Laparoscopic extraperitoneal approach for lateral lymph node dissection for patients with metachronous lateral pelvic lymph node metastases following surgery for rectal cancer: a case series and short-term outcomes.

BACKGROUND: There have been few reports of a totally extraperitoneal approach for laparoscopic lateral lymph node dissection (LLND) for patients with metachronous lateral pelvic lymph node metastases following surgery for rectal cancer. Therefore, this study reports the short-term outcomes of LLND via an extraperitoneal approach. METHODS: A total of 10 patients underwent LLND through a laparoscopic extraperitoneal approach in our hospital since October 2018. Patients with suspected resectable lateral lymph node recurrence after surgery for rectal cancer on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography CT (PET-CT) were selected for this procedure. RESULTS: Nine of the 10 cases were completed using this procedure, but one case was converted to an intraperitoneal approach. The median operative time was 231 min, and the median estimated blood loss was 10 ml. There was one case of wound infection, but no other postoperative complications were seen. In one patient, no metastases were found in the retrieved lymph nodes. CONCLUSION: The short-term outcomes of LLND through a laparoscopic extraperitoneal approach were acceptable. Because this procedure can be performed without violating the peritoneum, it is less invasive than the conventional intraperitoneal approach and is useful for metachronous lateral pelvic lymph node metastases.

Perioperative, function, and positive surgical margin in extraperitoneal versus transperitoneal single port robot-assisted radical prostatectomy: a systematic review and meta-analysis.

BACKGROUND: Extraperitoneal and transperitoneal approaches are two common modalities in single-port (SP) robot-assisted radical prostatectomy (RARP), but differences in safety and efficacy between the two remain controversial. This study aimed to compare the perioperative, function, and positive surgical margin of extraperitoneal with transperitoneal approaches SP-RARP. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, this study is registered with PROSPERO (CRD 42023409667). We systematically searched databases including PubMed, Embase, Web of Science, and Cochrane Library to identify relevant studies published up to February 2023. Stata 15.1 software was used to analyze and calculate the risk ratio (RR) and weighted mean difference (WMD). RESULTS: A total of five studies, including 833 participants, were included in this study. The SP-TPRP group is superior to the SP-EPRP group in intraoperative blood loss (WMD: - 43.92, 95% CI - 69.81, - 18.04; p = 0.001), the incidence of postoperative Clavien-Dindo grade II and above complications (RR: 0.55, 95% CI - 0.31, 0.99; p = 0.04), and postoperative continence recovery (RR: 1.23, 95% CI 1.05, 1.45; p = 0.04). Conversely, the hospitalization stays (WMD: 7.88, 95% confidence interval: 0.65, 15.1; p = 0.03) for the SP-EPRP group was shorter than that of the SP-TPRP group. However, there was no significant difference in operation time, postoperative pain score, total incidence of postoperative complications, and positive surgical margin (PSM) rates between the two groups (p > 0.05). CONCLUSIONS: This study demonstrates that both extraperitoneal and extraperitoneal SP-RARP approaches are safe and effective. SP-TPRP is superior to SP-EPRP in postoperative blood loss, the incidence of postoperative Clavien-Dindo grade II and above complications, and postoperative continence recovery, but it is accompanied by longer hospital stays.

Laparoscopic Extraperitoneal Approach for Lateral Pelvic Node Dissection in Rectal Cancer: Techniques and Short-Term Outcomes.

BACKGROUND: Lateral pelvic lymph node dissection has been performed selectively in rectal cancer cases; however, it involves highly skilled techniques because of the complex adjacent anatomical structures. MATERIALS AND METHODS: Laparoscopic EP-LPND was performed in Korea University Anam Hospital from June 2018, and short-term surgical outcomes were analyzed from June to December 2018. Among the patients with histologically diagnosed rectal adenocarcinoma, patients who were suspected Lateral pelvic lymph node metastasis at magnetic resonance imaging were selected for this procedure. RESULTS: Seven patients underwent laparoscopic extraperitoneal approach for lateral pelvic lymph node dissection in the study period. The mean number of retrieved lymph node was 4.57, and metastatic lymph nodes were identified in 3 patients (42.8%). All of the lymph nodes with suspected metastasis preoperatively were removed in postoperative images. There was no immediate postoperative complication beyond the moderate grade associated with lateral pelvic lymph node dissection. The median follow-up was 9 months, and there were no local recurrence nor complications related to sexual and voiding functions. CONCLUSIONS: The laparoscopic extraperitoneal approach might be an efficient way to perform lateral pelvic lymph node dissection using the same principles as the conventional method without violation of the peritoneum.

