Reduced-port endo-laparoscopic surgery using umbilical zigzag incision for concomitant operations: A case series.

INTRODUCTION: Recently, use of reduced-port surgery has become widespread; however, it is a difficult operation. Hachisuka et al. developed a method called the umbilical zigzag incision, which enlarges the fascial incision using only an umbilical skin incision. We believe this method will be feasible for concomitant laparoscopic surgery. We report our surgical techniques for concomitant laparoscopic surgery using an umbilical zigzag incision. METHODS: The patient who should receive more than 2 places of abdominal operation were indicated this procedure. In all cases, we made the zigzag incision in the umbilical region. After the linea alba and peritoneum were incised, the wound retractor was inserted through the incision, which enlarges the fascial opening. GelPoint was attached to the wound retractor and the operation was started. RESULTS: We could create a fascial opening of up to 6 cm with the umbilical zigzag incision, which improves the triangulation of forceps and reduces interference among the trocars. The trocars in the center of the abdomen could be utilized for almost all intraperitoneal operations. This procedure was especially useful in cases that included lymph node dissection because dissection of a malignant tumor is a delicate procedure. Furthermore, extraction of specimens and anastomosis went very smoothly because the fascial incision was large enough such that no extension of the incision was needed. No early or late postoperative complications occurred in any case. Postoperative wounds were clear and therefore patient satisfaction levels were high. CONCLUSION: Umbilical zigzag incision may be feasible especially in concomitant laparoscopic surgery.

Transumbilical Hidden-Scar High Anterior Resection for Sigmoid Colon Cancer Using GelPOINT® Through an Umbilical Zigzag Skin Incision.

Introduction: Hidden-scar surgery is a new method by which surgeons perform abdominal operations through one incision made in the folds of the patient's umbilicus. However, with a straight incision in the umbilicus, the maximal opening of the fascia is 2 cm. The 2-cm fascial opening is not enough to allow for the triangulation of instruments, the removal of specimens, and the performance of anastomosis, particularly during gastrectomy and colectomy. To overcome this problem, we developed an umbilical zigzag skin incision with a 6-cm opening of the fascia and peritoneum in collaboration with plastic surgeons and used Gelport® to maintain pneumoperitoneum, which resulted in a scarless wound.1 Plastic surgeons modified this technique from umbilicoplasties for umbilical deformities.2,3 We have performed gastrectomies, colectomies, cholecystectomies, and transabdominal preperitoneal hernia repairs using this method without any complications and have succeeded in hiding scars in the umbilicus. GelPOINT® is a newly developed device for minimally invasive surgery that provides a flexible, air-tight fulcrum to facilitate the triangulation of standard instrumentation. By offering an increased range of motion and maximum retraction and exposure, the GelPOINT platforms assure maximum versatility and access for a wide range of abdominal procedures. We report herein a video (559 seconds) describing a new method of transumbilical hidden-scar surgery using GelPOINT through an umbilical zigzag skin incision. Materials and Surgical Technique: A 64-year-old woman underwent laparoscopic sigmoidectomy for sigmoid colon cancer. The procedure was performed as previously described1; after marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPOINT double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The GelPOINT was latched to the wound retractor ring, and the pneumoperitoneum was then inflated using CO2. One additional port was inserted in the right-lower abdomen for safety. Laparoscopic high anterior resection with lymph node dissection was performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical zigzag incision, and the double-staple technique was used for anastomosis without any complications. The wound in the umbilical region was virtually hidden in the bottom of the umbilicus after surgery. Results and Conclusion: We performed an umbilical zigzag skin incision technique using GelPOINT for laparoscopic high anterior resection without any complications. We consider that this zigzag skin incision technique is one way to lessen the technical difficulties of laparoscopic surgery, resulting in a hidden scar in the umbilicus. The authors have no conflicts of interest or financial ties to disclose. Runtime of video: 9 mins 19 secs.

[A very elderly case of recurrent gastric cancer with peritoneal dissemination effectively treated by combination chemotherapy of docetaxel (DOC) and S-1].

