First 200 consecutive transumbilical single-incision laparoscopic TEPs.

BACKGROUND: Endoscopic pre-peritoneal mesh repair (TEP) through single-incision laparoscopy (SIL) permits placement of a large mesh through a final millimetric umbilical scar. This prospective study evaluates the first 200 consecutive SILTEPs performed by a single surgeon. PATIENTS AND METHODS: Between November 2011 and September 2015, 200 consecutive SILTEPs were performed in 161 patients. The mean age was 49.8 ± 16.3 years and the mean BMI was 24.5 ± 3.4 kg/m2. The technique involved one 11-mm trocar, one 10-mm 0° scope and curved reusable instruments. A supplementary 1.8-mm straight trocarless grasping forceps was percutaneously inserted for perioperative complications or difficulties. RESULTS: A unilateral hernia repair was performed in 122 patients, and a bilateral repair in 39 patients. The total operative time was 57.4 ± 22.3 min, and pure laparoscopic time was 46.6 ± 21.6 min. There was no need for insertion of a supplementary 5-mm trocar, and the need for insertion of 1.8-mm trocarless grasper was 32.9%. Perioperative complications occurred in 73 patients. The mean final scar length was 15.3 ± 2.6 mm. The mean hospital stay was 1.0 ± 0.3 days. Postoperative complications at the access site affected 15 patients and at the hernia site 31 patients. After a mean follow-up of 25.4 ± 12.3 months, there was one asymptomatic, small incisional hernia at the access site as well as one reoperation for recurrent inguinal hernia at 16 months. No other late complications were registered. CONCLUSION: Transumbilical SILTEP permits placement of a large mesh through a final millimetric scar. Getting over the learning curve in conventional multitrocar TEP is mandatory. As per our institute's algorithm, the contraindications continue to be giant inguino-scrotal, incarcerated and recurrent inguinal hernias.

Colorectal anastomotic leakage corrected by transanal laparoscopy.

AIM: Interest in transanal laparoscopy has increased in the last decade. This approach can allow primary procedures such as polypectomy, total mesorectal excision and the treatment of postoperative complications such as bleeding, leakage and fistula formation. METHOD: Two patients treated by transanal repair for leakage of a colorectal anastomosis after laparoscopic anterior resection of the rectum are reported. The first developed leakage immediately during the surgery and in the second leakage presented at 4 weeks. A new transanal platform according to DAPRI (Karl Storz-Endoskope, Tuttlingen, Germany), formed by a reusable port and reusable monocurved instruments was developed to permit manipulation of sutures introduced via the anus in a maximally ergonomic manner. Laparoscopic suturing was performed transanally and a protective ileostomy was added as well. RESULTS: The transanal procedures took 60 and 45 min and the patients were discharged after 5 days and 2 days. At 2 months both defects were found to be healed on contrast radiology and endoscopy; therefore the ileostomy was closed. Anal function was satisfactory with a frequency of two and one times per 24 h with no incontinence or evidence of sepsis. CONCLUSION: Intra-operative or late leakage of colorectal anastomosis can be safely treated by transanal laparoscopy. This new transanal platform offers the surgeon the possibility to work in ergonomic positions, without increasing the cost of the procedure thanks to the reusable nature of the material used.

En bloc laparoscopic sigmoidectomy, left adnexectomy, small bowel loop and piece of urinary bladder resection for advanced sigmoid tumor.