Prospective, randomized clinical trial of laparoscopic totally extraperitoneal inguinal hernia repair using conventional versus custom-made (mosquito) mesh performed in Cameroon: a short-term outcomes.

BACKGROUND: Adverse economic conditions often prevent the widespread implementation of modern surgical techniques in third world countries such as in Sub-Sahara Africa. AIM OF THE STUDY: To demonstrate that a modern technique (laparoscopic totally extraperitoneal inguinal hernioplasty [TEP]) can safely be performed at significantly lower cost using inexpensive mesh material. SETTINGS: Douala University Hospital Gynecology, Obstetrics and Pediatrics and two affiliated centers, Ayos Regional Hospital and Edéa Regional Hospital in Cameroon. PATIENTS AND METHODS: Prospective randomized controlled trial (RCT) of consecutive adult patients presenting with primary inguinal hernia treated by TEP, comparing implantation of sterilized mosquito mesh (MM) with conventional polypropylene mesh (CM). Primary endpoints were peroperative, early and midterm postoperative complications and hernia recurrence at 30 months. RESULTS: Sixty-two patients (48 males) were randomized to MM (n = 32) or CM (n = 30). Groups were similar in age distribution and occupational features. Peroperative and early outcomes differed in terms of conversion rate (2/32 MM) due to external (electrical power supply) factors and mesh removal for early obstruction (1/30 CM). No outcome differences, including no recurrences, were noted after a median follow-up of 21 months. CONCLUSION: In this RCT with medium-term follow-up, TEP performed with MM appears not inferior to CM.

Extraperitoneal kidney transplantation: a comparison between children weighting ≤15 kg and >15 kg. Experience of a single institution.

Extraperitoneal approach is sometimes recommended for kidney transplantation (KT) in children weighting <15 kg. We hypothesized that this approach might be as successful as in patients with normal weight. Data of all consecutive KTs performed between 2013 and 2019 were retrospectively reviewed. Early outcomes and surgical complications were compared between children weighing ≤15 kg (low-weight (LW) group) and those weighing >15 kg (Normal-weight (NW) group). All the 108 KTs were performed through an extraperitoneal approach. The LW group included 31 patients (mean age 3.5 ± 1.4 years), whose mean weight was 11.1 ± 2.0 kg. In the LW group,-a primary graft nonfunction (PNGF) occurred in one patient (3.2%), surgical complications occurred in nine (29%), with four venous thrombosis. In the NW group, PNGF occurred in one case (1.3%), delayed graft function (DGF) in eight (10%), surgical complications in 11 (14%) with only one case of venous thrombosis. In both groups, no need for patch during wound closure and no wound dehiscence were reported. The extraperitoneal approach can be effectively used in LW children. No differences were observed in the overall complication rate (P = 0.10), except for the occurrence of venous thrombosis (P = 0.02). This might be related to patients' characteristics of the LW group.

Totally extraperitoneal approach for open complex abdominal wall reconstruction.

BACKGROUND: Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. METHODS: This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. RESULTS: One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively. CONCLUSIONS: TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.

Appropriate mesh size in the totally extraperitoneal repair of groin hernias based on the intraoperative measurement of the myopectineal orifice.

