Transvesical robot-assisted simple prostatectomy with 360° circumferential reconstruction: step-by-step technique.

OBJECTIVE: To present the step-by-step technique of a 360° mucosal reconstruction after transvesical robot-assisted simple prostatectomy (RASP). PATIENT AND METHODS: We analysed the first 23 consecutive patients who underwent RASP using our 360° reconstruction between December 2015 and October 2017. After transperitoneal intravesical adenoma enucleation, a circumferential 360° reconstruction is performed. The first suture is placed at the 9 o'clock position and the edge of the urethra and bladder mucosa is approximated using 2-0 barbed suture. The reconstruction is continued counter-clockwise and the bladder mucosa is approximated to the urethra circumferentially. RESULTS: The mean (sd) operating time was 160.6 (28.1) min and the estimated blood loss was 98.6 (99.8) mL. No patients required conversion to open surgery. No intra-operative or postoperative transfusions were needed. No intra-operative complications occurred. The mean (sd) length of hospital stay was 2.1 (0.6) days. One postoperative complication was reported (respiratory distress in a patient with chronic obstructive pulmonary disease, requiring intensive care unit admission). CONCLUSION: Our 360° reconstruction during RASP is feasible and safe. The aim of the technique is to minimize use of electrocautery and decrease the raw surface area on the prostate capsule. This technical modification could potentially lessen postoperative bleeding after RASP and therefore the need for continuous bladder irrigation. In addition, it could potentially lead to mitigation of burning and irritative postoperative symptoms. Longer follow-up and comparative studies of different RASP techniques are still needed.

Robotic Parastomal Hernia Repair With Biologic Mesh.

INTRODUCTION: Parastomal hernia is a common and vexing problem after ileal conduit urinary diversion that can cause pain, bowel symptoms, and problems with the stoma appliance, resulting in leakage, odor, and impairment of quality of life. Historically, these hernias have been managed open surgically, which requires considerable dissection of the abdominal wall for mesh placement, and may also require relocating the stoma to the contralateral side. Further, open parastomal hernia repair can be a morbid procedure with recurrence rates of approximately 30%. MATERIALS AND METHODS: We present our technique of robotic parastomal hernia repair with a biologic mesh. We used a biologic mesh with the keyhole technique to avoid risk of erosion into the bowel segment. We present a case series of 3 patients undergoing robotic parastomal hernia repair. The illustrative case in the video is that of a 63-year-old obese woman with a parastomal hernia resulting in poor stoma appliance adhesion and bothersome urinary leakage. RESULTS: Robotic repair was completed successfully without intraoperative complications in all 3 patients. The mean age was 72 years. Mean body mass index was 30 kg/m2. Mean operating time was 3.5 hours. Mean estimated blood loss was 7.5 mL. Mean length of hospital stay was 3 days. On follow-up, all 3 patients were asymptomatic with stoma appliance issues and had no recurrence. CONCLUSION: Our initial series suggests that robotic repair of parastomal hernia is safe and feasible with minimal morbidity and good short-term outcomes. Further studies are required to confirm the efficacy of our technique.

Patient profile and outcome of pilomatrixoma in district general hospital in United kingdom.

INTRODUCTION: A pilomatrixoma is a benign appendage tumour related to hair cells matrix. Most of the literature review about pilomatrixoma is in the form of case reports with fewer cohort studies. The objective of this cohort is to study the variable demographic characteristics, presentation and histopathology of this condition among a larger group of patients. MATERIALS AND METHODS: We conducted a retrospective study of patients who had excision of pilomatrixoma between February 1998 and August 2011 in a District General Hospital in UK. RESULTS: The study included 67 patients with histopathologically diagnosed pilomatrixoma. The mean age was 32 years. Male to Female ratio was 35:32. The average diameter of the lesion at presentation was 13 mm (range: 2-30 mm). 66 of 67 (98.5%) patients presented with solitary lesion, while 1 patient (1.5%) had two lesions. CONCLUSION: Pilomatrixoma is not an uncommon benign lesion. It is more common in the maxillofacial area.

Portal venous gas and pneumatosis intestinalis; radiologic signs with wide range of significance in surgery.

BACKGROUND: Portal vein gas (PVG) was described as an uncommon ominous radiologic sign usually harboring an intra-abdominal catastrophe. When accompanied by pneumatosis intestinalis (PI), it is more predictive of bowel ischemia. Since the wide use of computed tomography (CT), both signs could also be viewed as incidental findings during routine radiologic investigations. METHODS: We present a series of 12 cases that showed either or both signs, collected in a district general hospital between 1991 and 2011. RESULTS: The diagnoses in these cases varied between fatal bowel ischemia and the mere presence of radiologic signs in the absence of significant pathology. CONCLUSION: PVG and PI are radiologic signs that can represent a wide range of pathology.

