Laparoscopic Left Gastric Artery Aneurysm Resection.

Aneurysmal degeneration of the visceral branches of the abdominal aorta is a rare and potentially life-threatening disease entity. Visceral artery aneurysms (VAAs) are exceedingly rare and have a prevalence of 0.1 to 2%. The left gastric artery aneurysm (LGAA) is even more rare and accounts for less than 4% of all VAAs. There is scarce literature on treatment of LGAA by embolization; however, to date successful laparoscopic repair of an LGAA has not been described. We describe the successful treatment of an LGAA by laparoscopic ligation and resection in a 68-year-old male patient.

Competence acquisition for single-incision laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Within the past few years, there has been a push for an even more minimally invasive approach to biliary disease with the adoption of single-incision laparoscopic cholecystectomy. We sought to compare 4 individual surgeon experiences to define whether there exists a learning curve for performing single-incision laparoscopic cholecystectomy. METHODS: We performed a retrospective review 290 single-incision laparoscopic cholecystectomies performed by a group of general surgeons, with varying levels of experience and training, at 3 institutions between May 2008 and September 2010. The procedure times were recorded for each single-incision laparoscopic cholecystectomy, ordered chronologically for each surgeon, and subsequently plotted on a graph. The patients were also combined into cohorts of 5 and 10 cases to further evaluate for signs of improvement in operative efficiency. RESULTS: Of the 4 surgeons involved in the study, only 1 (surgeon 4, laparoscopic fellowship trained with <5 years' experience) confirmed the presence of a learning curve, reaching proficiency within the first 15 cases performed. The other surgeons had more variable procedure times, which did not show a distinct trend. When we evaluated the cases by cohorts of 5 cases, surgeon 4 had a significant difference between the first and last cohort. Increased body mass index resulted in a slightly longer operative time (P < .0063). The conversion rate to multiport laparoscopic surgery was 3.1%. CONCLUSIONS: Our results indicate that among experienced general surgeons, there does not seem to be a significant learning curve when transitioning from conventional laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy. The least experienced surgeon in the group, surgeon 4, appeared to reach proficiency after 15 cases. Greater than 5 years of experience in laparoscopic surgery appears to provide surgeons with a sufficient skill set to obviate the need for a single-incision laparoscopic cholecystectomy learning curve.

Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy.

BACKGROUND: Minimally invasive techniques have become an integral part of general surgery with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents the final 1-year results of a prospective, randomized, multicenter, single-blinded trial of SILC vs multiport cholecystectomy (4PLC). STUDY DESIGN: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC vs 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Patients were followed for 12 months. RESULTS: Two hundred patients underwent randomization to SILC (n = 119) or 4PLC (n = 81). Enrollment ranged from 1 to 50 patients with 4 sites enrolling >25 patients. Total adverse events were not significantly different between groups (36% 4PLC vs 45% SILC; p = 0.24), as were severe adverse events (4% 4PLC vs 10% SILC; p = 0.11). Incision-related adverse events were higher after SILC (11.7% vs 4.9%; p = 0.13), but all of these were listed as mild or moderate. Total hernia rates were 1.2% (1 of 81) in 4PLC patients vs 8.4% (10 of 119) in SILC patients (p = 0.03). At 1-year follow-up, cosmesis scores continued to favor SILC (p < 0.0001). CONCLUSIONS: Results of this trial show SILC to be a safe and feasible procedure when compared with 4PLC, with similar total adverse events but with an identified significant increase in hernia formation. Cosmesis scoring and patient preference at 12 months continue to favor SILC, and more than half of the patients were willing to pay more for a single-site surgery over a standard laparoscopic procedure. Additional longer-term population-based studies are needed to clarify if this increased rate of hernia formation as compared with 4PLC will continue to hold true.

Consensus statement of the consortium for LESS cholecystectomy.

Many surgeons attempting Laparo-Endoscopic Single Site (LESS) cholecystectomy have found the operation difficult, which is inconsistent with our experience. This article is an attempt to promote a standardized approach that we feel surgeons with laparoscopic skills can perform safely and efficiently. This is a four-trocar approach consistent with the four incisions utilized in conventional laparoscopic cholecystectomy. After administration of general anesthesia, marcaine is injected at the umbilicus and a 12-mm vertical incision is made through the already existing anatomical scar of the umbilicus. A single four-trocar port is inserted. A 5-mm deflectable-tip laparoscope is placed through the trocar at the 8 o'clock position, a bariatric length rigid grasper is inserted through the trocar at the 4 o'clock position (to grasp the fundus), and a rigid bent grasper is placed through the 10-mm port (to grasp the infundibulum). This arrangement of the instruments promotes minimal internal and external instrument clashing with simultaneous optimization of the operative view. This orientation allows retraction of the gallbladder in a cephalad and lateral direction, development of a window between the gallbladder and the liver which promotes the "critical view" of the cystic duct and artery, and provides triangulation with excellent visualization of the operative field. The operation is concluded with diaphragmatic irrigation of marcaine solution to minimize postoperative pain. Standardization of LESS cholecystectomy will speed adoption, reduce intraoperative complications, and improve the efficiency and safety of the approach.

