First human surgery using a surgical assistance robotics device for laparoscopic cholecystectomies.

BACKGROUND: Over the past 20 years, surgeons involved in soft tissue minimally invasive surgery have experienced the pros and cons of both conventional and tele-robotic laparoscopic approaches. The Maestro System, developed by Moon Surgical (Paris, France) aims to overcome the challenges inherent to both approaches thanks to a new concept that augments the surgeon's performance at the bedside during a laparoscopic procedure. METHODS: The current study aims to present the first human experience with laparoscopic cholecystectomy with the Maestro system on 10 patients. RESULTS: All ten procedures were completed successfully. No significant complications related to the use of the Maestro system werenoted. CONCLUSION: Our preliminary observations appear to support the benefits of the Maestro system in non-emergent laparoscopic cholecystectomies. It goes without saying that further research is necessary to demonstrate the safety of this approach in other procedures.

Evaluation of the SafeHeal Colovac+ anastomosis protection device after low anterior resection for rectal cancer: the safe anastomosis feasibility evaluation (SAFE) 2019 trial.

BACKGROUND: Protective ileostomy (PI) is the current standard of care to protect the anastomosis after low anterior resection (LAR) for rectal cancer, but is associated with significant morbidity. Colovac is an anastomosis protection device designed to shield the anastomosis from fecal content. A second version (Colovac+) was developed to limit the migration risk during the implantation period. The objective of this clinical trial was to evaluate the preliminary efficacy and safety of the Colovac+. METHODS: This was a prospective, multicenter, pilot study aiming to enroll 15 patients undergoing LAR with Colovac+ placement. After 10 days, a CT scan was performed to evaluate the anastomosis and the Colovac+ was retrieved endoscopically. During the 10-day implantation and 3-month follow-up period, we collected data regarding predefined efficacy and safety endpoints. The primary endpoint was the rate of major (Clavien-Dindo III-V) postoperative complications related to the Colovac+ or LAR procedure. RESULTS: A total of 25 patients were included (68% male), of whom 15 were consecutively treated with the Colovac+ and Vacuum Loss Alert System. The Colovac+ was successfully implanted in all 15 patients. No major discomfort was reported during the implantation period. The endoscopic retrieval was performed in 14/15 (93%) patients. The overall major postoperative morbidity rate was 40%, but none of the reported complications were related to the Colovac+. A device migration occurred in 2 (13%) patients, but these were not associated with AL or stoma conversion. Overall, Colovac+ provided effective fecal diversion in all 15 patients and was able to avoid the PI in 11/15 (73%) patients. CONCLUSIONS: Colovac+ provides a safe and effective protection of the anastomosis after LAR, and avoids the PI in the majority (73%) of patients. The improved design reduces the overall migration rate and limits the clinical impact of a migration.

Side-to-side magnet anastomosis system duodeno-ileostomy with sleeve gastrectomy: early multi-center results.

INTRODUCTION: Gastrointestinal anastomoses with classical sutures and/or metal staples have resulted in significant bleeding and leak rates. This multi-site study evaluated the feasibility, safety, and preliminary effectiveness of a novel linear magnetic compression anastomosis device, the Magnet System (MS), to form a side-to-side duodeno-ileostomy (DI) diversion for weight loss and type 2 diabetes (T2D) resolution. METHODS: In patients with class II and III obesity (body mass index [BMI, kg/m2] ≥ 35.0- ≤ 50.0 with/without T2D [HbA1C > 6.5%]), two linear MS magnets were delivered endoscopically to the duodenum and ileum with laparoscopic assistance and aligned, initiating DI; sleeve gastrectomy (SG) was added. There were no bowel incisions or retained sutures/staples. Fused magnets were expelled naturally. Adverse events (AEs) were graded by Clavien-Dindo Classification (CDC). RESULTS: Between November 22, 2021 and July 18, 2022, 24 patients (83.3% female, mean ± SEM weight 121.9 ± 3.3 kg, BMI 44.4 ± 0.8) in three centers underwent magnetic DI. Magnets were expelled at a median 48.5 days. Respective mean BMI, total weight loss, and excess weight loss at 6 months (n = 24): 32.0 ± 0.8, 28.1 ± 1.0%, and 66.2 ± 3.4%; at 12 months (n = 5), 29.3 ± 1.5, 34.0 ± 1.4%, and 80.2 ± 6.6%. Group mean respective mean HbA1C and glucose levels dropped to 1.1 ± 0.4% and 24.8 ± 6.6 mg/dL (6 months); 2.0 ± 1.1% and 53.8 ± 6.3 mg/dL (12 months). There were 0 device-related AEs, 3 procedure-related serious AEs. No anastomotic bleeding, leakage, stricture, or mortality. CONCLUSION: In a multi-center study, side-to-side Magnet System duodeno-ileostomy with SG in adults with class III obesity appeared feasible, safe, and effective for weight loss and T2D resolution in the short term.

