Robotic Surgery Program, University Hospital of Caracas, Caracas, Venezuela (all authors).

ABSTRACT

Introduction: Unsolved choledocholithiasis by endoscopic retrograde cholangiopancreatography is a complicated condition to manage. The incorporation of robotic surgery, a choledochoscope, and a holmium laser as therapeutic tools is likely to increase surgery effectiveness. Our purpose is to present the first Latin American case report of the combined use of these tools to extract a large impacted bile duct stone.

Case Description: A 42-year-old man with obstructive jaundice syndrome underwent endoscopic retrograde cholangiopancreatography. Bile duct dilatation was evidenced by a 1.5-cm-diameter stone that could not be extracted, and biliary prosthesis placement was not possible. Given that stone clearance was not achieved, robot-assisted laparoscopic common bile duct exploration using a holmium laser for lithotripsy was performed. The entire procedure was performed with a robot-assisted technique. The docking time and console time were 10 minutes and 120 minutes, respectively. The patient progressed satisfactorily and was discharged after 48 hours without complications. He had no evidence of residual common bile duct stones or duct strictures after 12 months of follow-up.

Discussion: Laparoscopic common bile duct exploration is an excellent option for the treatment of common bile duct stones. The holmium laser is a useful tool for the treatment of complex choledocholithiasis. Incorporation of the da Vinci System (Intuitive Surgical, Sunnyvale, California) allows greater precision and effectiveness, thus increasing surgery success rates.

Key Words: Robotic surgery, Choledocholithiasis, Holmium laser.

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Department of Gynecology, Vita Batel Hospital, Paraná, Brazil (Drs Kondo and Zomer). Department of Pathology, Citolab Laboratory, Paraná, Brazil (Dr Cavalcanti).

ABSTRACT

Introduction: Spontaneous rupture of the bladder is a rare condition that is usually secondary to an underlying pathologic process. We report a rare case of spontaneous bladder rupture due to endometriosis in a young woman.

Case Description: The patient presented with abdominal pain and features of acute renal injury in the absence of prior trauma. She underwent successful laparoscopic repair, and pathology confirmed the presence of endometriosis at the site of perforation.

Discussion: The most important key to prompt diagnosis of bladder rupture is to keep in mind the potential for this disorder to arise in patients with peritonitis, especially in those with urologic symptoms and the features of acute renal failure. It requires immediate surgical treatment to avoid serious life-threatening peritonitis, preferentially by means of laparoscopy in patients with stable conditions.

Key Words: Bladder endometriosis, Endometriosis lesion, Laparoscopic bladder repair, Urinary bladder perforation.

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AGORA Centre for Women’s Health, Epworth Hospital, Melbourne, Victoria, Australia (both authors).

ABSTRACT

Introduction: Transabdominal cerclage (TAC) is a procedure for cervical insufficiency in women in whom transvaginal cerclage cannot be performed. In recent years, laparoscopic transabdominal cerclage has gained favor by eliminating the need for laparotomy and reducing surgical morbidity.

Case Description: We present a case of laparoscopic removal of a TAC in a 27-year-old woman with uterus didelphys, who presented with fetal death in utero at 21 weeks 3 days.

Conclusion: This successful, minimally invasive technique eliminated the need for hysterotomy and the potential corresponding morbidity associated with the operation and allowed for normal spontaneous vaginal delivery.

Key Words: Hysterotomy, Transabdominal cerclage, Transvaginal cerclage, Uterine malformation, Uterus didelphys.

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Department of General Surgery, Ipswich General Hospital, Queensland, Australia (all authors).

ABSTRACT

Introduction: Iliopsoas abscess is a rare condition that carries a risk of mortality when not treated appropriately. There is a paucity of high-level evidence concerning the management of this abscess and very sparse data is available in the literature regarding treatment options. This article discusses the treatments for iliopsoas abscess and reports a case effectively drained laparoscopically through an extraperitoneal approach.

Case Description: We present a case report of primary iliopsoas abscess.

Discussion: Computed tomography (CT) is the best imaging modality for visualizing iliopsoas abscess, and retroperitoneal laparoscopic drainage is an ideal approach for treatment of primary abscesses. Management options include antibiotics, percutaneous aspiration, percutaneous drainage, and laparoscopic or open surgical drainage. A laparoscopic extraperitoneal approach is an effective treatment option, as it allows more complete drainage compared with washout of the abscess cavity, reduced postoperative pain, and a shorter hospital stay.

