Anibal Wood Branco

International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients.

Objectives: Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases. Methods: Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented. Results: Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients. Conclusions: Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.

Transumbilical laparoscopic urological surgery: are special devices strictly necessary?

To evaluate the safety and feasibility of transumbilical laparoscopic surgery using conventional laparoscopic instruments and ports.

A comparison of hand-assisted and pure laparoscopic techniques in live donor nephrectomy.

PURPOSE To compare hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy techniques in live donor nephrectomy. METHODS In this retrospective study, we included all patients submitted to hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy between May 2002 and December 2007. The operative data and post-operative courses were reviewed. Information was collected on the operative time, warm ischemia time, estimated blood loss, intra-operative complications, time to first oral intake, length of hospital stay, and post-operative complications. The data were analyzed using Student’s t –tests and Fisher exact tests as appropriate, with statistical significance defined as p < 0.05. RESULTS The means of the operative duration, warm ischemia time and intra-operative bleeding were 83 min, 3.6 min and 130.9 cc, respectively, for hand-assisted laparoscopic donor nephrectomy, and 78.4 min, 2.5 min and 98.9 cc, respectively, for pure laparoscopic live donor nephrectomy (p=0.29, p<0.0001 and p=0.08, respectively). Intra-operative complications occurred in 6% of patients submitted to hand-assisted laparoscopic donor nephrectomy and in 4.5% of those submitted to pure laparoscopic live donor nephrectomy (p=0.68). Only one patient from each group required conversion to open surgery; one person receiving hand-assisted laparoscopic donor nephrectomy had bleeding and one person receiving pure laparoscopic live donor nephrectomy had low carbon dioxide levels during the warm ischemia period. Compared with patients receiving hand-assisted laparoscopic donor nephrectomy, patients submitted to pure laparoscopic live donor nephrectomy were able to take their first meal earlier (12.5 vs. 9.2 hours, p=0.046), were discharged home sooner (2.8 vs. 1.4 days, p<0.0001) and had fewer post-operative complications (7.5% vs. 0.6%, p=0.04). CONCLUSIONS Pure laparoscopic live donor nephrectomy had some advantages over hand-assisted laparoscopic donor nephrectomy in terms of the warm ischemia time, time to first oral intake, length of hospital stay, and post-operative donor complications.

MAXIMIZING THE RIGHT RENAL VEIN LENGTH IN LAPAROSCOPIC LIVE DONOR NEPHRECTOMY

Laparoscopic donor nephrectomy has become the standard of care at increasing numbers of renal transplant programs worldwide. The majority of laparoscopic living donor kidneys are procured from the left side because of the longer renal vein and improved transplantation. The aim of this article is to report a technique to maximize the right renal vein length by performing a hand-assisted cavotomy.

Retrocervical Deep Infiltrating Endometriotic Lesions Larger than Thirty Millimeters are Associated with an Increased Rate of Ureteral Involvement

STUDY OBJECTIVE To estimate the presence of ureteral involvement in deep infiltrating endometriosis (DIE) affecting the retrocervical area. DESIGN Retrospective study of women undergoing laparoscopic treatment of DIE affecting the retrocervical area. DESIGN CLASSIFICATION Canadian Task Force classification II-3. SETTING Tertiary referral private hospital. PATIENTS We evaluated 118 women who underwent laparoscopy for the treatment of retrocervical DIE lesions between January 2010 and March 2012. INTERVENTIONS All women underwent laparoscopic surgery for the complete treatment of DIE. After surgery all specimens were sent for pathologic examination to confirm the presence of endometriosis. MEASUREMENTS Patients with pathologically-confirmed retrocervical DIE were divided into 2 groups according to the size of the lesion (group 1: lesions ≥ 30 mm; group 2: lesions < 30 mm) and the rate of ureteral endometriosis was compared between both groups. MAIN RESULTS Ureteral involvement was present in 17.9% (95% confidence interval [CI] 10%-29.9%) of women with retrocervical lesions ≥ 30 mm whereas in only 1.6% (95% CI 0.4%-8.5%) of those with lesions <30 mm (odds ratio = 13.3 [95% CI 1.6-107.3]). CONCLUSION Patients undergoing surgery for retrocervical DIE lesions ≥ 30 mm in diameter have a greater risk of having ureteral involvement (17.9%).

Laparocopic ureteral reimplantation in ureteral stenosis after gynecologic laparoscopic surgery

Pelvic surgery is the most common cause of iatrogenic ureteral injury, and traditionally repair of such injuries requires laparotomy. We report the case of a 48-year-old woman with an iatrogenic ureteral injury after laparoscopic ophorectomy which was laparoscopically reimplanted using the Lich-Gregoire technique. Total operating time was 150 minutes and estimated blood loss was 100 mL. Two months after surgery she is asymptomatic with normal renal function.

Transvaginal Endoscopic Tubal Sterilization

BACKGROUND Tubal sterilization is one of the most widely used options for female contraception. It can be performed by laparotomy, minilaparotomy, colpotomy, laparoscopy, and hysteroscopy. In this paper, we report the use of the transvaginal endoscopic approach to perform tubal ligation. CASE The access to the abdomen was obtained by a 1.5-cm colpotomy. The flexible endoscope was introduced into the peritoneal cavity, and carbon dioxide was instilled to get the pneumoperitoneum. Fallopian tubes were identified and electrocauterized with a 40-W coagulation current. Total procedure time was 45 minutes. A single dose of intravenous dypirone was administered for pain. She was discharged 10 hours after the procedure. CONCLUSION Transvaginal endoscopic tubal ligation is feasible and can be considered an alternative approach to perform female sterilization.