BACKGROUND: Insufficient coverage of the area of a possible groin hernia is an important risk factor in hernia recurrence. To prevent recurrence, it is important to use the appropriate mesh size based on the size of the myopectineal orifice (MPO), which is the weak area of the abdominal wall where inguinal hernias occur. We aimed to estimate the appropriate mesh size for groin hernias by investigating MPO size. METHODS: Four hundred and six patients underwent groin hernia repair using a totally extraperitoneal (TEP) approach at the Zeze Hospital between July 2009 and December 2017. We investigated patients' backgrounds, MPO components dimensions, and hernia recurrence, and evaluated the appropriate mesh size. RESULTS: The 359 male and 47 female patients had an average age of 63 ± 15 years. In 171, 147, and 88 cases, hernias were localized to the right, left, and bilaterally, respectively. The number of lateral, medial, femoral, and combined hernias was 317, 124, 11, and 42, respectively. The 95th percentile for the horizontal and vertical lengths in cases of hernia orifice ≥ 3 cm were 9.6 cm and 7.0 cm, respectively, while it was 9.2 cm and 6.4 cm in cases of hernia orifice < 3 cm. We added 2 cm and 3 cm to the 95th percentile for the length and width of the MPO, resulting in 13.2 × 10.4 cm and 15.6 × 13.0 cm in cases with hernia orifice < 3 cm and ≥ 3 cm, respectively. Relapse after TEP occurred in 1 patient (0.2%). CONCLUSION: The appropriate mesh size for TEP repair, derived from intraoperative MPO measurements, was estimated as 13.2 × 10.4 cm and 15.6 × 13.0 cm when the hernia orifice was < 3 cm and ≥ 3 cm, respectively. Using appropriate mesh sizes based on MPO measurement may reduce groin hernia recurrence after TEP.

Hybrid versus open retromuscular abdominal wall repair: early outcomes.

BACKGROUND: The hybrid approach to abdominal wall reconstruction (AWR) for abdominal wall hernias combines minimally invasive posterior component separation and retromuscular dissection with open fascial closure and mesh implantation. This combination may enhance patient outcomes and recovery compared to the open approach alone. The purpose of this study is to evaluate the operative outcomes of hybrid vs. open abdominal wall reconstruction. METHODS: A retrospective review was conducted to compare patients who underwent open versus hybrid AWR between September 2015 and August of 2018 at Anne Arundel Medical Center. Patient demographics and perioperative data were collected and analyzed using univariate analysis. RESULTS: Sixty-five patients were included in the final analysis: 10 in the hybrid and 55 in the open groups. Mean age was higher in the hybrid vs. open group (65.1 vs. 56.2 years, p < 0.05). The hybrid and open groups were statistically similar (p > 0.05) in gender distribution, mean BMI, and ASA score. Intraoperative comparison found hybrid patients parallel to open patients (p > 0.05) in mean operative time (294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area, and drain placement. The mean total hospital cost was lower in the hybrid group compared to the open group ($16,426 vs. $19,054, p = 0.43). The hybrid group had a shorter length of stay (5.3 vs. 3.6 days, p = 0.03) after surgery and was followed for a similar length of time (12.3 vs. 12.6 months, p = 0.91). The hybrid group showed a lower trend of seroma, hematoma, wound infection, ileus, and readmission rates after surgery. CONCLUSION: A review of patient outcomes after hybrid AWR highlights a trend towards shorter length of stay, lower hospital cost, and fewer complications without significant addition to operative time. Long-term studies on a larger number of patients are definitively needed to characterize the comprehensive benefits of this approach.

Impact of Body Mass Index (BMI) on perioperative outcomes following minimally invasive retromuscular abdominal wall reconstruction: a comparative analysis.

