Intracorporeal antimesenteric ancillary trocar: an anastomotic technique facilitating natural orifice specimen extraction in left-sided colorectal surgery.

AIM: Natural orifice specimen extraction (NOSE) in left-sided colorectal surgery requires application of the circular stapler anvil to the proximal bowel without exteriorization through an additional abdominal incision. We describe an intracorporeal method to secure the stapler anvil, termed the intracorporeal antimesenteric ancillary trocar (IAAT) technique. METHOD: The ancillary trocar is attached to the stapler anvil before introduction into the abdominal cavity through the anal or vaginal orifice. The colon is incised before the trocar spike is brought out through the antimesenteric surface 3-4 cm within the cut edge. A linear stapler is used to seal the bowel end. The ancillary trocar is detached and retrieved via the NOSE conduit. Following the NOSE procedure, a side-to-end colorectal anastomosis is performed with the transanal circular stapler. RESULTS: Ten consecutive patients underwent elective left-sided colorectal resection with IAAT for NOSE (seven transanal, three transvaginal) from January to June 2023. Median age and body mass index were 66 (range 47-74) years and 24.3 (range 17.9-30.8) kg/m2 respectively. Two (20%) patients underwent sigmoid colectomy for sigmoid volvulus while eight (80%) underwent anterior resection for colorectal cancer. Median operating time, operative blood loss and postoperative length of hospital stay were 170 (range 140-240) min, 20 (range 10-40) mL and 1 (range 1-3) day respectively. There were no postoperative complications, readmissions or reoperations. Median follow-up duration was 3 (range 1-6) months. CONCLUSION: The IAAT double-stapling side-to-end anastomotic technique is safe and feasible for patients undergoing left-sided colorectal resection with NOSE, resulting in good outcomes.

Trocar-site incisional hernia after 8-mm robotic trocar placement: A prospective study.

BACKGROUND: The current literature supports the closure of trocar sites ≥10-mm for the risk of developing incisional hernias, while there is no need to suture the abdominal fascia when using 5-mm trocars. To date, evidence regarding the closure of 8-mm trocars that are use by new robotic systems is weak. The aim of our study was to investigate the incidence of incisional hernia for 8-mm trocars. METHODS: We prospectively collected data on all patients undergoing robotic-assisted abdominal wall surgery from 2020 to 2023, in whom the abdominal fascia of all 8-mm trocars was not closed. The enrolled patients underwent a follow-up visit during which we conducted clinical and sonographic evaluations of all 8-mm trocars, in addition to assessing the satisfaction levels of the patients. The primary outcome was the incidence of port-site hernia. RESULTS: We enrolled 166 patients, 155 men and 11 women, for a total of 513 trocars accessed. Mean age was 61.1 ± 14.0 years, and mean BMI was 27.0 ± 3.9 kg/m2. The follow-up visits were carried out after a median follow-up of 14.5 (9.0-23.2) months. Only one case developed an asymptomatic 1 × 1 cm supra-umbilical hernia that was not treated. Patient reported a satisfaction regarding the 8-mm trocars and skin sutures of 9.8 ± 0.5 out of 10 points. CONCLUSIONS: The occurrence of a trocar-site hernia after 8-mm robotic access is extremely low. Hence, the fascia closure may not be necessary.

Laparoscopic Trocars: Marketed Versus True Dimensions-A Descriptive Study.

