Open Pyelolithotomy in a Pelvic Ectopic Kidney: Case Report and Current Literature Review

BACKGROUND: Advances in urology have significantly reduced the indications for open surgery to treat staghorn kidney stones. Nevertheless, according to our experience, open surgery is still the preferred treatment for rare cases of the ectopic pelvic kidney. CASE PRESENTATION: A 49-year-old man complained about pain in the lower umbilical region for five months. The pain drastically changed into a sharp pain two months before. The vital sign is normal; on physical examination, the palpation of the suprapubic area elicits pain when pressed, no mass is detected. The abdominal computed tomography without contrast showed a right ectopic kidney located anteriorly of the fifth lumbar to the second sacrum. There was also mild hydronephrosis (grade I) and staghorn stones measuring 4 cm x 2.3 cm. The stone was surgically treated with open pyelolithotomy through a midline infra umbilical incision. The patient was discharged five days postoperatively without distinct complications. CONCLUSION: Open surgery can represent a valid alternative in the treatment of kidney stones of very selected cases, including anomalous kidneys, in a setting where resources are limited.

Fundamentals of the Robotic Assisted Laparoscopic Single Port System and Utility in Minor Gynecologic Surgery

This chapter will introduce the single port robotic system. Topics include an introduction to the robotic single site port, the trocars, and the single site instruments. Step-by-step instruction is provided on how to create the umbilical incision and properly insert the single site port and trocars. The advantages and disadvantages of single port robotic surgery compared to multiple port robotic surgery and laparoscopic single site surgery are reviewed. Surgical tips and tricks are provided throughout each section to maximize efficiency, minimize complications, and overcome inherent limitations of the robotic single site system. The utility of the robotic single site platform for performing minor gynecologic surgery is discussed. Finally, a simple method for umbilical closure is described.

Laparoscopic Cholecystectomy for Large/Giant Gallstones: Case Report and Brief Review of Literature.

Background Gallstones disease (GSD) is the most common biliary pathology. GSD is one of the common surgical problems in which lead people admit to the hospital in Nepal. Its prevalence is found to be 4.87%. The size of a gallstone is important, as giant/large gallstones have a higher risk of complications and present technical difficulties during laparoscopic cholecystectomy (LC). Open cholecystectomy is preferred in most cases with giant gallstones. With the availability of experienced laparoscopic surgeons and modern laparoscopic equipment LC is also feasible in large/giant gallstones. In this case report, we report 2 cases of one large and one giant gallstone each which were successfully done laparoscopically.Case Presentation Case 1 A 51 years old female presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty food with no significant past medical and surgical history.Ultrasound abdomen showed normal gallbladder with multiple gallstones, largest measuring approximately 4cms. She was planned for elective LC. The gallbladder was removed out after extension of the infra-umbilical incision. On the cut section, we found multiple gallstones with one large gallstone measuring 4*3.3*3 cm and weighted 23.2 gm. Her post-operative period was uneventful. Case 2 A 39 years old female, known case of hypertension under calcium channel blocker(CCB) and angiotensin receptor blocker(ARBs) presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty foods with non-significant surgical history. Ultrasound abdomen showed a normal gallbladder with a single large gallstone (approximately 4.7 cm). Elective LC was performed and the gallbladder was removed out after extension of infraumbilical incision. On the cut section, we found a single giant gallstone measuring 5* 3*2.8 cm and weighted 24.7 gm. Her post-operative period was uneventful.Conclusion Large/giant gallstones are associated with a high risk of complications and cholecystectomy is warranted in symptomatic and asymptomatic patients. Even for large/giant gallstones, LC appears to be the treatment of choice over open cholecystectomy and should be performed by an experienced laparoscopic surgeon, taking into consideration the possibility of conversion to open in case of inability to expose the anatomy and any intraoperative technical difficulties.

Single-site Laparoscopic High Ligation of the Extraperitoneal Hernia Sac with an Epidural Needle for Incarcerated Ovarian Hernia in Infants

Background: The purpose of this study was to evaluate the safety and efficacy of single-site laparoscopic extraperitoneal hernia sac ligation with an epidural needle for incarcerated ovarian hernia in infants and young children.Methods: The clinical data of 38 infants with incarcerated ovarian hernia who underwent single-site laparoscopic extradural needle extraperitoneal hernia sac ligation from January 2015 to January 2018 were retrospectively analysed.Results: All procedures were successfully performed in laparoscopy with no need for conversions to open surgery. All patients were discharged 1-2 days after the operation. During hospitalization and follow-up, there were no complications, such as intestinal or bladder injury, abdominal wall vascular injury, ovarian atrophy, hernia recurrence and contralateral indirect hernia. However, three patients had complications, including two cases of poor healing of the umbilical incision and one case of suture granuloma. Conclusions: Single-site laparoscopic high ligation of the extraperitoneal hernia sac with an epidural needle is a safe and feasible method for the treatment of incarcerated ovarian hernia in infants and young children. It has the advantages of minimal trauma, no scarring and good cosmetic effects.

