Contralateral Exploration During TEP: Should or Shouldn't Be Done?
Deepak Arora, MD
Background: Over the past two decades, laparoscopic repair of inguinal hernia has made the transition from experimental to a proven procedure. Apart from its well known benefits of decreased post operative pain and shorter recovery time, this procedure also provides the advantage of exploration of the side contralateral to the clinically diagnosed hernia. The aim of this study was to evaluate the incidence of occult or unsuspected contralateral hernia during TEP repair.
Methods: In a retrospective study from July 2003 to July 2007, 200 consecutive male patients clinically diagnosed to have unilateral inguinal hernia were included in this study. Patients with known bilateral hernia, recurrent hernia, femoral and combined hernias were excluded. All the patients underwent TEP with exploration of contralateral side. The procedure was performed by the same team of surgeons. The preoperative clinical impression and existence of unilateral or bilateral hernia on operative findings were noted. A second mesh prosthesis was placed if contralateral hernia was found.
Results: TEP was performed a 200 male patients. Bilateral exploration was done in all the patients and 37 (18.5%) were diagnosed to have contralateral hernia at the time of operative procedure. Out of these 26(70.2%) had direct inguinal hernias and `11 (29.8%) had indirect inguinal hernia. Mean operative time was 57 min (30 - 100 mm). Median age was 46.5 yrs (22-75yrs). Mean period of return to normal activity was 7.5 days (4 -14 days). Time taken for contralateral repair was 8-12 min.
Conclusion: Our study revealed 18.5% occurrence of inguinal hernia on the side contralateral to clinically diagnosed hernia. Routine contralateral groin exploration during TEP appears to be valuable. It is a safe approach and does not greatly increase the operative time. Patients with early identification and repair of contralateral hernia benefit from bilateral TEP repair and it obviates the need for subsequent possible surgery especially in elderly patients and further discomfort & work loss for the patients.
Laparoscopic Ventral Hernia Repair (LVHR): Endoscopic Defect Closure with IPOM, Without Any 10mm Port (P10) & Atraumatic Suture Fixation of Mesh
Brij Bushan Agarwal
Sir Ganga Ram Hospital, New Delhi, India
Background: Recurrence, seroma, suture site pain (SSP), visible / palpable fascial defect, prosthetic mass, P10 and port site hernias (PSH) are concerns in LVHR. I report anatomical defect closure, mesh insertion, without P10, generous overlap and atraumatic transfixation.
Methods: Prospective study of consecutive LVHRs. Hernial defects (HD) closed in “Vest over Pant (VOP)” manner by passing sutures using spinal needles in an innovative way. A transcutaneous 10 mm trocar (T10) was guided through the HD. This avoided necessity for P10. Mesh was introduced through T10. T10 was withdrawn, VOP suture tied to close HD thus separating mesh from skin by the reconstructed wall. Mesh was positioned providing 5 cm overlap on sides and ends of the suture line of closed HD & transfixed using the spinal needles.
Results: 29 patients (36 defects, 18 females / 11 males, 13 incisional, 4 recurrent with various comorbidities) were operated on day care basis. General anesthesia was used for all except one (Epidural anesthesia). Mean closed HD length 10 cms and OT time were 85 minutes. There was no technical difficulty, use of energy source or conversion. No compression bandage was done. Paracetamol was used as painkiller. There was no seroma, significant SSP, visible/ palpable defect, rehospitalization or recurrence (Mean follow up 31 months).
Conclusion: “VOP” HD closure reinforced by mesh introduced wihtout P10 and suturing with spinal needle technique is better for anatomical continuity, reduction of sac space, overlap with smaller mesh fixed by atraumatic sutures ensuring scientific application of Pascal's law and eliminating PSH.
Laparoscopic Cholectstectomy in Tuberculosis of Abdomen When To Operate?
Venugopa Venkatesh, MD
Objective: To determine whether to proceed with Laparoscopic Cholecystectomy when abdominal tuberculosis is found incidentally. I am presenting my experience of 12 cases of cholecystitis ( 8 Acute and 4 Chronic) where abdominal tuberculosis was encountered.