Fluorescence of Deep Infiltrating Endometriosis During Laparoscopic Surgery: A Preliminary Report on 6 Cases.

BACKGROUND: The standard treatment of rectovaginal deep infiltrating endometriosis nodules (RVDIEN) consists in their surgical removal. RVDIEN are anatomically neovascularized. Indocyanine green (ICG) reveals vascularized structures when becoming fluorescent after exposure to near-infrared (NIR) light. This study aims to evaluate if fluorescence-guided surgery can improve the laparoscopic resection of RVDIEN, thus avoiding a rectal perforation. MATERIALS AND METHODS: Patients with a symptomatic RVDIEN, scheduled for a laparoscopic rectal shaving, were enrolled in the study. Technically, the RVDIEN was targeted and removed with the help of the NIR imager device Image 1 Spies (Karl Storz GmBH & Co KG, Tuttlingen, Germany) or Visera Elite II (Olympus Europe SE & Co KG, Hamburg, Germany), after an intraoperative, intravenous injection of ICG (0.25 mg/kg). RESULTS: Six patients underwent a fluorescence-guided laparoscopic shaving procedure for the treatment of a nonobstructive RVDIEN. Fluorescence of the RVDIEN was observed in all the patients. In one patient, once the main lesion was removed, the posterior vaginal fornix still appeared fluorescent and was removed. No intraoperative rectal perforation occurred. The postoperative hospital stay was 2 days. No postoperative rectovaginal fistula occurred within a median follow-up of 16 months (range = 2-23 months). CONCLUSION: In this preliminary study, fluorescence-guided laparoscopy appeared to help in separating the RVDIEN from the healthy rectal tissue, without rectal perforation. Moreover, this technique was helpful in deciding if the resection needed to be enlarged to the posterior vaginal fornix.

Three Trocars Laparoscopic Total Gastrectomy + D2 Lymphadenectomy with Intracorporeal Manual Esojejunostomy.

BACKGROUND: Minimally invasive surgery (MIS) is proved to be feasible and safe oncologically. In the past decade, a new philosophy of MIS, reducing abdominal trauma and improving the cosmetic results, has been popularized. 1-3 The authors report a three trocars laparoscopic total gastrectomy + D2 lymphadenectomy for lesser curvature gastric adenocarcinoma. VIDEO: A 52-year-old woman presenting a nondifferentiated gastric adenocarcinoma at the incisura angularis was admitted at consultation. Preoperative workup showed a T3N+M0 tumor. After neoadjuvant chemotherapy, laparoscopy was scheduled. Three trocars (5, 12, 5 mm) were placed in the abdomen. The operative field's exposure was improved by temporary percutaneous sutures. En bloc total gastrectomy and omentectomy was performed with a D2 lymphadenectomy, including the nodes of the stations 1, 2, 3, 4, 5, 6, 7, 8a, 8p, 9, 10, 11p, 11d, and 12a. Completely manual end-to-side esophago-jejunal anastomosis (Fig. 1a, b) and linear mechanical side-to-side jejuno-jejunal anastomosis were realized with the closure of both mesenteric and mesocolic defects. The specimen was retrieved through a suprapubic access. RESULTS: Operative time was 4 hours and 45 minutes (anastomosis: 30), and perioperative bleeding was 100 cc. Pathologic report confirmed nondifferentiated adenocarcinoma, mucinous, G3, infiltrating entirely the gastric wall, with 63 (4 positive) nodes removed; 7 edition UICC stage: pT4aN2aM0; keratine AE1/AE3 negative, HER2/neu, and HER2/CEP17 nonamplified. During postoperative follow-up, no recurrence was detected after 2 years. CONCLUSIONS: Reduced port laparoscopic surgery provides the same quality of oncologic surgery as conventional multitrocar laparoscopy with added superior cosmesis and reduced abdominal trauma.