STUDY OBJECTIVE: To establish true dimensions of single-use laparoscopic trocars compared with marketed dimensions, calculate corresponding incision sizes, examine what trocar size categories are based on, and outline accessibility of information regarding true dimensions. DESIGN: Descriptive study. SETTING: Laparoscopic disposable trocars available in North America and Europe are marketed in several distinct categories. In practice, trocars in the same-size category exhibit different functionality (ability to introduce instruments/needles and retrieve specimens) and warrant different incision lengths. PATIENTS: Not applicable. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: True dimensions for 125 trocars (bladeless, optical, and balloon) were obtained from 9 vendors covering 8 marketed size categories (3-, 3.5-, 5-, 8-, 10-, 11-, 12-, and 15-mm trocars). On average, true inner cannula diameter was 0.92 mm wider (SD, 0.41 mm; range, 0-2.4 mm) than the marketed size category, with the widest range in the 5 mm category. For 5-mm trocars, mean true inner diameter was 6.1 mm (SD, 0.45; range, 5.5-7.4) and true outer diameter 8.3 mm (SD, 0.71; range, 8.0-10.7). For 12-mm trocars, mean true inner diameter was 13.0 mm (SD, 0.21; range, 12-13.3) and outer diameter 15.3 mm (SD, 0.48; range, 14.4-16.8). Five-mm trocars necessitate a mean incision size of 13.0 mm (SD, 1.1; range, 12.1-16.8) and 12-mm trocars a mean incision of 24.0 mm (SD, 0.75; range, 22.6-26.4). No vendors stated actual diameters on company website or catalog. In one instance the Instructions For Use document contained the true inner diameter. CONCLUSION: Trocar size categories give a false sense of standardization when in actuality there are considerable within-category differences in both inner and outer diameters, corresponding to differences in functionality and required incision sizes. There is no universally applied definition for trocar size categories. Accessibility of information on true dimensions is limited.

The influence of microwave ablation parameters on the positioning of trocar in different cancerous tissues: a numerical study.

The present study analyzed the microwave ablation of cancerous tumors located in six major cancer-prone organs and estimated the significance of input power and treatment time parameters in the apt positioning of the trocar into the tissue during microwave ablation. The present study has considered a three-dimensional two-compartment tumour-embedded tissue model. FEA based COMSOL Multiphysics software with inbuilt bioheat transfer, electromagnetic waves, heat transfer in solids and fluids, and laminar flow physics has been used to obtain the numerical results. Based on the mortality rates caused by cancer, the present study has considered six major organs affected by cancer, viz. lung, breast, stomach/gastric, liver, liver (with colon metastasis), and kidney for MWA analysis. The input power (100 W) and ablation times (4 minutes) with apt and inapt positioning of the trocar have been considered to compare the ablation volume of various cancerous tissues. The present study addresses one of the major problems clinicians face, i.e. the proper placement of the trocar due to poor imaging techniques and human error, resulting in incomplete tumor ablation and increased surgical procedures. The highest values of the ablation region have been observed for the liver, colon metastatic liver and breast cancerous tissues compared with other organs at the same operating conditions.

The present study has investigated the application of microwave ablation for cancer treatment in six major organs, specifically emphasizing the evaluation of ablation volume during the procedure. Using COMSOL-Multiphysics software, the study has investigated MWA of tumor embedded organs in the lung, breast, stomach, liver, and kidney. The positioning of the trocar, a crucial element in the treatment process, has been examined to address challenges in effectively ablating tumors.From the results, it has been revealed that liver, colon metastatic liver, and breast cancer tissues exhibited the largest areas of ablation volume compared with other organs.Organs like the breast and hepatic glands, characterized by lower heat capacity and density, have shown larger ablation zones. Trocar positioning significantly influenced the stomach, liver, and kidney, where improper placement led to notable increases in ablation volume, posing a risk of unintended damage to healthy tissue.Further, the study has concluded that precise trocar positioning plays a crucial role in optimizing microwave ablation. This precision has the potential to enhance the effectiveness of cancer treatments while minimizing harm to healthy tissue. The insights gained from this research offer valuable information for clinicians looking to enhance the precision of cancer therapies, ultimately aiming for improved outcomes for patients.

The influence of prolonged instrument manipulation on gas leakage through trocars.

BACKGROUND: During laparoscopic surgery, CO2 insufflation gas could leak from the intra-abdominal cavity into the operating theater. Medical staff could therefore be exposed to hazardous substances present in leaked gas. Although previous studies have shown that leakage through trocars is a contributing factor, trocar performance over longer periods remains unclear. This study investigates the influence of prolonged instrument manipulation on gas leakage through trocars. METHODS: Twenty-five trocars with diameters ranging from 10 to 15 mm were included in the study. An experimental model was developed to facilitate instrument manipulation in a trocar under loading. The trocar was mounted to a custom airtight container insufflated with CO2 to a pressure of 15 mmHg, similar to clinical practice. A linear stage was used for prolonged instrument manipulation. At the same time, a fixed load was applied radially to the trocar cannula to mimic the reaction force of the abdominal wall. Gas leakage was measured before, after, and during instrument manipulation. RESULTS: After instrument manipulation, leakage rates per trocar varied between 0.0 and 5.58 L/min. No large differences were found between leakage rates before and after prolonged manipulation in static and dynamic measurements. However, the prolonged instrument manipulation did cause visible damage to two trocars and revealed unintended leakage pathways in others that can be related to production flaws. CONCLUSION: Prolonged instrument manipulation did not increase gas leakage rates through trocars, despite damage to some individual trocars. Nevertheless, gas leakage through trocars occurs and is caused by different trocar-specific mechanisms and design issues.

