudoaneurysm was successfully treated and at follow-up, the patient’s symptoms were resolved.

Salvage of a DIEP Flap after Injury to the Inferior Epigastric Vessels after Laparoscopic Surgery

The problem of previous laparoscopic scars specifically endangering the DIEP flap harvest for breast reconstruction has not been described yet. Even though in our center, preoperative imaging by means of an magnetic resonance angiography (MRA) is routinely performed before a bilateral DIEP-flap reconstruction, it may not correspond with the intraoperative findings. This case was presented to increase awareness among plastic surgeons about the complications after laparoscopic surgery and to emphasize the importance of thorough history taking when performing a DIEP flap breast reconstruction after previous laparoscopic procedures.

Intraperitoneal hemorrhage following primary cytoreductive surgery for ovarian cancer: Successful treatment with superior epigastric artery embolization

Hemoperitoneum often occurs due to abdominal trauma, abdominal tumors, gastro-intestinal perforation and more rarely it's spontaneous due to coagulopathies. Superior epigastric artery (SEA) iatrogenic damage is rarer than the Inferior epigastric artery injury, it may occur during laparotomy and, in most cases, it causes a rectus muscle hematoma. We present the case of a caucasian 44 years-old-woman with hemoperitoneum after cytoreductive surgery for ovarian cancer. Active bleeding from the distal branch of the SEA was diagnosed at computed tomography and coil embolization followed by surgical laparotomic drainage of the hemoperitoneum was performed. After initial resolution, active bleeding from the same vessel was observed. Further embolization of the same vessel was necessary to stop bleeding. Ultrasound follow-up showed a complete resolution of the hemoperitoneum.

Successful Foley catheter tamponade of an epigastric vessel trocar injury in a toddler - A case report

•

Epigastric vessel injury is a well recognized complication during laparoscopic trocar placement.

•

Precautionary measures to prevent trocar induced injuries should be implemented to lower the incidence of this complication.

•

If this complication is encountered, tamponade by Foley catheter placement is an effective measure to provide hemostasis.

•

Hemorrhage control using a Foley catheter is feasible even in small children and toddlers.

Introduction and importance

Injuries to the inferior epigastric vessels during laparoscopic surgery are rare but reported. They can lead to significant morbidity. We report the successful tamponade of a bleeding epigastric vessel during laparoscopic inguinal hernia repair in a child using a Foley catheter. A Foley catheter has not been routinely used in pediatric surgery for this indication so far.

Case presentation

A 32-month-old boy underwent laparoscopic left inguinal hernia repair. During insertion of a 2 mm trocar, the left inferior epigastric vessels were lacerated, leading to a brisk bleed into the abdominal wall and into the abdomen through the trocar site during the procedure. When the hemorrhage was noted, the trocar was removed. The trocar tract was slightly dilated using a blunt forceps and a 12 F Foley catheter was introduced into the abdomen. The balloon was insufflated with 10 ml of water and the catheter was retracted towards the abdominal wall, tamponading the bleed. The inguinal hernia repair was completed, and after desufflating the catheter at the end of the procedure, the hemorrhage had stopped.

Clinical discussion

Postoperatively, the hemoglobin had dropped by 1.5 g/dl to 9.3 g/dl. The patient was observed and then discharged on the same day. Besides an additional 2 mm scar in the right lower quadrant, he had no further sequellae or adverse effects.

Conclusion

Hemorrhage resulting from trocar injury of the inferior epigastric vessels during laparoscopy can be controlled by Foley catheter insertion and tamponade in children. Pediatric surgeons should be aware of this useful maneuver to manage this complication.

Guidelines on the management of ascites in cirrhosis

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.

Development of a safety zone for rectus abdominis fascia graft harvest based on dissections of the ilioinguinal and iliohypogastric nerves

BACKGROUND

As a result of the vaginal mesh controversy, surgeons are performing more nonmesh, autologous fascia pubovaginal slings to treat stress urinary incontinence in women. The rectus abdominis fascia is the most commonly harvested site for autologous pubovaginal slings, so it is crucial that surgeons are familiar with the relationship between this graft harvest site and the ilioinguinal and iliohypogastric nerves, which can be injured during this procedure.

OBJECTIVE

The aims of this study were as follows: (1) to estimate the safest area between the bilateral courses of the ilioinguinal and iliohypogastric nerves in which a rectus abdominis fascia graft could be harvested with minimal risk of injury to these nerves and (2) to determine the location and dimensions of a graft harvest site that maximized graft length while remaining close to the pubic symphysis.