BACKGROUND: Morbidity and recurrence rates are higher in obese patients undergoing open abdominal wall reconstruction (AWR). Historically, body mass index (BMI) ≥ 40 has served as a relative contraindication to open AWR. The purpose of this study is to evaluate the impact of minimally invasive surgery (MIS) on outcomes after AWR for higher versus lower BMI patients. METHODS: A retrospective review of a prospectively maintained database was conducted of all patients who underwent MIS AWR between September 2015 and April 2019 at our institution. Patients were subdivided into two groups based on their BMI: BMI ≤ 35 kg/m2 and BMI > 35 kg/m2. Patient demographics and perioperative data were evaluated using univariate and multivariate analysis. RESULTS: 461 patients were identified and divided into two groups: BMI ≤ 35 (n = 310) and BMI > 35 (n = 151). The two groups were similar in age (BMI ≤ 35: 56.3 ± 14.1 years vs. BMI > 35: 54.4 ± 11.9, p = .154). BMI > 35 group had more patients with ASA score of 3 (81% vs. 32%, p < .001) and comorbid conditions such as hypertension (70% vs. 45%, p < .001), diabetes mellitus (32% vs. 15%, p < .001), and history of recurrent abdominal wall hernia (34% vs. 23%, p = .008). BMI > 35 group underwent a robotic approach at higher rates (74% vs. 45%, p < .001). Patients who underwent a Rives-Stoppa repair from the higher BMI cohort also had a larger defect size (5.6 ± 2.4 cm vs. 6.7 ± 2.4 cm, p = .004). However, there were no differences in defect size in patients who underwent a transversus abdominus release (BMI ≤ 35: 9.7 ± 4.9 cm vs. BMI > 35: 11.1 ± 4.6 cm, p = .069). Both groups benefited similarly from a short length of stay, similar hospital charges, and lower postoperative complications. CONCLUSION: Initial findings of our data support the benefits of elective MIS approach to AWR for patients with higher BMI. These patients derive similar benefits, such as faster recovery with low recurrence rates, when compared to lower BMI patients, while avoiding preoperative hernia incarceration, postoperative wound complications, and hernia recurrences. Future follow-up is required to establish long-term perioperative and quality of life outcomes in this patient cohort.

Para-aortic and Right Obturator Lymphadenectomy for Surgical Staging of Advanced Cervical Cancer through the TU-LESS Extraperitoneal Approach.

OBJECTIVE: To present an innovative transumbilical laparoendoscopic single-site (TU-LESS) extraperitoneal approach for lymphadenectomy in a patient with advanced cervical carcinoma. DESIGN: Demonstration of the novel technique through video. SETTING: In advanced cervical cancer, determining the status of the para-aortic lymph nodes is essential because extended-field radiologic therapy is recommended for a patient with positive para-aortic lymph nodes [1]. Nonetheless, the sensitivity and specificity of currently available imaging workup for positive lymph nodes are limited. Surgical staging enables precise evaluation. However, laparotomy has potential wound complications and leads to treatment delay. Multiport laparoscopic transperitoneal and extraperitoneal approaches limit surgeons' ability to reach the para-aortic area or obturator fossa in the same operation [2]. Thus, we take full use of these approaches' advantages and avoid their disadvantages to design a promising minimally invasive surgery approach [3]. INTERVENTIONS: Para-aortic and obturator lymphadenectomy through the TU-LESS extraperitoneal approach was successfully performed without complications. The patient recovered quickly and received subsequent concurrent chemoradiation on schedule. CONCLUSION: TU-LESS extraperitoneal para-aortic lymphadenectomy provides satisfactory exposure and easy access to both the para-aortic area and obturator fossa. In addition, the bowels are uplifted by an extraperitoneal air cushion to achieve excellent exposure and reduce the risk of bowel injury. With quick recovery, the patient could start accurate radiation treatment promptly.

[Extraperitoneal robot-assisted laparoscopic radical prostatectomy through single incision: Establishment and application of a modified channel].

Objective: To assess the feasibility and validity of the establishment of a modified channel for extraperitoneal robot-assisted laparoscopic radical prostatectomy (RARP) through single incision. METHODS: From November 2020 to January 2021, 35 cases of localized PCa were treated by extraperitoneal RARP through single incision in our center. All the operations were performed by the same surgeon, none via the multichannel port for the establishment of the channel. We recorded and analyzed the intra- and postoperative parameters, operation cost, complications, pathological findings and follow-up data. RESULTS: All the operations were successfully completed, without conversion to open surgery or additional channels, or serious postoperative complications, the time for establishing the extraperitoneal space averaging 25.4 (20.0－45.0) min, the operation time 67.3 (35.0－125.0) min, intraoperative blood loss 75.5 (60.0－150.0) ml, time to first postoperative anal exhaust 26 (8－48) h, and postoperative hospital stay 7.89 (7－10) d. Postoperative pathology showed adenocarcinoma in all the cases, with Gleason score (GS) 3+3 in 9 (25.7%), GS 3+4 in 9 (25.7%), GS 4+3 in 8 (22.9%), and GS ≥ 8 in 9 (25.7%) of the cases, 23 (65.7%) in the