Key Words: Iliopsoas abscess, Percutaneous abscess drainage, Retroperitoneoscopic drainage, Extra peritoneal, Primary abscesses.

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Urology Division, Hartford Healthcare Medical Group, Hartford, Connecticut (all authors).

ABSTRACT

Introduction: In an era of ultrasonography and computed tomography (CT), urachal remnants have been detected with increasing frequency. If these remnants become infected, they can mimic a variety of intra-abdominal pathologies. We present the case histories of two patients with an infected urachal cyst that developed after laparoscopic cholecystectomy and necessitated excision.

Case Descriptions: Patient 1: Four years after a laparoscopic cholecystectomy, a 36-year-old man presented with dysuria, abdominal pain, leukocytosis, and fluid leakage from the umbilical port site. CT imaging revealed an infected urachal cyst with an adherent loop of sigmoid colon. Antibiotic treatment preceded laparoscopic excision of the urachal cyst with partial cystectomy and closure of the sigmoid-to-urachus fistula. In a 3-year follow-up, there was no recurrence. Patient 2: A 68-year-old woman presented 11 months after laparoscopic cholecystectomy with abdominal pain, intermittent fever, and leukocytosis. CT imaging revealed an infected urachal cyst with an associated phlegmon in the abdominal wall. Antibiotic treatment preceded two incision-and-drainage procedures. Six weeks later, the patient underwent robotic excision of the urachal cyst and partial cystectomy. A 3-year follow-up showed no recurrence.

Discussion: The urachus can be punctured during laparoscopic periumbilical port placement and convert into a draining sinus or abscess. Subsequent infection can present with umbilical drainage, abdominal pain, urinary symptoms, and systemic infection. Surgical excision is a reasonable option once the acute infection has been treated. Any images that include the urachus should be reviewed before procedures involving an umbilical port, as puncture of urachal cysts may increase the risk of infection.

Key Words: Cholecystectomy, Infection, Laparoscopy, Urachal cyst.

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Central California Institute of Minimally Invasive Surgery, Fresno, CA, USA.

ABSTRACT

Introduction: This case report describes a procedure-related mortality due to abdominal compartment syndrome following endoscopic stomal reduction as a revisional procedure for Roux-en-Y gastric bypass. This procedure is increasing in popularity due in part to the well-documented safety profile.

Case Description: The patient presented recurrent morbid obesity and GERD 11 years following Roux-en-Y gastric bypass and underwent a laparoscopic hiatal hernia repair and transoral outlet reduction. Severe distension developed following this 45-minute endoscopic procedure leading to ischemia of the bilateral lower extremities. Urgent laparotomy was performed to relieve the compartment syndrome but the patient developed refractory disseminated intravascular coagulation (DIC), cardiogenic shock, and succombed.

Discussion: Although a rare event, patients undergoing prolonged endoscopic procedure using air insufflation under general anesthesia may be at risk.

Key Words: Endoluminal stomal reduction, Endoscopic revision, Outlet reduction.

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Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA (Drs. Ikoma and Shah); Keio University, School of Medicine, Tokyo, Japan (Drs. Ikoma, Itano, Oshima, and Kitagawa); Department of Surgery, Eiju General Hospital, Tokyo, Japan (Drs. Ikoma, Itano, and Oshima); Department of Surgery, Beth Israel Medical Center, New York, New York, USA (Dr. Fukuhara); Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, Texas, USA (Dr. Shah).

ABSTRACT

Hepatic malignancies are frequently associated with primary liver disease, including hepatitis and cirrhosis. It is not uncommon for selected patients to require repeated operations for tumor recurrence. Subsequent operations are more challenging because of dense adhesions from prior operations combined with the inherent risk for liver dysfunction. We present the case of a 64-year-old man with a 20-year history of hepatitis B who developed recurrent hepatocellular carcinoma and underwent repeated laparoscopic hepatectomies on 4 separate occasions. We found that the laparoscopic approach in repeat hepatectomy offers significant advantages, including minimal adhesions, superior visualization, and favorable effect by generated by pneumoperitoneum. Laparoscopic hepatectomy will potentially become a standard strategy for the treatment of liver malignancies associated with background liver abnormalities, which carry the high possibility of reemergence of the liver malignancy in the remnant of the liver.

Key Words: Laparoscopic surgery, Hepatectomy, HCC, Hepatitis.

