Laparoscopic modified Sugarbaker parastomal hernia repair with 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh technique.

BACKGROUND: The ideal mesh and mesh fixation technique for laparoscopic Sugarbaker (SB) parastomal hernia repair have not yet been identified. METHODS: Sixteen patients with parastomal hernia who underwent laparoscopic modified SB repair (LSB) between June 2012 and October 2015 were retrospectively analyzed. LSB was performed using a developed standardized 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh (PCO-PM) technique. RESULTS: Out of 16 cases, 14 were primary and 2 recurrent hernias; 13 were para-end colostomy and 3 were para-ileal conduit (PIC) hernias. The median longitudinal and transverse diameters of the hernia orifice were 5 cm (2.5-7 cm) and 4.2 cm (2-6 cm), respectively. Five cases had a concomitant midline incisional hernia, which was simultaneously repaired. In all cases, the mesh was placed without deflection. The median operation time was 193 (75-386) min. Perioperative complications occurred in two cases (13 %) with PIC, one intra-operatively and the other postoperatively. The intra-operative complication was enterotomy close to the ureteroenteric anastomosis of the ileal conduit; it was repaired through a mini-laparotomy. LSB was accomplished without any subsequent postoperative complications. The postoperative complication was ureteral obstruction that required creation of nephrostomy. Mini-laparotomy was necessary in those two cases (13 %) because of intra-operative enterotomy and severe intra-abdominal adhesions. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed with a median follow-up of 14.5 (2-41) months. CONCLUSIONS: Our LSB using standardized mesh fixation technique is safe and feasible, and the PCO-PM seems to be the most optimal prosthesis.

A comparison of laparoscopic energy devices on charges in thermal power after application to porcine mesentery.

INTRODUCTION: Advances in energy devices have played a major role in the rapid expansion of laparoscopic surgery. However, complications due to these energy devices are occasionally reported, and if the characteristics of these devices are not well understood, serious complications may occur. This study evaluated various typical energy devices and measured temperature rises in the adjacent tissue and in the devices themselves. EQUIPMENT AND METHODS: We used the following 7 types of energy devices: AutoSonix (AU), SonoSurg (SS), Harmonic Scalpel (HS), LigaSure Atlas (LA), LigaSure Dolphin Tip (LD), monopolar diathermy (Mono), and bipolar scissors (Bi). Laparoscopy was performed under general anesthesia in pigs, and the mesentery was dissected using each energy device. Tissue temperature at a distance of 1 mm from the energy device blade before and after dissection was measured. Temperature of the device blade both before and after dissection, time required for dissection, and interval until the temperature fell to 100°C, 75°C, and 50°C were documented. RESULTS: Temperature of the surrounding tissue using each device rose the most with the Mono (50.5±8.0°C) and the least with the HS in full mode (6.2±0.7°C). Device temperature itself rose the highest with the AU in full mode (318.2±49.6°C), and the least with the Bi (61.9±4.8°C). All ultrasonic coagulation and cutting devices (AU, SS, and HS) had device temperatures increase up to ≥100°C, and even at 8 seconds after completing dissection, temperatures remained at ≥100°C. CONCLUSIONS: Because the adjacent tissue temperature peaked with the Mono, cautious use near the intestine and blood vessels is necessary. In addition, the active blades of all ultrasonic coagulation and cutting devices, regardless of model, developed high temperatures exceeding 100°C. Therefore, an adequate cooling period after using these devices is therefore necessary between applications.

Mesothelial cyst with endometriosis mimicking a Nuck cyst.

We report a case of mesothelial cyst protruding from the right femoral ring with suspected endometriosis in a 35-year-old woman, who complained of a lump with a diameter of 6 cm in the right inguinal region. Although she had the hormone therapy during the next 8 months for the diagnosis of extragenital endometriosis, her symptoms did not improve. The clinical suspicion of a Nuck cyst with endometriosis, supported by ultrasonography and magnetic resonance imaging, was confirmed by histopathological examination of the surgical specimen. Authors herein report this unusual case and review the literature.

Transumbilical defunctioning ileostomy: A new approach for patients at risks of anastomotic leakage after laparoscopic low anterior resection.

BACKGROUND: The use of a protective defunctioning stoma in rectal cancer surgery has been reported to reduce the rates of reoperation for anastomotic leakage, as well as mortality after surgery. However, a protective defunctioning stoma is not often used in cases other than low rectal cancer because of the need for stoma closure later, and hesitation by patients to have a stoma. We outline a novel and patient-friendly procedure with an excellent cosmetic outcome. This procedure uses the umbilical fossa for placement of a defunctioning ileostomy followed by a simple umbilicoplasty for ileostomy closure. PATIENTS AND METHODS: This study included a total of 20 patients with low rectal cancer who underwent a laparoscopic low anterior resection with defunctioning ileostomy (10 cases with a conventional ileostomy in the right iliac fossa before March 2012, and 10 subsequent cases with ileostomy at the umbilicus) at the Jikei University Hospital in Tokyo from August 2011 to January 2013. The clinical characteristics of the two groups were compared: operative time, blood loss, length of hospital stay and postoperative complications of the initial surgery, as well as the stoma closure procedure. RESULTS: There were no differences between the groups in the median operative time for initial surgery (248 min vs. 344 min), median blood loss during initial surgery (0 ml vs. 115 ml), and median hospital stay after initial surgery (13 days vs. 16 days). Complication rates after the initial surgery were similar. There were no differences between the groups in median operative time for stoma closure (99 min vs. 102 min), median blood loss during stoma closure (7.5 ml vs. 10 ml), and median hospital stay after stoma closure (8 days in both groups). Complications after stoma closure such as wound infection and intestinal obstruction were comparable. Thus, no significant differences in any factor were found between the two groups. CONCLUSION: The transumbilical protective defunctioning stoma is a novel solution to anastomotic leakage after laparoscopic rectal cancer surgery, with patient-friendliness as compared to conventional procedures in light of the cosmetic outcome.