[Ventral hernia surgery†: New minimally invasive approaches]. / Chirurgie des hernies ventrales†: nouvelles approches minimalement invasives.

Ventral hernia surgery has undergone major changes over the past decade with the emergence of new minimally invasive techniques. They merge fundamental concepts of parietal reconstruction of open surgery into a laparoscopic approach, aiming to reduce surgical site complications and to enhance recovery. The spread of robotic assistance systems in the field of abdominal wall surgery facilitates access to this type of procedures and allows their application in increasingly complex cases. Parietal relaxation techniques allow large hernial orifices to be closed without tension. They are now also performed with a minimally invasive approach and in a less aggressive manner. Even if the exact place of all these techniques still needs to be better defined depending on the different hernia types, these laparoscopic or robot-assisted approaches already tend to allow faster post-operative recovery.

Avec l'apparition de nouvelles techniques minimalement invasives, la chirurgie des hernies ventrales connaît depuis une dizaine d'années de profonds remaniements. Elles ont en commun d'intégrer les concepts fondamentaux de reconstruction pariétale de la chirurgie ouverte à une voie d'abord laparoscopique, dans le but de réduire les taux de complication du site opératoire et de permettre une réhabilitation accélérée. La diffusion des systèmes d'assistance robotique en chirurgie de la paroi facilite l'accès à ce type de procédure et permet d'envisager leur application dans des cas de plus en plus complexes. Les techniques de relaxation pariétale permettent la fermeture sans tension d'orifices herniaires larges. Elles sont maintenant aussi réalisées par voie minimalement invasive et de manière moins délabrante. Même si la place exacte de l'ensemble de ces techniques doit encore être mieux définie en fonction du type de hernie, ces prises en charge laparoscopiques ou robot-assistées semblent déjà permettre une récupération postopératoire plus rapide.

Cannabinoid Hyperemesis Syndrome: A Case Report of Cyclic Severe Hyperemesis and Abdominal Pain with Long-Term Cannabis Use.

Introduction. Cannabinoid Hyperemesis Syndrome (CHS) is a rare condition that includes cyclic severe vomiting in subjects who have been consuming large doses of cannabis for several years. One of the major diagnostic criteria is the alleviation of symptoms by hot showers. The syndrome was first described in 2004 and is so far neither completely understood nor well known. The latter leads to continued morbidity in concerned subjects and unnecessary expenses for futile investigations. Standard treatments of vomiting as 5-HT3 or D2-receptor antagonists have been shown to be ineffective in alleviating the symptoms. The only long-term satisfying treatment option is the complete abstinence from cannabis consumption. Case Summary. In this case report we describe a 26-year-old male Caucasian long-term cannabis consumer who repeatedly presented in our emergency room with cyclic severe nausea and vomiting ceased by hot showers and resistant to all other treatments. The final diagnosis was not established until his third visit to the ER. Conclusion. CHS is an important differential diagnosis in patients who present with cyclic vomiting and abdominal pain with a history of long-term cannabis use. Recognition of this syndrome is important in order to avoid unnecessary clinical testing and to help the patients break the cycle of drug use.

Robotic laparoendoscopy single site surgery: a transdisciplinary review.

BACKGROUND: Recent developments in minimal invasive surgery have led to laparoendoscopic single site surgery (LESS). This new approach has great potential but remains technically challenging. In order to relieve these difficulties many authors have adapted robotic technology to single site surgery. Numerous approaches have been developed and there is no real consensus. METHODS: A transdisiplinary systematic review of the literature and analysis of the techniques were performed using PubMed up to 31 December 2011. RESULTS: A total of 41 publications were found and included. Seven used the da Vinci Single Site Instrumentation (Intuitive Surgical, Sunnyvale, CA, USA) whereas others used various access devices including: GelPort/GelPOINT (Applied Medical, Rancho Santa Margarita, CA, USA) and a glove technique. CONCLUSIONS: The technical feasibility of robotic LESS is established for numerous and various procedures. However, each kind of procedure requires a customized selection from among the da Vinci new platform, glove technique or GelPort/GelPOINT as well as instrument crossing with respect to minimal distances.