Results: Laparoscopic cholecystectomy was done on all 8 patients with Acute cholecystitis followed by ATT. The 4 chronic cholecystitis cases were managed conservatively with ATT for 3 months & later operated.
Conclusions: Laparoscopic cholecystectomy can be done in patients with Acute Cholecystitis where Abdominal was an incidental finding TB as standard procedure followed by ATT.Chronic Cholecystitis can be operated after 3 months of ATT.
Laparoscopic Cholecystectomies in Patients Over 65 Years of Age
Aslan Sakarya, MD
Celal Bayar University Faculty of Medicine Department of General Surgery, Manisa-Turkey
It has been estimated that within few years persons older than 65 will constitute 25% of worlds population especially in western countries. More and more surgeons will be confronted with elderly patients who need surgical interventions. We have investigated retrospectively the patients older than 65 years of age who had undergone laparoscopic cholecystectomies in our department during January 2000 and August 2007. Total Laparoscopic cholecystectomies were numbered 469 and the number of patients over 65 is 86 (18.3%).There were 56 female and 27 male patients. Octogenerians were numbered 9 (10.5%). The mean age was 71.3 and the oldest patient was 87 years old. There was no mortality and there were 3 (3.5%) complications namely: 1 AV block, 1 intraabdominal hemorrhage and 1 biliary leak. We can conclude that laparoscopic cholecystectomy is a safe procedure in patients over 65 years of age.
Laparoscopic Liver Resections for the Lesions in the Different Locations
Ho-Seong Han MD, PhD
Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
Background: Despite the increasing experience of laparoscopic and hepatic surgery, laparoscopic liver resection is still limited to lesions localized on the antero-lateral segments of the liver. The aim of this study is to evaluate the feasibility of laparoscopic liver resection for tumors located in the postero-superior segments of the liver (Segments I, VII, VIII, and the superior part of IV), and to compare operative outcomes with the antero-lateral segments of the liver (Segments II, III, V, VI, and the inferior part of IV).
Methods: Out of 120 consecutive laparoscopic liver resections from September 2003 to July 2007, we analyzed the clinical data of 77 patients who underwent laparoscopic liver resection for tumors. Five (6.5%) conversions occurred. Patients were classified into two groups according to tumor location: group AL (antero-lateral segments; n=50) and group PS (postero-superior segments, n=22).
Results: There was no mortality, reoperation, or life threatening complications. The predominant type of resection was a minor liver resection in group AL, and a major liver resection in group PS (P<0.001). The mean operative time in group PS (346 min) was longer than that in group AL (222 min; P<0.001). However, there was no difference in the conversion rate (P=0.099), mean blood loss (P=0.061), the rate of intraoperative transfusion (P=0.098), the rate of complications (P=0.293), mean tumor-free margin (P=0.557), and mean hospital stay (P=0.183) between the two groups.
Conclusion: Laparoscopic liver resection for tumors located in PS is more difficult than in AL, but is still feasible and leads to comparable outcome.
Endoscopic Breast Surgery Scarless Excision of Breast Lumps
Brij Bhushan Agarwal, MD, MBBS, MS
Sir Ganga Ram Hospital, India
Introduction: Breast an index of femininity is not uncommonly a seat of lumps necessitating surgery. Scar on breast is a high charge socio-cultural issue and a psychological scar as well. Axilla, an anatomically contiguous access route enables excision of BBL endoscopically. This betters the cosmetic results and the sociopsychological well being of the lady as well.
Material and Methods: 27 consecutive, unselected, participating ladies having BBL without any exclusion criteria were operated. Clinical examination, mammography / sonography and FNAC were done to establish the benign nature of BBL. Video of technique is available at http://endosurgeon.googlepages.com
Results: 29 BBLs from all quadrants in 27 (16 married, 11 unmarried) were excised. There were no histopathological surprises. There was no technical difficulty, bleeding, conversion, per/post operative evidence of axillary trauma. All ladies could resume their activity (A), bath (B), commitments (C), diet (D), exercise (E) and fun/family life (F) within 48 hrs of surgery. There was no postoperative collection, hematoma or evidence of axillary injury. All the ladies were pleased and effusively appreciative.