Dual pathology in a patient with right lower quadrant pain.

Meckel diverticula are remnants of the omphalomesenteric duct. They have 2% incidence in the general population, are usually asymptomatic, and tend to be diagnosed incidentally. The generally held principle had been that asymptomatic cases do not require resection, as exemplified by a 2008 systematic review of over 200 studies. However, a recent series reported an increased risk of malignancies, and recommended mandatory resection. We present a case of Meckel diverticulitis with concurrent infiltrative appendiceal carcinoid in a patient with right lower quadrant pain.

Robotic vs. laparoscopic colorectal surgery: an institutional experience.

BACKGROUND: Robotic colorectal surgery is gaining interest in general and colorectal surgery. The use of the da Vinci(®) Robotic system has been postulated to improve outcomes, primarily by increasing the dexterity and facility with which complex dissections can be performed. We report a large, single institution, comparative study of laparoscopic and robotic colectomies, attempting to better elucidate the benefits of robotic surgery in patients with colorectal disease. METHODS: We conducted a retrospective review of 171 patients who underwent robotic and laparoscopic colectomies (79 and 92, respectively) at our institution between November 2004 and November 2009. Patients in both groups had well-matched preoperative parameters. All cases were further subdivided by their anatomical location into right-sided and left-sided colectomy, and analysis was performed within these two subgroups. Perioperative outcomes reported include operative time, operative blood loss, time to return of bowel function, time to discontinuation of patient controlled analgesia, length of stay, and intraoperative or postoperative complications. RESULTS: Our results indicate that there is no statistical difference in length of stay, time to return of bowel function, and time to discontinuation of patient-controlled analgesia between robotic and laparoscopic left and right colectomies. Interestingly, the total procedure time difference between the laparoscopic and robotic colectomies was much smaller than previously published accounts (mean 140 min vs. 135 min for right colectomy; mean 168 min vs. 203 min for left colectomy). CONCLUSIONS: Our study is one of the largest reviews of robotic colorectal surgery to date. We believe that our results further demonstrate the equivalence of robotic surgery to laparoscopic surgery in colorectal procedures. Future research should focus on surgeon-specific variables, such as comfort, ergonomics, distractibility, and ease of use, as other ways to potentially distinguish robotic from laparoscopic colorectal surgery.

Intermediate results of a prospective randomized controlled trial of traditional four-port laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy.

BACKGROUND: Minimally invasive techniques have become an integral part of general surgery, with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents a prospective, randomized, multicenter, single-blind trial of SILC compared with four-port cholecystectomy (4PLC) with the goal of assessing safety, feasibility, and factors predicting outcomes. METHODS: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC or 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Pain, cosmesis, and quality-of-life scores were documented. Patients were followed for 12 months. RESULTS: Two hundred patients were randomized to SILC (n = 117) or 4PLC (n = 80) (3 patients chose not to participate after randomization). Patients were similar except for body mass index (BMI), which was lower in the SILC patients (28.9 vs. 31.0, p = 0.011). One SILC patient required conversion to 4PLC. Operative time was longer for SILC (57 vs. 45 min, p < 0.0001), but outcomes, including total adverse events, were similar (34% vs. 38%, p = 0.55). Cosmesis scores favored SILC (p < 0.002), but pain scores were lower for 4PLC (1 point difference in 10-point scale, p < 0.028) despite equal analgesia use. Wound complications were greater after SILC (10% vs. 3%, p = 0.047), but hernia recurrence was equivalent for both procedures (1.3% vs. 3.4%, p = 0.65). Univariate analysis showed female gender, SILC, and younger age to be predictors for increased pain scores, while SILC was associated with improved cosmesis scores. CONCLUSIONS: In this multicenter randomized controlled trial of SILC versus 4PLC, SILC appears to be safe with a similar biliary complication profile. Pain scores and wound complication rates are higher for SILC; however, cosmesis scores favored SILC. For patients preferring a better cosmetic outcome and willing to accept possible increased postoperative pain, SILC offers a safe alternative to the standard 4PLC. Further follow-up is needed to detail the long-term risk of wound morbidities, including hernia recurrence.

Spontaneous intrahepatic hemorrhage: a case report.

Etiology of the acute abdomen can be difficult to determine in the acute care setting, as both medical and surgical emergencies can present with a similar clinical presentation. Prompt work-up is essential to reveal the diagnosis and allow for successful treatment. We present a rare case of spontaneous intrahepatic hemorrhage in a patient with multiple comorbidities, including multiple myeloma and lung cancer. Although the underlying cause of hemorrhage remained unknown, appropriate recognition of the patient's presenting signs and symptoms allowed for immediate treatment and satisfactory outcome.