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Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal (all authors). ICVS/3B’s—PT Government Associate Laboratory, Braga/Guimarães, Portugal (all authors). Department of Obstetrics and Gynecology, Centro Hospitalar do Porto, Porto, Portugal (Dr Ferreira). Department of Obstetrics and Gynecology, Hospital de Braga, Braga, Portugal (Dr Nogueira-Silva). Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal (Dr Correia-Pinto).

ABSTRACT

Background: The sentinel lymph node (SLN) concept might minimize surgical aggressiveness in gynecological oncology, namely in cervical and endometrial malignancies. Therefore, we assessed the feasibility of SLN identification, dissection, and harvesting by using minilaparoscopic surgical instruments in an animal model. We compared the minilaparoscopic approach, which is known to bring important advantages, with the use of conventional laparoscopic instruments.

Methods: Two groups of 7 female pigs were enrolled in this experiment that was performed by the same surgical team. In group A, all animals were approached by a similar minilaparoscopic surgical instrumentation, namely a 5-mm 30° endoscope (supraumbilical port) and 3 ancillary 3.5-mm trocars. In group B, a 5-mm conventional laparoscopic instrument set was used. The patent blue (4.0 mL) was injected on the paracervical region. The time for SLN coloring, identification, localization, dissection, and excision, as well as complications were recorded. The sealing of the lymphatic vessels was observed in the 2 groups. During this experiment, and for the both groups, the Trendelenburg position was kept the same, as well as the carbon dioxide–pneumoperitoneum pressure. Finally, a laparotomy was then performed to evaluate whether any stained SLN still remained.

Results: All endoscopic procedures were performed without major complications. SLN were identified and excised in all animals in both groups. The SLN localization varied between animals from external iliac to preaortic regions. The surgical times, from skin incision to SLN removal, was 28.4 ± 5.6 minutes for minilaparoscopy and 25.3 ± 6.8 minutes for conventional laparoscopy (P=.36). In group B, 1 stained SLN remained and was only detected by laparotomy.

Conclusions: We confirmed the feasibility of the minilaparoscopic surgical approach for identification, dissection, and excision of SLN, as well as for sealing the lymphatic vessels that supply the nodes. This procedure might be considered a potentially better alternative to reduce morbidity during staging procedures for gynecological malignancies.

Key Words: Gynecology, Instrumentation, Malignancy, Minilaparoscopy, Sentinel lymph node, Surgery

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Department of Obstetrics and Gynaecology (Drs. L. Eghdami and M. A. Bedaiwy), Division of Reproductive Endocrinology and Infertility (Dr. M. A. Bedaiwy), University of British Columbia, Vancouver, BC, Canada; Department of Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH, USA (Drs. S. Elguero and B. Patel).

ABSTRACT

An interstitial pregnancy is an ectopic pregnancy that is implanted in the interstitial segment of the fallopian tube and embedded within the muscular layer of the uterus. Because of the rich vascular supply of this region, maintaining hemostasis during surgical management of interstitial pregnancies is a recognized challenge. Visualizing the entirety of the gestational sac beneath the uterine serosa can also present a challenge, especially in cases of uncomplicated interstitial ectopic pregnancies. Here we present a case in which intraoperative transvaginal ultrasound was used to assist with a laparoscopic cornual wedge resection in a 24-year-old woman with a confirmed interstitial pregnancy. The use of intraoperative transvaginal ultrasound during the laparoscopy helped accurately delineate the location and extent of invasion of the interstitial pregnancy. It guided the placement of the uterine incision and helped ensure that the entire gestational sac and products of conception had been removed. This case demonstrates that transvaginal ultrasound can be used as an intraoperative tool to enhance surgical safety and minimize patient risk.

Key Words: Ultrasonography, Pregnancy, Ectopic, Laparoscopy.

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University of Pittsburgh Medical Center and Bandaid Surgery, PC, Pittsburgh, PA, USA (both authors).

ABSTRACT

Introduction: Endoscopic therapy is a potentially valuable tool for treating colorectal anastomotic leaks and avoids the complications associated with reoperation.

Case Description: This brief report concerns the endoscopic application of an extracellular matrix graft for the treatment of a patient with a complicated anastomotic leak. The patient was successfully treated with no procedureassociated complications and with complete healing of the anastomosis, no stricture development, and normal bowel function.

Discussion: We describe a technique and device for treating colorectal anastomotic leaks.

Key Words: Anastomotic leak, Rectal, Extracellular matrix.

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