Conclusion: Endoscopic excision of BBL is safe and patient friendly procedure. It is helpful in preserving physical as well as psychological femininity.
Who Should Be Doing Surgery in Pelvic Endometriosis? Is There a Need to Certify Such Surgeon?
Paul I. Lee, MD
Laparoscopy in Emergency Surgery
Venugopa Venkatesh, MD
Aim: Laparoscopy is a valuable diagnostic and therapeutic instrument in the management of abdominal emergencies. I present my experience with the use of laparoscopy in patients with symptoms of localised or diffuse peritonitis over the past 10 years.
Material and Results: From 1996 - 2006, 1597 patients with localized on diffuse peritonitis were operated upon,941 Appendectomies, 544 Cholecystectomies, 43 Sutures for perforated ulcer, 38 for Acute Pancreatitis and 31 procedures for Abdominal Trauma. The percentage of patients undergoing Laparoscopic emergency surgery gradually increased over a period of last 10 years to reach 96% today. The conversion rate was 3.1% in Appendectomy 9.2% in Cholecystectomy, 14.4% in Peforated Ulcer and 7.3% with Acute Pancreatitis.
Retrospectively, we found that the length of hospital stay, post operative pain and post operative complication rate was markedly lower in patients operated laparoscopically.
Conclusion: Laparoscopic surgery offers effective treatment in most of abdominal emergencies. Also, hospital stay is shorter and complication rate is markedly lower among patients operated laparoscopically.
Management of the Surgical Center for Smooth Endoscopic Surgery and Efficient Use of Operative Rooms
Hisashi Usuki MD, PhD, Kunihiko Izuishi MD, PhD, Yasuyuki Suzuki MD, PhD
Faculty of Medicine, Kagawa University
The surgical center is a department making large profit in the hospital. Then, the management of the surgical center has big influence on the finance of the hospital. On the other hand, it takes long time to perform endoscopic surgery for cancers of various organs more than open surgery. Therefore, it is very important to deal with the operations in the environment of limited operation rooms, limited equipments for endoscopic surgery and limited medical staffs. For this purpose, efficient improvement of operation rooms is very important. Then, in the first step, the discrepancy between the scheduled time of the operations and the time spent actually was investigated. In the result, the operations finished within the scheduled time were 52.4% of all operations. The other operations were extended more than scheduled times. In the second step, the reasons of the extension of the operative periods were examined. The reasons of the extension of the operation were classified into four groups, which were “preoperative misdiagnosis”, “technical problem of surgeon”, ”systematic problem of surgical center”, ”application of shorter time on purpose”. The most frequent reason of the extension of operation was preoperative misdiagnosis of the stage of the disease, the degree of the adhesion or etc. The correctness of the schedule is important to the efficient management of the surgical center and for the comfort of the medical staffs and the family members. And the solution of the systematic problems is also important for efficient improvement.
Laparoscopic Cholecystectomy Without Using Any Energy Source—Ensuring Better Results
Brij Bhushan Agarwal, MD, MBBS, MS
Sir Ganga Ram Hospital, India
Introduction: Structured skills training, pre / perioperative anatomical imaging and system's approach have failed to bring the outcomes of Laparoscopic Cholecystectomy(LC) at par with open cholecystectomy. Electrocautery (EC) accepted as a culprit that can be done away with as shown by us continuous to be used. I present the outcomes of LC done with or without EC.
Material and Methods: 135 consecutive unselected symptomatic cholelithiasis patients without any exclusion were randomized for LC with or without EC. Video of technique is available at http://endosurgeon.googlepages.com <http://endosurgeon.googlepages.com/> . They were monitored for hemodynamic instability, post - separation hemostasis at liver bed (LB), vascular / visceral injuries, gallbladder (GB) perforation by dissecting instruments, conversion, peritonism/constipation, beyond 24 hrs, rehospitalization, re-exploration, biliary leak and mortality.