Metabolic consequences of the incorporation of a Roux limb in an omega loop (mini) gastric bypass: evaluation by a glucose tolerance test at mid-term follow-up.

BACKGROUND: In the technique used in our department, Roux-en-Y gastric bypass (RYGB) anatomically only differs from the mini- or omega loop gastric bypass (OLGB) by the incorporation of an isolated alimentary limb, called the Roux limb. The metabolic consequences of the incorporation of a Roux limb are unknown. OBJECTIVES: To evaluate differences in glucose and insulin dynamics between RYGB and OLGB in normoglycemic patients, by submitting them to a glucose challenge after stabilization of their weight. METHODS: Nondiabetic patients who had undergone OLGB 4 years earlier were matched with nondiabetic patients who had undergone RYGB around the same time and with healthy controls. Participants underwent oral (OGTT) and intravenous glucose tolerance test (IVGTT). Endpoints of the study were: progression of plasma glucose and insulin, changes in their concentration [calculated by area under the curve (AUC)] at OGTT and IVGTT, incretin effect and incidence of hypoglycemia. RESULTS: Each of the three groups comprised 14 participants. At OGTT, plasma glucose and insulin incremental values were comparable after OLGB and RYGB, and substantially higher than in controls. Overall glucose concentration, however, did not vary across the three groups. Thirty-minute and overall insulin plasma concentration, indicators of early and total insulin secretion, respectively, was significantly higher in both bypass groups than in controls, and was greatest in OLGB. Severe hypoglycemia occurred in one out of two patients in both bypass groups. At IVGTT, no differences were registered across the three groups and no participant experienced hypoglycemia. The incretin effect was higher after OLGB than after RYGB, but the difference was not statistically significant. CONCLUSIONS: The incorporation of a Roux limb in a loop gastric bypass appears to create a statistically nonsignificant tendency toward reducing insulin hypersecretion observed at OGTT after OLGB, and consequently toward tapering the incretin effect.

Minimally invasive treatment of traumatic high rectovaginal fistulas.

BACKGROUND: We propose a new minimally invasive technique by laparoscopic approach which minimizes parietal damage and allows precise location of the fistula, hence reduces blind dissection. METHODS: Ten consecutive patients suffering from a HRVF benefited from the described technique. Location and time frame were east of the Democratic Republic of Congo and September 2012 through January 2014. By laparoscopy, dissection of the mesorectum in the "holy plane" is taken posteriorly as distally on the sacrum as possible. Dissection subsequently continues laterally beyond the fistula in an effort to maximally circumvene the fistulous area where no plane of cleavage can be found. If the cleavage plane beyond the fistula addresses a healthy rectum, a suture of vaginal and rectal defect is performed. If the cleavage plane beyond the fistula involves significant laceration of the rectum, while leaving at least 2 cm of healthy rectum above the sphincter, rectal resection and colorectal anastomosis are performed. If the rectal laceration involves the distal 2 cm but halts short of the sphincter (large fistula), the pull-through technique is performed. RESULTS: Of ten participants, four had large HRVF and two presented significant fibrosis. Three underwent simple suture of rectal and vaginal defect, one rectal resection and six a "pull-through" technique. The median procedure time was 1h50 (1h00-3h30). There was no morbidity. None of the patients required protective ileostomy or colostomy. Nine patients were declared clinically cured with a median follow-up of 14.3 months (11-36). The Cleveland Clinic Incontinence Score was 20 in all patients before the treatment and was significantly (p = 0.004) reduced to 2.6 [0-20] after the treatment. CONCLUSIONS: This minimally invasive technique allowed us to treat HRVF, including complex ones in ten patients without significant morbidity. Clinical success with a median follow-up of 14.3 months was 90%.

