Bilateral inguinal hernia repair by laparoscopic totally extraperitoneal (TEP) vs. laparoscopic transabdominal preperitoneal (TAPP).

BACKGROUND: The guidelines recommend laparoscopic repair for bilateral inguinal hernia. However, few studies compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques in bilateral inguinal hernias. This study aimed to compare the outcomes of TEP and TAPP in bilateral inguinal hernia. METHODS: We conducted a retrospective cohort study of patients operated on for bilateral inguinal hernia by TEP and TAPP repair from 2016 to 2020. Intraoperative complications, operative time, acute postoperative pain, hospital stay, postoperative complications, chronic inguinal pain, and recurrence were compared. RESULTS: A total of 155 patients were included in the study. TEP was performed in 71 patients (46%) and TAPP in 84 patients (54%). The mean operative time was longer in the TAPP group than in the TEP group (107 min vs. 82 min, p < 0.001). The conversion rate to open surgery was higher in the TEP group than in the TAPP group (8.5% vs. 0%, p = 0.008). The mean hospital stay was longer in the TAPP group than in the TEP group (p < 0.001). We did not observe significant differences in the proportion of postoperative complications (p = 0.672), postoperative pain at 24 h (p = 0.851), chronic groin pain (p = 0.593), and recurrence (p = 0.471). We did not observe an association between the choice of surgical technique (TEP vs. TAPP) with conversion rate, operative time, hospital stay, postoperative complications, chronic inguinal pain, or hernia recurrence when performing a multivariable analysis adjusted for the male sex, age, BMI, ASA, recurrent hernia repair, surgeon, and hernia size > 3cm. CONCLUSIONS: Bilateral inguinal hernia repair by TEP and TAP presented similar outcomes in our study.

Direct gallbladder indocyanine green injection technique to achieve critical view of safety in laparoscopic cholecystectomy.

INTRODUCTION: Bile duct injury is one of the most severe complications after cholecystectomy. The aim of this study is to demonstrate how with a simple technique, an optimal critical view may be achieved by injecting indocyanine green directly into the gallbladder. METHODS: Twenty-three patients were prospectively studied in which direct gallbladder injection of indocyanine green during laparoscopy was administered with a fine needle using an easily reproducible technique. RESULTS: Biliary tree identification was reported before and after injection. Critical view of safety was achieved in all cases. CONCLUSIONS: Our technique of direct gallbladder injection of indocyanine green is simple, efficient and shows a real time fluorescent cholangiography and an optimal critical view of safety decreasing the risk for bile duct injury.

Direct gallbladder Indocyanine Green injection technique to achieve critical view of safety in laparoscopic cholecystectomy. / Técnica de punción de verde de indocianina intravesicular para conseguir una visión crítica de seguridad durante la colecistectomía por laparoscopia.

INTRODUCTION: Bile duct injury is one of the most severe complications after cholecystectomy. The aim of this study is to demonstrate how with a simple technique, an optimal critical view may be achieved by injecting indocyanine green directly into the gallbladder. METHODS: Twenty-three patients were prospectively studied in which direct gallbladder injection of indocyanine green during laparoscopy was administered with a fine needle using an easily reproducible technique. RESULTS: Biliary tree identification was reported before and after injection. Critical view of safety was achieved in all cases. CONCLUSIONS: Our technique of direct gallbladder injection of indocyanine green is simple, efficient and shows a real time fluorescent cholangiography and an optimal critical view of safety decreasing the risk for bile duct injury.

Laparoscopic Right Adrenalectomy in a Large Right Adrenal Oncocytic Carcinoma.

BACKGROUND: Adrenocortical carcinomas are rare and aggressive tumors. The recently described oncocytic subtype has been reported approximately 40 times in the literature.1 In this video, we describe an unusual case of a large adrenal oncocytic carcinoma, its minimally invasive approach, and its anatomopathological features. CASE DESCRIPTION: A 43-year-old male presented to the emergency room with acute abdominal pain and fever. Blood tests showed 20,000 white blood cells and a reactive C-protein of 25. Tomography showed a large right adrenal tumor with necrosis. Antibiotics were started at the intensive care unit. A complete study showed normal tests, including hormones, cortisol, and metanephrines. At the multidisciplinary team meeting it was decided to perform a right transabdominal laparoscopic adrenalectomy. The tumor was approached from the medial side to the lateral side, always controlling the inferior vena cava. Indocyanine green was used to identify vascular structures. Anatomical pathology revealed a 15 cm lesion corresponding to a malignant adrenal oncocytic carcinoma according to the modified Lin-Weis-Bisceglia criteria.2 The patient was discharged without complications on the fifth day. He is receiving mitotane and is disease-free 5 months after surgery. CONCLUSIONS: Oncocytic subtype is a rare entity described only a few times in the literature. Surgical treatment is of choice due to its curative potential, and the open versus laparoscopic approach will be chosen depending on the size of the tumor and the surgeon's experience. It is believed that this subtype may have a less aggressive behavior than the typical adrenal carcinoma,1 therefore its better understanding may help to define therapeutic decisions and prognosis in the future.