UNLABELLED: The laparoscopic surgery of colon increasingly replaces the conventional surgery of colon on a global and regional scale. Many randomized studies demonstrate the advantages with regard to the shorter postoperative hospital stay, faster recovery, and identical results of the indexes of survival and frequency of relapses. The en bloc resection in cases of locally advanced colon cancer is the most secure method for achieving of R0 resection . The growth of the tumoral mass towards the adjacent structures manifests with histological tumor invasion in approximately 50% of the cases. The cases of laparoscopic en bloc resection for the treatment of colorectal cancer, which are described in the literature, increase. In this report we present a clinical case of substenotic sigmoid colon cancer and perioperative finding of infiltration towards a small intestinal loop and part of the urinary bladder, as well as towards the left uterine tube and the left adnex. In the case of this patient laparoscopic en bloc resection of the tumor formation was performed according to the so called "laparoscopic no touch technique". Approximately 15-20% of the cases of colorectal cancer are still in T4 stage, with involvement of the adjacent organs (1), despite the advance of the examination methods. CLINICAL CASE: A 67 year old female was admitted to the hospital for a substenotic sigmoid colon lesion, syndrome of anemia, resulted adenocarcinoma at colonoscopy. Endoscopy showed an endoluminal tumor at 25 cm from the anal margin and preoperative work-up did not evidence any secondary lesions or invasion of other organs. METHODS: Four abdominal trocars were placed. The laparoscopic exploration of the abdominal cavity showed the presence of a colic mass with suspected invasion of a small bowel loop and part of the urinary bladder, the left uterine tube, and the left ovary. The tumor formation was dissected en bloc with resection of the left uterine tube and ovary, the urinary bladder, and a small bowel loop. Colorectal anastomosis with laparoscopic manual technique was performed. The anastomosis was tested for leak-tightness. The specimen was removed by enlargenemt of the 5 mm. suprapubic trocar. RESULTS: The mean operative time was 285 minutes with blood loss of 300 ml. Patient was discharged on Postoperative Day 5. The histological result verified tumoral invasion towards the urinary bladder, the small bowel, and the ovary. The final staging according to the TNM classification is pT4N0Mx. CONCLUSION: The en bloc laparoscopic resection for the treatment of sigmoid colon cancer, engaging the adjacent organs, is indicated and feasible, with surgical results, comparable with a conventional surgical intervention at the same volume.

Single-access laparoscopic primary and incisional prosthetic hernia repair: first 50 patients.

BACKGROUND: Primary and incisional hernia can be repaired by multitrocar laparoscopy. Single-access laparoscopy (SAL) recently gained interest to decrease the invasiveness and to reduce the abdominal trauma, besides improved cosmetic results. The authors report first 50 patients who consulted for primary and incisional hernia and treated by SAL prosthetic repair. PATIENTS AND METHODS: Between December 2009 and March 2012, 50 patients (24 females, 26 males) were submitted to SAL for primary (23) and incisional hernia (27). Mean age was 49.1 ± 15.1 years (17-75), and mean body mass index 29.7 ± 5.7 kg/m(2) (19-44.1). A total of 26 primary and 30 incisional hernias were treated. The technique consisted in implied the use of an 11-mm trocar for 10-mm scope, curved reusable instruments without trocars, and dualface prosthesis fixed by tacks without transfascial closures. RESULTS: No conversion to open surgery nor addition of one or more trocars was necessary. Mean perioperative hernia sizes were 7.0 ± 5.0 cm (2-24) in length and 6.0 ± 3.4 cm (1-16) in width, for a surface of 55.0 ± 64.6 cm(2) (2.8-268.2). Mean prosthesis size used was 188.1 ± 113.4 cm(2) (56.2-505.6). Mean laparoscopic time was 60.2 ± 32.8 min (26-153), and mean final scar length was 21.2 ± 4.5 mm (13-35). Mean hospital stay was 2.2 ± 1.2 days (1-8). Perioperative complications were registered in 4 patients and minor early complications in 13 patients of each group. After a mean follow-up of 16.1 ± 8.8 months (4-34), 2 late complications were observed in one patient of each group. CONCLUSION: Primary and incisional hernia can safely be treated by SAL prosthetic repair, but a learning curve is unavoidable. Thanks to this approach, in patients with primary hernia, only a small scar is finally visible, and in patients who proved to be prone to develop incisional hernia, the number of fascial incisions can be reduced.

Laparoscopic conversion of Roux-en-Y gastric bypass to biliopancreatic diversion.