A New Reusable Platform for TransAnal Minimally Invasive Surgery: First Experience.

INTRODUCTION: TransAnal Minimally Invasive Surgery (TAMIS) has generated interest and attracted research in the last decade. This approach is used to treat primary benign and malignant diseases, but it can also be adopted to resolve colorectal complications, such as leak and fistula, bleeding and stenosis. A new reusable transanal platform formed by a new port and monocurved instruments has been invented and here presented. MATERIALS AND METHODS: The first experience included 13 patients submitted to TAMIS for rectal adenocarcinoma (8), immediate colorectal leak (1), early rectovaginal fistula (1), late colorectal fistula (1), immediate colorectal bleeding (1), and benign stenosis (1). Mean age was 62.3 years (38-74), and mean BMI was 25.2 kg/m2 (20.5-32.1). RESULTS: Mean operative time for transanal total mesorectal excision (TME) was 149.2 minutes (96-193) and for the other procedures 80.6 minutes (15-163). Mean operative bleeding was 51.1 cc (0-450). Mean hospital stay was 5.0 days (2-8). The 3 patients with coloanal anastomosis presented diarrhea postoperatively. No other early postoperative complications were registered. Pathologic report in the oncologic diseases showed that a mean number of 14.7 nodes (16-20) were removed. After a mean follow-up of 8 months (1-14), there were no late complications in any of the 13 patients treated. CONCLUSION: TAMIS is a feasible alternative approach to treat rectal cancer and a completely new technique to manage colorectal complications. Moreover, this new transanal platform offers surgeons a satisfactory working ergonomy, with no increase in cost of the procedures, because entirely reusable materials are adopted.

Sleeve gastrectomy with duodenoileal bipartition using linear magnets: feasibility and safety at 1-year follow-up.

BACKGROUND: Single-anastomosis metabolic/bariatric surgery procedures may lessen the incidence of anastomotic complications. This study aimed to evaluate the feasibility and safety of performing side-to-side duodenoileal (DI) bipartition using magnetic compression anastomosis (MCA). In addition, preliminary efficacy, quality of life (QoL), and distribution of food through the DI bipartition were evaluated. METHODS: Patients with a body mass index (BMI) of ≥35.0 to 50.0 kg/m2 underwent side-to-side DI bipartition with the magnet anastomosis system (MS) with sleeve gastrectomy (SG). By endoscopic positioning, a distal magnet (250 cm proximal to the ileocecal valve) and a proximal magnet (first part of the duodenum) were aligned with laparoscopic assistance to inaugurate MCA. An isotopic study assessed transit through the bipartition. RESULTS: Between March 14, 2022 to June 1, 2022, 10 patients (BMI of 44.2 ± 1.3 kg/m2) underwent side-to-side MS DI. In 9 of 10 patients, an SG was performed concurrently. The median operative time was 161.0 minutes (IQR, 108.0-236.0), and the median hospital stay was 3 days (IQR, 2-40). Paired magnets were expelled at a median of 43 days (IQR, 21-87). There was no device-related serious advanced event within 1 year. All anastomoses were patent with satisfactory diameters after magnet expulsion and at 1 year. Respective BMI, BMI reduction, and total weight loss were 28.9 ± 1.8 kg/m2, 15.2 ± 1.8 kg/m2, and 34.2% ± 4.1%, respectively. Of note, 70.0% of patients reported that they were very satisfied. The isotopic study found a median of 19.0% of the meal transited through the ileal loop. CONCLUSION: Side-to-side MCA DI bipartition with SG in adults with class II to III obesity was feasible, safe, and efficient with good QoL at 1-year follow-up. Moreover, 19% of ingested food passed directly into the ileum.

Side-to-side magnetic duodeno-ileostomy in adults with severe obesity with or without type 2 diabetes: early outcomes with prior or concurrent sleeve gastrectomy.

