A rare case of solitary gallbladder metastasis from an early cutaneous melanoma.

Solitary gallbladder metastasis from melanoma is a rare phenomenon, in this case manifesting as biliary symptoms during and following pregnancy. It is important to consider uncommon causes of biliary symptoms to aid in prompt diagnosis and treatment. This patient was successfully treated with laparoscopic cholecystectomy and adjuvant immunotherapy.

Fewer Ports Cut Opioid Use and Length of Stay in Elective Laparoscopic Cholecystectomy.

BACKGROUND: Postoperative pain is one of the most common reasons for prolonged hospital stay with opioid analgesia the mainstay of treatment. OBJECTIVES: The purpose of this study was to determine whether the degree of abdominal trauma, reflected by the number and sizes of ports used in elective laparoscopic cholecystectomy, correlated against opioid analgesia requirements and length of stay. METHODS: A retrospective clinical audit was undertaken of 144 patients who underwent elective laparoscopic cholecystectomies with 3-port (12/5/5) and 4-port approaches (12/5/5/5 and 12/10/5/5). In the reduced port cases, liver retraction was achieved using a suction retractor, removing the requirement for a fourth port. The number of ports and total cross-sectional area of all ports were compared against the procedure time, length of stay, and opioid analgesia required. RESULTS: The smaller total cross-sectional area associated with the 3-port approach (12/5/5, 277.25 mm2) resulted in significantly lower total oral morphine equivalent daily dose required compared to 12/10/5/5 (453.96 mm2) and 12/5/5/5 (327.52 mm2) approaches, being 30.7 mg and 21.0 mg less, respectively (p < 0.001). The 3-port approach had a mean length of stay 0.8 days which was significantly shorter compared to both 4-port approaches (p = 0.001, length of stay of 1.1 and 1.2 days for 12/5/5/5 and 12/10/5/5, respectively). Laparoscopic cholecystectomy patients in the study hospitals routinely stayed overnight. CONCLUSIONS: The absolute number of ports used in elective laparoscopic cholecystectomies appears to play an important role in postoperative recovery. In particular, 3-port configurations may result in less postoperative pain without the burden of an increase in length of stay, morbidity, or mortality rates.

Hybrid Transvaginal NOTES and Mini-Laparoscopic Colectomy: Benefit Through Synergy.

BACKGROUND AND OBJECTIVES: Hybrid-natural orifice surgery combines the advantages of traditional transabdominal laparoscopic surgery, while limiting surgical trauma to the abdominal wall. Among various routes of intra-abdominal access, the transvaginal method is most appealing because of its utility and proven safety. We describe a series of 4 colonic resections performed with this approach, combined with minilaparoscopy and needlescopic approaches, and discuss the technical aspects, efficacy, and applicability of this technique. METHODS: Three patients were selected to undergo hybrid transvaginal natural-orifice right hemicolectomy. A fourth patient, who underwent a segmental resection of a splenic flexure carcinoma, was included. Transvaginal port access was obtained via posterior colpotomy, and was used for dissection, vascular ligation, bowel division, and anastomosis. We used a combination of standard laparoscopic, minilaparoscopic, and needlescopic instruments transabdominally, focusing on reduced size and number of access points. RESULTS: Duration of laparoscopy, oncologic outcomes and rate of operative morbidity were comparable to the published literature. Early return of gastrointestinal function and low analgesic requirements was observed in all patients. No morbidity related to transvaginal access was observed and the procedure was performed without difficulty in all cases. CONCLUSION: Colonic resection performed by hybrid natural-orifice technique offers several advantages over purely transabdominal laparoscopic procedures. Transvaginal access is easy to perform and offers excellent safety, efficacy, and versatility, especially for right hemicolectomy. Techniques to reduce abdominal wall surgical trauma, such as minilaparoscopy and needlescopic graspers, can be combined effectively in colonic resections, and may act synergistically to reduce postoperative pain and improve outcomes.

Vacuum Stabilization of the Spleen in Laparoscopic Splenectomy.