The safety and efficacy of the trans-umbilical approach for pyloroplasty in the management of post-acid corrosive gastric outlet obstruction in children

Background Gastric outlet obstruction (GOO) may follow acid corrosive ingestion. Several surgical techniques have been reported after the failure of endoscopic dilatation. The aim of this study was to evaluate the feasibility and safety of Heinecke-Mikulicz pyloroplasty (HMP) through a circum-umbilical skin incision in children with pyloric stricture after accidental acid corrosive ingestion. Results Seven patients were males and 4 were females, their ages ranged from 17 months to 6 years at the time of definitive treatment. The surgery was completed successfully in all patients through the circum-umbilical incision. Vertical extension of skin incision was needed in one patient. The pylorus was grossly affected in 9 patients. Both pylorus and gastric antrum were involved in 2 patients. Nine patients had an excellent postoperative course with the cessation of vomiting and progressive weight gain. One patient developed postoperative recurrent stricture treated by gastrojejunostomy. Another patient with associated esophageal stricture responded to repeated endoscopic dilatation for the esophageal stricture and pyloroplasty for the pyloric stricture. No surgical site infection or wound dehiscence occurred in any patient. Conclusion Heinecke-Mikulicz pyloroplasty through a circum-umbilical approach is both feasible and safe in the majority of children with post-acid corrosive GOO. It is associated with satisfactory wound healing and excellent cosmetic outcome. Different techniques are recommended in cases of severe pyloric stricture associated with significant proximal gastric antral scarring.

IS UMBILICAL TUBE TECHNIQUE THE BEST METHOD TO GAIN INTRAPERITONEAL ACCESS? A PROSPECTIVE ANALYSIS OF 1532 CASES

Background: Intraperitoneal access in laparoscopic surgery is the first and most important step to start a procedure. Many methods have been described in literature for the same. We share our experience of umbilical tube technique using a vertical infra umbilical or supra umbilical incision for the better cosmetic result. Methods: This study is a retrospective study of laparoscopy performed for various indications. Umbilical tube technique was performed. In 1532 cases performed from July2016to January 2019. A vertical incision was used instead of a commonly performed curve incision to access the umbilical tube. A vertical incision is again taken after exposing the junction of rectus sheath and umbilical tube. Vertical incision is again taken over the tube to gain access to peritoneal cavity. The closure is done in a similar way with skin closed in subcuticular fashion. No Institutional Review Board (IRB) approval was required for this paper. Result: The technique is found to be safe, can be performed with technical ease as anatomy is well defined, good cosmesis is achieved. The longest follow up is for a period of one year. No incidence of port site hernia or infection was seen. Conclusion: The umbilical tube technique using a vertical incision is found to be safe and effective, can be reproduced with technical ease. In our opinion this method can be considered as a standard approach to intraperitoneal access. Keywords: umbilical tube, intraperitoneal access, port site infection, port site hernia. Laparoscopy.

Native Umbilical Defect for Laparoscopic Entry

Background: The presence of defects in native umbilical in adults and its use as laparoscopic first entry site is poorly documented. It would likely be a safer method than the Veress needle and direct trocar insertion. This work aimed to report the prevalence and size of native umbilical defects, and their relationship with gender, age and body mass index. Methods: In 160 consecutive laparoscopic operations, a trans-umbilical incision was made and a defect at its base was looked for. When found, the defect was measured and used as the first port entry site. Relationships of presence of native defects and their sizes in relation to gender, age and BMI were analyzed. Results: The prevalence of a native defect in this series was 90%. Its presence had no relation with gender, age or BMI. Its size, however, positively correlated with age and BMI. No complications were related to the defect’s use for first laparoscopic entry site. Conclusion: A native umbilical defect is present in 90% of adults. Whenever present, it is recommended for use as the first port entry site by an open technique. This method is simple and safe and avoids unnecessarily inducing another defect. Keywords: Laparoscopy, Open technique, Access, Native defect, Umbilical defect