Fascial closure of laparoscopic port sites: a new technique

The laparoscopic operative procedure is not complete until the port sites are closed with a fascial suture. Herein, we report a simple new technique that uses a venous catheter for suture placement and direct laparoscopic visualization to secure the abdominal wall fascia and peritoneum.     

A new technique applicable to pediatric laparoscopic surgery: abdominal wall 'area lifting' with subcutaneous wiring

BACKGROUND: Recently, the authors developed a unique method of laparoscopic surgery without pneumoperitoneum: "area lifting of the abdominal wall with subcutaneous wiring." METHODS: In this gasless procedure, the anterior abdominal wall is pulled upward by a pair of wires placed subcutaneously and held by thick sutures for "hanger lifting." Simultaneous lifting of a pair of subcutaneous wires across the abdomen, produces a wide, roof-shaped intraabdominal space sufficient for laparoscopic surgical procedures. The practical aspects of this gasless technique, as well as the authors' limited experience with this method in 24 children, ranging from 8 days to 15 years of age is presented. These children have had various pathologies including splenomegaly, rectal prolapse, ovarian cyst, gall stone, adrenal neuroblastoma, and abdominal wall abscess. CONCLUSIONS: Gasless laparoscopic surgery with double subcutaneous wiring is safe for children including neonates and those with respiratory compromise because all operative procedures are performed under normal abdominal pressure. Because of the highly elastic abdominal wall musculature inherent in children, this selective area lifting of abdominal wall creates a relatively larger peritoneal volume than in adults.     

CT of abdominal wall implantation metastases after abdominal percutaneous procedures

PURPOSE: Our goal was to report the CT manifestations of abdominal wall implantation metastases occurring after abdominal percutaneous procedure. METHOD: CT scans and clinical data of six patients with abdominal wall implantation metastases at the puncture site following abdominal percutaneous procedure were reviewed. The abdominal percutaneous procedures included drainage of intraperitoneal abscess in patients with colon or gastric cancer (n = 2), transhepatic biliary drainage in a patient with hilar cholangiocarcinoma (n = 1), biopsy of intrahepatic hepatocellular carcinoma (n = 1), biopsy of a metastatic left adrenal gland (n = 1), and laparoscopic cholecystectomy in a patient with unsuspected gallbladder cancer (n = 1). RESULTS: CT enabled the diagnosis of abdominal wall implantation metastasis in all six patients and showed coexisting intraabdominal tumor sites in five patients. All abdominal wall implantation metastases were homogeneous before intravenous administration of iodinated contrast material and became moderately heterogeneous on contrast-enhanced CT scan with marked enhancement relative to adjacent tissues. CONCLUSION: Abdominal wall implantation metastases are moderately heterogeneous on contrast-enhanced CT scan with marked enhancement relative to adjacent tissues. In most cases of abdominal wall implantation metastasis following abdominal percutaneous procedure, CT shows additional intraabdominal tumor sites. This complication may occur following a variety of abdominal percutaneous procedures (either radiological or surgical).     

The postpubertal change in the playful defense of male rats depends upon neonatal exposure to gonadal hormones

Only 19 cases of metastases at the cannula insertion site after laparoscopy for gynecological malignancy have been reported in the literature. One case has been diagnosed with cervical squamous cell carcinoma, whereas the others have been diagnosed with ovarian cancer and borderline ovarian tumor. We present a novel case of laparoscopy-site abdominal wall metastasis from endometrial cancer after laparoscopic-assisted vaginal hysterectomy (LAVH). The 56-year-old female patient exhibited metastases of an abdominal wall trocar site and a perineal site after undergoing LAVH and laparoscopic-assisted (LA) bilateral pelvic lymph node sampling as well as LA para-aortic lymph node sampling for treating endometrial carcinoma, surgical staging IIIC, G3. The interval between the surgical extirpation of endometrial carcinoma and diagnosis of the tumor recurrence was 6 months, suggesting that overmanipulation of the diseased organ during laparoscopic surgery may have resulted in tumor spillage, intraperitoneal dissemination, and wound contamination. Although this procedure has been proven beneficial to patients with benign disease or early-stage gynecologic malignancies, laparoscopic-assisted vaginal hysterectomy may not be efficacious to eradicate advanced gynecological malignancy.     

Collagen type XVI expression is modulated by basic fibroblast growth factor and transforming growth factor-beta

A new instrument for laparoscopic access consists of a trocarless, reusable, visual-access cannula with an external thread that ends in a blunt tip. The device has no sharp ends or moving parts. The cannula does not transect but radially stretches and elevates vessels, fascia, and muscle fibers, preserving the fascia's natural gridiron shutter mechanism at the access site. The outer thread stabilizes the cannula, and no fascial suture is necessary. In a prospective clinical trial between 1994 and 1997, the instrument was used in 203 patients requiring 234 access ports for diagnostic and operative laparoscopies. No device-related complications or failed attempts were recorded. The cannula caused less tissue trauma at access sites, and may decrease the frequency of hernias and postoperative access site pain.     

