E-ISSN 2587-0610
Laparoscopic Endoscopic Surgical Science (LESS) - Laparosc Endosc Surg Sci : 27 (4)
Volume: 27  Issue: 4 - 2020
1.Bladeless optical trocar insertion technique for initial access in morbidly obese patients: Technique and results
Murat Coşkun, Adem Yüksel
doi: 10.14744/less.2020.35682  Pages 193 - 198
INTRODUCTION: The initial access into the abdomen during laparoscopic surgery can become difficult and complex, especially in morbidly obese patients. No ideal technique to solve this issue has been elucidated. In this study, we aimed to evaluate the safety and feasibility of using a bladeless optical trocar for abdominal entry without producing pneumoperitoneum in morbidly obese patients.
METHODS: The study included 170 patients who underwent surgery to treat morbid obesity from January 2015 to December 2017. Demographic data, data about the initial access to the abdomen, and the complications were recorded.
RESULTS: All surgical procedures were performed by the same team of two surgeons. The mean body mass index (BMI) of the patients was 45.8±6.0 kg/m². The Veress needle access failed in the first five patients. The initial access was successfully achieved in all patients, including the first five patients, by using a bladeless optical trocar without producing pneumoperitoneum. After the skin incision, insufflation and trocar insertion were completed in a mean period of 58±35.3 (range; 23–272) seconds. Omental injury due to trocar insertion occurred in two patients. No other complications developed. Fascial defect closures were not performed for any patient. The mean operating times for sleeve gastrectomy and the Roux-en-Y gastric bypass were 76±19 (range: 45–135) and 203±61.4 (range: 100–345) minutes, respectively. During the follow-up period of 24 months, no patient developed trocar site hernia.
DISCUSSION AND CONCLUSION: Initial access to the abdomen by a bladeless optical trocar without producing pneumoperitoneum is a practical, fast, safe, and effective method in morbidly obese patients.

2.Endoscopic retrograde cholangiopancreatography in the elderly: Some considerations and approaches
Bahtiyar Muhammedoğlu, Eyüp Mehmet Pircanoğlu, Vehbi Şirikçi, Fatih Sumer
doi: 10.14744/less.2020.26429  Pages 199 - 205
INTRODUCTION: Cholelithiasis is an old age disease but old age is not a disease. Biliary tract disorders are increasingly seen in elderly patients and this is related to the aging of the global population. In the current study, our main concern was to communicate the message that the ERCP is a safe procedure in elderly patients with signs of biliary sepsis and adverse comorbid conditions.
METHODS: Between June 2014 and May 2018, endoscopic retrograde cholangiopancreatography (ERCP) was carried out on patients in our hospital with obstructive jaundice and acute cholangitis. There were 154 patients over 80 years of age, 236 patients in the 65–79-year age group, and 422 patients under the age of 65, who served as the control group.
RESULTS: Our study was conducted on three age groups: under 65 years, from 65–79 years, and 80 years and older. The length of hospital stays and cost among the groups was compared. Duodenal diverticula were significantly more common in patients over 65 years of age (p>0.001). Significantly lower costs were found for patients under 65 years of age (Group A) in comparison with both Groups C and B (both p=0.001). The average length of hospital stay differed significantly among age groups and was significantly shorter in patients under 65 years of age than the 65–79-year age group as well as patients 80 years of age and older (p=0.001).
DISCUSSION AND CONCLUSION: In conclusion, ERCP is a safe and effective procedure in patients from 65 to 79 years of age and patients aged 80 and older. We suggest that emergency or early ERCP should be performed within 24–48 hours in elderly patients with acute cholangitis and biliary sepsis irrespective of the severity of the disease unless there are major contraindications.