Not deep enough: Modeling the effect of shallow placement of the DaVinci Xi "bariatric" long trocar on the muscular abdominal wall.

INTRODUCTION: The DaVinci Xi Robotic Surgical System (Xi) long cannula (Intuitive Surgical Company, Sunnyvale, CA) provides five additional centimeters of distal length compared to the standard Xi trocar. The extra length allows the cannula to traverse prohibitively thick body wall tissue. Our aims are to quantitatively model the consequences of not preserving the rotational centerpoint of motion (RCM) at the muscular abdominal wall. This is an essential tenet in robotic surgery; it is violated with shallow placement of the long trocar. This leads to unchecked, unnoticed blunt widening of port sites by the robotic arm, increasing hernia risk. METHODS: We begin with an exploration of the schematic of the Xi robotic arm as patented by Intuitive (U.S. Patent #5931832). We trigonometrically model the lateral displacement of the abdominal wall at the trocar site with respect to vertical trocar shallowness, instrument tip depth, and instrument tip lateral motion from neutral midline. RESULTS: The rigid parallelogram movement structure of the Xi preserves the RCM at the thick black marker printed on every Xi cannula. By limitation of design, both long and standard trocars must have this marker at the exact same distance from their proximal end. The value ranges of our model parameters (presuming a reasonable maximum orientation angle of 45° from midline) are: trocar shallowness [1 cm, 7 cm]; instrument tip depth [0 cm, 20 cm]; instrument tip lateral movement [0.0 cm, 14.1 cm]. Abdominal wall displacement increased proportionally as each instrument tip parameter reached its maximum deviation from the orthogonal midline as described in the plot figure. Maximal wall displacement at maximal shallowness was approximately 7.0 cm. CONCLUSION: Robotic surgery revolutionizes modern operation, particularly within bariatrics. However, the current Xi arm design disallows a true long trocar to be used safely without compromising the RCM, thereby risking hernia development.

Development of a deep learning model for safe direct optical trocar insertion in minimally invasive surgery: an innovative method to prevent trocar injuries.

BACKGROUND: Direct optical trocar insertion is a common procedure in laparoscopic minimally invasive surgery. However, misinterpretations of the abdominal wall anatomy can lead to severe complications. Artificial intelligence has shown promise in surgical endoscopy, particularly in the employment of deep learning models for anatomical landmark identification. This study aimed to integrate a deep learning model with an alarm system algorithm for the precise detection of abdominal wall layers during trocar placement. METHOD: Annotated bounding boxes and assigned classes were based on the six layers of the abdominal wall: subcutaneous, anterior rectus sheath, rectus muscle, posterior rectus sheath, peritoneum, and abdominal cavity. The cutting-edge YOLOv8 model was combined with a deep learning detector to train the dataset. The model was trained on still images and inferenced on laparoscopic videos to ensure real-time detection in the operating room. The alarm system was activated upon recognizing the peritoneum and abdominal cavity layers. We assessed the model's performance using mean average precision (mAP), precision, and recall metrics. RESULTS: A total of 3600 images were captured from 89 laparoscopic video cases. The proposed model was trained on 3000 images, validated with a set of 200 images, and tested on a separate set of 400 images. The results from the test set were 95.8% mAP, 89.8% precision, and 91.7% recall. The alarm system was validated and accepted by experienced surgeons at our institute. CONCLUSION: We demonstrated that deep learning has the potential to assist surgeons during direct optical trocar insertion. During trocar insertion, the proposed model promptly detects precise landmark references in real-time. The integration of this model with the alarm system enables timely reminders for surgeons to tilt the scope accordingly. Consequently, the implementation of the framework provides the potential to mitigate complications associated with direct optical trocar placement, thereby enhancing surgical safety and outcomes.