Unreferred: a chance to air my prejudices?

STUDY OBJECTIVE: To discern the best method of wound closure after laparoscopy based on patient acceptability of pain, complications, and cosmetic result. DESIGN: Randomized, prospective study. SETTING: A university-affiliated hospital. PATIENTS: Fifty-four women. Interventions. The women received interrupted 3-0 nylon sutures, subcuticular 3-0 polyglactin 910 sutures, or adhesive strips for skin closure. At the umbilical port site the rectus sheath was closed with a single 0 polyglactin suture and then one of the three materials for skin closure. The lateral ports were closed with a combination of these materials, allowing each patient to act as her own control. MEASUREMENTS AND MAIN RESULTS: Pain was significantly less in wounds closed by subcuticular technique than in those closed by either transcutaneous suture or adhesive strips. This was seen for the 5-mm, 10-mm, and umbilical port sites. There was no statistically significant difference in the rate of reported complications or patient satisfaction between subcuticular and transcutaneous wound sites. CONCLUSION: We believe these results support subcuticular methods of wound closure after laparoscopic procedures.     

Manual vs robotically assisted laparoscopic surgery in the performance of basic manipulation and suturing tasks

OBJECTIVE: To compare the surgical performance of manual and robotically assisted laparoscopic instruments on basic maneuvers and intracorporeal suturing in inanimate models. DESIGN: A set of laparoscopic tasks was used to evaluate basic endoscopic movements and intracorporeal suturing: positioning a cylinder on a Peg-Board, dropping beads into receptacles, running a 25-cm rope, and capping a hypodermic needle. Intracorporeal knot tying and running a suture through predetermined points were evaluated separately. The sutures used for these tasks were 2-0 and 4-0 silk and 6-0 and 7-0 polypropylene. PARTICIPANTS: Twenty surgeons completed the set of laparoscopic tasks manually and then with a robotically assisted system. None had used the robotic system before. MAIN OUTCOME MEASURES: Time required to complete the tasks and the precision in performing them. RESULTS: The robotic system accurately reproduced the movements of the surgeons and filtered their hand tremors efficiently. In the basic tasks, operative times were significantly longer for the robotic system (P<.001). In the suturing tasks, operative times were longer with the use of the robotic system for sutures sizes 2-0 and 4-0 (P<.001). However, time differences were not significant for suture sizes 6-0 and 7-0 (P> or =.07). Precision measurements were similar for all tasks using the manual instruments and the robotically assisted system. No significant differences were found between the performance of advanced laparoscopic surgeons and laparoscopic fellows. CONCLUSIONS: Laparoscopic maneuvering and suturing is faster and just as precise when performed manually as when performed with the prototype robotic system. These differences in speed are inversely proportional to the size of the suture. Future generations of the robotic system may eliminate these differences.     

Laparoscopic myomectomy. 102 cases

Myomectomy was performed by laparoscopy in 102 patients, according to a precise technique using the monopolar hook for the uterine incision and intraperitoneal sutures. Myomes were mostly removed through the suprapubic puncture site after fragmentation or by colpotomy. A laparotomy during the laparoscopic procedures was necessary in 2 cases. No complications were observed. A second-look laparoscopy or a cesarean section was performed in 24 cases. Post-operative adhesions were noted in 3 cases. In our experience, operative laparoscopy has several advantages over laparotomy and the risks of complications is low in selected cases.     

Peripheral blood granulocytes and mononuclear cell responses in monkeys with experimental shigellosis

Between January 1992 and November 1992, four consecutive patients (ages 53 to 81 years) underwent early surgical repair of postinfarction ventricular septal ruptures using a new simple operative technique. The principles of the technique are longitudinal incision of the infarcted left anterior ventricular wall, placement of a saccular patch of single equine pericardium that covers the infarcted left ventricular wall, and large buttressed suture closure of the left ventriculotomy. The infarcted septum and infarcted left ventricular wall are completely separated from the left ventricular cavity. In this procedure, the infarcted myocardium is not resected, and left and right ventricular muscles are preserved. This technique is simple and safe for use in the acute phase of myocardial infarction, and it preserves ventricular function after surgery.     