STUDY DESIGN

The ilioinguinal and iliohypogastric nerves were dissected bilaterally in 12 unembalmed female anatomical donors. The distances of these nerves to a 10 × 2 cm rectus abdominis fascia graft site located 4 cm above the pubic symphysis were measured. Nerve courses inferior to the graft site were determined for each donor by linearly extrapolating measurement points; analysis was performed with and without extrapolation. Average nerve trajectories were estimated assuming a linear regression function to predict the horizontal measurement as a quadratic function of the vertical distance; 95% confidence bands were also estimated. An estimated safety zone was determined to be the region between all credible nerve bounds.

RESULTS

The largest safety zone that was closest to the pubic symphysis was located at 5.4 cm superior to the pubic symphysis. At this location, the inferior border of the graft could measure 9.4 cm in length (4.7 cm bilaterally from the midline). Extrapolated nerve courses below the study graft site yielded a smaller safety zone located 2.7 cm superior to the pubic symphysis, allowing for the inferior border of the graft to be 4.8 cm (2.4 cm bilaterally from the midline).

CONCLUSION

A rectus abdominis fascia graft harvested 5.4 cm superior to the pubic symphysis with the inferior border of the graft measuring 9.4 cm in length should minimize injury to the ilioinguinal and iliohypogastric nerves. These dimensions allow for the longest graft while remaining relatively close to the pubic symphysis. The closer a graft is harvested to the pubic symphysis, the smaller in length the graft must be to avoid injury to the ilioinguinal and iliohypogastric nerves.

Comparison of Single-Incision and Conventional Laparoscopic Sleeve Gastrectomy for Morbid Obesity: a Meta-Analysis

BACKGROUND

Single-incision laparoscopic sleeve gastrectomy (SILSG) has been proposed as an alternative to conventional laparoscopic sleeve gastrectomy (CLSG) in obese patients. This study aims to compare the surgical outcomes of these two techniques.

METHODS

A meta-analysis of existing literature obtained through a systematic literature search in the PubMed, EMBASE, and Cochrane Library CENTRAL databases from 2009 to 2019 was conducted.

RESULTS

Eleven articles including 1168 patients were analyzed. Patients in the SILSG group reported greater satisfaction with cosmetic scar outcomes than those in the CLSG group (SMD = 2.47, 95% CI = 1.10 to 3.83, P = 0.00). There was no significant difference between the SILSG group and the CLSG group regarding operative time, intraoperative estimated blood loss, conversion rate, intraoperative complications, length of hospital stay, postoperative analgesia, postoperative complications, excess weight loss (EWL), and improvements in comorbidities (P > 0.05).

CONCLUSIONS

Compared to CLSG, SILSG resulted in improved cosmetic satisfaction and showed no disadvantages in terms of surgical outcomes; thus, SILSG can serve as an alternative to CLSG for obese patients. Nonetheless, high-quality randomized controlled trials (RCTs) with large study populations and long follow-up periods are needed.

Perforator Mapping of the Superficial and Deep Inferior Epigastric Artery in the Abdominal Region of the Vietnamese

BACKGROUND

Previous studies worldwide have investigated the anatomy of the perforators of the deep inferior epigastric arteries to figure out the navigation patterns of the perforators on the abdominal wall. This has been inconsistent amongst the researchers about how to select the perforator to increase the blood supply area for the flap.

AIM

To explore the blood supply area of the perforators of the superficial and deep inferior epigastric artery in the abdominal region of the Vietnamese by dissection and 64-slice multislice computed tomography (64-slice MSCT).

METHODS

A descriptive cross-sectional study Center from September 2014 to September 2016 on two groups including 30 cadavers fixed by formalin 10% in Anatomy Department of UPNT, and 37 patients getting the 64-slice MSCT abdominal arteries angiogram.

RESULTS

The superficial epigastric arteries at the level of the inguinal ligament were located in the middle region, with 96% (right) and 88.5% (left). The anterior superior iliac spine level was in the middle, and lateral regions of 68% and 32% respectively. The level of the umbilical cord was in the lateral region with 66.7% and 85.7%, respectively. There were about 6 perforators of the deep inferior epigastric arteries located in the navel area. These perforators were 70% in the medial region and 30% in the middle region.