Short-term outcomes of laparoscopic colorectal resection in patients with previous abdominal operations.

BACKGROUND: Laparoscopic colorectal procedures (LCPs) are technically demanding; previous abdominal surgery may add to their complexity. The aim of our study was to assess the effect of previous abdominal surgery (PAS) on laparoscopic colorectal surgery. SUBJECTS AND METHODS: A prospective database was used to record LCPs between 2001 and 2011. Patients were divided into two groups: Group A consisted of patients with no PAS, and Group B of patients with PAS. Data collected included prior abdominal operations, type of LCP, operative time, and conversions. Operative mortality, morbidity, and ward stay in both groups were compared. Statistical analysis was performed using Fisher's exact test and Student's t test. RESULTS: One hundred eighty-one patients underwent LCPs: 113 in Group A and 68 in Group B. Mean operative time in Group A and Group B was 216.5 (range, 60-520) minutes and 233.2 (range, 114-544) minutes, respectively (P = .17). In the first 90 cases, the mean operative time was significantly lower for Group A (203 minutes) than in Group B (236.5 minute) (P = .02). The rate of conversion was 10.6% (12/113) in Group A and 13.2% (9/68) in Group B (P = .6). Two patients in Group B had small bowel enterotomies (1 missed on the operating table) compared with none in Group A. Morbidities were comparable in both groups. Median hospital stay was 4.5 and 4 days in Groups A and B, respectively (P=.9). There were 3 deaths in Group A (2 due to medical causes and 1 surgical-related). One surgical-related death (missed enterotomy) occurred in Group B. CONCLUSIONS: Short-term outcomes of laparoscopic colorectal surgery in patients with PAS are acceptable. There is no significant difference in conversion rate, hospital stay, morbidity, or mortality. The difference in the operative time is significant only in the early part of the learning curve. Meticulous adhesiolysis to avoid and recognize enterotomy is of paramount importance.

Appendicitis in paediatric age group: correlation between preoperative inflammatory markers and postoperative histological diagnosis.

INTRODUCTION: Clinical diagnosis of appendicitis can be challenging, particularly in the paediatric age group. There is an increased risk of perforation in paediatrics; therefore, a need for sensitive and specific diagnostic tool is mandatory. AIM: The aim of this study is to evaluate the role of preoperative inflammatory markers in supporting the clinical diagnosis of appendicitis in the paediatric age group. MATERIALS AND METHODS: Retrospective study of 268 emergency paediatric appendicectomies performed in a District General Hospital in Wales, over a period of seven years (2002-2009). The data collected from hospital database include preoperative inflammatory markers, C-reactive protein (CRP) and white blood cells count (WBCC) and post-operative histology. Statistical analysis was performed using Fisher's exact test. RESULTS: The median age group in the study was 12 (2-16). 141 (53%) patients were <12 years, while 127 (47%) patients were 12-16 years old. Male : female ratio = 1 : 1 (134 each). Inflammatory markers were not done for 94 patients (35%). CRP was done for 149 cases (55.6%), while WBCC was done for 172 cases (64%). Both markers were done together for 147 cases (54.8%). Histology was positive (inflamed / gangrenous appendix) in 202 cases (75.4%). Eight cases were associated with Enterobious vermicularis infestation and one patient had carcinoid tumour. The sensitivity and specificity of CRP were 82% and 60%, respectively, with positive predictive value (PPV) of 87% (P<0.0001), while those of WBCC were 80% and 59%, respectively, with PPV of 88% (P<0.0001). The sensitivity and specificity of both markers together were 80% and 70%, respectively, with PPV= 81% (P = 3.11E-8). 94 patients (35%) had an appendicectomy operation based on clinical diagnosis alone without preoperative inflammatory markers having been tested. In 28 cases (30%) out of these, postoperative histology revealed normal appendix (P = 0.18). CONCLUSION: CRP and WBCC are simple tests that can provide a significant role supporting the clinical diagnosis of acute appendicitis in the paediatric age group.

Transanal division of the anorectal junction followed by laparoscopic low anterior resection and coloanal pouch anastomosis: A technique facilitated by a balloon port.

We performed a laparoscopic ultra low anterior resection in two patients with low rectal cancers (3 cm from dentate line). A transanal division and continuous suture closure of anorectal junction was performed first followed by laparoscopic low anterior resection. A handsewn anastomosis between colonic pouch/transverse coloplasty and anal canal was facilitated by use of a transanal balloon port.