3.Laparoscopic nephrectomy in renal pathologies: A single-center experience
Osman Barut, Mehmet Kutlu Demirkol, Yavuz Selim Okyay, Faruk Küçükdurmaz, Tayfun Şahinkanat, Sefa Resim
doi: 10.14744/less.2020.58569  Pages 206 - 210
INTRODUCTION: This study aimed to retrospectively evaluate our first experience of laparoscopic nephrectomy for benign or malignant renal pathologies.
METHODS: This study evaluated the data of 32 patients who underwent laparoscopic simple nephrectomy and laparoscopic radical nephrectomy for benign and malign kidney pathologies in our clinic between March, 2016 and January, 2020. Demographic characteristics, operation time, blood loss, duration of hospital stay, pathology, and intraoperative and postoperative complications were examined.
RESULTS: Laparoscopic simple nephrectomy was performed in 17 (53.2%) and laparoscopic radical nephrectomy was performed in 15 (45.8%) of 32 patients. The median age was 57.8 (range, 19–86) years. While 19 (59.4%) of the renal pathologies were on the right side, 13 (40.6%) were on the left side. The median operation time was 136 (range, 102–262) min. Open surgery was started because the kidney was highly adherent to the surrounding tissues in two (6.3%) patients. In the postoperative period, one unit of blood was transfused to one (3.1%) patient. The median hospital stay was 4.1 (range, 3–8) days.
DISCUSSION AND CONCLUSION: Laparoscopic nephrectomy is a minimally invasive surgical method that can be performed safely and effectively. The most important advantages of laparoscopic nephrectomy over open surgery are better tolerance, shorter hospital stay, less need for postoperative pain relief, and better cosmetic results.

4.Initial experience with laparoscopic repair of incisional hernia
Pınar Yazıcı, Esin Kabul Gürbulak
doi: 10.14744/less.2020.93695  Pages 211 - 214
INTRODUCTION: The development of the laparoscopic approach has changed the approach to incisional hernia, which is one of the most common surgical operations. In this study, we aimed to analyze the results of laparoscopic incisional hernia cases performed in our clinic.
METHODS: Between April 2015 and March 2019, 234 patients underwent surgery for incisional hernia (abdominal wall) in our clinic, and those who underwent laparoscopic incisional hernia repair were included in this study. All procedures were performed using the same surgical technique. Demographic data, operation history, length of hospital stay, postoperative complications and recurrence were recorded. The minimum follow-up period for recurrence was 6 months.
RESULTS: Forty-seven (20%) patients underwent laparoscopic incisional hernia repair during four-year period. Thirteen male and 34 female patients with a mean age of 53±9 years were identified. Primary operations were classified as umbilical hernia operation (n=12), gynecologic operations (n=9), colorectal surgery (n=9), port site hernia (n=6), and others (n=11). The mean defect diameter was 5.8±1.7 cm. Seven patients underwent primary repair with prolene, while a composite mesh for repair was used with or without prolene suture support in the other patients (n=40). The postoperative complication rate was 12% [seroma (3), hematoma (1), infection (1), parietal wall defect (1)]. Recurrence was detected in 4 (8.5%) patients with a mean follow-up of 31±14 months.
DISCUSSION AND CONCLUSION: In our series investigating laparoscopic incisional hernia repairs, acceptable results including short hospital stay and complication rates were achieved. On the other hand, the slightly higher recurrence rate has been expected due to the small population of patients and large group of surgeons. For this reason, better results can be achieved with the implementation of restrictions on patient selection (small defect diameter, weak patient, etc.) and increased experience.