CONCLUSION

Mapping the blood supply based on the fourth space in the abdominal region in which the superfical inferior epigastric arteries supplied the lateral area. The middle and the internal ones were the perforators of the deep inferior epigastric arteries.

Double direct hernia, triple indirect hernia, double Pantaloon hernia (Jammu, Kashmir and Ladakh Hernia) with anomalous inferior epigastric artey: Case report

•

First kind of case report in literature.

•

A unique case with double direct and triple indirect type of inguinal hernia.

•

Named as Jammu Kashmir and Ladakh Hernia.

•

Inferior epigastric artery may traverse an anomalous course in inguinal canal.

•

Presence of multiple hernia sacs ,if undetected, is risk for recurrence.

Introduction

Double direct and triple indirect type hernia in unilateral inguinal hernia is unique. Anomaly of pathway traversed by inferior epigastric artery is always of surgical importance. Meticulous exploration of the groin is mandatory for diagnosis of rare hernia.

Case report

A 46 year old male presented with the right groin swelling. An inguinal hernia having two direct types separated by anamalous inferior epigastric artery and three indirect types of hernia were present. There was one bubonocele and two funicular types of indirect type of hernia present on the single cord. Anamalous inferior epigastric artery lying superficially at midpoint of inguinal canal was buttresed in the posterior wall to prevent its entrapping in mesh. Individual ligation of the indirect sacs and Lichtenstein repair was done.

This is first kind of unique case report with the new type of hernia reported in the English literature after searching Pubmed, Medline, Google Scholar and Embase database. This new hernia, Double Pantaloon hernia, as a mark of respect and unity, is named after its State of origin, “Jammu, Kashmir and Ladakh” so called as “Jammu Kashmir and Ladakh Hernia”.

Conclusion

Double direct and triple indirect type hernia in a unilateral inguinal hernia is unique. Presence of multiple hernia sacs in the inguinal hernia is a risk for recurrence, if not detected. Inferior epigastric artery in inguinal canal may traverse an aberrant course.

Open versus minimally invasive surgery for rectal cancer: a single-center cohort study on 237 consecutive patients

Minimally invasive surgery (MIS) is gaining popularity in rectal tumor treatment. However, contrasting data are available regarding its safety and efficacy. Our aim is to compare the open and MIS approaches for rectal cancer treatment. Two-hundred-thirty-seven patients were included: 113 open and 124 MIS rectal resections. After the propensity score matching analysis (PS), the cases were matched into 42 open and 42 MIS. Short- and long-term outcomes, and pathological findings were analyzed before and after PS. A further comparison of the same outcomes and costs was conducted between the laparoscopic and the robotic approaches. As a whole, a sphincter-preserving procedure was more frequently performed in the MIS group (110 vs 75 cases; p < 0.0001). The estimated blood loss during MIS was significantly lower than during open surgery [127 (± 92) vs 242 (± 122) mL; p < 0.0001], with clear advantages for the robotic approach over laparoscopy [113 (± 87) vs 147 (± 93) mL; p 0.01]. Complication rate was comparable between the two groups. A higher rate of CRM positivity was evidenced after open surgery (12.4% vs 1.7%; p 0.004). A higher number of lymph nodes was harvested in the MIS group [12.5 (± 6.4) vs 11 (± 5.6); p 0.04]. After PS, no difference in terms of perioperative outcomes was noted, with the only exception of a higher blood loss in the open approach [242 (± 122) vs 127 (± 92) mL; p < 0.0001]. For the matched cases, no difference in 5-year overall and disease-free survival was evidenced (p 0.50 and 0.88, respectively). Mean costs were higher for robotics as compared to laparoscopy [9812 (±1974)€ vs 9045 (± 1893)€; p 0.02]. MIS could be considered as a treatment option for rectal cancer. The PS study evidenced clear advantages in terms of estimated blood loss over the open surgery. Costs still remain the main limit for robotics.

Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

Ex vivo radiocontrast description of the caudal epigastric arteries in horses

OBJECTIVE

To determine the location of the deep and superficial caudal epigastric arteries in relation to 3 midline positions and the relationship between the location of these arteries, body circumference, and body condition score.

STUDY DESIGN

Descriptive anatomical study.

SAMPLE POPULATION

Nine horses, aged 1-28 years (mean 10.61 ± 8.89 SD).