Injuries incurred from minimally invasive access for abdominal surgery.

BACKGROUND: Injuries during initial port placement in minimally invasive abdominal surgery are rare but can cause major morbidity. We aimed to characterize the incidence, consequence, and risk factors for injury occurring on initial port placement. METHODS: This is a retrospective review of a General Surgery quality collaborative database with supplementary input from the Morbidity and Mortality conference database at our institution between 6/25/2018 and 6/30/2022. Patient characteristics, operative details, and postoperative course were assessed. Cases with an injury on entry were compared to cases without an injury to identify risk factors for injury. RESULTS: 8844 minimally invasive cases were present between the two databases. Thirty-four injuries (0.38%) occurred during initial port placement. Seventy-one percent of injuries were bowel injuries (full or partial thickness) and the majority (79%) of injuries were recognized during the index operation. Median surgeon experience for the cases with an injury was 9 years (IQR 4.25-14.5) compared to 12 years of experience for all surgeons contributing to the database (p = 0.004). Previous laparotomy was also significantly correlated with the rate of injury on entry (p = 0.012). There was no significant difference in the rate of injury based on method of entry (cut-down: 19 (55.9%), optical entry without Veress: 10 (29.4%), Veress followed by optical entry: 5 (14.7%), p = 0.11). BMI > 30 kg/m2 (injury: 16/34 vs no injury: 2538/8844, p = 0.847) was not associated with an injury. Fifty-six percent (19/34) of patients with an injury on initial port placement required laparotomy at some point in their hospital course. CONCLUSIONS: Injuries are rare during initial port placement for minimally invasive abdominal surgery. In our database, history of a previous laparotomy was a significant risk factor for an injury and appears to be more consequential than commonly implicated factors such as technique, patient body habitus, or surgeon experience.

Does trocar puncture of the bladder during midurethral sling impact postoperative urinary storage and voiding symptoms?

INTRODUCTION AND HYPOTHESIS: The incidence of trocar bladder puncture during midurethral sling (MUS) surgery varies widely. We aim to further characterize risk factors for bladder puncture and examine its long-term impact on storage and emptying. METHODS: This is an Institutional Review Board-approved, retrospective chart review of women who underwent MUS surgery at our institution from 2004 to 2018 with ≥12 months of follow-up. Unless prolonged catheterization was necessary, a voiding trial was performed prior to discharge, or the next morning in outpatients, regardless of puncture. Preoperative and postoperative details were obtained from office charts and operative records. RESULTS: Of 1,500 women, 1,063 (71%) had retropubic (RP) and 437 (29%) had transobturator MUS surgery. Mean follow-up was 34 months. Thirty-five women (2.3%) sustained a bladder puncture. RP approach and lower BMI were significantly associated with puncture. No statistical association was found between bladder puncture and age, previous pelvic surgery, or concomitant surgery. Mean day of discharge and day of successful voiding trial were not statistically different between the puncture and nonpuncture groups. There was no statistically significant difference in de novo storage and emptying symptoms between the two groups. Fifteen women in the puncture group had cystoscopy during follow-up and none had bladder exposure. Level of the resident performing trocar passage was not associated with bladder puncture. CONCLUSIONS: Lower BMI and RP approach are associated with bladder puncture during MUS surgery. Bladder puncture is not associated with additional perioperative complications, long-term urinary storage/voiding sequelae, or delayed bladder sling exposure. Standardized training minimizes bladder punctures in trainees of all levels.

Major and minor complications in Veress needle (VN) and direct trocar insertion (DTI) for laparoscopic closed-entry techniques: an updated systematic review and meta-analysis.