BACKGROUND: Conventional metabolic/bariatric surgical anastomoses with sutures/staples may cause severe adverse events (AEs). OBJECTIVES: The study aim was to evaluate the feasibility, safety, and effectiveness of primary and revisional side-to-side duodeno-ileostomy (DI) bipartition using a novel magnetic compression anastomosis device (Magnet Anastomosis System [MS]). SETTING: Multicenter: private practices and university hospitals. METHODS: In patients with body mass index ([BMI, kg/m2] ≥35.0 to ≤50.0 with/without type 2 diabetes [T2D] glycosylated hemoglobin [HbA1C > 6.5 %]), two linear MS magnets were delivered endoscopically to the duodenum and ileum with laparoscopic assistance and aligned, initiating magnet fusion and gradual DI (MagDI). The MagDI-after-SG group had undergone prior sleeve gastrectomy (SG); the MagDI + SG group underwent concurrent SG. AEs were graded by Clavien-Dindo Classification (CDC). RESULTS: Between November 22, 2021 and May 30, 2023, 43 patients (88.0% female, mean age 43.7 ± 1.3 years) underwent the study procedures. The MS met feasibility criteria of magnet device placement, creation of patent anastomoses confirmed radiologically, and magnet passage in 100.0% of patients. There were 64 AEs, most were CDC grade I and II, significantly fewer in the MagDI-after-SG group (P < .001). No device-related AEs including anastomotic leakage, bleeding, obstruction, infection, or death. The MagDI-after-SG group experienced 6-month mean weight loss of 8.0 ± 2.5 kg (P < .01), 17.4 ± 5.0% excess weight loss (EWL). The MagDI + SG group had significantly greater weight loss (34.2 ± 1.6 kg, P < .001), 66.2 ± 3.4% EWL. All patients with T2D improved. CONCLUSIONS: In early results of a multicenter study, the incisionless, sutureless Magnet System formed patent, complication-free anastomoses in side-to-side DI with prior or concurrent SG.

Suprapubic single-incision laparoscopic right hemicolectomy with intracorporeal anastomosis.

BACKGROUND: Single-incision laparoscopy (SIL) has gained significance recently. The umbilicus has been the preferred access site for SIL. Suprapubic access site (SAS) can be an alternative, especially for a right hemicolectomy (RH). METHODS: Between November 2011 and July 2012, 7 consecutive patients underwent suprapubic SIL RH (SSILRH). The median age was 53 years, and the median body mass index was 23.9 kg/m2. Indications for surgery included appendicular tumor (1) and adenocarcinoma of the right colon (6). Three reusable trocars were used, and the resection was performed through the SAS. An intracorporeal linear stapled anastomosis was performed, the mesenteric defect was closed, and the access site was used for specimen extraction. RESULTS: No patient required additional trocars or conversion to an open surgery. The median laparoscopic time was 222 minutes, and the median final incision length was 50 mm. The median Visual Analogue Scale score (0-10) at 6, 18, 30, 42, 54, 66, and 78 postoperative hours was 6, 6, 2, 2, 2, 2, and 2, respectively. The median hospital stay was 4 days. CONCLUSIONS: SSILRH is useful because the SAS can be enlarged for extraction of the specimen without compromising the cosmetic outcome. The mesocolic and mesenteric dissections are on the same axis as the access site. The intracorporeal anastomosis can be performed without traction. Finally, positioning of the operative table improves exposure of the operative field and allows the surgeon to maneuver the colon and small bowel intracorporeally.

Transumbilical single-access laparoscopic perforated gastric ulcer repair.

INTRODUCTION: In patients presenting with peritonitis, laparoscopy offers the possibility of diagnosis as well as treatment, with less abdominal trauma, reduced postoperative pain, and shorter hospital stay. CASE REPORT: A 30-year-old woman, presenting with diffuse abdominal pain and free pneumoperitoneum, was submitted to transumbilical single-access laparoscopy. The procedure was performed using a standard 11-mm reusable trocar in the umbilicus and curved reusable instruments inserted transumbilically without trocars. The cavity exploration showed a perforated gastric ulcer at the anterior surface of the prepyloric area. A gastric suture repair, omentoplasty, and lavage of the cavity were performed. RESULTS: The umbilical incision was 15 mm and laparoscopy lasted 86 minutes. Use of painkillers was minimal, and the patient was discharged on the fifth postoperative day. After 6 months, the umbilical scar was no visible. CONCLUSIONS: Transumbilical single-access laparoscopy can be proposed in selected patients presenting perforated gastric ulcer, with the main advantage of improved cosmetic results.