Laparoscopic versus open sigmoid resection for diverticulitis: long-term results of a prospective, randomized trial.

BACKGROUND: Elective laparoscopic sigmoid resection for diverticulitis has proven short-term benefits, but little data are available from prospective randomized trials regarding long-term outcome, quality of life, and functional results. METHODS: Of 113 patients randomized to undergo laparoscopic (LAP) versus open (OP) sigmoid resection for diverticulitis, 105 (93%, LAP = 54, OP = 51) patients were examined and answered the Gastrointestinal Quality of Life Index (GIQLI) questionnaire, with a median follow-up of 30 (range, 9-63) months after surgery. RESULTS: Incisional hernias were detected in five (9.8%) patients in the OP group versus seven (12.9%) in the LAP group, P = 0.84). Overall satisfaction with the operation on a scale of 0 (very poor) to 10 (excellent) was 9 (range, 2-10) in the OP group versus 9 (range, 2-10) in the LAP group (P = 0.78). Median GIQLI score was 115 (range, 57-144) in the OP group versus 110 (range, 61-134) in the LAP group (P = 0.17). Overall satisfaction with the cosmetic aspect of the scar on a scale of 0 (very poor) to 10 (excellent) was 8 (range, 1-10) in the OP group versus 9 (range, 0-10) in the LAP group (P = 0.01). Finally, median hospital cost (including reoperations for hernias) was 11,606 (5,230-147,982) CHF in the LAP group versus 12,138 (6,098-39,786) CHF in the OP group (P = 0.47). CONCLUSIONS: Both open and laparoscopic approaches for sigmoid resection achieve good long-term results in terms of gastrointestinal function, quality of life, and patients' satisfaction. Significant long-term benefits of laparoscopic surgery are restricted to cosmetic (ClinicalTrials.gov protocol #NCT00453830).

Choosing the cosmetically superior laparoscopic access to the abdomen: the importance of the umbilicus.

BACKGROUND: Single-incision laparoscopy (SIL) is a rapidly growing procedure in the field of surgery. The most frequent site of abdominal access is the umbilicus. Its appearance can be altered during SIL procedures. The literature suggests that the umbilicus plays an important role in the overall physical appearance of patients. This study therefore investigated the perception of the general population regarding the cosmetics of the umbilicus. METHODS: An online survey with 10 questions about the aesthetic importance of the umbilicus was circulated worldwide in both the English and French languages. All the answers then were gathered and analyzed. RESULTS: The majority of the participants considered both their umbilicus and that of their partner as "unimportant." The total loss of their umbilicus and any undesired changes in its size, shape, and skin color were considered disturbing by most participants, but not its depth. In this survey, 39% of the women and 29% of the men agreed on a negative impact of an undesired change in their umbilicus, whereas 19% of the women and 36% of the men agreed on a negative impact of such a change in the umbilicus of their partner. The majority of the participants did not consider the umbilicus as playing a major role in sexual attractiveness. CONCLUSIONS: The majority of the participants gave a limited cosmetic role to the umbilicus and would therefore be good candidates for an umbilical surgical access. Among the minority of participants who considered the umbilicus to be cosmetically important, the men tended to be more concerned about the aesthetic aspect of their partner's umbilicus, and a one-third of them agreed on its role in sexual appeal. Although not the majority, a significant proportion of participants were sensitive about the aspect of their umbilicus. Special care should be given to identify this population and choose the appropriate minimally invasive access.

Robotic single-incision transabdominal and transvaginal surgery: initial experience with intersecting robotic arms.

