Barbara Binda

Feasibility of Colonic and Gastric Standard Laparoscopic Procedures With a Single Skin Incision Approach

W e read with great interest the article by Leroy et al about their innovative singleaccess laparoscopic sigmoidectomy for diverticulitis. The rationale for this minimally invasive procedure is the improved cosmetic results; the potential decrease in morbidity related to visceral and vascular injuries during trocar placement; and the lower risk of postoperative wound infection, hernia formation, and pain. By using technical innovations like umbilical, multichannel, single-port, magnetic anchoring; roticulated graspers; and intraluminal assistance for traction, they performed a sigmoidectomy for diverticulitis via a 2-cm single skin incision. However, because of the difficulty in performing full mesenteric dissections, they consider this procedure unsuitable for oncologic resections. We share the authors’ enthusiasm for this innovative technique, but we believe that its promising benefits can also be achieved with a single 4-cm periumbilical skin incision and 3 adjacent trocars inserted through separated fascial sites; conventional instruments; and traction stitches. Using this technique, in the last 6 months we were able to reproduce the standard laparoscopic procedures in performing 12 (8 left and 4 right) colonic resections for cancer, 4 distal gastrectomies for benign (n=2) and malignant (2 D1-resections) diseases, and 1 left hepatic sectionectomy for a recurrent giant cyst. Mortality and morbidity were nil, but 1 left colectomy was converted for bleeding. In conclusion, we think that the singleincision laparoscopic approach is also safe and feasible for gastric and colonic cancer, even if its clinical advantages over standard laparoscopy should be demonstrated by future studies.

Laparoscopic Transperitoneal Decortication of a Giant Peripelvic Renal Cyst

Laparoscopic decortication is currently considered the standard treatment of peripelvic renal cysts, in spite of the technical challenge due to the close contiguity with renal hilar structures. However, to date, few small series or single cases of laparoscopic decortication for symptomatic peripelvic cyst have been reported. In this paper, we report the first case of a giant peripelvic cyst (25 x 18 x 9 cm) treated by transperitoneal laparoscopic decortication in a young adult female. Pain relief and hypertension control were obtained early after surgery, and the patient is symptom free at a 30-month follow-up.

Needlestick Injuries, Glove Perforation and Round-Tipped Blunt Needles

Dear Sir, We read with great interest the article by Battersby et al. [1] about the impairment of surgical knot quality due to double gloving. The practice to wearing two pairs of gloves during surgical procedures to reduce the risks of exposure to patient’s blood and transmission of infectious organisms has been recommended worldwide, by several healthcare authorities, also on the basis of a Cochrane review showing the absence of compromised dexterity as a result of double gloving [2]. The study performed by Battersby and Colleagues clearly shows that double gloving reduces the quality of surgical knots by 24%, no matter the suture type used. A wider reduction of knot quality (50%) was noted with 4.0 sutures. These results question the safety of surgical knots tied wearing double gloves and, as a consequence, push surgeons to consider other precautions to reduce bloody contamination during surgery. The use of blunt needles seems to be a valid modality to reduce the risk of intraoperative glove perforation, percutaneous injuries and contact between exposed skin and patient’s blood. We performed a randomized study designed to determine whether the use of a round-tipped blunt needle for abdominal fascia closure after an emergency operation could be effective in reducing the frequency of injuries and glove perforation and increasing surgeons’ safety [3]. During the abdominal fascia suture, there is, in fact, the greatest risk for contamination, with a needlestick injury rate of 52–76% [4, 5], because a great effort is required to pass the needle through muscles and fascia, the needle tip is often hidden from the direct vision of the surgeon, and the surgeon may have decreased attention, being often at the end of an exhausting emergency procedure. In our experience, sharp needles were responsible for all needlestick injuries and the risk of glove perforation was sevenfold lower when blunt needles were used. From that time, we routinely use the blunt needle for celiotomy closure with excellent results. In conclusions, we believe that blunt needles represent one of the more effective modalities to prevent hand needlestick injuries and contamination and that they should always be used, especially in emergency surgical procedures.