Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies.

BACKGROUND: This study aims to evaluate the impact of conversion from retrograde dissection to fundus-first technique (FF) or laparoscopic partial cholecystectomy (LPC) on complication rates, operation time, and duration of hospitalization. METHODS: The medical records of 210 consecutive patients who underwent laparoscopic cholecystectomy between January 2010 and December 2014 were retrospectively evaluated. All laparoscopic cholecystectomies were initiated with retrograde dissection (RD). In cases of difficulty in dissection of critical view of safety , the operation strategy was first converted to FF and then to LPC when FF was considered insufficient for safe cholecystectomy. RESULTS: Of the 210 cases, LC was initiated and completed with RD in 197 cases. FF was implemented in 13 cases due to difficulties in dissection. In the FF group, laparoscopic total cholecystectomy was successfully accomplished in seven patients, and LPC was performed in the remaining six cases. Three postoperative complications occurred in the RD group and two in the LPC group. No major intraoperative complications or perioperative mortality occurred in any patients. CONCLUSION: In elective, noncomplicated cases, the safe posterior window (critical view of safety) principle should be implemented. However, in complicated cases where anatomic uncertainties are dominant, the performance of FF technique or LPC may decrease conversion rates to open surgery and contribute to accomplishing the laparoscopic intervention safely.

A robotic indenter for minimally invasive measurement and characterization of soft tissue response.

The lack of experimental data in current literature on material properties of soft tissues in living condition has been a significant obstacle in the development of realistic soft tissue models for virtual reality based surgical simulators used in medical training. A robotic indenter was developed for minimally invasive measurement of soft tissue properties in abdominal region during a laparoscopic surgery. Using the robotic indenter, force versus displacement and force versus time responses of pig liver under static and dynamic loading conditions were successfully measured to characterize its material properties in three consecutive steps. First, the effective elastic modulus of pig liver was estimated as 10-15 kPa from the force versus displacement data of static indentations based on the small deformation assumption. Then, the stress relaxation function, relating the variation of stress with respect to time, was determined from the force versus time response data via curve fitting. Finally, an inverse finite element solution was developed using ANSYS finite element package to estimate the optimum values of viscoelastic and nonlinear hyperelastic material properties of pig liver through iterations. The initial estimates of the material properties for the iterations were extracted from the experimental data for faster convergence of the solutions.

Thoracoscopic diaphragm plication in children and indications for conversion to open thoracotomy.

Thoracoscopic plication of the diaphragm has been recently described as an alternative treatment for eventration. It is considered to be much less traumatic than the conventional method. We attempted thoracoscopic diaphragm plication on three patients. Two patients were treated successfully by the minimally invasive technique and were discharged from hospital on the second postoperative day. In the third case, the presence of a mobile intrathoracic kidney due to previous diaphragmatic hernia repair necessitated conversion to open thoracotomy. This patient was discharged on postoperative day six following an uneventful recovery. All patients are well and asymptomatic on followup. We advocate thoracoscopic diaphragm plication in children as a safe procedure with less morbidity and excellent cosmetic results.

Laparoscopic vagotomy using mini-instruments in the rat: a new laparoscopic small animal model.

PURPOSE: Animal models are necessary for research, technical developments, and training purposes in laparoscopic surgery. Although various operations on small animals have been described, there is still a need for a simple and practical laparoscopic small animal model. We acknowledged truncal vagotomy as a simple procedure, and aimed to develop a model of laparoscopic truncal vagotomy (LTV) in the rat, an inexpensive and easily available animal. METHODS: Fifty Wistar rats were randomized into an LTV group (n = 25) and an open truncal vagotomy (OTV) group (n = 25). LTV was effected with two minitrocars inserted into the left upper and right lower quadrants. Two techniques of vagotomy were developed: first, with the esophagus in its anatomical position, and second, with the distal esophagus retracted anteriorly with a grasper inserted into the retroesophageal space. OTV was performed through a midline incision. Animals were sacrificed 24h postoperatively, and autopsy was performed. RESULTS: The mean +/- SD operating time was 8.3+/-1.4 min in the LTV group and 5.5+/-0.2 min in the OTV group (P < 0.05). The laparoscopically magnified view provided a better distinction of vagal fibers compared with open surgery, with the second laparoscopic technique providing the best exposure. Complications developed in three rats (12%) from the LTV group and one (4%) from the OTV group (P > 0.05). Vagotomy was confirmed to be complete at autopsy in all of the animals. CONCLUSION: This is the first technical description of laparoscopic peptic ulcer surgery in the rat. Although subsequent histopathological and physiological studies may be required, technically, laparoscopic vagotomy in the rat seems to be a simple, inexpensive, and expeditious small-animal model for laparoscopic research.