Single-port laparoscopic left adrenalectomy (SILS): 3 years' experience of a single institution.

BACKGROUND: Laparoscopic adrenalectomy by 3 or 4 trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. METHODS: Between April 2010 and January 2013, all consecutive patients with adrenal masses who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5 cm subcostal incision was the sole point of entry. Data of patients undergoing SILS adrenalectomy were compared with those from an uncontrolled group of patients undergoing conventional laparoscopic adrenalectomy during the same study period. RESULTS: There were 40 patients in each study group. SILS was successfully performed and none of the patients required conversion to an open procedure. In 1 case of SILS procedure, an additional lateral 5 mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 80 (20) minutes in the SILS group and 75 (8) minutes in the conventional laparoscopic adrenalectomy group (P=0.150). No intraoperative or postoperative complications occurred. Differences between the 2 study groups in postoperative pain, number of patients resuming oral intake within the first 24 hours, final pathologic diagnosis (Conn syndrome, Cushing adenomas, nonfunctioning adrenal tumors), and length of hospital stay were not observed. CONCLUSIONS: SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients and seems to have results similar to a conventional approach in our initial comparison.

Total extraperitoneal (TEP) hernioplasty with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia.

We describe the first clinical case of a total extraperitoneal hernioplasty combined with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia. The patient was a 94-year-old woman admitted to the emergency room with signs and symptoms of acute small bowel obstruction. Diagnosis of a strangulated left Richter femoral hernia was only possible during the initial exploratory laparoscopy. The extraperitoneal approach for mesh positioning was performed gaining access through an infraumbilical 12 mm trocar incision, and assistance of two 5 mm laparoscopic ports at the hipogastrium and right flank. Laparoscopy was resumed and segmental intestinal resection with primary anastomosis was performed. The patient recovered without complications and was discharged home at the fourth postoperative day. The total extraperitoneal approach for acute hernia repair was successful in our particular case. However, factors such as laparoscopic surgical experience, careful patient selection, and correct preoperative diagnosis must be considered before studies in the emergency setting.

Single-incision laparoscopic cholecystectomy for day surgery procedure: are we prepared?

Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of fast track surgery. This report describes our experience with SILS cholecystectomy in patients that stay overnight. Between February 2009 and July 2010, patients referred for cholecystectomy to the day surgery unit who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery and the same operative technique was used in all cases. Postoperative pain and nausea were assessed using a 10-cm visual analogue scale on a self-completion questionnaire on the night of operation and the morning of discharge. A total of 107 patients (58% women, mean age 56 years) with symptomatic gallstones were included in the study. SILS was successfully performed in all patients and no patient required conversion to an open procedure. There were no significant differences in the median visual analogue scale for postoperative pain and nausea between the night of surgery and the next morning. The mean length of hospital stay was 23 hours, and 98 per cent of patients were satisfied with the results of surgery and would be willing to undergo the same procedure again. SILS cholecystectomy is a valid alternative to standard laparoscopic cholecystectomy as an outpatient surgery or overnight stay procedure. According to these promising results, SILS cholecystectomy could be included in a major ambulatory surgery program.