Bilateral retroperitoneoscopic lumbar sympathectomy by unilateral access for plantar hyperhidrosis in women.

OBJECTIVES Primary focal hyperhidrosis is a disorder of excessive, bilateral, and relatively symmetric sweating occurring in the axillae, palms, soles, or craniofacial region. Armpits are affected in 51% of patients, feet in 29%, palms in 25%, and the face in 20%. There is a wide range of nonsurgical and surgical treatments available for patients with focal hyperhidrosis. Surgical treatments for plantar hyperhidrosis include thoracic and/or lumbar sympathectomy. In this article, we report on a new technique of bilateral retroperitoneoscopic lumbar sympathectomy by unilateral access for plantar hyperidrosis. MATERIALS AND METHODS The sample consisted of female patients who presented with plantar hyperhidrosis at the time of surgery and received bilateral retroperitoneoscopic lumbar sympathectomy by a unilateral access technique at our hospital. All patients had already been submitted to a previous thoracic sympathectomy with no improvement of the plantar hyperhidrosis. RESULTS Five procedures were performed successfully from January through March 2009. Mean operative time and mean estimated blood loss were 59 minutes and 54 cc, respectively. We had no intraoperative complications, and patients were discharged home 12.8 hours after surgery. Immediate warming of the feet was observed at the end of all procedures. On follow-up consultations, all patients referred a complete resolution of the plantar hyperhidrosis and 1 case of compensative hyperhidrosis on the back. CONCLUSIONS Retroperitoneoscopic lumbar sympathectomy by unilateral access seems to be feasible when performed by a surgeon with experience on advanced laparoscopy. Larger series comparing unilateral to bilateral access are necessary to establish the real benefits and potential disadvantages of this new technique.

Hand-assisted right laparoscopic live donor nephrectomy

PURPOSE Laparoscopic live donor nephrectomy has acquired an important role in the era of minimally invasive surgery. Laparoscopic harvesting of the right kidney is technically more challenging than that of the left kidney because of the short right renal vein and the need to retract the liver away from the right kidney. The aim of this article is to report our experience with right laparoscopic live donor nephrectomies. MATERIALS AND METHODS We performed a retrospective review of 28 patients who underwent right laparoscopic donor nephrectomies at our service. Operative data and postoperative outcomes were collected, including surgical time, estimated blood loss, warm ischemia time, length of hospital stay, conversion to laparotomy and complications. RESULTS The procedure was performed successfully in all 28 patients. The mean operative time was 83.8 minutes (range 45 to 180 minutes), with an estimated blood loss of 111.4 mL (range 40 to 350 mL) and warm ischemia time of 3 minutes (range 1.5 to 8 minutes). No donor needed conversion to open surgery and all kidneys showed immediate function after implantation. The average time to initial fluid intake was 12 hours (range 8 to 24 hours). Two cases of postoperative ileus and a case of hematoma on the hand-port site were observed. The mean postoperative hospital stay was 3 days (range 1 to 7 days). CONCLUSIONS Our data confirm the safety and feasibility of right laparoscopic donor nephrectomy and we believe that the right kidney should not be avoided for laparoscopic donor nephrectomy when indicated.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (Notes): Surgical Technique and Results

In recent decades, surgical specialties have experienced numerous changes and developments, and minimally invasive surgical techniques have been adopted to reduce patient morbidity (Branco et al., 2008a). Laparoscopy has a well-established role in the modern era of surgery. Despite the difficulties in terms of learning curve early in the clinical implementation of this method, almost all surgical specialties have adopted the minimally invasive surgical approach as the gold standard. This results in less postoperative pain, shorter hospital stay, faster recovery and better aesthetic results (Jin et al., 2009; Keus et al., 2010; Kondo et al., 2006). Recently, a new minimally invasive surgical approach has been increasingly described in the literature as NOTES (Natural Orifice Transluminal Endoscopic Surgery). This is an access to the abdominal cavity without any incisions in the abdominal wall (scarless surgery), and the natural orifices serve as the gateway to the peritoneal cavity. Thus, an endoscope is inserted into the abdominal cavity through the stomach, vagina, bladder or colon (de la Fuente et al., 2007). The first report of this surgical technique was described by Gettman et al. (2002), at The University of Texas in 2002, which demonstrated that transvaginal nephrectomy in an experimental animal model was feasible. Two years later, Kalloo et al. (2004) performed transgastric liver biopsies at the Johns Hopkins University. After these initial reports, several researchers have demonstrated the safety of the transgastric access to perform tubal ligation (Jagannath et al., 2005), cholecystectomy (Park et al., 2005), gastrojejunostomy (Kantsevoy et al., 2005), subtotal hysterectomy with oophorectomy (Wagh et al, 2005; Wagh et al, 2006), splenectomy (Kantsevoy et al., 2006), gastric bypass (Kantsevoy et al., 2007), nephrectomy (Lima et al., 2007) and pancreatectomy (Matthes et al., 2007), all based on experimental studies in the porcine model. Since 2007, reports of cholecystectomy (Branco Filho et al., 2007; Marescaux et al., 2007; Zorron et al., 2007), nephrectomy (Branco et al., 2008b) and tubal ligation (Kondo et al., 2009)