5.Laparoscopic right hemicolectomy: A single center experience
Serdar Şenol, Servet Karagül, Oktay Karaköse
doi: 10.14744/less.2020.36450  Pages 215 - 219
INTRODUCTION: To evaluate the early postoperative results of patients who underwent laparoscopic right hemicolectomy for colon cancer in our center.
METHODS: Patients with right colon cancer who underwent elective laparoscopic right hemicolectomy between December 2017 and March 2020 at the Samsun Training and Research Hospital were included in this study. The patients were evaluated in terms of age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) class, comorbidities, previous abdominal surgery, tumor location, preoperative bowel cleansing, prophylactic antibiotherapy, operative time, pathological staging, number of lymph nodes removed, anastomosis type and construction (intracorporeal or extracorporeal), postoperative complications, reoperation, hospital length of stay, and rates of mortality and morbidity.
RESULTS: The study included nine men and three women with a median age of 65 years (range 48–81 years)and median BMI of 26.9 (range: 23–33). The median operative time was 167.5 min (range: 120–240 min). Mean blood loss was 95±41 ml. Three patients were stage I, six were stage II, and one was stage III. Two had noninvasive cancer on pathologic examination. The median number of lymph nodes removed was 12 (range: 0–49). All of the anastomoses were side-to-side; five were constructed intracorporeally (IA) and seven extracorporeally (EA). The median operative times were 165 min (range: 120–240 min) and 165 min (range: 135–200 min), median length of skin incision was 6.7 cm and 8.7 cm in patients with IA and EA, respectively. Morbidity was observed in three patients (25%) and consisted of an anastomotic leak in one patient, incision site infection in one patient, and paralytic ileus in one patient. The median hospital length of stay was 6.5 days (range: 5–40 days). There was no mortality and incisional hernia.
DISCUSSION AND CONCLUSION: Laparoscopic right hemicolectomy is a safe and effective technique for the surgical treatment of right colon tumors.

6.Treatment of acute cholecystitis and risk factors for mortality in hemodialysis patients
Aydın Aktaş, Cüneyt Kayaalp, Mehmet Uluşahin, Arif Burak Çekiç, Müfit Şansal, Kutay Sağlam, Serdar Türkyilmaz, Fatih Sümer
doi: 10.14744/less.2020.59354  Pages 220 - 228
INTRODUCTION: There have been few studies on the treatment of acute cholecystitis (AC) in hemodialysis (HD) patients. The aim of this study was to investigate the risk factors for mortality in HD patients who developed AC, and to compare the results of treatment.
METHODS: The records of HD patients who developed AC between 2009 and 2019 were analyzed retrospectively. The diagnosis and severity of AC was made according to Tokyo Guideline (TG) 18. The American Society of Anesthesiologists (ASA) scores were used for surgical risk. The Charlson comorbidity index (CCI) was used for comorbid conditions of patients. Risk factors were investigated for mortality. Medical treatment and cholecystectomy results were compared.
RESULTS: Thirty-four patients were included in the study. Mortality occurred in six patients (17.6%). Age ≥65 years, an ASA IV score, a CCI ≥8, Tokyo Guideline 18 (TG 18) grade III, and blood urea nitrogen ≥60 mg/dL were increased those who died (p=0.03, p=0.001, p=0.02, p<0.001, p=0.03; respectively). According to TG 18, there was no difference between the medical treatment and cholecystectomy groups in terms of clinical success, readmission, and mortality rates (p=1.00, p=0.64, p=1.00; respectively). However, length of hospital stay was longer in the cholecystectomy group (p=0.01).
DISCUSSION AND CONCLUSION: Despite the suggestions in the TG 18, medical treatment and in-hospital early cholecystectomy can be performed with similar clinical success, readmission, and mortality rates in HD patients who develop AC.

7.Has laparoscopic surgery reduced negative appendectomy rates?
Mürşit Dinçer, Rümeysa Kevser Liman
doi: 10.14744/less.2020.50465  Pages 229 - 233
INTRODUCTION: Negative appendectomies can still be performed despite improvements in imaging methods. As a result of advances in minimally invasive surgery, laparoscopic appendectomy rates have increased in the treatment of acute appendicitis. The aim of this study was to investigate the effect of laparoscopic surgery on negative appendectomy rates.
METHODS: Patients who underwent appendectomy for acute appendicitis between December 2016 and December 2018 were retrospectively reviewed. A total of 293 patients were involved in the study. The patients were divided into two groups: open appendectomy and laparoscopic appendectomy. The demographic characteristics and histopathological diagnosis of the patients were recorded. Differences in patients with histopathological diagnoses, except for acute appendicitis, were analyzed.
RESULTS: There were 119 cases in the laparoscopic appendectomy group and 174 cases in the open appendectomy group. The mean age was 35.82 (± 16.48) years. One hundred seventy-six of the cases were male and 117 were female. There was no statistically significant difference between the two groups in terms of demographic characteristics. The same number of negative appendectomy cases was found in both groups. The result was also statistically insignificant.
DISCUSSION AND CONCLUSION: This study showed that laparoscopic appendectomy did not reduce the negative appendectomy rates. Despite the advances in imaging methods, such as ultrasound and computed tomography, and the advantages of laparoscopy in abdominal exploration, the rates of negative appendectomy are still considerable. Despite all technological developments, anamnesis and physical examination remain important in the diagnosis of acute appendicitis.