Single-access transumbilical laparoscopic unroofing of a giant hepatic cyst using reusable instruments.

INTRODUCTION: Single-access laparoscopy has garnered growing interest in recent years in an attempt to improve cosmesis, reduce postoperative pain, and minimize abdominal wall trauma. CASE DESCRIPTION: A female patient suffering from a symptomatic giant biliary cyst of the liver segments 4-7-8 was admitted for transumbilical single-access laparoscopic cyst unroofing. The procedure was performed using a standard 11-mm reusable trocar for a 10-mm, 30 degree-angled, rigid scope and curved reusable instruments inserted transumbilically without trocars. Operative time was 90 minutes, and the final incision length was 14 mm. The use of minimal pain medication permitted discharge on the third postoperative day, and after 25 months, the patient remains asymptomatic with a no visible umbilical scar. CONCLUSIONS: Giant biliary cysts can be removed by single-access laparoscopy. Because of this technique, surgeons work in ergonomic positions, and the cost of the procedure remains similar to that of the multitrocar technique. The incision length and the use of pain medication are kept minimal as well.

Implications of bacteriological study in complicated and uncomplicated acute appendicitis.

Purpose: Bacteriological sample in the presence of intraabdominal free fluid is necessary to adapt the antibiotherapy and to prevent the development of resistance. The aim was to evaluate the differences between uncomplicated (UAA) and complicated acute appendicitis (CAA) in terms of bacterial culture results and antibiotic resistance, and to evaluate the factors linked with CAA. Methods: We performed a single-center, retrospective observational study of all consecutive patients who presented with appendicular peritonitis and underwent emergent surgery in a tertiary referral hospital in Brussels, Belgium, between January 2013 and December 2020. The medical history, parameters at admission, bacterial culture, antibiotic resistance, and postoperative outcomes of 268 patients were analyzed. UAA was considered catarrhal or phlegmonous inflammation of the appendix. CAA was considered gangrenous or perforated appendicitis. Results: Positive microbiological cultures were significantly higher in the CAA group (68.2% vs. 53.4%). The most frequently isolated bacteria in UAA and CAA cultures were Escherichia coli (37.9% and 48.6%). Most observed resistances were against ampicillin (28.9% and 21.7%) and amoxicillin/clavulanic acid (16.4% and 10.5%) in UAA and CAA, respectively. A higher Charlson comorbidity index, an elevated white blood cell count, an open procedure, and the need for drainage were linked to CAA. Culture results, group of bacterial isolation, and most common isolated bacteria were not related to CAA. Conclusion: CAA presented a higher rate of positive cultures with increased identification of gram-negative bacteria. Bacterial culture from the peritoneal liquid does not reveal relevant differences in terms of antibiotic resistance.

Thoracoscopic esophagectomy in prone position.

INTRODUCTION: Esophagectomy can be performed by different minimal invasive techniques. We report a technique of Ivor Lewis esophagogastrectomy with manual anastomosis performed by thoracoscopy in prone position. Readers are encouraged to view the streaming video that accompanies this article. CASE REPORT: A 51-year-old man was consulted for adenocarcinoma of the distal esophagus without lymph nodes invasion. Anesthesia was realized using a double-lumen endotracheal tube. The procedure started with the patient supine, and five abdominal trocars were placed. Celiac lymphadenectomy, wide Kocher maneuver, and pyloroplasty were performed. A wide gastric tube was advanced through the hiatus into the right chest. Subsequently the patient was placed in prone position and three trocars (two 5-mm, one 10-mm) were placed in the 5th, 7th, and 9th right intercostal space. The intrathoracic esophagus was dissected, and mediastinal lymphadenectomy with en bloc resection of the left inferior mediastinal pleura was performed. After sectioning the azygos vein, the esophagus was transected by scissors 1 cm cranially. A completely thoracoscopic manual double-layer anastomosis was performed using running sutures with PDS 2/0 (externally) and Maxon 4/0 (internally). Finally the patient was replaced supine; the gastric tube was fixed to the hiatus, and the specimen was retrieved by suprapubic incision. RESULTS: Thoracoscopy lasted 157' (anastomosis 40'), laparoscopy 160', and second laparoscopy 20'. Blood loss was 170 cc. The patient was discharged on postoperative day 6. CONCLUSIONS: Thoracoscopy in prone position allows the surgeon to perform a thoracoscopic esogastric anastomosis completely manually using only three trocars and without selective lung desufflation.