We report a case of a 77-year-old man with gastric cancer of Borrmann type 3, pyloric stenosis and liver invasion. Distal gastrectomy with liver film resection was performed. Pathological staging was IV(sig, pT4, pN2, H0, P0, CY0, M0, ly3, v3). We recommended adjuvant chemotherapy but the patient refused. He was diagnosed with a recurrence of peritoneal dissemination 4 months after the operation. He received docetaxel(DOC)at a starting dose of 40 mg/m2 by iv infusion on day 1 and S- 1 at a full dose of 100 mg/body daily for two weeks every three weeks. After 5 cycles of this combination therapy, the gastric cancer with peritoneal dissemination completely disappeared. He was recognized to have grade 2 hematologic toxicity, hand foot syndrome and stomatitis, and all treatment-related toxicities were resolved. No re-growth of gastric cancer has been seen for 9 months with this chemotherapy.

Quick recovery of serum diamine oxidase activity in patients undergoing total gastrectomy by oral enteral nutrition.

BACKGROUND: Total parental nutrition (TPN) meets the metabolic needs of postoperative patients, but introduces potential complications, including intestinal mucosal atrophy. Surgical advances have increased the certainty of esophagoenteric anastomosis making early oral enteral feeding after surgery feasible. The objective of the current report is to compare the benefits of enteral nutrition (EN) and TPN in patients undergoing total gastrectomy for gastric cancer. METHODS: Forty-two patients who underwent total gastrectomy for gastric cancer were randomized to receive oral EN beginning on postoperative day (POD) 3 with peripheral supplements or TPN beginning on POD 3. Serum concentrations of albumin and retinol-binding protein (RBP) as nutritional parameters and diamine oxidase (DAO) activity, an enzyme reflecting mucosal integrity, were measured preoperatively and 1, 4, 7, and 14 days postoperatively and compared between the 2 groups. Complications, abdominal symptoms, duration of hospital stay, and treatment cost per hospitalization were also compared. RESULTS: Albumin and RBP concentrations changed little in either group. DAO activity decreased in both groups and recovered within 1 week in the EN group but not in the TPN group. Complications were similar in the 2 groups. Treatment cost was less and length of hospital stay was shorter in the EN group. CONCLUSIONS: EN is an efficient way to provide nutrition to patients and possibly prevent intestinal atrophy in the patient who must endure prolonged postoperative fasting. Compared to TPN, EN reduces treatment cost and hospital length-of-stay.

Femoral hernia repair.

Femoral hernia repair has a long history. In the nineteenth century, simple closure of the femoral orifice by the femoral approach was favored. Such renowned surgeons as Bassini, Marcy, and Cushing authored papers about the femoral approach to femoral hernia. The recurrence rate was so high, however, that it was replaced by the inguinal approach. The man who popularized the inguinal approach was Chester McVay, who demonstrated the precise insertion of the tranversus abdominis muscle and transversalis fascia to the Cooper's ligament. He used Cooper's ligament for the femoral hernia repair by the inguinal approach. The complication and recurrence rate after the Cooper's ligament repair for femoral hernia was not satisfactory, however, due to tension on the approximated tissues, which caused postoperative pain and inability to resume normal activities. Irving Lichtenstein first introduced the plug technique to femoral hernia repair and it was further developed by Gilbert and Rutkow. In the present series, all elective cases were repaired by the PerFix mesh plug technique without any complications. Patients were discharged from the hospital on the first postoperative day and returned to normal activities shortly thereafter. These patients had few complaints of pain in the groin. The operating time using a PerFix plug was markedly shorter when contrasted with the Cooper's ligament repair. No infection of the prosthesis occurred, even in the cases in which the small intestine was necrotic and resected. From our 7-year experience of mesh plug femoral hernia repairs, I have come to regard this operation as the first choice in elective and noninfected cases of femoral hernia. In strangulated cases in which severe infection occurs. Cooper's ligament repair should be used, because there is a risk or infection to implanted prosthesis. Finally, femoral hernia is usually thought of as requiring emergency surgical treatment. Only 30% of our cases were treated as emergency operations, however, whereas 70% were elective. Unless patients complain of severe abdominal pain or ileus, surgeons need not perform emergency operations. In summary, the PerFix mesh plug hernia repair for femoral hernia has resulted in a reduced recurrence rate, shortened hospital stay, and a low rate of postoperative complications.