8.Yield of screening and diagnostic colonoscopy for polyp and cancer detection
Nidal İflazoğlu, Ecem Memişoğlu
doi: 10.14744/less.2020.56578  Pages 234 - 242
INTRODUCTION: Colorectal cancer is the third most common disease affecting the global population, with 1.8 million new cases reported per year and a mortality rate of 8%. Currently, the optimum approach to the diagnosis and follow-up of the disease is colonoscopy. The present study aimed to compare the yield of the colonoscopy procedure among ages, genders, reasons for requesting a colonoscopy, presence/absence of family history and presence/absence of polyp/cancer detection history.
METHODS: A retrospective examination was made of patients who were referred to the Endoscopy Unit of the Department of General Surgery of our center and who underwent colonoscopy for diagnostic and screening purposes within a three-year period between June 2016 and May 2019.
RESULTS: Of the 2,075 patients included in the study from within the three-year period, 1,181 (57%) were male and the median age was 45 (18–93) years. Colonoscopy was performed for screening purposes on 105 (5%) of the patients, while the remaining 1.970 (95%) patients underwent colonoscopy due to the presence of various symptoms and complaints (bleeding, constipation, diarrhea, abdominal pain, inflammatory bowel disease, etc.). The total polyp detection rate was 13.8% (287) and the total adenoma detection rate was 9% (188). Of the patients who underwent colonoscopy, five (0.26%) were identified with interval colorectal cancer when the procedure was repeated for various indications.
DISCUSSION AND CONCLUSION: Colonoscopic examination is the optimum approach to the detection, follow-up, and treatment of colorectal cancer or its precursors. The adenoma detection rates, polyp detection rates, and the interval cancer rates are the guiding tools that point out the importance and quality of colonoscopy.

9.The role of laparoscopy in the diagnosis of ascites of unknown etiology
Gökalp Okut, Güleç Mert Doğan, Sait Murat Doğan
doi: 10.14744/less.2020.26121  Pages 243 - 246
INTRODUCTION: Ascites is a pathological accumulation of detectable fluid in the peritoneal cavity. The standard procedure for diagnosis includes laboratory examinations and imaging methods. Diagnostic laparoscopy is a method that has been used for many years in patients whose etiology cannot be determined. The aim of this study was to define the value of diagnostic laparoscopy and histology in revealing the etiology of ascites of unknown origin.
METHODS: This retrospective study was completed at İnönü University Turgut Özal Medical Center General Surgery Department between June 2010 and July 2020. The study was approved by the ethics committee. Patients were diagnosed with ascites by gastroenterology and hepatology. All patients with open heart surgery, kidney or advanced liver disease, and patients younger than 18 years of age were excluded.
RESULTS: Six of the 23 patients in our study were male. The final diagnosis after laparoscopy was made by biopsy and laparoscopic fluid cytology. The pathology of specimens indicated 11 had tuberculosis, three had malignancy, four had mesothelioma, one had a malignant epithelial tumor, one had a gastrointestinal stromal tumor, and one had lymphoma. The etiology was unknown in two patients. Preoperative imaging and laparoscopic exploration were not possible in three patients. In this study, the accuracy of laparoscopy in the diagnosis of ascites of unknown origin was 91%.
DISCUSSION AND CONCLUSION: Laparoscopy has had an important role in the diagnosis, staging, and treatment of peritoneal and other abdominal diseases in recent years. The cause of ascites of unknown etiology varies according to the location of the study. Although different results have been reported in the literature, diagnostic laparoscopy is a successful diagnostic method in cases that cannot be diagnosed with preoperative imaging and laboratory methods. According to these data, diagnostic laparoscopy is a fast and reliable method for ascites cases of unknown etiology.