Home care. Doing right for the wrong reason

Abomasal fistulae resulting from right paramedian abomasopexy in eight adult dairy cattle were treated by primary closure of the abdominal wall after surgical resection of the fistulae. The median elapsed time from the abomasopexy to recognition of fistula formation was 16 days (range, 10 to 90 days). All cows had normal electrolyte values, and five cows had mildly increased base excess values (range = 4.0 to 7.8 mEq/L). Surgery was performed with the cows in dorsal recumbency using general anesthesia. The fistulated tissue was resected and the abomasum and body wall were closed primarily. One or two layers of appositional sutures using #2 or #3 polyglactin 910 were used to close the body wall. Mean surgical time was 2.2 hours (range, 1.8 to 2.9 hours). Two cows were lost to follow-up. Five of the remaining six cows returned to production (range, 5 to 30 months). Primary closure of the abdominal wall should be considered in the surgical repair of abomasal fistulae in cows that do not have diffuse peritonitis.     

Surgical closure of persisting failed tracheoesophageal voice fistula

Tracheoesophageal puncture (TEP) is a highly successful procedure for voice restoration. Occasionally, however, patients fail to achieve satisfactory voice or develop salivary leakage through the fistula into the trachea. Closure of the TEP is then necessary. In most cases, spontaneous closure occurs once the prosthesis has been removed. When the fistula does not close spontaneously, surgical closure is indicated to prevent aspiration and pulmonary complications. We describe a three-layer technique that employs interposition of dermal graft. The technique was used on 14 patients over a 7-year period. Most patients received irradiation to the neck. Complete closure was achieved in 13 of 14 cases; 1 patient developed partial breakdown of the closure. Our technique is relatively easy to perform and has a high success rate (92%). Irradiation did not adversely affect the closure rate.     

Comparison of the degree of abdominal adhesion formation associated with chromic catgut and polypropylene suture materials

OBJECTIVE: To evaluate the histologic pattern and biomechanical properties of adhesions caused by chromic catgut and polypropylene sutures, using an enteropexy model. DESIGN: Enteropexies were created in dogs, using chromic catgut and polypropylene suture. The adhesions associated with the enteropexies were examined histologically and mechanically. ANIMALS: 6 mixed-breed dogs weighing 16 to 20 kg. PROCEDURE: 72 enteropexies were created between the jejunum and abdominal wall. 36 sites were sutured with chromic catgut and 36 were sutured with polypropylene. 3 dogs were euthanatized after 1 week. The remaining dogs were euthanatized after 1 month. Samples of the enteropexy sites were obtained for histologic examination. The remaining sites were mechanically distracted until failure of the enteropexy site or adjacent tissue occurred. RESULTS: Histologic examination of the enteropexy sites did not reveal substantial differences in the degree of inflammation between the 2 suture types at 1 week or 1 month. The degree of inflammation decreased and the maturity of fibrous tissue formed at the enteropexy sites increased for all specimens over time. No statistically significant difference in breaking strength was observed between suture types at 1 week or 1 month. CONCLUSION: In dogs, the formation and strength of intentionally created abdominal adhesions are not increased by use of chromic catgut. CLINICAL RELEVANCE: Selection of chromic catgut suture for use in surgical procedures where adhesions are desired is unwarranted.     

Calibration of a reflectance pulse oximeter in fetal lambs for arterial oxygen saturations below 70%

Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.     

A modified suture in the surgical treatment of middle ventral hernias

Mechanical stability of the front abdominal wall median anatomic structure tissues has been examined in 49 experiments on cadavers. It was found that aponeurotic tissue of the edges of sheaths of the rectus abdominis is the most firm one. The article analyses different types of sutures used in hernioplasty. The authors propose original method of hernioplasty using the most stable anatomic structure, formation of narrow tissue duplication with a minimal amount of suture material. This method has been used in surgical treatment of 58 patients with umbilical, postoperative and linea alba hernias. There were no recurrences for 3 years.     

Laparoscopic cholecystectomy--analysis of the first 100 operations

Laparoscopic cholecystectomy is a surgical method of removing the gallbladder through four small incisions on the abdominal wall using laparoscopic technique with specially designed equipment and instruments. The method is characterized with the following: reduced operative trauma and postoperative pain, shorter hospital stay, quicker recovery and better cosmetic effect. This method is in surgical practice in the last 10 years, whereas in General Hospital in Senta, in the surgical department it was introduced in June 1995. In the period June 16, 1995-March 1, 1996 one hundred patients underwent laparoscopic cholecystectomy. The median age of patients was 48 years; 79% were females and 21% were males. There was no operative mortality. Four (4%) mild complications occurred. Conversion was performed in only one patient (1%). The average operation time was 54 minutes, while the postoperative hospital stay was 2.3 days.     