METHODS

Body condition score and body circumference were measured prior to euthanasia. Angiographic studies of the deep and superficial caudal epigastric arteries were performed on resected abdominal walls. The distances between the deep and the superficial caudal epigastric arteries and 3 midline positions were measured. Correlations among these distances, body circumference, and body condition score were analyzed.

RESULTS

The location of the deep caudal epigastric artery correlated with body circumference and body condition score at the umbilicus (r = 0.53 and 0.68, respectively), midpoint landmark (r = 0.79 and 0.83, respectively), and prepubic tendon attachment (r = 0.69 and 0.78, respectively). The course of this artery could be estimated by multiplying body circumference by 0.04 ± 0.02 at the umbilicus, 0.07 ± 0.01 at the midpoint landmark, and 0.03 ± 0.015 at the prepubic tendon attachment. The course of the superficial caudal epigastric artery did not correlate with anatomic landmarks.

CONCLUSION

The course of the deep caudal epigastric artery could be estimated at 3 midline landmarks on the basis of body circumference and body condition score in equine cadavers.

CLINICAL SIGNIFICANCE

Predicting the course of the caudal epigastric arteries in the equine abdomen based on correlation among location, body circumference, and body condition score may prevent iatrogenic damage during creation of laparoscopic portals.

The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations

PURPOSE

Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap.

METHODS

We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients' characteristics, such as abdominal surgery history.

RESULTS

CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm).

CONCLUSIONS

Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.

Better With Ultrasound: Paracentesis

Paracentesis is a commonly performed procedure and generally considered to be low risk. Despite its overall favorable safety profile, use of ultrasound has been demonstrated to reduce the incidence of complications, especially in higher risk patients. Many individual ultrasound techniques have been described in the literature, each with the goal of making paracentesis safer. This article presents a systematic approach for incorporating many of these tools into bedside practice and includes a series of illustrative figures and narrated video presentations to demonstrate the techniques described.

Survey of Abdominal Access and Associated Morbidity for Robot-Assisted Radical Prostatectomy: Does Palmer's Point Warrant Further Awareness and Study?

INTRODUCTION

Laparoscopic access for robot-assisted radical prostatectomy (RARP) is often initiated in the periumbilical location. Palmer's point, located in the left upper quadrant, has been reported as an alternative access site for pelvic laparoscopy to reduce morbidity, but not widely reported among urologists. To better understand surgeons' preferences for access and its associated morbidity during RARP, we surveyed surgeons from two urologic organizations.

METHODS

An anonymous online questionnaire (SurveyMonkey) consisting of 17 questions that assessed training, experience, and preferences for RARP was emailed in December 2014 and collected until February 2015 to members performing RARP of the Endourology Society (ES) and the Michigan Urological Society Improvement Collaborative (MUSIC). Surgeons were also asked to share their personal experience with a vascular, death or life-threatening event (DOLTE), or bowel injury during RARP.

RESULTS

Questionnaires were answered by 111 surgeons in total (ES, n = 71 and MUSIC, n = 40) with an estimated total response rate of 5.5%. In total, 77% reported prior experience with the Veress needle method before exposure to RARP and 71% of respondents primarily use the Veress needle for RARP, with 73% reporting access primarily at the periumbilical location. A personal experience with a vascular or a bowel injury during Veress needle insertion was reported in 18% and 9% of surgeons, respectively; furthermore, 26% of respondents were personally aware of at least 1 DOLTE among colleagues (5% reported 3 or more). The majority (56%) of respondents were unaware of Palmer's point, while among the minority aware of Palmer's point, only 33% reported ever using this location.

CONCLUSION

In this survey, surgeons most commonly access the abdomen at the periumbilical location with a Veress needle for RARP with the majority not aware or utilizing Palmer's point. Nearly one in five surgeons reported a personal experience with a vascular injury during access for RARP. Palmer's point, located away from major vasculature, may reduce the morbidity of access for RARP and warrants further awareness and study.

Unexpected hemorrhage during robot-assisted laparoscopic prostatectomy: a case report

Background

Robot-assisted laparoscopic prostatectomy is increasingly performed as a minimally invasive option for patients with organ-confined prostate cancer. This technique offers several advantages over other surgical methods. However, concerns have been raised over the effects of the steep head-down tilt necessary during the procedure. We present a case in which head-down positioning and abdominal insufflation masked the signs of an intraoperative hemorrhage.