OBJECTIVE: Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. We conducted a systematic review and meta-analysis to compare these two entry closed techniques. DATA SOURCE: A systematic review of the literature was done on PubMed, MEDLINE, Embase, Scopus, and EBSCO. METHODS: The literature search was constructed until May 01, 2022, around search terms for "Veress," "direct trocar," "needle," "insertion," and "laparoscopic ways of entry." This systematic review was reported according to the PRISMA Statement 2020. RESULTS: Sixteen controlled trials (RCTs) and 5 observational studies were included in the systematic review. We found no significant differences in the risk of major complication during the access manoeuvres between DTI and VN: bowel injuries (OR = 0.76, 95% CI: 0.24-2.36, P = 0.63), major vascular injuries (OR = 1.74, 95% CI 0.56-5.38, P = 0.34), port site hernia (OR = 2.41, 95% CI: 0.28-20.71, P = 0.42). DTI has a lower risk of minor complications such as subcutaneous emphysema (OR = 5.19 95% CI: 2.27-11.87, P < 0.0001), extraperitoneal insufflation (OR = 5.93 95% CI: 1.69-20.87, P = 0.006), omental emphysema (OR = 18.41, 95% CI: 7. 01-48.34, P < 0.00001), omental bleeding (OR = 2.32, 95% CI: 1.18-4.55, P = 0.01), and lower number of unsuccessful entry or insufflation attempts (OR = 2.25, 95% CI: 1.05-4.81, P = 0.04). No significant differences were found between the two groups in terms of time required to achieve complete insufflation (MD = - 15.53, 95% CI: - 91.32 to 60.27, P = 0.69), trocar site bleeding (OR = 0.66, 95% CI, 0.25-1.79, P = 0.42), and trocar site infection (OR = 1.19, 95% CI, 0.34-4.20, P = 0.78). CONCLUSION: There were no statistically significant differences in the risk of major complications during the access manoeuvres between DTI and VN. A lower number of minor complications were observed in DTI compared with those in Veress access.

Vascular Anatomy and Variations of the Anterior Abdominal Wall - Significance in Abdominal Surgery.

Detailed knowledge of the human anatomy is an integral part of every surgical procedure. The majority of surgery related complications are due to a failure to possess appropriate knowledge of human anatomy. However, surgeons pay less attention of the anatomy of the anterior abdominal wall. It is composed of nine abdominal layers, which are composed of fascias, muscles, nerves, and vessels. Many superficial and deep vessels and their anastomoses supply the anterior abdominal wall. Moreover, anatomical variations of these vessels are often presented. Intraoperative and postoperative complications associated with entry and closure of the anterior abdominal wall could compromise the best surgical procedure. Therefore, sound knowledge of the vascular anatomy of the anterior abdominal wall is fundamental and a prerequisite to having a favourable quality of patient care. The purpose of the present article is to describe and delineate the vascular anatomy and variations of the anterior abdominal wall and its application in abdominal surgery. Consequently, the most types of abdominal incisions and laparoscopic accesses will be discussed. Furthermore, the possibility of vessels injury related to different types of incisions and accesses will be outlined in detail. Morphological characteristics and distribution pattern of the vascular system of the anterior abdominal wall is illustrated by using figures either from open surgery, different types of imaging modalities or embalmed cadaveric dissections. Oblique skin incisions in the upper or lower abdomen such as McBurney, Chevron and Kocher are not the topic of the present article.

Management of abdominal gas leakage from surgical trocars in laparoscopic surgery: a preclinical study.

Introduction: There is an ongoing concern about the potential infectious risk due to pneumoperitoneal gas leakage from surgical trocars in laparoscopic surgery. We aimed to visually confirm the presence of leakage from trocars and investigate the changes in the leakage scale according to intra-abdominal pressures and trocar types. Material and methods: We established a porcine pneumoperitoneum model and performed experimental forceps manipulation using 5-mm grasping forceps with 12-mm trocars. The gas leakage, if any, was imaged using a Schlieren optical system, which can visualize minute gas flow invisible to the naked eye. For measuring the scale, we calculated the gas leakage velocity and area using image analysis software. Four types of unused and exhausted disposable trocars were compared. Results: Gas leakage was observed from trocars during forceps insertion and removal. Both the gas leakage velocity and area increased as the intra-abdominal pressure increased. Every type of trocar we handled was associated with gas leakage, and exhausted disposable trocars had the largest scale gas leakage. Conclusions: We confirmed gas leakage from trocars during device traffic. The scale of leakage increased with high intra-abdominal pressure and with the use of exhausted trocars. Current protection against gas leakage may not be sufficient and new surgical safety measures and device development may be needed in the future.

First completely robot-assisted retroperitoneal nephroureterectomy with bladder cuff: a step-by-step technique.