Endoscopic totally extraperitoneal approach (TEA) technique for primary ventral hernia repair.

BACKGROUND: Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space). METHODS: Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall. RESULTS: All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85-145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1-3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10-27 months). CONCLUSION: In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

Extraperitoneal pediatric kidney transplantation of adult renal allograft using an en-bloc native liver and kidney mobilization technique.

BACKGROUND: We describe the safety and efficacy of performing pediatric kidney transplantation with a modified extraperitoneal approach that includes mobilization of the native liver and kidney. METHODS: We retrospectively identified pediatric renal transplants performed using this technique between 2015 and 2019. Data on patient demographics, surgical technique, and intraoperative details were collected. Outcomes were measured by morbidity and re-operation at 90 days, as well as serum creatinine, allograft survival, and overall survival at 1 year. RESULTS: Twenty-one patients with a median age of 5 (IQR 3-9) years, weighing 17.5 (IQR 14.5-24) kg were included. Median donor age was 24 (IQR 19-31) years. No intraoperative complications occurred. One child required a right native nephrectomy to allow sufficient space. Postoperatively, all patients had immediate graft function without urine leak or allograft thrombosis. 90-day morbidity and re-operation rates were zero. Both 1-year allograft and overall survival were 100% (on follow-up of all 21 patients through 1 year post-transplant), with a median serum creatinine of 0.58 (IQR 0.47-0.70) mg/dl at 1 year post-transplant. CONCLUSIONS: Pediatric kidney transplantation of adult renal allografts using an extraperitoneal approach with native liver and kidney mobilization has promising allograft and patient survival outcomes that eliminates peritoneal violation and may diminish the need for native nephrectomy.

Totally extraperitoneal approach to laparoscopic lateral lymph node dissection for patients with recurrent lateral pelvic lymph nodes after rectal cancer surgery: a novel technique-M TEP LLND.

Lateral lymph node dissection (LLND) for recurrence of lateral pelvic lymph node metastasis after rectal cancer surgery is technically demanding because of the need for re-do surgery. We herein report a novel technique of laparoscopic LLND via a totally extraperitoneal (TEP) approach. Since October 2018, we have performed LLND based on a TEP approach, called "M TEP LLND", with two cases treated. By peeling in the caudal direction in the dorsal layer of the rectus abdominis muscle, a working space is created once the extraperitoneal space is reached, and LLND is performed. All lateral pelvic lymph node dissection procedures have been successfully completed, and there have been no intraoperative or postoperative complications. This procedure allows TEP-experienced colorectal surgeons to perform safe and complete LLND without any influence of intraperitoneal adhesion or intestinal obstruction. M TEP LLND is less invasive than the conventional intraperitoneal approach and appears to be useful, particularly for recurrence of lateral pelvic lymph node metastasis.

Comparison of laparoscopic percutaneous extraperitoneal closure versus conventional herniotomy in extremely low birth weight infants.