Single-incision transumbilical laparo-endoscopic gastric benign tumor resection.

INTRODUCTION: The authors report resection of a gastric benign tumor through single-incision laparoscopy, guided by peroperative gastroscopy. VIDEO: A 25-year-old man consulted after diagnosis of a 40 × 20 cm(2) endoluminal lesion of the gastric cardia. Preoperative work-up showed a stromal tumor with invasion of the muscular layer. The umbilical scar was incised and, after placement of a purse-string suture, an 11-mm nondisposable trocar was inserted for a 10-mm 30° angled scope. Curved and reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) and straight ultrasonic shears (Ethicon Endosurgery, Cincinnati, OH, US) were inserted transumbilically. Peroperative gastroscopy located the lesion on the smaller gastric curvature, 1 cm from the gastroesophageal junction. A stitch was placed in the center of the lesion, and gastroscopic grasper helped in maintaining the limits of resection. Gastrostomy was closed using two converting absorbable running sutures. Because of the curves of the instruments there was no conflict between the instruments' tips inside the abdomen (Fig. 1a), or between the surgeon's hands outside the abdomen (Fig. 1b). Leak test with the gastroscope checked the integrity of the suture. The specimen was retrieved transumbilically in a plastic bag. RESULTS: Operative time was 150 min, and the umbilical incision was less than 15 mm. The patient was discharged after 5 days, and he is doing well 3 months postoperatively. CONCLUSIONS: Laparoscopic gastric resection can be safely performed through a single-access. Peroperative gastroscopy permits the limits of resection to be precisely determine, and use of curved and reusable instruments allows surgeon to achieve ergonomic conditions as in classic laparoscopy, without increasing the laparoscopic cost.

Single-access transumbilical diagnostic laparoscopy for pancreatic tumor using curved and reusable instruments.

INTRODUCTION: Diagnostic laparoscopy in pancreatic tumors remains controversial. The main argument in favor of this procedure is that it helps prevent a delay of chemotherapy in cases of unresectable tumors or peritoneal/lymph node metastasis. We report a technique of performing this exploration through single-incision laparoscopy. VIDEO: The umbilicus is incised, and a purse-string suture is applied. An 11-mm nondisposable trocar is inserted for a 10-mm, 30° angled scope. Curved and reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) are inserted transumbilically. Laparoscopic exploration of the cavity allows the visualization of suspected peritoneal or lymph node metastasis. Peritoneal lavage for cytology is performed. Biopsy is accomplished through the curved shape of the instruments, which establishes the working triangulation inside the abdomen as well as externally. Laparoscopic ultrasonography of the liver and of the pancreas (after opening the lesser sac) is performed after replacement of the 11-mm trocar with a 13-mm trocar and the use of a 5-mm scope. The procedure can be continued either by laparoscopy or by open surgery. At completion, the umbilicus is meticulously closed to avoid complications. RESULTS: Operative time is 45-60 minutes, blood loss is minimal, and the size of the umbilical incision is less than 15 mm. CONCLUSIONS: In case of unresectable tumors or peritoneal metastasis, single-access diagnostic laparoscopy for pancreatic tumors permits the start of chemotherapy after less than 7 days. Curved and reusable instruments allow the achievement of ergonomic conditions as classic laparoscopy, without increasing of conventional laparoscopic cost.

Transoral rotational esophagogastric fundoplication: technical, anatomical, and safety considerations.