Case presentation

A 73-year-old Asian man developed severe hypotension caused by an unexpected hemorrhage during robot-assisted laparoscopic prostatectomy for prostate cancer. Although our patient’s blood pressure steadily decreased during the procedure, his systolic blood pressure remained above 80 mmHg while he was tilted head downward at an angle of 28°. However, his blood pressure dropped immediately after he was returned to the horizontal position and abdominal insufflation – to create a pneumoperitoneum – was ceased at the end of surgery. We returned the patient to a head-down tilt to keep his blood pressure stable and began fluid infusion. Blood test results indicated that a hemorrhage was the cause of his hypotension. Open abdominal surgery was performed to stop the bleeding. The surgeons found blood pooling inside his abdomen from a longitudinal cut in a small arterial vessel in his abdominal wall, possibly a branch of his external iliac artery. The surgeons successfully controlled the hemorrhage and our patient was moved to our intensive care unit. Our patient recovered completely over the next few days, without any neurological deficits.

Conclusions

We suspect that blood began to pool in our patient’s superior abdomen during surgery, and that increased intra-abdominal pressure suppressed the hemorrhage. When our patient was returned to the horizontal position and insufflation of his abdomen was discontinued, the resulting increased rate of hemorrhage caused a sudden drop in blood pressure. Surgeons and anesthesiologists must understand the hemodynamic changes that result from head-down patient positioning and abdominal insufflation.

Abdominal Wall Vascular Injury by Drain Insertion after Anterior Lumbar Spinal Fusion

A 64-year-old gentleman presented with haemoglobin drop and an increase in fresh blood output in abdominal drain after anterior lumbar spinal fusion. Urgent re-exploration was performed, and injury to abdominal wall vessel during drain insertion leading to active bleeding was noted. Here, we report this rare case and summarize the characteristics of vasculature of abdominal wall, which may help reduce the possibility of this rare complication.

Location of the Deep Epigastric Vessels in the Resting and Insufflated Abdomen

STUDY OBJECTIVE

To determine whether the location of the superior and inferior epigastric vessels (deep epigastric vessels) change with abdominal insufflation.

DESIGN

Descriptive study (Canadian Task Force classification III).

SETTING

Tertiary care academic institution.

PATIENTS

Patients undergoing gynecologic laparoscopic surgery were recruited. A total of 35 subjects were enrolled.

INTERVENTIONS

Subjects underwent color Doppler ultrasound assessment of deep epigastric vessel location preoperatively and intraoperatively following abdominal insufflation. The deep epigastric vessels were identified at 5 points along the abdomen (pubic symphysis, anterior superior iliac spine [ASIS], umbilicus, xiphoid, and midpoint from umbilicus to xiphoid), with the distance from vessels to midline measured. Paired t tests and split-plot analysis of variance were used as appropriate.

MEASUREMENTS AND MAIN RESULTS

The mean patient age was 45.6 ± 16.5 years, and mean BMI was 29.8 ± 7.2. A significant difference between vessel location in the resting abdomen and insufflated abdomen was noted bilaterally at the ASIS, umbilicus, and midpoint from the umbilicus to the xiphoid. At each of these points, the deep epigastric vessels were found more laterally after insufflation on average, ranging from 0.6 ± 0.9 cm (p < .001) more laterally at the midpoint between the umbilicus and xiphoid to 1.1 ± 0.8 cm (p < .001) more laterally at the umbilicus. The most lateral location of the deep vessels after insufflation was seen at the ASIS (10.6 cm) and the umbilicus (10.9 cm). In a subanalysis of subjects grouped by body mass index (obese vs nonobese), deep epigastric vessels were more lateral in the insufflated abdomen of obese subjects compared with that of nonobese subjects at the ASIS, umbilicus, and midpoint from umbilicus to xiphoid (p < .05 for each point bilaterally).

CONCLUSION

The deep epigastric vessels shift laterally with abdominal insufflation, and may be found as far as 10.9 cm from the midline; this is more lateral than previously described and is clinically significant. Obesity is associated with a more lateral location of the deep epigastric vessels.

Vulvar Haematoma Following Laparoscopic Endometrioma Excision: Report of A Rare Complication

Vulvar haematoma as a complication of laparoscopic adnexal surgery has rarely been reported. Indeed, to our knowledge, there are only two case reports describing postlaparoscopic vulvar haematoma in the literature. Although complications associated with laparoscopy are mostly related to bowel or retroperitoneal vessel injury, vulvar haematoma may seldom develop. Vulvar haematoma after laparoscopy may indicate abdominal wall or pelvic vascular injury. We present a case of postoperative vulvar haematoma following laparoscopic endometrioma excision.