INTRODUCTION: While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach. METHODS: Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed. RESULTS: The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m2; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9-6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100-250). No patient experienced postoperative complications exceeding Clavien-Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission. CONCLUSION: We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Bladed and bladeless conical trocars do not differ in terms of caused fascial defect size in a Porcine Model.

INTRODUCTION: Trocar insertion during laparoscopy may lead to complications such as bleeding, bowel puncture and fascial defects with subsequent trocar site hernias. It is under discussion whether there is a difference in the extent of the trauma and thus in the size of the fascia defect between blunt and sharp trocars. But the level of evidence is low. Hence, we performed a Porcine Model. METHODS: A total of five euthanized female pigs were operated on. The average weight of the animals was 37.85 (Standard deviation SD 1.68) kg. All pigs were aged 90 ± 5 days. In alternating order five different conical 12-mm trocars (3 × bladeless, 2 × bladed) on each side 4 cm lateral of the mammary ridge were placed. One surgeon performed the insertions after conducting a pneumoperitoneum with 12 mmHg using a Verres' needle. The trocars were removed after 60 min. Subsequently, photo imaging took place. Using the GSA Image Analyser (v3.9.6) the respective abdominal wall defect size was measured. RESULTS: The mean fascial defect size was 58.3 (SD 20.2) mm2. Bladed and bladeless trocars did not significant differ in terms of caused fascial defect size [bladed, 56.6 (SD 20) mm2 vs. bladeless, 59.5 (SD 20.6) mm2, p = 0.7]. Without significance the insertion of bladeless trocars led to the largest (Kii Fios™ First entry, APPLIEDMEDICAL©, 69.3 mm2) and smallest defect size (VersaOne™ (COVIDIEN©, 54.1 mm2). CONCLUSION: Bladed and bladeless conical 12-mm trocars do not differ in terms of caused fascial defect size in the Porcine Model at hand. The occurrence of a trocar site hernia might be largely independent from trocar design.

Trocar layouts in laparoscopic liver surgery.

BACKGROUND: Since the first laparoscopic wedge resection reported by Reich, laparoscopic liver resection (LLR) has been progressively developed, acquiring safety and feasibility. The time has witnessed a milestone leap for laparoscopic hepatectomy from pure laparoscopic partial hepatectomy to anatomical hepatectomy and from minor liver resection to major liver resection. The numerous previous studies have paid more attention to the short-time and long-time surgical outcomes caused by surgical techniques corresponding to various segments and approaches. However, focus on trocar layouts remains poorly described, but it plays an indispensable role in surgical process. METHODS: We have searched PubMed for English language articles with the key words "trocar," "laparoscopic liver resection," and "liver resection approaches." RESULTS: This review highlighted each type of trocar layouts corresponding to specific circumstances, including targeted resection segments with various approaches. Notably, surgeon preferences and patients body habitus affect the trocar layouts to some extent as well. CONCLUSIONS: Although there were fewer researches focus on trocar layouts, they determine the operation field and manipulation space and be likely to have an impact on outcomes of surgery. Therefore, further studies are warranted to firm the role of trocar layouts in LLR.

Trocar site hernia after gastric sleeve.

BACKGROUND: Laparoscopy is common in abdominal surgery. Trocar site hernia (TSH) is a most likely underestimated complication. Among risk factors, obesity, the use of larger trocars and the umbilical trocar site has been described. In a previous study, CT scan in the prone position was found to be a reliable method for the detection of TSH following gastric bypass (LRYGB). In the present study, our aim was to examine the incidence of TSH after gastric sleeve, and further to investigate the proportion of symptomatic trocar site hernias. METHODS: Seventy-nine patients subjected to laparoscopic gastric sleeve in 2011-2016 were examined using CT in the prone position upon a ring. Symptoms of TSH were assessed using a digital survey. RESULTS: The incidence of trocar site hernia was 17 out of 79 (21.5%), all at the umbilical trocar site. The mean follow-up time was 37 months. There was no significant correlation between patient symptoms and a TSH. CONCLUSIONS: The incidence of TSH is high after laparoscopic gastric sleeve, a finding in line with several recent studies as well as with our first trial on trocar site hernia after LRYGB. Up to follow-up, none of the patients had been subjected to hernia repair. Although the consequence of a trocar site hernia can be serious, the proportion of symptomatic TSH needs to be more clarified.

