A prospective randomized comparison of traditional laparoendoscopic single-site surgery with needlescopic-assisted laparoscopic nephrectomy in the porcine model.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site (LESS) surgery produces virtually no scar but is technically challenging because of the loss of triangulation. The objective of this study is to compare classic transumbilical LESS nephrectomy with needlescopic-assisted laparoscopy (NAL) surgery. In doing so, we evaluated whether the addition of a single 2-mm subcostal port could restore triangulation while not jeopardizing recovery or cosmetic outcome in the porcine model. MATERIALS AND METHODS: Ten female farm pigs were randomized to laparoscopic nephrectomy with either LESS or NAL. In LESS, a TriPort was placed through a single 2.5-cm umbilical incision. In NAL, 5- and 10-mm ports were placed in the umbilicus and a 2-mm port was placed in the midclavicular line. Preoperative, perioperative, and postoperative parameters were compared. Variables were analyzed with the Wilcoxon signed-rank test and two-tailed Fisher exact test. Cosmesis was evaluated objectively using the Vancouver Scar Scale and subjectively by a blinded dermatologist. A cost analysis was performed. RESULTS: Estimated blood loss was minimal in both groups (28.8 mL in LESS and 9.4 mL in NAL). Operative time was significantly shorter in NAL (103 vs 150 min; P<0.001). There was no difference in complications (2 vs 1; P=0.500), objective cosmesis (3.9 vs 3.8; P>0.2), or subjective cosmesis (2 vs 3; P=0.500). The NAL protocol had significantly lower disposable equipment costs ($363 vs $1696). CONCLUSIONS: The addition of a 2-mm subcostal port and the restoration of triangulation in the NAL protocol enable shorter operative times, increased surgeon comfort, improved technical ease, and lower costs while maintaining the scarless cosmesis of the traditional LESS protocol.

A case of tuberculosis in a patient on Efalizumab and Etanercept for treatment of refractory palmopustular psoriasis and psoriatic arthritis.

We discuss a patient with a history of a positive tuberculin skin test, who presented with severe, recalcitrant palmoplantar pustular psoriasis with psoriatic arthritis whose symptoms did not resolve with monotherapy of etanercept (Enbrel) or efalizumab (Raptiva) alone, but did respond to a combination of both biologics. However, our patient was later found to have re-activation tuberculosis after long-term treatment. This case highlights many key points for treatment of psoriasis and psoriatic arthritis with biologics. Namely, that recalcitrant psoriatic skin lesions may have good clearing on one biologic, such as efalizumab, and arthritic symptoms can be well-controlled with etanercept, leading patients to be on two different biologics concurrently to control symptoms. However, it also highlights the importance of determining a patient's tuberculosis status, initiating prophylactic anti-tuberculosis therapy prior to starting treatment with etanercept, and setting up an adequate treatment regime if the patient develops active tuberculosis during therapy with etanercept.