Pneumoperitoneum simulation based on mass-spring-damper models for laparoscopic surgical planning

Laparoscopic surgery, which is one minimally invasive surgical technique that is now widely performed, is done by making a working space (pneumoperitoneum) by infusing carbon dioxide ([Formula: see text]) gas into the abdominal cavity. A virtual pneumoperitoneum method that simulates the abdominal wall and viscera motion by the pneumoperitoneum based on mass-spring-damper models (MSDMs) with mechanical properties is proposed. Our proposed method simulates the pneumoperitoneum based on MSDMs and Newton's equations of motion. The parameters of MSDMs are determined by the anatomical knowledge of the mechanical properties of human tissues. Virtual [Formula: see text] gas pressure is applied to the boundary surface of the abdominal cavity. The abdominal shapes after creation of the pneumoperitoneum are computed by solving the equations of motion. The mean position errors of our proposed method using 10 mmHg virtual gas pressure were [Formula: see text], and the position error of the previous method proposed by Kitasaka et al. was 35.6 mm. The differences in the errors were statistically significant ([Formula: see text], Student's [Formula: see text]-test). The position error of the proposed method was reduced from [Formula: see text] to [Formula: see text] using 30 mmHg virtual gas pressure. The proposed method simulated abdominal wall motion by infused gas pressure and generated deformed volumetric images from a preoperative volumetric image. Our method predicted abdominal wall deformation by just giving the [Formula: see text] gas pressure and the tissue properties. Measurement of the visceral displacement will be required to validate the visceral motion.

Inferior epigastric artery pseudoaneurysms

INTRODUCTION

Inferior epigastric artery (IEA) pseudoaneurysms are recognised complications of abdominal wall procedures, and a variety of approaches including surgical excision and ligation, percutaneous procedures and conservative management have been employed in treating this rare complication.

METHODS

We describe a case of an IEA pseudoaneurysm diagnosed on computed tomography (CT) angiography, 14 days following a laparoscopic assisted low anterior resection, which was managed successfully with surgical excision and ligation. A review of the literature identified 32 reports of this complication since 1973 with 69% of cases occurring since 2000.

FINDINGS

The main aetiology of IEA pseudoaneurysm was abdominal surgery (n=20); 65% of cases were attributable to abdominal wound closure or laparoscopic surgery. Two-thirds (66%) of patients presented between 11 and 63 days, and all except 1 case presented with discomfort, abdominal mass or haemodynamic instability. Colour Doppler ultrasonography was the imaging modality of choice (n=18), either alone or in combination with computed tomography and/or angiography. Surgical ligation and excision and percutaneous coil embolisation formed the mainstay of attempted treatments (69%), particularly following treatment failure using an alternative technique.

CONCLUSIONS

The incidence of iatrogenic IEA pseudoaneurysms appears to be increasing. Awareness of this rare complication is of clinical importance to avoid excessive morbidity for affected individuals.

Laparoscopy in trauma: An overview of complications and related topics

The introduction of laparoscopy has provided trauma surgeons with a valuable diagnostic and, at times, therapeutic option. The minimally invasive nature of laparoscopic surgery, combined with potentially quicker postoperative recovery, simplified wound care, as well as a growing number of viable intraoperative therapeutic modalities, presents an attractive alternative for many traumatologists when managing hemodynamically stable patients with selected penetrating and blunt traumatic abdominal injuries. At the same time, laparoscopy has its own unique complication profile. This article provides an overview of potential complications associated with diagnostic and therapeutic laparoscopy in trauma, focusing on practical aspects of identification and management of laparoscopy-related adverse events.

Hemorrhagic shock after minor laparoscopic procedures

Severe bleeding from injury to abdominal wall blood vessels during minor laparoscopic procedures can occur. Two cases of shock presenting several hours after surgery are presented.

Two-detector Computed Tomography Map of the Inferior Epigastric Vessels for Percutaneous Transabdominal Intervention Procedures

BACKGROUND

It is crucial to know anatomic variations and the exact course of an inferior epigastric artery (IEA) to prevent any complications during percutaneous abdominal interventions.

AIMS

The aim of this study was to map the inferior epigastric vessels using reconstructed two-detector computed tomography images and measure the distance from the inferior epigastric artery (IEA) to the midline to determine a safe route for percutaneous abdominal interventions.