Results: There were 3 biliary injuries, 1 duodenal injury, 11 GB perforations, 2 hemodynamic instabilities, 7 re-hospitalizations, 5 re-exploration for biliary leak and 2 deaths in EC group (n=70) as against 1 biliary leak (retained CBD stone with cystic stump leak) in non EC group (n-65). There was 1 conversion common to both groups as EC was used to avoid conversion in this case originally from non EC group.
Discussion: EC has been recognized as a potential source of morbidity and its consequences in LC. LC can be done safely without using any energy sources. Yet reliance on EC in LC leads to unfavaorable outcomes as shown in this study.
Conclusion: EC is associated with significant avoidable morbidity and mortality in LC.
Approach and Management of Bile Leaks After Laparoscopic Cholecystectomies
Atilla Cokmez, MD
The four basic principles in treatment of a biliary leak are
1. Control of the leak externally (ie, converting any
undrained collection of bile to an external fistula)
2. Control of systemic sepsis
3. Definition of the biliary anatomy
4. Decompression of the major biliary sphincter
The management of bile leaks following laparoscopic cholecystectomy(LC) has evolved with increased experience of ERCP and laparoscopy. Twenty patients were with a bile leak following LC were recorded between 1996 and 2006 in our institution.
Ultrasound is inexpensive and may be a useful first step in diagnosing postoperative intra-abdominal fluid collections. Interpretation of ultrasound images may be limited by the presence of intestinal gas, and this technique also is quite dependent on individual operator expertise. Abdominal CT provides a more detailed view of intra-abdominal structures as well as any undrained fluid collections.
Abdominal CT scan was used in all our patients with suspicion of bile leak and CT pictures identified bile accumulation in 8 patients.
Bile leaks presented as bile in drain routinely left during index procedure or biliary peritonitis.
Four patients underwent laparotomy, six patients were were treated by ES, endobiliary stent, or a combination of both modalities. Ten patients recovered with conservative treatment.
There was one mortality and median hospital stay after laparoscopic cholecystectomy with bile leak was 12 days(6-45).
The introduction of ERCP /Stenting and re-laparoscopy or laparotomy offers an effective algorithm for the management of bile leaks after LC.
We concluded that stent insertion was superior to ES alone in controlling post-cholecystectomy bile leak but acknowledged the limitations of our retrospective study design.
Single Port Access (SPA) Bilateral Oopherectomy and Hysterectomy
Stephanie A. King, MD, Ata Atogho, MD, Erica Podolsky MD, Paul G. Curcillo II MD
Drexel University College of Medicine, Philadelphia PA
Introduction: Laparoscopic techniques have been widely accepted in gynecologic surgery since the 1960's facilitating easier dissection and visualization in the confines of the pelvis. A variety of procedures have become the standard of care making sometimes difficult open procedures safer and quicker. In the 1970's, the single arm operative scope was employed for tubal ligations. This scope required a single abdominal port of entry and allowed one rigid functional instrument to be inserted alongside the scope. Its use was limited in other procedures by the rigidity of the instruments. A single port access (SPA) surgical technique has been developed at our institution. Using one umbilical incision with articulating instrumentation, this technique reduces surgical scarring while broadening the variety of procedures to be performed through a single incision.
Methods: Five SPA bilateral salpingoophorectomies were performed at our institution. A transverse umbilical incision following the medial fold was used as the portal of entry for all five procedures. A 5mm trocar was inserted at the midline for a 5mm scope. Skin flaps were raised laterally allowing for two 5mm accessory trocars to be inserted inferior and lateral to the initial trocar. Using the accessory trocars the round ligament and infundibulopelvic ligaments were transected. The suspensory ligament, fallopian tube, and mesosalpinx were then dissected. The ovary was removed through the umbilicus. The same procedure was repeated on the opposite side. The fascia was closed using 0 Vicryl and the skin with a running 4 Vicryl subcuticular stitch.
