Department of Surgery, Hackensack University Medical Center, Hackensack, NJ, USA (Drs. Tiesi, Eid). Department of Surgical Oncology, Hackensack University Medical Center, Hackensack, NJ, USA (Dr. McCain).

ABSTRACT

Introduction: Despite evolving experience with laparoscopic resections of gastric gastrointestinal stromal tumors (GISTs), there are few data describing robotic resections. Here we describe the robotic removal of a gastric GIST using laparoscopic ultrasonography for tumor localization.

Case Description: The patient is a 46-year-old African-American man with a biopsy-proven 3.5 X 3.5-cm GIST along the greater curvature of the stomach, and with no evidence of metastatic disease on preoperative computed tomographic staging. Three robotic ports (12-mm umbilical, 8-mm left lower quadrant, and 8-mm subxiphoid) were combined with a 12-mm right lower quadrant assist port and a right midabdomen 8-mm port for the laparoscopic liver retractor. Mass localization was facilitated by intraoperative ultrasonography and dissection performed with bipolar electrocautery via dissecting forceps. Resection was performed using a stapled technique and the specimen removed via the assist port. Total operative time was 104 minutes and estimated blood loss was 25 mL. There was no significant morbidity. Length of stay was 3 days, and the patient returned to work within 1 week. The retrieved specimen was CD117- and DOG1-positive with 2 to 3 mitoses/hpf. At 1-year follow-up, there was no evidence of disease.

Discussion: This case report describes a novel and efficient technique for the robotic removal of a gastric GIST. This resection can be safely performed with the aid of intraoperative ultrasonography instead of gastroscopy or gastrotomy for identification of resection margins.

Key Words: Gastrointestinal stromal tumor, Robotics, Laparoscopic ultrasonography.

The post Ultrasound-Guided, Robotic Gastrointestinal Stromal Tumor Resection first appeared on JSLS.

USC Institute of Urology, Center for Advanced Robotic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA (all authors).

ABSTRACT

Introduction: Pelvic lymphoceles are a known complication of pelvic lymph node dissection after robotic-assisted radical prostatectomy (RARP). However, large symptomatic inguinal lymphoceles after RARP have hitherto not been reported.

Case Description: We present the case of a 71-year-old morbidly obese man who developed large, symptomatic, bilateral inguinal lymphoceles after RARP and pelvic lymph node dissection. The surgery itself was uneventful, as was the hospital stay. The patient returned 3 weeks postoperatively with bilateral inguinal pain and swelling, which was confirmed on imaging to be bilateral inguinal lymphoceles. These were initially treated with bilateral percutaneous pigtail catheter drainage, but this treatment was complicated by repeated tube blockages, fever, and conversion of the lymphoceles into multiloculated abscesses. Definitive treatment consisted of open left lymphocele excision first. After excision of the left inguinal lymphocele, the right lymphocele became infected and formed a large inflammatory phlegmon, necessitating open right inguinal lymphocele excision with right orchiectomy. Culture demonstrated gram-negative Prevotella bivia.

Discussion: This case was unique because the patient presented with bilateral, large, symptomatic, recurrent inguinal lymphoceles, as opposed to the more common pelvic lymphoceles. To our knowledge, this is the first reported case of bilateral, symptomatic inguinal lymphoceles after RARP with pelvic lymph node dissection.

Key Words: Lymphocele, Radical prostatectomy, Robotics, Complications.

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The post Bilateral Inguinal Lymphoceles Following Robotic Radical Prostatectomy first appeared on JSLS.

Department of Anesthesiology, Hôpital Foch and University Versailles Saint-Quentin en Yvelines, 92150 Suresnes, France (Drs. Pruszkowski, Schlumberger, and Fischler). Department of Cardio-Vascular Radiology, Hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France (Dr. Petit).

ABSTRACT

Introduction: Robotic prostatectomy is considered by many urologists as the new standard of care.

Cases Description: We encountered 2 patients scheduled for a robotic prostatectomy whose past medical history was remarkable for a cerebral palsy that had been considered to be due to a patent foramen ovale. At this time, it was decided that foramen ovale closure was not necessary. Because of the high risk of gas embolism during the robotic prostatectomy, we decided to close the foramen ovale preoperatively. This procedure and the prostatectomy were without any complication.

Conclusions: Our choice of a prophylactic closure of a patent foramen ovale before a procedure at risk of gas embolism is unusual and can be discussed.

Key Words: Foramen Ovale, Laparoscopy, Patent, Prostatectomy, Robotics.

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The post Patent Foramen Ovale Closed Before Robotic Radical Prostatectomy first appeared on JSLS.

Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, PA, USA (Dr. Pereira). Department of Surgery, Danbury Hospital, Danbury, CT, USA (Dr. Hallock). Drexel University College of Medicine, Philadelphia, PA, USA (Dr. Yen). Division of Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, PA, USA (Drs. Grias, Green).

ABSTRACT

Introduction: Brachial plexus injuries are infrequent but preventable complications of laparoscopic and robot-assisted gynecologic surgery.

Case Description: A 32-year-old woman with a history of uterine leiomyomata, menorrhagia, and chronic pelvic pain underwent a robot-assisted laparoscopic myomectomy. Preoperative radiologic imaging showed an enlarged uterus with a large, 8.6 7.2 9.2–cm, intramural left uterine body leiomyoma. Bleeding and difficulty visualizing the surgical dissection planes complicated intraoperative enucleation of the leiomyoma. This resulted in a total surgical time of 400 minutes, during which the patient spent approximately 320 minutes in the steep Trendelenburg position. On postoperative day 1, the patient reported weakness and tingling in her left arm and fingers and was found to have an acute left brachial plexus injury. After a course of oral corticosteroids and outpatient physical therapy, the patient reported no residual neurologic deficits during her subsequent postoperative visits.

Discussion: As gynecologists cope with the learning curve associated with laparoscopic and robot-assisted laparoscopic surgery, longer operating times will be encountered, with patients spending a significant amount of intraoperative time in the Trendelenburg position. The resulting risks of intraoperative nerve injuries, particularly brachial plexus injuries, may therefore be higher than expected. Because these injuries can cause significant postoperative morbidity, and sometimes even have medicolegal implications, every effort should be made to prevent them. To achieve this, we emphasize the combined efforts of the nursing, surgical, and anesthesia teams to ensure proper patient positioning in the operating room.

Key Words: Brachial plexus injury, Laparoscopy, Robotics, Patient positioning, Trendelenburg.

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The post Trendelenburg-Related Brachial Plexus Injuries in Gynecologic Surgery first appeared on JSLS.