BACKGROUND: Single-incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology. METHODS: The da Vinci Standard and S System (Intuitive, Sunnyvale, USA) were used in human cadavers and pigs to perform single-incision transabdominal and transvaginal surgery. Robotic arms were crossed and control-switched to achieve intuitive control. RESULTS: It was possible to perform robotic single-incision laparoscopy in the typical, intuitive fashion. Transvaginal set-up, including docking of the system and introduction of instruments into the abdominal cavity, was possible but no useful manipulation could be performed. CONCLUSIONS: While robotic NOTES with the da Vinci surgical system was not successful, robotic single-incision surgery is feasible using the above set-up. This new approach seems to offer the advantages of single-incision surgery while maintaining the intuitive control of robotic surgery. Clinical application appears justified.

A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis.

OBJECTIVE: The aim of this study was to compare open and laparoscopic sigmoid resection for diverticulitis with the patient and the nursing staff blinded to the surgical approach. METHODS: A total of 113 patients scheduled for an elective sigmoidectomy were randomized to receive either a conventional open (54 patients) or a laparoscopic (59 patients) approach. Postoperatively, an opaque wound dressing was applied and left in place for 4 days, and patients from both groups were managed similarly. The primary endpoints for analysis were (1) postoperative pain; (2) duration of postoperative ileus; and (3) duration of hospital stay (ClinicalTrials.gov, number NCT 00453830). RESULTS: The median duration of procedure was 165 minutes (range, 90-285) in the laparoscopy group and 110 minutes (range, 70-210) in the open group (P < 0.0001). The median delay between surgery and first bowel movement was 76 (range, 31-163) hours in the laparoscopy group versus 105 (range, 53-175) hours in the open group (P < 0.0001). The median score for maximal pain (assessed by a visual analog scale) was 4 (range, 1-10) in the laparoscopy group and 5 (range, 1-10) in the open group (P = 0.05). Finally, the median duration of hospital stay was 5 days (range, 4-69) in the laparoscopy group versus 7 days (range, 5-17) in the open group (P < 0.0001). CONCLUSION: Laparoscopic sigmoid resection is associated with a 30% reduction in duration of postoperative ileus and hospital stay; by comparison, benefits in terms of postoperative pain appear less impressive, when the patient is blinded to the surgical technique.

Set-up and docking of the da Vinci surgical system: prospective analysis of initial experience.

BACKGROUND: Set-up and docking of the da Vinci surgical system are assumed to extend overall operating times. We hypothesized that these tasks could be achieved in adequate times. Therefore, a prospective analysis of set-up and docking times of the da Vinci Surgical System was conducted. METHODS: We prospectively analysed set-up and docking times with the da Vinci surgical system in our division. RESULTS: Ninety-six patients were operated on over 30 months in our institution. Median set-up time was 22 (range 9-50) min and median docking time was 10 (range 2-70) min. Surgeons with previous docking experience were significantly faster than inexperienced surgeons: 8 (range 2-50) vs. 17.5 (range 10-70) min. Both set-up and docking showed a fast learning curve. CONCLUSION: The data support the conclusion that both set-up and docking of the robot can be achieved in adequate times and have a low impact on overall operating time.

Hospital experience, body image, and cosmesis after laparoscopic or open splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) is becoming the "gold standard" technique for splenectomy. The aim of this study was to evaluate the hospital experience, body image, and cosmesis after LS or open splenectomy (OS). METHODS: Patients who underwent LS or OS were invited to fill out questionnaires evaluating their hospital experience, body image, and cosmetic results. A total of 72 patients (34 LS and 38 OS) agreed to participate in the study. RESULTS: No significant difference was observed between the groups in terms of age, sex, body mass index, or indication for splenectomy. Mean spleen weight and postoperative complications were slightly higher (P>0.05) and the postoperative hospital stay was significantly longer (P<0.05) in the OS group compared with the LS group. Scores from the modified Body Image, Hospital Experience, and Photo Series Questionnaires were higher (favorable) in the LS group compared with the OS group (P<0.01, P<0.001, and P<0.001, respectively). CONCLUSIONS: LS is the procedure of choice for most indications of splenectomy, which has comparable or better perioperative outcomes and complication rate as well as the advantages of better body image, cosmesis, and hospital experience compared with OS. Our results presenting improved outcomes with LS will contribute to the widespread application of laparoscopy for splenectomy.