BACKGROUND AND OBJECTIVES: Recovery from laparoscopic splenectomy is greatly enhanced when compared with recovery from the laparotomy approach, yet a minority of spleens are removed laparoscopically. The spleen is smooth, rounded, and vascular, making it difficult to directly grasp, stabilize, or retract laparoscopically. The LiVac Retractor is a laparoscopic liver retractor comprising a soft silicone open ring that apposes 2 substantially planar surfaces when a vacuum is applied. It was evaluated for its efficacy in stabilization of the spleen during 2 laparoscopic splenectomies. METHODS: The 2 patients gave consent for laparoscopic splenectomy with splenic retraction using the LiVac Retractor. The entire 3-port laparoscopic procedure was video recorded, with the resected spleens weighed as wet specimens. The patients' postoperative courses are described. RESULTS: The spleen was retracted securely for the duration of the hilar dissection in both patients. Exposure of the splenic hilum was excellent. There were no visible signs of injury to either spleen and recovery of both patients was unremarkable. CONCLUSIONS: The LiVac Retractor provided stable retraction and excellent exposure of the splenic hilum during both laparoscopic splenectomies, without organ injury. Early hilar dissection with vascular control was facilitated, reducing the risk of bleeding from other components of the dissection.

A clinical study of the LiVac laparoscopic liver retractor system.

BACKGROUND: All retractors for laparoscopic operations on the gallbladder or stomach apply an upward force to the under-surface of the liver or gallbladder, most requiring an additional skin incision. The LiVac laparoscopic liver retractor system (LiVac retractor) comprises a soft silicone ring attached to suction tubing and connected to a regulated source of suction. The suction tubing extends alongside existing ports. When placed between the liver and diaphragm, and suction applied, a vacuum is created within the ring, keeping these in apposition. Following successful proof-of-concept animal testing, a clinical study was conducted to evaluate the performance and safety of the retractor in patients. METHODS: The study was a dual-centre, single-surgeon, open-label study and recruited ten patients scheduled to undergo routine upper abdominal laparoscopic surgery including cholecystectomy, primary gastric banding surgery or fundoplication. The study was conducted at two sites and was approved by the institutions' ethics committees. The primary objective of the study was to evaluate the performance of the LiVac retractor in patients undergoing upper abdominal single- or multi-port laparoscopic surgery. Performance was measured by the attainment of milestones for the retractor and accessory bevel, where used, and safety outcomes through the recording of adverse events, physical parameters, pain scales, blood tests and a post-operative liver ultrasound. RESULTS: The LiVac retractor achieved both primary and secondary performance and safety objectives in all patients. No serious adverse events and no device-related adverse events or device deficiencies were reported. CONCLUSION: The LiVac retractor achieved effective liver retraction without clinically significant trauma and has potential application in multi- or single-port laparoscopic upper abdominal surgery. As a separate incision is not required, the use of the LiVac retractor in multi-port surgery therefore reduces the number of incisions.

A novel liver retractor for reduced or single-port laparoscopic surgery.

BACKGROUND: Retraction of either lobe of liver is required for surgical access to the respective organ. A novel liver retractor device and technique is described, which applies a vacuum between the liver and diaphragm to lift the liver, and which does not require additional incisions. METHODS: A novel liver retractor was tested in two anesthetized sheep at incrementally higher levels of suction from -100 to -700 mmHg (-13 to -93 kPa), and any signs of trauma were recorded. The animals recovered for 5 days, then were humanely killed and postmortem examination of the liver and diaphragms performed. RESULTS: Successful liver retraction was achieved from -200 to -600 mmHg (-27 to -80 kPa) suction. An imprint of the retractor was observed on the liver surface, but there was no breach of the liver serosa. Negligible ecchymoses were observed on the corresponding surface of the diaphragms. Both sheep recovered well after surgery. There was no macroscopic evidence of injury to the liver and diaphragm 5 days postoperatively. Histological examination revealed normal liver parenchyma deep to the site where the devices had been placed, and hemorrhagic changes within the serosa only varied between a few microns to a maximum of 1.4-mm depth. CONCLUSIONS: The novel liver retractor described achieved an effective liver retraction without trauma. It has potential application in reduced or single-port laparoscopic upper abdominal surgery.

Peritoneal oleogranulomatosis after laparoscopic gastric banding.

Laparoscopic adjustable gastric banding is one of the most frequently performed bariatric operations worldwide owing to its low incidence of iatrogenic complications. Peritoneal oleogranulomatosis, a sequelae of mineral oil contact with tissues, has not been reported in the context of bariatric surgery. We present the case of a 52-year-old woman with an incidental finding of peritoneal oleogranulomatosis at laparoscopic cholecystectomy, who had previously undergone laparoscopic gastric banding. A potential mechanism linking the two is postulated and the importance of histological diagnosis highlighted, given the macroscopic resemblance to carcinomatosis peritonei.