STUDY DESIGN

Retrospective comparative study.

METHODS

Coronal reconstructed two-detector computed tomography images of 200 patients were evaluated to measure the distances between the IEA and midline at three levels (origin, middle, and distal). Vein and artery arrangements were documented.

RESULTS

The most frequently encountered arrangement (41.5%) was a single vein and artery on both sides. Mean distances on the right and left sides were 4.01 and 4.47 cm at the umbilical level, 3.81 and 4.26 cm at the midlevel, and 5.62 and 5.51 cm at the origin level. On both sides, measurement differences between the three levels were highly significant (p<0.05). In addition, a total of 56 IEA bifurcations were depicted in all 200 patients. Thirteen of the 56 bifurcations occurred only on the right side, 11 only on the left side, and 32 on both sides.

CONCLUSION

It is important to be attentive to the IEA's course, at different midline levels, when attempting percutaneous interventions via an abdominal approach.

Single-incision videolaparoscopic appendectomy with conventional videolaparoscopy equipment

Background

Acute appendicitis is the most common surgical emergency in daily practice, and is approached laparoscopically in many centers. Efforts have been undertaken for the development of minimally invasive techniques that reduce tissue trauma and offer improved cosmetic results, one of such being the single-incision laparoscopic surgery (SILS).

Aim

To present a minimally invasive technique for appendectomy (SILS) undertaken with conventional instruments.

Method

Eleven patients were treated in the emergency care center presenting abdominal pain in the right iliac fossa that was suggestive of appendicitis. Diagnostic investigation was subsequently conducted, including physical examination, laboratory and imaging exams (CT scan with intravenous contrast or total abdominal ultrasound), and the results were consistent with acute appendicitis. Thus, after consent, these patients underwent SILS appendectomy under general anesthesia with three trocars (two 10 mm and one 5 mm), using conventional and optical laparoscopic tweezers (10 mm, 30º). The base and pedicle of the appendix were ligated with titanium LT 400 clips. The procedure occurred uneventfully. Inclusion criteria were absence of diffuse peritonitis, BMI (body mass index) less than 35 and absence of serious comorbidities or sepsis.

Results

Seven men and four women were operated with average age of 25.7 years and underwent appendectomy through this technique. Mean procedure duration was of 37.2 min. Regarding surgical findings, three had appendicitis in stage 1, four in stage 2 and four in stage 3. All patients improved well, without surgical complications, and did not require conversion to open surgery or conventional laparoscopy technique.

Conclusion

Appendectomy conducted through Single Incision Laparoscopic Surgery is a feasible and promising technique that can be performed with conventional laparoscopic instruments.

Prospective, randomized comparative study between single-port laparoscopic appendectomy and conventional laparoscopic appendectomy

INTRODUCTION

Laparoscopic appendectomy is probably the technique of choice in acute appendicitis. Single port laparoscopic surgery (SILS) has been proposed as an alternative technique. The objective of this study is to compare the safety and efficacy of SILS against conventional laparoscopic appendectomy (LA).

MATERIAL AND METHODS

From January 2011 to September 2012, 120 patients with acute appendicitis were prospectively randomized; 60 for SILS and 60 for LA. Patients between 15 to 65 years were selected, with onset of symptoms less than 48h. We compared BMI, surgery time, start of oral intake, hospital stay, postoperative pain, pathology and costs.

RESULTS

The median age, BMI, sex and time of onset of symptoms to diagnosis were similar. There were no statistically significant differences in the operative time, start of oral intake or hospital stay. There was a significant difference in postoperative pain being higher in SILS (4±1.3) than in LA (3.3±0.5) with a P=.004. Flemonous appendicitis predominated in both groups in a similar percentage. A total of 3 cases with intra-abdominal abscess (SILS 2, LA 1) required readmission and resolved spontaneously with intravenous antibiotic treatment. One case of SILS required assistance by a 5mm trocar in the RLC for drainage placement. The cost was higher in SILS due the single port device.

CONCLUSION

SILS appendectomy is safe, effective and has similar results to LA in selected patients, and although the cost is greater, the long term results will determine the future of this technique.