Impact of IQ, computer-gaming skills, general dexterity, and laparoscopic experience on performance with the da Vinci surgical system.

BACKGROUND: Due to improved ergonomics and dexterity, robotic surgery is promoted as being easily performed by surgeons with no special skills necessary. We tested this hypothesis by measuring IQ elements, computer gaming skills, general dexterity with chopsticks, and evaluating laparoscopic experience in correlation to performance ability with the da Vinci robot. METHODS: Thirty-four individuals were tested for robotic dexterity, IQ elements, computer-gaming skills and general dexterity. Eighteen surgically inexperienced and 16 laparoscopically trained surgeons were included. Each individual performed three different tasks with the da Vinci surgical system and their times were recorded. An IQ test (elements: logical thinking, 3D imagination and technical understanding) was completed by each participant. Computer skills were tested with a simple computer game (hand-eye coordination) and general dexterity was evaluated by the ability to use chopsticks. RESULTS: We found no correlation between logical thinking, 3D imagination and robotic skills. Both computer gaming and general dexterity showed a slight but non-significant improvement in performance with the da Vinci robot (p > 0.05). A significant correlation between robotic skills, technical understanding and laparoscopic experience was observed (p < 0.05). CONCLUSIONS: The data support the conclusion that there are no significant correlations between robotic performance and logical thinking, 3D understanding, computer gaming skills and general dexterity. A correlation between robotic skills and technical understanding may exist. Laparoscopic experience seems to be the strongest predictor of performance with the da Vinci surgical system. Generally, it appears difficult to determine non-surgical predictors for robotic surgery.

Who should do NOTES? Initial endoscopic performance of laparoscopic surgeons compared to gastroenterologists and untrained individuals.

INTRODUCTION: Natural orifice transluminal endoscopic surgery (NOTES) is a multidisciplinary surgical technique. If conventional endoscopic instrumentation can be easily mastered, surgeons with laparoscopic experience could head NOTES interventions. MATERIALS AND METHODS: Thirty individuals were tested for endoscopic dexterity. Group 1 included seven gastroenterologists, group 2 included 12 laparoscopically experienced surgeons lacking endoscopic experience, and group 3 included 11 interns who had no hands-on endoscopic or surgical experience. Each individual repeated an easy (T1), medium (T2), and difficult (T3) task ten times with endoscopic equipment on a NOTES skills-box. RESULTS: Group 3 had significantly poorer performances for all three tasks compared to the other groups. No significant differences were seen between groups 1 and 2 for T1 and T2. The initial T3 performance of group 1 was better than that of group 2, but their performance after repetition was not statistically different. Groups 2 and 3 improved significantly with repetition, and group 2 eventually performed as well as group 1. CONCLUSIONS: The data indicate that laparoscopic surgeons quickly learned to handle the endoscopic equipment. This suggests that a lack of endoscopic experience does not handicap laparoscopic surgeons when performing endoscopic tasks. Based on their knowledge of anatomy and the complication management acquired during surgical education, surgeons are well equipped to take the lead in interdisciplinary NOTES collaborations.

Management of malignant pleural effusion and ascites by a triple access multi perforated large diameter catheter port system.

BACKGROUND: Pleural or peritoneal effusions (ascites) are frequent in terminal stage malignancies. Medical management may be hazardous. METHODS: A 60-year-old man with metastatic malignant melanoma presented refractory ascites as well as bilateral pleural effusions. After failure of the medical treatment, bilateral pleural aspiration and paracentesis became necessary two to three times a week. A multi perforated 15F silicone catheter connected with a subcutaneous port was implanted in peritoneal and both pleural cavities surgically under general anesthesia. Leakage around the catheter is prevented by subcutaneous tunneling. Surgical technique is described and illustrated in a video. RESULTS: Implanted systems were immediately operational. Follow up period was 41 days. Each port was accessed 10 times and a total of 65'200 ml of fluid was drained. By the end of the forth week, pleural effusions diminished, systems were controlled for permeability and chest x-rays confirmed absence of effusion. CONCLUSION: Implanted port systems for refractory ascites and pleural effusions avoid morbidity and the patient's anxiety related to repeated puncture-aspiration. Large catheter diameter allows an easy and fast drainage of large volumes. Compared to chronic indwelling catheters, subcutaneous location of port system allows an entire integration, giving the patient a total liberty in daily life between two sessions of drainage. Drainage can be performed in an outpatient basis as an ambulatory procedure. This patient-friendly technique may be a treatment option in case of failure of other techniques.