10.Is the Ambu® aScope™ equivalent for laparoscopic common bile duct exploration as a re-usable choledochoscope?
Yousif Mahmood Aawsaj, Liam Horgan, Duncan Light
doi: 10.14744/less.2020.79663  Pages 247 - 252
INTRODUCTION: We have previously reported our institution’s early experience on the use of the Ambu® aScope ™ in LCBDE2. We demonstrated that the disposable scope was safe to use in LCBDE along with the benefits on cost reduction compared to reusable choledocoscopes.
METHODS: A retrospective cohort study was performed where cases between groups from June 2011 to June 2015 (for a re-usable choledochoscope (Group A)) and from July 2015 to January 2018 (for the Ambu® aScope™ (Group B)) were collected and matched retrospectively. A survey was conducted among eight surgeons who had used the Ambu® aScope™ on their views regarding its use and in comparison to a re-usable choledochoscope.
RESULTS: A total of 80 patients underwent an emergency LCBDE (40 in the re-usable choledochoscope group and 40 patients in the Ambu® aScope™ Group). The patients presented with acute cholecystitis, cholangitis, biliary colic, and pancreatitis, and there was no significant difference between the two groups. One of the 40 cases in the Ambu® aScope™ group and three of the 40 cases in the reusable scope group was converted to an open procedure. The success of CBD clearance, rate of post-operative bile leak, and conversion to an open procedure was equivalent in both groups. The majority of respondents (7/8) felt that the dexterity of the Ambu® aScope™ was inferior to the re-usable choledochoscope, and the same number (7/8) thought that the irrigation system using Ambu® aScope™ was inferior to the re-usable choledochoscope. Six of the eight surgeons reported more difficulties in using instrumentation with the Ambu® aScope™ in comparison to the re-usable choledochoscope.
DISCUSSION AND CONCLUSION: We have shown that a disposable scope may be used safely in LCBDE. However, we feel that the Ambu® aScope™ is not ideal for this task. We would open the call to the industry to support the development of a disposable choledocoscope specific for this purpose.

11.Incidental cancer in elderly versus younger patients underwent laparoscopic and open cholecystectomy: A retrospective analysis of 2389 patients
Ufuk Uylaş, Ramazan Gündoğdu
doi: 10.14744/less.2020.26680  Pages 253 - 258
INTRODUCTION: Routine histopathological examination allows the detection of incidental gallbladder cancers. In the present study, we aimed to determine the rate of incidental gallbladder cancer and other pathology outcomes in young and elderly patients who underwent laparoscopic and open cholecystectomy.
METHODS: Patients who underwent laparoscopic and open cholecystectomy in the acute or elective period in our center were retrospectively analyzed. A total of 2389 patients were included in the study. The patients were divided into two groups, as the younger (<60 years old) and elderly (≥60 years old).
RESULTS: Of all patients, 476 (19.9%) were male and 1913 (80.1%) were female; the mean age was 46 years (range 17-90). There were 486 patients in the elderly group (18.7%). Chronic cholecystitis was detected in 2228 patients, acute cholecystitis in 141, Xanthogranulomatous cholecystitis in eight, gangrenous cholecystitis in six, and follicular cholecystitis and adenocarcinoma in three patients each. Chronic cholecystitis was more common in the young group, while acute cholecystitis was more common in the elderly group (p<0.05). Adenocarcinoma was detected in three patients (0.13%), all of whom were in the elderly group (p<0.05).
DISCUSSION AND CONCLUSION: Acute or chronic cholecystitis accompanied by a thickened gallbladder wall and a prolonged history of gallstones may be accompanied by malignancy, especially in elderly patients.