Telesurgical consultation

PURPOSE: We evaluated the feasibility of "telesurgical" consultation during laparoscopic surgery. Telesurgical consultation is a distinct application of telemedicine in which a surgeon at a primary operating site can consult another experienced surgeon or colleague for complex and/or unexpected problems encountered during surgery. MATERIALS AND METHODS: Telesurgical consultation was used in 6 complex laparoscopic cases, including upper pole nephrectomy, diagnostic laparoscopy with inguinal hernia repair, orchiectomy, gastric augmentation with bladder suspension, bladder reconstruction and ureteral lithotomy. RESULTS: In each case an experienced laparoscopic surgeon at the primary operative site consulted a surgical specialist at the remote site who had expertise in the particular procedure being performed. All procedures were accomplished successfully without intraoperative or post-operative complications. CONCLUSIONS: Complex laparoscopic procedures that normally require a surgical specialist can be performed successfully by an experienced laparoscopic surgeon consulting a remote specialist via the tele-operative system.     

A new fine probe for electric cautery during endoscopic surgery

The present paper introduces a new fine probe for electric cautery (1.65 mm in diameter, 22 cm long) that can be connected to a conventional cylindrical hand-controlled cautery holder, which is monopolar and widely used in general surgery. When cautery was required, a 14-gauge intravenous catheter was inserted at an appropriate site under the guidance of a videoscope. After removing the steel inner needle, the extra tube was used as the fine surgical port for the cautery probe. The position of insertion could be altered according to the operating field. Cautery was performed by conventional methods. There was no bleeding or air leakage at the site of puncture during or after surgery. The puncture wound was closed without any sutures. Based on these results, the new fine probe for cautery can reduce the number of surgical ports required for instruments during video-assisted surgery, thus improving the ease and safety of endoscopic surgery.     

Methods of analysis and resources available for genetic trait mapping

Stones can be spilled from the gallbladder during laparoscopic cholecystectomy. These stones can be left in the peritoneal cavity or trapped at the trocar site. The potential late sequel and associated morbidity are not well documented. We reviewed the records of four patients who underwent laparoscopic cholecystectomy at Mount Sinai Medical Center in New York City who suffered from late complications attributed to gallstones left in the peritoneal cavity or abdominal wall. Four patients presented 1-14 months after laparoscopic cholecystectomy with intraabdominal and abdominal wall abscesses. The spillage of gallstones was noticed during the initial operation only in one of the patients. Three patients required laparotomy and open drainage of intraabdominal abscesses with drainage of pus and gallstones after failed attempts at percutaneous drainage. Two patients underwent local exploration of an abdominal wall abscess containing stones. Stones left in the abdominal cavity or trapped in trocar sites after laparoscopic cholecystectomy can cause serious late complications requiring repeated surgical interventions. Every effort should be made in order to avoid spillage of stones during dissection of the gallbladder and cystic duct and during retrieval of the gallbladder through the abdominal wall.     

Wound metastases following laparoscopic and open surgery for abdominal cancer in a rat model

The recent application of laparoscopic resection techniques to malignant disease has raised safety concerns due to metastasis to surgical access wounds. The significance and incidence of this problem are controversial. In the present study a rat model, in which an implanted tumour was lacerated, was used to investigate whether application of laparoscopic techniques for malignant abdominal disease leads to an increased risk of tumour dissemination and implantation within the peritoneal cavity, and abdominal wall wounds. Malignant cells were implanted into the abdominal wall of 42 rats, resulting 7 days later in the growth of a tumour measuring 20-25 mm in diameter. There were three control groups: no surgery (n = 6); blunt manipulation of the tumour laparoscopically (n = 6); and blunt manipulation of the tumour at laparotomy (n = 6). Twenty-four rats underwent surgical laceration of the tumour capsule at either laparoscopy (n = 12) or laparotomy (n = 12). All rats were killed 1 week later, and examined for macroscopic evidence of tumour metastasis. The abdominal surgical wounds were excised for independent microscopic examination by a histopathologist. Growth of the primary tumour was greater in rats that had an operation than in unoperated controls, and was greater after laparotomy. However, wound metastases were five times more likely after laparoscopic tumour laceration than after the same procedure through an open incision (ten of 12 rats versus two of 12, P = 0.0033). Wound metastases following laparoscopic tumour manipulation are an important and real problem, with significant implications for the application of laparoscopic techniques to excise malignant disease in humans.     

Laparoscopic cholecystectomy using the abdominal wall lift in a cardiac patient

We present a case report of a patient with impaired cardiac function after aortic valve replacement and open mitral commissurotomy who underwent a laparoscopic cholecystectomy for cholecystolithiasis. In preventing reduced cardiac output due to pneumoperitoneum, the laparoscopic operative procedure was performed using the abdominal wall lift. Cardiac function was continuously evaluated by transesophageal echocardiographic examination and remained stable during the surgery. Because of the patient's co-existing chronic atrial fibrillation and prosthetic aortic valve, perioperative anticoagulation management was carried out. The patient's post-operative course was uneventful, and he was discharged on the 7th post-operative day.