Abstract:

Laparoscopy has gained a place in everyday surgical routine as an alternative surgical approach that decreases morbidity and postoperative hospitalization. Single port laparoscopic surgery has been introduced as a further development of laparoscopy. The feasibility and safety of single port laparoscopy is under extensive evaluation in specialized laparoscopic centers. Nevertheless, wide acceptance of the technique requires adequate documentation of the advantages of the approach over conventional laparoscopy and further refinement of surgical instrumentation to overcome intraoperative ergonomic problems.

Authors:

Umut Barbaros, MD, Associate Professor of General Surgery, University of Istanbul Faculty of Medicine, Istanbul, Turkey, Tugrul Demirel, MD, Specialist of General Surgery, Department of General Surgery, Gaziantep Sehitkamil State Hospital, Gaziantep, Turkey, Osman Gozkun, MD, Assistant of General Surgery, University of Istanbul Faculty of Medicine, Istanbul, Turkey, Kursat Serin, MD, Specialist of General Surgery, University of Istanbul Faculty of Medicine, Istanbul, Turkey, Orhan Bilge, MD, Professor of Surgery, University of Istanbul Faculty of Medicine, Istanbul, Turkey, Murat Kalayci, MD, Specialist of General Surgery, University of Yeditepe Faculty of Medicine, Istanbul, Turkey, Aziz Sumer, MD, Assistant Professor of Surgery, University of Yuzuncu Yil Faculty of Medicine, Van, Turkey, Berkay Kiliç, MD, Resident of General Surgery, University of Istanbul Faculty of Medicine, Istanbul, Turkey, Wei-Liang Loh, MD, Assistant of General Surgery, National University of Singapore Faculty of Medicine, Singapore, Ahmet Dinççag, MD, Professor of Surgery, University of Istanbul Faculty of Medicine, Istanbul, Turkey, Ridvan Seven, MD, Professor of Surgery, University of Istanbul Faculty of Medicine, Istanbul, Turkey, Selcuk Mercan, MD, Professor of Surgery,University of Istanbul Faculty of Medicine, Istanbul, Turkey

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Abstract:

In view of the fact that appendectomy is the most common operation for an acute abdomen, laparoscopic appendectomy has evolved as the most frequently performed procedure. Hospitals, therefore, require at all times the expertise, technique, and staff to ensure a high quality of standard for appendectomies, which not only supports the requirements of the high caseload but also takes into consideration the socio-economical aspects. A critical step is the closure of the appendicular stump. The three most widely employed techniques are an endo-stapler, an endo-loop, or a clip. Although the endo-stapler is fairly expensive, it combines closing and transecting the appendix in one step, offers the possibility of a partial caecal resection, and can be used if the appendicular base is inflamed. Endo-loop and clip are equally cost-effective, but the clip appears to be simpler in handling than the endo-loop and, like the stapler, offers closing and cutting the appendix before dissecting the mesoappendix. However, only appendices up to 16 mm in diameter can be clipped, a disadvantage not shared with the loop.

Authors:

Lars Ivo Partecke, MD, Board Certified Surgeon, Wolfram Kessler, MD, Board Certified Surgeon, Maciej Patrzyk, MD, Medical Sub-Director, Claus-Dieter Heidecke, MD, PhD, Professor, Chairman, and Head of the Department, Wolfram v. Bernstorff MD, PhD, Attending Surgeon, Department of General, Visceral, Thoracic, and Vascular Surgery, University Medicine, Greifswald, Germany

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Abstract:

The resection in partial pancreatico-duodenectomy as the standard treatment for malignancies of the pancreatic head is commonly performed starting from the hepatoduodenal ligament after division of the bile duct, stomach, or proximal duodenum and pancreatic body. The "Uncinate First" approach is a technical modification with a retrograde dissection of the pancreatic head as a novel surgical procedure. Caudo-cranial resection of the pancreatic head is characterized by starting with the uncinate process after division and mobilization of the first jejunal loop. Transection of the upper gastrointestinal structures (bile duct, stomach or duodenum and pancreas) is performed at the end of the resection. The retrograde Uncinate First technique offers a comfortable and innovative approach for partial pancreatico-duodenectomy. The superior mesenteric artery as well as the portal and superior mesenteric vein can be very accurately dissected and controlled during the resection phase associated with potentially less blood loss and a more radical resection along the medial margin, which is often the site of R1 resections. Future studies are required to evaluate this procedure regarding operative parameters and postoperative outcome compared with the standard resection.