Study of the course of inferior epigastric artery with reference to laparoscopic portal

INTRODUCTION:

Laparoscopy has been in vogue for more than 2 decades. Making portals in the anterior abdominal wall for introducing laparoscopic instruments is done with trocar and cannula which is a blind procedure. Stab incision and trocar insertion, though safe, at times can lead to injury of blood vessels of anterior abdominal wall more so the inferior epigastric artery (IEA). Trauma to abdominal wall vessels is 0.2%-2% of laparoscopic procedures and said to be 3 per 1000 cases. Injury to IEA is one of the commonest complications seen. Purpose of the present study was to observe the course of IEA in 50 formalin preserved cadavers, by dissection.

MATERIALS AND METHODS:

In 50 formalin fixed cadavers, IEA was exposed by opening the rectus sheath. Rectus was divided and IEA was exposed. Five reference points A, B, C, D, and E were defined. A was at pubic symphysis, while E at umbilicus. B, C, and D were marked at the distance of 3.5, 7, and 10.5 cm, respectively from pubic symphysis. Distances of the IEA from these midline points were measured with the help of sliding vernier calipers.

RESULTS:

Significant observation was variations in the length of IEA. It was seen to end at a lower level than normal (three cases on right and four on left side) by piercing rectus. In 14, cadavers artery did not reach up to umbilicus on both sides. Nearest point of entry of IEA in to rectus sheath at the level of pubic symphysis was 1.2 cm on left and 3.2 cm on right side. Farthest point from point A was 6.8 cm on right and 6.9 cm on left side. Width of strip of abdominal wall which was likely to have IEA beneath was up to 4 cm till level C and beyond which it widened up to 5cm on left side and 6 cm on right at umbilicus.

DISCUSSION:

Present study did reveal notable variations in length and termination of IEA. No uniformity in entry of IEA in to the rectus sheath was observed. Findings did concur with earlier observations but the strip of skin of arterial zone was not equidistant from midline but had moved more medially on left side. Medial limit of this safety zone found to be lesser than 2 cm on left side. However, the lateral limit of the zone was within 7.5 cm. Additional variation was strip of abdominal wall likely to have IEA beneath was up to 4 cm till level C and had diverging limits beyond C. IEA was more notorious in its course. These variations prompt for a preoperative mapping of IEA and thus a useful step in preoperative protocol.

Inferior epigastric artery pseudoaneurysm in a kidney transplant recipient

Pseudoaneurysm of inferior epigastric artery (IEA) is a very rare clinical entity. We reported a case of combined kidney transplant and pseudoaneurysmectomy in a young HBV-HCV-HIV recipient. This case emphasizes the possibility of planning a safe and correct surgical treatment and the best timing to treat IEA pseudoaneurysm. An exhaustive preoperative radiological study in all patients candidate to kidney transplant could identify the possible aortoiliac disease both stenotic or dilatative even if it is rare and helps to define the best treatment options.

Single-port Roux-en-Y gastric bypass: toward a less invasive procedure with the same surgical results and a better cosmesis

BACKGROUND

The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach.

METHODS

A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m(2), and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device.

RESULTS

The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m(2), and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m(2) (range, 18-35 kg/m(2)). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose.

CONCLUSIONS

Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach.

Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy

INTRODUCTION

The use of single-incision laparoscopic surgery may represent an improvement over conventional laparoscopic surgery. In recent years, more and more articles have been published demonstrating the feasibility of this approach. Hence, for this reason, we present this randomized prospective study to compare the 2 techniques.

METHODS

Between September 2009 and December 2010, a total of 184 patients with a diagnosis of acute appendicitis and indicated for surgery were included in the study, of whom, 91 received an appendectomy via a single umbilical incision and 93 via conventional laparoscopy. The study protocol was approved by the ethical committee of the Virgen de la Arrixaca University Hospital (Murcia). The study was registered on ClinicalTrials.gov with inscription number NCT0151529. All the operations were performed by the same team of surgeons.

RESULTS

As far as the demographical results of the study population are concerned, there were no significant differences between the 2 groups for age, weight, sex, body mass index, and removed appendix type. Operating time was longer with the single-port approach: 38.13 ± 13.49 versus 32.12 ± 12.44 minutes (P = 0.02). Significant differences were observed for postoperative pain, which was measured on the visual analog scale, with less pain reported in the single-incision group: 2.76 ± 1.64 versus 3.78 ± 1.76 (P < 0.001). There were no significant differences between the 2 groups for early and late complications and lengths of hospital stay measured in postoperative hours.

CONCLUSIONS

The transumbilical single-port approach is seen as a feasible technique for performing appendectomy. It does not increase the rate of complications and represents a possible alternative to conventional laparoscopic appendectomy.