BACKGROUND: This report describes the laparoscopic conversion of a Roux-en-Y gastric bypass (RYGBP) to biliopancreatic diversion (BPD). CASE REPORT: In January 1995, a 47-year-old woman with a body mass index (BMI) of 54 kg/m(2) benefited from a silicon ring vertical banded gastroplasty (SRVBG) for morbid obesity. She showed significant weight loss and reached a BMI of 30 kg/m(2). After 7 years, she experienced weight regain (BMI, 34.5 kg/m(2)), so a laparoscopic conversion to RYGBP was proposed. The patient again had a successful weight loss (BMI, 26 kg/m(2)), but 6 years later, she mentioned a weight regain (BMI, 33 kg/m(2)) with invalidating retrosternal pain. The nutritionist's analysis of the patient showed a certain modification of the alimentary character with frequent meals (grazing/polyphagia), and the psychologist's consultation identified an important binge-eating disorder. A laparoscopic conversion of RYGBP to BPD was proposed. The procedure consisted of (1) adhesiolysis and reduction of a hiatal hernia, (2) sectioning of the gastric pouch proximally to the gastrojejunostomy, (3) resection of the fundus of the gastric remnant excluded by the previous SRVBG, (4) restoration of the continuity of the stomach between the gastric pouch and the gastric remnant, (5) resection of the gastric antrum and pylorus, (6) deconstruction of the previous jejunojejunostomy, (7) restoration of the continuity of the small bowel, (8) measurement of the new common and alimentary limbs and construction of the jejunoileostomy, (9) closure of the mesenteric defect, (10) construction of the gastroileostomy, (11) closure of Petersen's space, and (12) repair of the hiatal hernia followed by a leak test. RESULTS: The operative time was 320 min, and the blood loss was 380 ml. The patient had an uneventful recovery and was discharged on postoperative day 5. Her BMI was 30.5 kg/m(2) after 3 months and 26 kg/m(2) after 6 months. The barium swallow showed good transit through the gastrointestinal tract. CONCLUSIONS: The laparoscopic conversion of RYGBP to BPD is technically feasible and effective during the short term for cases of repeated weight regain.

Ivor Lewis esophagectomy with manual esogastric anastomosis by thoracoscopy in prone position and laparoscopy.

INTRODUCTION: Only a few authors have reported the technique of Ivor Lewis esophagectomy by minimally invasive means, and anastomosis was usually performed by a circular stapler. We report an Ivor Lewis esophagogastrectomy with manual esogastric anastomosis performed by thoracoscopy in the prone position. CASE REPORT: An adenocarcinoma of the distal esophagus without lymph nodes invasion was diagnosed in a 51-year-old man. General anesthesia and double-lumen endotracheal tube intubation were used. First the patient was placed in the supine position, and five abdominal trocars were placed. Celiac lymphadenectomy was performed with section of the left gastric vessels. A wide Kocher maneuver and pyloroplasty were performed. A wide gastric tube was performed and advanced through the hiatus into the right chest. Subsequently the patient was placed in the prone position. Three trocars (two 5-mm and one 11-mm) were placed on the posterior axillary line in the fifth, seventh, and ninth right intercostal space. The intrathoracic esophagus was dissected. Mediastinal lymphadenectomy with en bloc resection of the left inferior mediastinal pleura was performed. The azygos vein was sectioned, and the esophagus was transected by scissors 1-cm cranial to the azygos vein. A completely thoracoscopic manual double-layer anastomosis was performed by using running sutures with PDS 2/0 externally and Maxon 4/0 internally. Finally the patient was replaced in the supine position to retrieve the specimen through a suprapubic incision, and the gastric tube was fixed to the hiatus. RESULTS: Thoracoscopy lasted 157' (anastomosis 40'), laparoscopy 160', and second laparoscopy 20'. Blood loss was estimated at 170 ml. The gastrograffin swallow on postoperative day 4 showed absence of stenosis and leak. The patient was discharged on postoperative day 6. CONCLUSIONS: Thoracoscopy in the prone position allows the surgeon to perform a thoracoscopic esogastric anastomosis completely handsewn without selective lung desufflation, and using only three trocars.