Authors:

Thilo Hackert, MD, Attending Surgeon, University of Heidelberg, Heidelberg, Germany, Markus W. Büchler, MD, Head of the Department of Surgery, University of Heidelberg, Heidelberg, Germany

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Abstract:

Although Argon Beam Coagulators (ABCs) are widely used in urological and gynecological procedures, there have been only two studies published so far on their use and benefits in breast surgery. This study compares the incidence of breast seroma following mastectomy upon the use of ABC versus standard monopolar diathermy. This is a retrospective cohort study, with data collected from January 2006 to August 2008 for all patients who underwent a simple mastectomy and axillary surgery. Outcomes included incidence of seroma, amount of drainage on day of discharge, and timing of seroma formation. Fifty-six patients were studied, with 30 undergoing simple mastectomy using ABC diathermy and 25 using simple diathermy. The incidence of postoperative breast seroma development was 30% (n = 9) in the former group and 36% (n = 9) in the latter. In the ABC group, a high postoperative drainage at discharge was predictive of developing a seroma; this was not observed in the monopolar group. The search for methods to reduce the incidence of seroma in breast surgery is ongoing worldwide. Despite a previous report, this study failed to show any significant difference between ABC and monopolar diathermy in the incidence of breast seroma formation following simple mastectomy and axillary surgery. ABC diathermy is more costly, and its use needs to be carefully considered in an era of a stretched National Health Service financial budget.

Authors:

Valentina Lefemine, MD, MRCS, Specialist Registrar in General Surgery, Julie A. Cornish, MBBCh, MRCS, Specialist Registrar in General Surgery, Walid Abou-Samra, MD, Consultant General Surgeon, Department of Surgery, Glan Clwyd Hospital, Rhyl, United Kingdom

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Abstract:

Reduced port surgery (RPS) is a new surgical modality producing increased cosmetic benefits over conventional endoscopic surgery. We herein report the first case of insulinoma of the pancreas treated by RPS. RPS enucleation was performed for a 23-year-old Japanese female who was admitted to our hospital with repeated episodes of hypoglycemia attributable to an insulinoma. The preoperative examinations confirmed the diagnosis of a solitary insulinoma of the pancreatic tail. Enucleation of the insulinoma using RPS was performed. A 2.5-cm umbilical incision was made, and three laparoscopic trocars were individually inserted into the abdominal cavity via this incision. Another 3-mm trocar was inserted from the left subcostal region. All procedures that were usually performed in conventional laparoscopic surgery were also performed by RPS: intraoperative ultrasonography, mobilization of the tail of the pancreas, enucleation of the tumor, and suturing of the stump. A mechanical manipulator, the Radius Surgical System (Radius), was used for suturing and ligation. The Radius was sufficient to overcome in-line viewing and hand/instrument collisions, and enabled us to perform precise suturing and ligation. Serial blood sugar, C-peptide immunoreactivity (CPR), and immunoreactive insulin (IRI) measurements revealed that all values were normal after resection. The patient had an uneventful postoperative course. RPS was successfully applied for enucleation of a solitary mass in the tail of the pancreas, and represents an alternative to conventional laparoscopic surgery. This method is technically feasible and results in superior cosmesis. The Radius facilitated advanced laparoscopic surgery and may also have advantages in RPS.

Authors:

Kazunori Shibao, MD, PhD, Assistant Professor, Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan, Aiichiro Higure, MD, PhD Assistant Professor, Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan, Koji Yamaguchi, MD, PhD, Professor, Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan, Noritaka Minagawa,MD, PhD, Assistant Professor, Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan

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Abstract:

Currently, there is a new transanal approach to be used for the excision of selected low-risk rectal cancers and broad-based polyps, the transanal endoscopic surgery using a single-port device. We transferred the single port access surgery (SPA) well-established from laparoscopic surgery as an improvement of the transanal endoscopic microsurgery (TEM). The aim of this article is to give an overview about the technical options and our experiences with different devices. Thirteen patients with selected low-risk rectal cancers or broad-based polyps with dysplasia underwent the SPA modified TEM using the SILS™ Port (Covidien Norwalk, CT), the TriPort™ (Olympus KeyMed, Southend, UK) or TriPort+™ (Olympus KeyMed, Southend, UK), and laparoscopic instruments. The transanal single port procedure was in all cases completely successful without major complications. The transanal placement of SILS™ Port (Covidien) and TriPort/TriPort+™ (Olympus) was easy to perform; a prior dilatation of the anal sphincter was not necessary. With an excellent view, accurate dissection was possible, all of them are appropriate for transanal single-port device. The postoperative follow-up showed an unremarkable examination. The transanal single port surgery with its benefits is a modified way to replace the TEM procedure. Our first experiences showed comfortable feasibility, less postoperative discomfort, and a reduced risk of damage to the anal sphincter.

Authors:

Cornelia Lorenz, MD, Consultant Surgeon, Department of General and Visceral-Surgery and Minimal-Invasive-Surgery, Lutheran Amalie Sieveking-Hospital, Hamburg, Germany, Thomas Nimmesgern, MD, Consultant Surgeon, Department of General and Visceral-Surgery and Minimal-Invasive-Surgery, Lutheran Amalie Sieveking-Hospital, Hamburg, Germany, Thomas E. Langwieler, MD, Chief Physician, Department of General and Visceral-Surgery and Minimal-Invasive-Surgery, Lutheran Amalie Sieveking-Hospital, Hamburg, Germany.

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