401 consecutive minimally invasive distal pancreatectomies: lessons learned from 20 years of experience.

BACKGROUND: This study aimed to discuss and report the trend, outcomes, and learning curve effect after minimally invasive distal pancreatectomy (MIDP) at two high-volume centres. METHODS: Patients undergoing MIDP between January 1999 and December 2018 were retrospectively identified from prospectively maintained electronic databases. The entire cohort was divided into two groups constituting the "early" and "recent" phases. The learning curve effect was analyzed for laparoscopic (LDP) and robotic distal pancreatectomy (RDP). The follow-up was at least 2 years. RESULTS: The study population included 401 consecutive patients (LDP n = 300, RDP n = 101). Twelve surgeons performed MIDP during the study period. Although patients were more carefully selected in the early phase, in terms of median age (49 vs. 55 years, p = 0.026), ASA class higher than 2 (3% vs. 9%, p = 0.018), previous abdominal surgery (10% vs. 34%, p < 0.001), and pancreatic adenocarcinoma (PDAC) (7% vs. 15%, p = 0.017), the recent phase had similar perioperative outcomes. The increase of experience in LDP was inversely associated with the operative time (240 vs 210 min, p < 0.001), morbidity rate (56.5% vs. 40.1%, p = 0.005), intra-abdominal collection (28.3% vs. 17.3%, p = 0.023), and length of stay (8 vs. 7 days, p = 0.009). Median survival in the PDAC subgroup was 53 months. CONCLUSION: In the setting of high-volume centres, the surgical training of MIDP is associated with acceptable rates of morbidity. The learning curve can be largely achieved by several team members, improving outcomes over time. Whenever possible resection of PDAC guarantees adequate oncological results and survival.

A new treatment of an intravesical eroded mesh after TVM: 3 mm trocar-assisted cystoscopic approach.

INTRODUCTION AND HYPOTHESIS: To present a novel technique to remove intravesical eroded mesh through a 3-mm trocar-assisted cystoscopy. METHODS: First, a 3-mm trocar was inserted into the bladder under ultrasound guidance after the bladder had been infused with 600 ml normal saline. Second, we inserted the forceps through the trocar into the bladder and pulled the mesh through the 3-mm trocar. Last, cystoscopic scissors were used to remove the eroded mesh completely. RESULTS: The patient was managed adequately in the inpatient department. The urethral catheter was left in situ for 3 days, and the patient was discharged within 5 days. CONCLUSION: Surgery under 3-mm trocar-assisted cystoscopy offers the advantage of lower risk of morbidity and complications compared to other surgical techniques. It is an effective and feasible procedure for treatment of synthetic mesh erosion into the bladder after TVM surgery.

Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review.

BACKGROUND: In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min. CASE PRESENTATION: A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence. CONCLUSIONS: The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Trocar site hernia after laparoscopy: Early recognition prevents catastrophic sequelae.

BACKGROUND: Trocar site hernia is a rare but potentially serious complication of laparoscopic surgery that may lead to bowel incarceration and strangulation. Prompt diagnosis by emergency physicians facilitates timely intervention that prevents bowel necrosis. We report a case of trocar site hernia presenting to the emergency department (ED) with abdominal pain that was correctly diagnosed and promptly managed. CASE REPORT: A 25-year-old woman, gravida 2, abortion 2, underwent outpatient surgery and laparoscopic removal of a ruptured right-sided tubal pregnancy without any intraoperative difficulties. However, 48 h later, she presented to the ED complaining of acute abdominal pain and nausea. Computed tomography revealed a loop of small bowel herniating through a 12-mm right lower quadrant trocar site defect in the fascia. She was taken back to the operating room, where the computed tomography findings were confirmed and the entrapped bowel was successfully reduced and the fascial defect repaired. The patient was discharged home feeling much improved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Trocar site hernia is a rare but potentially dangerous complication that can present with acute symptoms or be asymptomatic if late in onset. Intestinal necrosis begins as soon as 6 h after constriction of blood flow to entrapped bowel, so timely intervention is critically important. Therefore, trocar site hernias should be considered in patients presenting with abdominal complaints after laparoscopic surgery and included in the differential diagnosis of bowel obstruction.