Pyoderma gangrenosum after totally implanted central venous access device insertion.

BACKGROUND: Pyoderma gangrenosum is an aseptic skin disease. The ulcerative form of pyoderma gangrenosum is characterized by a rapidly progressing painful irregular and undermined bordered necrotic ulcer. The aetiology of pyoderma gangrenosum remains unclear. In about 70% of cases, it is associated with a systemic disorder, most often inflammatory bowel disease, haematological disease or arthritis. In 25-50% of cases, a triggering factor such as recent surgery or trauma is identified. Treatment consists of local and systemic approaches. Systemic steroids are generally used first. If the lesions are refractory, steroids are combined with other immunosuppressive therapy or to antimicrobial agents. CASE PRESENTATION: A 90 years old patient with myelodysplastic syndrome, seeking regular transfusions required totally implanted central venous access device (Port-a-Cath(R)) insertion. Fever and inflammatory skin reaction at the site of insertion developed on the seventh post-operative day, requiring the device's explanation. A rapid progression of the skin lesions evolved into a circular skin necrosis. Intravenous steroid treatment stopped the necrosis' progression. CONCLUSION: Early diagnosis remains the most important step to the successful treatment of pyoderma gangrenosum.

[The da Vinci surgical system in digestive surgery]. / Le robot da Vinci en chirurgie viscérale.

Since 1990, laparoscopy and minimally invasive techniques in general, have been widely adopted in the field of digestive surgery. However, due to its technical limitations, the use of conventional laparoscopy remains limited to procedures of low (cholecystectomy, appendectomy) or intermediate (Nissen fundoplication, sigmoidectomy) complexity. This paper reviews the technical aspects of the da Vinci robot, as well as its potential applications to digestive surgery. While robotic-assisted cholecystectomy and fundoplication are feasible, this approach is not superior to conventional laparoscopy; by contrast, preliminary data suggest that robotic-assisted surgery might be superior to laparoscopy in more complex procedures, such as gastric bypass and total mesorectum excision for rectal cancer.

Multimedia article. Laparoscopic repair of parastomal hernia using a porcine dermal collagen (Permacol) implant.

BACKGROUND: Surgical repair of parastomal hernias is usually performed through a laparotomy (stoma translocation) or a peristomal incision (mesh repair). Laparoscopic approach may minimize the risks of mesh infection and, thus, represents an attractive alternative. Permacol (Tissue Science Laboratories plc, Aldershot, Hampshire, U.K.) is a new biomaterial implant, which combines the strength and biocompatibility. TECHNIQUE: Case 1: A 67-year-old patient presented with paracolostomal hernia causing discomfort and intermittent obstructive episodes, 12 months after a proctectomy for severe radiation proctitis. Case 2: A 74-year-old patient presented with a symptomatic paracolostomal hernia 18 years after abdominoperineal amputation. RESULTS: Both procedures took less than 120 minutes. Patients were started on a liquid and solid diet on postoperative Day 1 and discharged to home on the sixth and seventh postoperative days. There was no evidence of hernia recurrence or mesh-related complication at the time of last follow-up: nine months and three months postoperatively. CONCLUSIONS: Compared with the traditional open technique, the technique described has two potential benefits: 1) the laparoscopic approach provides a means to avoid operating in a contaminated field and may reduce the risks of mesh infection; and 2) the use of a biologic graft may minimize the incidence of synthetic mesh-related complications, such as erosion into viscera and fistula. The use of biologic implants in this indication seems promising and deserves further evaluation.