Single-incision transperitoneal laparoscopic left adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy via three or four trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy. METHODS: Between April 2010 and August 2011, all consecutive patients with adrenal masses, including Conn's syndrome, Cushing's adenoma, and nonfunctional adrenal tumors, who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5-cm subcostal incision was the sole point of entry. Data of patients who underwent SILS adrenalectomy were compared with those from an uncontrolled group of patients who underwent conventional laparoscopic adrenalectomy during the same study period. RESULTS: There were 20 patients in each study group (20 men, 20 women; mean age [SD] = 50 [6.5] years). SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5-mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 95 (20) min in the SILS group and 80 (8) min in the conventional laparoscopic adrenalectomy group (p = 0.052). There were no intraoperative or postoperative complications. There were no differences between the two study groups with respect to postoperative pain, number of patients who resumed oral intake within the first 24 h, final pathologic diagnosis, and length of hospital stay. CONCLUSION: SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients. The definitive clinical, aesthetic and functional advantages of this technique require further analysis.

Single-incision versus standard laparoscopic cholecystectomy: comparison of surgical outcomes from a single institution.

BACKGROUND: Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of mini-invasive surgery. We here described our 24-month experience SILS cholecystectomy. METHODS: Between February 2009 and 2011, patients referred for cholecystectomy to the General and Endocrine Unit of our institution who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing SILS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period. RESULTS: The SILS and standard cholecystectomy groups included 120 patients each. SILS was performed in all patients and none of them required conversion to an open procedure. The median operating time of 45 minutes in the SILS group was not significantly different from that in the standard laparoscopic cholecystectomy group. We suture fascial edge with simple stitches under direct vision, thus reducing the risk of incisional hernia in SILS group (P=.046). CONCLUSIONS: SILS cholecystectomy was technically feasible and safe and represents a reproducible alternative to standard laparoscopic cholecystectomy in selected patients. The definitive clinical, esthetic, and functional advantages of this technique require further analysis.

Suprapubic single-incision laparoscopic appendectomy: a nonvisible-scar surgical option.

BACKGROUND: At the present time, and given the increasing concern about body image, laparoscopic surgeons are faced with an increasing number of patients who want to conserve the umbilicus free of scars for cosmetic reasons. Single-incision laparoscopic surgery (SILS) using the suprapubic approach for appendectomy, while keeping the advantages of SILS through an umbilical incision, leaves the visible abdomen without scars. Moreover, insertion of an additional port in patients with retrocecal or purulent or gangrenous acute appendicitis requiring intra-abdominal drainage is avoided. This report describes the initial experience with suprapubic SILS appendectomy. METHODS: Between September 2009 and December 2010, patients with acute appendicitis admitted to the General Surgery and Emergency Unit of the authors' institution and who agreed to undergo SILS appendectomy through the suprapubic approach were included in a prospective study. Demographics, clinical characteristics, and surgical outcome were recorded. RESULTS: A total of 20 patients (12 men and 8 women) with a mean age of 30 ± 3 years underwent suprapubic SILS appendectomy. The mean duration of the operation was 40 ± 7 min. Placement of a suction drain was necessary in four patients. The mean length of hospital stay was 2 ± 0.5 days. The operation was completed successfully in all patients, and conversion to either multiport or open surgery was not required. No intraoperative or postoperative complications occurred. In all patients, the appearance of the suprapubic wound was good at 7 days after surgery. CONCLUSION: Suprapubic SILS appendectomy offers better, cosmetically appealing results than the standard umbilical access. In case of retrocecal or purulent or gangrenous acute appendicitis, the view provided via the suprapubic approach makes access to and dissection of the appendix easy, and it also enables exteriorization of a drain without adding new lateral incisions.

Laparoendoscopic single-site surgery appendectomy.

BACKGROUND: Laparoscopic appendectomy via the three-trocar technique is widely used for appendectomy. This report describes the initial experience with laparoendoscopic single-site surgery (LESS) appendectomy. METHODS: Between December 2008 and March 2009, patients with acute appendicitis admitted to the General Surgery and Emergency Unit of the authors' institution who agreed to undergo LESS appendectomy were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of emergency surgery. The umbilicus was the sole point of entry for all patients, and the same operative technique was used in all cases. The data for patients undergoing LESS appendectomy were compared with the data from an uncontrolled group of patients undergoing standard laparoscopic appendectomy during the same study period. RESULTS: The LESS and standard appendectomy groups included 15 patients each. The LESS procedure was performed successfully for all the patients, and none required conversion to an open procedure or a conventional laparoscopic appendectomy by the addition of more entry ports. The mean operating time of 51 min in the LESS group was not significantly different from the 46 min in the standard laparoscopic appendectomy group. CONCLUSIONS: In this study, LESS appendectomy was technically feasible and safe, representing a reproducible alternative to standard laparoscopic appendectomy.