PURPOSE: Laparoscopic percutaneous extraperitoneal closure (LPEC) has become routine for repairing pediatric inguinal hernia (IH). Reports on the effective repair of IH in challenging cases, such as extremely low birth weight infants (ELBWI) who become symptomatic soon after birth and have surgery before 1 year of age, are rare; and conventional herniotomy (CH) in ELBWI requires extensive experience of neonatal surgery. We compared LPEC with CH for treating ELBWI with IH. METHODS: Consecutive ELBWI with IH treated by either LPEC (n = 17) or CH (n = 22) before 1 year of age between 2012 and 2017 were reviewed. LPEC were performed by consultant pediatric surgeons (CPS; n = 3) with experience of at least 200 cases each. In CH, 11 cases were treated by CPS and 11 by CPS-supervised surgical trainees. RESULTS: There were no intraoperative complications. Operative time and anesthesia time for bilateral IH repairs were both shorter in LPEC. Postoperative sequelae were recurrence (LPEC; n = 1; repaired by redo LPEC 2 months after the initial repair) and intravenous rehydration (CH; n = 1; for persistent post-anesthetic vomiting). Recovery was unremarkable in all cases without additional analgesia. CONCLUSION: LPEC would appear to be a viable option for treating IH in ELBWI, especially bilateral cases.

New steps of robot-assisted radical prostatectomy using the extraperitoneal approach: a propensity-score matched comparison between extraperitoneal and transperitoneal approach in Japanese patients.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) is commonly performed using the transperitoneal (TP) approach with six trocars over an 8-cm distance in the steep Trendelenburg position. In this study, we investigated the feasibility and the benefit of using the extraperitoneal (EP) approach with six trocars over a 4-cm distance in a flat or 5° Trendelenburg position. We also introduced four new steps to the surgical procedure and compared the surgical results and complications between the EP and TP approach using propensity score matching. METHODS: Between August 2012 and August 2016, 200 consecutive patients without any physical restrictions underwent RARP with the EP approach in a less than 5° Trendelenburg position, and 428 consecutive patients underwent RARP with the TP approach in a steep Trendelenburg position. Four new steps to RARP using the EP approach were developed: 1) arranging six trocars; 2) creating the EP space using laparoscopic forceps; 3) holding the separated prostate in the EP space outside the robotic view; and 4) preventing a postoperative inguinal hernia. Clinicopathological results and complications were compared between the EP and TP approaches using propensity score matching. Propensity scores were calculated for each patient using multivariate logistic regression based on the preoperative covariates. RESULTS: All 200 patients safely underwent RARP using the EP approach. The mean volume of estimated blood loss and duration of indwelling urethral catheter use were significantly lower with the EP approach than the TP approach (139.9 vs 184.9 mL, p = 0.03 and 5.6 vs 7.7 days, p < 0.01, respectively). No significant differences in the positive surgical margin were observed. None of the patients developed an inguinal hernia postoperatively after we introduced this technique. CONCLUSIONS: The EP approach to RARP was safely performed regardless of patient physique or contraindications to a steep Trendelenburg position. Our method, which involved using the EP approach to perform RARP, can decrease the amount of perioperative blood loss, the duration of indwelling urethral catheter use, and the incidence of postoperative inguinal hernia development.

Extraperitoneal Endoscopic Total Retroperitoneal Lymphadenectomy: No Bowel Surgery.

STUDY OBJECTIVE: We describe our ultra-minimally invasive retroperitoneal lymphadenectomy using the extraperitoneal approach. This technique was developed to make traditionally invasive oncologic surgery more patient friendly and safer by eliminating the bowel from the operative field. DESIGN: Description of a surgical technique. Canadian Task Force II-3. SETTING: Urban general hospital in Japan. PATIENTS: 320 Women undergoing endoscopic extraperitoneal paraaortic and pelvic lymphadenectomy for endometrial cancer from Jan 2001 to Dec 2013. INTERVENTIONS: Patients underwent endoscopic extraperitoneal para-aortic and pelvic lymphadenectomy for endometrial cancer. We accessed the retroperitoneal space with a visual access cannula (Endotip). This device easily facilitates peritoneal tenting. After expanding the extraperitoneal space by blunt dissection with forceps, carbon dioxide was infused. The upper limit of our dissection was the renal vein and the lower limit was the iliac circumflex vein. The extraperitoneal approach naturally creates a bowel-free operative field, even when dissecting in the pelvis. This approach only requires a 5-mm access hole, making it the least invasive approach to this kind of surgery. MEASUREMENTS AND MAIN RESULTS: The 5-year survival rates for this intervention combined with hysterectomy and bilateral adnexectomy are extremely favorable at 90% for patients with stage I to III disease, making this technique a viable minimally invasive approach for selected patients. CONCLUSION: We can achieve a total para-aortic and pelvic retroperitoneal dissection with this extraperitoneal approach without the bowel invading the operative field. This procedure is focused on the barrier-free nature of working in the retroperitoneal space, meaning a space that is not hindered by the invasion of the bowel or other intraperitoneal structures.