12.Anterior abdominal wall hernia repair with e-TEP technique: A single-center experience with short term results
Metin Ertem, Tuncer Babür, Emel Özveri
doi: 10.14744/less.2020.32848  Pages 259 - 265
Introduction: Ventral hernia repair is one of the most common surgical procedures performed by surgeons. Extended-view totally extraperitoneal (e-TEP) hernia repair is an emerging surgical technique that can be applied in the surgical treatment of ventral hernias. We present our experience of an e-TEP technique with the corresponding short-term results.

Materials and Methods: Between June 2019 and February 2020, 18 patients with ventral hernia were operated on by the same surgeon using the e-TEP technique and were reviewed retrospectively. Patients diagnosed with diastasis recti defect ≥2 cm with concomitant umbilical hernia were included in the study.

Results: A total of 18 cases underwent eTEP until February 2020. Out of 18 patients, 10 (55.5%) were male while eight (44.5%) were female. The mean age was 46.4 years (29–68), mean body mass index (BMI) was 25.7 kg/m2 (18.7–30.8 kg/m2), average hospitalization time was 1.78 days (1–3 days), average ASA score was 1.7 (1–2), mean operation time was 145 minute (100–298 min.), and mean mesh area used was 266 cm2. Cyanoacrylate glue (Liquiband®Fix8™) was used to fix the mesh to the peritoneum in 14 patients, while no fixation method was used in 4 patients. None of the cases underwent open surgery. No recurrence was detected during the follow-up, with a maximum of 12 months and a minimum of 4 months (mean 8.3 months).

Conclusion: e-TEP is a safe and feasible emerging surgical technique for primary or incisional ventral hernia repairs. This new approach that has all the advantages of laparoscopic surgery allows flexible port insertion and the closure of defects by allowing large size mesh placement in the retromuscular area. Placing the meshes in the extraperitoneal area may also prevent the development of mesh-related complications from its contact with intraperitoneal organs.

13.Necrotizing appendicitis after transabdominal preperitoneal (TAPP) inguinal hernia
Tamer Akay, Metin Leblebici
doi: 10.14744/less.2020.72325  Pages 266 - 269
Inguinal hernia repair is one of the most common surgical procedures in general surgery. In the treatment of inguinal hernia, the transabdominal preperitoneal (TAPP) laparoscopic approach appears to be a suitable alternative to open inguinal hernia repair, provided that it is performed by a classic experienced surgeon. Although it has many advantages over open inguinal hernia repair, laparoscopic surgery has complications. Laparoscopic appendectomy was performed in a patient who had undergone bilateral inguinal hernia repair 4 months earlier due to intermittent sub-ileus complaints, which resulted from the development of clinical appendicitis during general surgery for clinical sub-ileus; during laparoscopic exploration, necrotic distal part of the appendix cleaved into the mesh. Although closure of the peritoneum with tacker in TAPP hernioplasty saves time, it requires much attention because incomplete closure may cause cleaving of intra-abdominal organs into the mesh.

14.A safe method for trocar site bleeding; external cauterization under laparoscopic vision
Kenan Binnetoğlu
doi: 10.14744/less.2020.09734  Pages 270 - 273
Trocar site bleeding is one of the unnoticeable complications of laparoscopic surgery that can lead to significant problems. With this method, we believe that we can simply and effectively stop trocar site bleeding, and this method can be a standard application.

In trocar site bleeding following laparoscopic surgery, the bleeding area is detected under laparoscopic vision. A standard cautery pen is passed into the skin to a sufficient extent. The cautery provides hemostasis in the bleeding area.

It has been demonstrated that trocar site bleeding is a preventable complication when appropriate methods are used. In preventing trocar site bleeding, certain methods are being used currently such as laparoscopic sealing devices, hemostasis with open surgery, and hemostatic patches. Hemostasis with cautery in our method was demonstrated to have an equivalent effect as open hemostasis. Hemostasis with cautery under laparoscopic vision provides a great advantage for the patient in terms of bleeding control, duration of surgery, and cost.

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