Concurrent robotic trans-abdominal pre-peritoneal (TAP) herniorrhaphy during robotic-assisted radical prostatectomy.

BACKGROUND: Robotic prostatectomy (RP) is now increasingly performed because it allows for precise dissection of neurovascular structures with better outcomes. It is estimated that 5-12% of candidates for radical prostatectomy have detectable inguinal hernias, and simultaneous mesh hernioplasty is now well supported. A disadvantage of radical prostatectomy is obliteration of the preperitoneal space of Bogros, which can make future totally extraperitoneal (TEP) herniorrhaphy difficult and prone to complication. METHODS: Four patients underwent RP using the DaVinci system. Six clinically detectable inguinal hernias were repaired. Upon completion of the prostatectomy, the peritoneum overlying the myopectineal orifice of Fruchaud was opened, the orifice was dissected free and the hernia reduced. A 3 x 6 inch polypropylene mesh or 4 x 6 inch polyester mesh was then affixed overlying the orifice with titanium tacks, and the peritoneum was closed over the mesh using a running absorbable suture. RESULTS: The mean operating time for the TAP was 24 min. There were no postoperative complications. At a mean follow-up of 34 months, no recurrence was noted. CONCLUSIONS: With the increasing incidence of RP, we advocate the concurrent repair of any detectable inguinal hernias at the time of prostatectomy. The preperitoneal placement of a polypropylene or polyester mesh secured with a tacking device and a peritoneal closure performed with a running absorbable suture is uniquely suited to the abilities of the robot, and provides a durable repair.

Laparoscopic Hartmann's procedure: a viable option for treatment of acutely perforated diverticultis.

BACKGROUND: A laparoscopic technique for acutely perforated diverticulitis (i.e., laparoscopic Hartmann's procedure) has not been described. The authors present their technique for laparoscopic sigmoid resection, end colostomy, and subsequent laparoscopic takedown of colostomy. METHODS: A retrospective review of patients with Hinchey III/IV diverticulitis who underwent a laparoscopic Hartmann's procedure was performed in this study. Laparoscopic takedown of sigmoid colostomy was performed 2 to 3 months later. Data from these procedures including estimated blood loss (EBL), length of the operative procedure, patient outcomes, and demographics were evaluated. RESULTS: Seven patients with a mean age of 49.7 years underwent laparoscopic sigmoid colectomy with end colostomy. None of these patients had a history of diverticulitis. Their mean EBL was 138 ml, and their mean operative time was 154 min. None of the procedures required conversion to use of a hand port or conversion to open procedure. The average time to return of bowel function was 3.7 days, with one patient experiencing a postoperative ileus. The mean postoperative hospital stay was 6.6 days. There were no complications. Laparoscopic Hartmann's takedown was performed for all the patients approximately 2 to 3 months later. The mean EBL was 107 ml, and the average operative time was 189 min. One patient had intraoperative anastomotic leak, which was successfully repaired and retested. Again, none of the procedures required the use of a hand port or a laparotomy. The average time to return of bowel function was 3.4 days. The average length of hospital stay was 5.3 days, with one patient experiencing a fat necrosis. CONCLUSIONS: Laparoscopic Hartmann's procedure and laparoscopic takedown are technically feasible procedures with reasonable outcomes.

A standardized technique for robotically performed sigmoid colectomy.

BACKGROUND: We describe a standarized eight-step technique to perform sigmoid colectomy using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) in both the left upper and lower abdominal quadrants. MATERIALS AND METHODS: Between March 2005 and June 2006, 11 robotic sigmoid colectomies were performed on patients with diverticulitis or cancer. The procedures were performed through 4 ports, using a medial to lateral approach and involved moving the robot during the procedure. RESULTS: We describe the data and results from our first 11 robotically performed sigmoid colectomies using this technique. Operative times during each step of the procedure were collected and reported. By the eighth case, our team required only 4 minutes to undock, move, and redock the robot. The average operative time was 197 minutes and the average length of hospital stay was 3.4 days. There were no complications and no conversions to open colectomy. CONCLUSION: Robotically performed sigmoid colectomy is a feasible and safe procedure. The robot can be moved efficiently during surgery to allow a totally robotically performed sigmoid colectomy. The three-dimensional view, articulating instruments, intuitive movement, motion scaling, stable camera platform, and comfortable surgeon ergonomics facilitate splenic flexure mobilization and dissection and division of the inferior mesenteric artery and inferior mesenteric vein. Further studies will be needed to determine clinical benefit and economic feasibility.

Long-standing unilateral jumped facets at C3-4 with no apparent history of antecedent trauma.

We report two cases of unilateral jumped facets at C3-4 in reliable historians with no apparent history of neck trauma. Lack of associated morphological abnormalities of the associated disc, adjacent vertebral bodies, and contralateral facet essentially exclude a developmental etiology. Based on the location of the injury and the presence of chronic, osteoarthritic changes we postulate that the jumped facets were due to remote childhood trauma that was forgotten.