BACKGROUND: Gastroesophageal reflux disease (GERD) results primarily from the loss of an effective antireflux barrier, which forms a mechanical barrier against the retrograde movement of gastric content. Restoration of the incompetent antireflux barrier is possible by longitudinal and rotational advancement of the gastric fundus about the lower esophagus, creating an esophagogastric fundoplication. This article describes the technique of performing a rotational and longitudinal esophagogastric fundoplication, performed transorally using EsophyX. METHODS: The transoral incisionless fundoplication (TIF) technique enables the creation of a full-thickness esophagogastric fundoplication with fixation extending longitudinally up to 3.5 cm above the Z-line and rotationally more than 270 degrees around the esophagus. A key element of the technique involves rotating the fundus around the esophagus with a tissue mold during gastric desufflation. Anatomic considerations and use of the device's tissue invaginator to push the esophagus caudally are important to ensure safe positioning of the plications below the diaphragm. The steps of the technique are described in detail, and suggestions are given about patient selection and care, as well as prevention and management of complications.

Single-access transumbilical laparoscopic splenectomy using curved reusable instruments.

BACKGROUND: The authors report a single-access transumbilical laparoscopic splenectomy (SATLS) performed with curved reusable instruments. METHODS: A 23-year-old female consulted for steroid-resistant idiopathic thrombocytopenic purpura and clinical evidence of secondary Cushing syndrome. Preoperative workup showed a normal-sized spleen and thrombocytopenia. The umbilicus was incised and a purse-string suture was applied. A reusable 11-mm trocar was inserted for a 10-mm, 30° angled scope. Curved reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) were advanced without trocars transumbilically. After opening the splenocolic and gastrosplenic ligaments, the main splenic artery and vein were dissected off at the level of the hilum, clipped with 5-mm clips introduced transumbilically, and sectioned. Posterior splenic attachments were freed at the hilum cranially and caudally. The spleen was finally retrieved transumbilically in a plastic bag. RESULTS: Addition of supplementary trocars or incisions was not necessary. Operative time was 180 min and final umbilical scar 16 mm. The patient was discharged on postoperative day 3, and after 6 months she was doing well. CONCLUSIONS: SATLS was feasible and safe to be performed using curved reusable instruments. The curves of the instruments permitted the surgeon to work in an ergonomic position, without the instruments clashing thanks to the obtained triangulation. Since only reusable instruments were used, the cost of SATLS remained similar to that of standard laparoscopy.

Single-access transumbilical laparoscopic appendectomy and cholecystectomy using new curved reusable instruments: a pilot feasibility study.

BACKGROUND: The umbilicus can be considered as the embryological opening for single-access laparoscopic procedures. We report on single-access transumbilical laparoscopic appendectomy (SATLA) and cholecystectomy (SATLC), performed using new curved reusable instruments. PATIENTS AND METHODS: A retrospective review of a prospectively maintained database of 30 patients who underwent SATLA and 20 patients who underwent SATLC between May and November 2009 was undertaken. All procedures were performed with an 11-mm nondisposable trocar for the scope, and curved reusable instruments (Karl Storz-Endoskope, Tuttlingen, Germany) placed transumbilically without trocars. Outcome measures were conversion to standard laparoscopy, operative time, scar length, complications, hospital stay, and use of pain medication. RESULTS: All SATLA patients had acute appendicitis, and SATLC patients had symptomatic gallstones (15), chronic cholecystitis (3), and acute cholecystitis (2). No extraumbilical trocars were necessary. Mean total operative times were 57.3 ± 15.9 min (SATLA) and 73.9 ± 20.1 min (SATLC). Mean laparoscopic times were 39 ± 13.1 min (SATLA) and 57.5 ± 18.9 min (SATLC). Mean scar lengths were 14.8 ± 2.2 mm (SATLA) and 15.8 ± 2.3 mm (SATLC). Five SATLA patients and one SATLC patient developed postoperative complications. Mean hospital stay was 2.9 ± 1.3 days for SATLA patients and 1.8 ± 0.8 days for SATLC patients. Pain medication used was minimal. At the minimum follow-up of 3 months no late complications were registered. CONCLUSIONS: SATLA and SATLC can be performed safely using curved reusable instruments, which helps avoid the conflict between the surgeon's hands or between the instruments' tips and allows the surgeon to operate in an ergonomic position. The reusable instruments kept the cost similar to that of classic laparoscopy.