Results: All five women tolerated the procedure well. Operative time and length of stay were comparable to the traditional multiple port procedures. Post operative recovery was uneventful. No complications were encountered. Cosmetic results were excellent with scars being hidden in the umbilicus.
Discussion: Gynecologic surgery was among the first surgical specialties to adopt minimally invasive surgery. Improved visualization allows for easier dissection of the tight pelvic anatomy. Laparoscopy also allows for reduction of surgical scarring.
In the 1970's the single arm operative scope further reduced operative scarring by utilizing a single incision at the umbilicus. This technique was limited because only one instrument could be inserted alongside the scope. A single eyepiece was used for visualization restricting this procedure to single operator.
Single port access (SPA) surgery uses the umbilicus for a single portal of entry into the abdominal cavity. In more difficult dissection, articulating instruments allowed us to maintain the procedure as a single port technique. The technique of dissection is the same as being done in standard pelvic minimally invasive surgeries. Although the articulating instruments were not necessary for all procedures their availability facilitated difficult dissections.
Laparoscopic Endometrioma Cystectomy Before IVF
Aygul Demirol, MD
Women Health, Infertility and IVF Center, Ankara/Turkey
Anovulation or oligo-ovulation is one of the main characteristics of the polycystic ovary syndrome (PCOS). When patients with PCOS complain of infertility, ovulation induction is the appropriate treatment. Various drugs and treatment regimens have been used for ovulation induction in PCOS, but none of them has become unique in achieving the goals. The reason for the existence of so many treatment regimens is related to the multifactorial pathophysiology of PCOS and consequently to the variability in clinical manifestations and the hormonal milieu.
Anovulation is a common cause of infertility. About 70% of infertile women presenting with oligomenorrhoea or amenorrhoea exhibit normal FSH and estradiol (E2) concentrations (World Health Organization [WHO], Type-2 anovulation). Normogonadotropic anovulatory infertility can be identified in 18-25% of the couples presenting with infertility. Polycystic ovary syndrome (PCOS) represents the most common diagnosis within this patient group.
In addition, assisted reproduction technologies (ART) like intrauterine insemination (IUI) or IVF are increasingly applied, although well-designed studies documenting efficacy and safety in PCOS are lacking in this patient group. Certainly, with improved outcome and the more frequent use of single embryo transfer, eliminating chances for multiple pregnancies, IVF has become a serious alternative to ovulation induction. In addition, favorable IVF outcomes have been reported applying in vitro oocyte maturation in PCOS. Despite this trend, uncertainty remains with regard to risk of ovarian hyperstimulation syndrome (OHSS), cycle cancellation rate, oocyte quality and fertilization rates in PCOS women undergoing IVF. Furthermore, it remains unclear whether pregnancy rates differ between PCOS and non-PCOS women. Most published data are derived from uncontrolled, observational studies with small study populations.
In the meta-analysis of Heijnen et al. (2006) it was demonstrated that despite the fact that more oocytes per cycle were obtained along with lower fertilization rates, PCOS and non-PCOS patients achieve similar pregnancy rates and live births per started IVF cycle.
Specific characteristics of PCOS considered to explain the higher incidence of OHSS include the presence of polycystic ovaries, an LH:FSH ratio > 2 and hyperandrogenism. Furthermore, an increased expression of vascular endothelial growth factor (VEGF) mRNA within the hypertrophic stroma of polycystic ovaries has been associated with increased risk of OHSS.
An increased number of oocytes were retrieved following ovarian stimulation in the PCOS group compared with controls, but the fertilization rate was higher in the control group resulting in an equal total number of oocytes fertilized in both groups. A number of published studies have addressed possible reasons for this observation. No significant difference in rate of metaphase II oocytes, rate of germinal vesicles oocytes and fertilization rate was showed between the two groups. This finding points to involvement of cytoplasmic factors instead of involvement of the nuclear maturity of oocytes.