Totally extraperitoneal laparoscopic hernioplasty versus open extraperitoneal approach for inguinal hernia repair: a meta-analysis of outcomes of our current knowledge.

BACKGROUND: The aim of this article is to explore the clinical effects between open extraperitoneal approaches and totally extraperitoneal laparoscopic hernioplasty (TEP) in the repair of inguinal hernias. METHODS: The electronic databases Pubmed, Medline, Embase, Web of science and the Cochrane Library were used to search for articles from January 1992 to March 2013. The present meta-analysis pooled the effects of outcomes of a total of 1157 patients with 1377 hernias enrolled into 10 randomized controlled trials and 2 comparative studies. The data was analyzed using the statistic software Stata12.0 and IBM SPSS Statistics 19. RESULTS: Significant advantages of totally extraperitoneal laparoscopic hernioplasty (TEP) compared to the open extraperitoneal approach include a lower incidence of total postoperative complications (Odds Ratio, 0.544; 95% confidence interval, 0.369-0.803), a reduction in urinary problems (0.206[0.064,0.665]), an earlier return to normal activities or work (SMD = -1.798[-3.322,-0.275]), and a shorter length of hospital stay (-1.995 [-2.358,-1.632]). No difference was found in operative time, the incidence of hernia recurrence, chronic pain, intraoperative complications, seromas or hematomas, wound infection and testicular problems between the two techniques. One significant advantage for the open extraperitoneal inguinal hernia repair was a lower incidence of peritoneal tears (46.504 [15.399,140.437]). CONCLUSIONS: Totally extraperitoneal laparoscopic hernioplasty (TEP) and open extraperitoneal mesh repair are equivalent in most of the analyzed outcomes. TEP is associated with shorter hospital stay, quicker return to normal activities or work, lower incidence of total postoperative complications and urinary problems, while the open extraperitoneal method has less incidence of peritoneal tears.

Telescopic Dissection as a Cost-Effective Alternative to Balloon Trocar for Preperitoneal Dissection in Total Extraperitoneal Inguinal Hernia Repair.

Background: Total extraperitoneal (TEP) approach is one of the commonly used minimally invasive method in inguinal hernia repair. There are limited data that compares the results of the telescopic dissection and balloon trocar for preperitoneal dissection. In our study, we aimed to retrospectively evaluate the TEP cases performed at our center and compare the results of these two techniques. Methods: TEP cases performed between 2020 and 2024 were evaluated. Strangulated and recurrent hernia cases were excluded. Telescopic dissection and balloon trocar techniques were compared in terms of conversion, postoperative pain, complications, and recurrence. Results: A total of 177 patients were included. Telescopic method was used in 122 cases, while a balloon trocar was used in 55 cases. The median age was 50 years (range: 20-86), and 163 patients (92%) were male. Bilateral inguinal hernia was present in 61 patients (35%). The median operative time was 100 minutes (IQR: 80-120 minutes). Conversion was required in a total of 3 cases (1.5%); specifically, the transabdominal preperitoneal method was employed in 2 cases, and Lichtenstein-style anterior approach hernia repair was performed in one case. Between the telescopic dissection and balloon trocar groups, no significant differences were observed in operation time (P = .407), conversion rates (P = .228), postoperative pain scores (P = .505, P = .264, P = .681, P = .743), complication rates (P = .205), or recurrence rates (P = .311). Conclusions: The results of using a balloon trocar and telescopic dissection in inguinal hernia repair with TEP are similar, and telescopic dissection could be a cost-effective alternative to the balloon trocar.