Given the importance of hyperinsulinemia in the development of hyperandrogenism and disrupted folliculogenesis, it seems likely that medications that act as insulin-sensitizing agents may be useful in restoration of normal endocrinologic and clinical parameters of this condition. Therapeutic measures directed at lowering insulin secretion in women with PCOS should theoretically ameliorate their hyperandrogenism and restore normal follicular growth, thus facilitating ovulation. Preliminary reports indicate that metformin may improve the IVF outcome and reduce pregnancy loss.
Reduced hyperandrogenaemia and insulin resistance in PCOS women should facilitate FSH stimulation. In PCOS patients it has been shown that metformin reduces insulin, testosterone and LH concentrations, which are elevated in these patients it was hypothesized that parallel administration of metformin before and during IVF cycles may reduce the requirement for FSH and improve the quality of embryos, increasing the pregnancy rate. Although the effects of metformin on FSH stimulation have been debated in the literature in recent years.
We performed a randomized study related to the metformin therapy that one-hundred patients with PCOS referred to IVF cycle were enrolled (ESHRE 2006, oral presentation). Metformin resulted in reduction in total gonadotropin dosage and OHSS rate. Embryo morphology was improved in metformin group. Implantation (26% in group II and 17% in group I) and pregnancy rates (68% in group II and 30% in group I) were higher in metformin group. In addition, abortion rate was lower in the metformin group.
A promising approach to the management of patients with PCOS in the context of IVF is the recently developed technique of in-vitro maturation of immature oocytes obtained from polycystic ovaries. Some clinics are reporting very high pregnancy rates with IVM. However, in most clinics, the pregnancy and live birth rates with IVM do not match those reported for IVF cases using ovulation induction. Therefore, only specific patients are currently considered for IVM, most notably PCOS patients who might be more sensitive to the elevated levels of gonadotropins and ovarian hyperstimulation syndrome (OHSS) might be prevented by IVM. We achieved the first IVM pregnancy in Turkey and the first pregnancy resulted in a healthy birth. We are continuing the IVM programme for PCOS patients but the pregnancy rate is lower than conventional protocols in our unit too.
Endometrioma and IVF
Endometriosis affects 2.5% - 3% of women in reproductive age and is diagnosed in 20% - 68% of the women with infertility. Extensive endometriosis may simply impair fertility by mechanical means. However, the main visible features of the minimal and mild stages of endometriosis are peritoneal or ovarian endometriotic implants and filmy adhesions on the fallopian tubes or ovaries and the causal link between these cases and infertility is much debated. There are a variety of treatment options for women with endometriosis. These include: expectant management, medical, and surgical therapy. It is generally agreed that women with moderate to severe endometriosis who desire pregnancy benefit from surgical therapy.The impact of ovarian endometriomas on ART (assisted reproduction technologies) outcomes is controversial. It has been suggested that the presence of an ovarian endometriotic cyst might impair oocytes quality in the ipsilateral ovary and the response to controlled ovarian hyperstimulation (COH), as well as fertilization and implantation rates might be decreased.
There is a controversy concerning the effect of surgery in patients with endometriosis on the future response and in vitro fertilization (IVF) outcome. Following ovarian endometrioma cystectomy, some studies have shown conflicting results on ovarian response, with some patients showing a detrimental and others showing no adverse effect. All studies concerning the effect of ovarian endometrioma cystectomy on ART outcome either retrospective or case-control studies. There is a lack of randomized controlled study to definitely report the impact of conservative surgery of ovarian endometriomas prior to IVF/ICSI cycle.
As far as we know, no randomized trials have been performed to evaluate the effect of removing endometriomas prior to IVF. In our prospective randomized controlled study, in the ovarian surgery group stimulation was significantly longer, total recombinant FSH dose was significantly higher and mean number of mature oocytes were significantly lower, and there were no significant differences in terms of fertilization, implantation and pregnancy rates (Demirol et al., 2006).