Transumbilical single-access perforated gastric ulcer repair

Background: Single-access laparoscopy (SAL) can be proposed in patients presenting peritonitis both for diagnosis and treatment. This video shows a transumbilical SAL performed for perforated gastric ulcer. Video: A 30 year-old woman with a body mass index of 22.9 kg/m2 was admitted to the emergency room for diffuse abdominal pain. Preoperative work-up showed a pneumoperitoneum, hence a SAL was proposed to the patient. The procedure was performed using a standard 11mm reusable trocar for a 10mm, standard length, 30-degree scope, and curved reusable instruments inserted transumbilically without trocars. The cavity exploration showed a perforated gastric ulcer at the anterior surface of the prepyloric area. A suture repair, omentoplasty and lavage of the cavity was performed. Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 108 minutes and laparoscopic time 86 minutes. Final umbilical incision length was 15mm. The patient’s pain medication could be kept low and the patient was allowed to be discharged on the 5th postoperative day. After 6 months, the patient was well with no visible umbilical scar. Conclusion: Transumbilical SAL can be proposed in selected patients for suspicion of perforated gastric ulcer, with the main advantage of cosmetic result.

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Transumbilical single-access perforated gastric ulcer repair

Authors

G Dapri, J Himpens, GB Cadière

Abstract

Background: Single-access laparoscopy (SAL) can be proposed in patients presenting peritonitis both for diagnosis and treatment. This video shows a transumbilical SAL performed for perforated gastric ulcer.

Video: A 30 year-old woman with a body mass index of 22.9 kg/m2 was admitted to the emergency room for diffuse abdominal pain. Preoperative work-up showed a pneumoperitoneum, hence a SAL was proposed to the patient. The procedure was performed using a standard 11mm reusable trocar for a 10mm, standard length, 30-degree scope, and curved reusable instruments inserted transumbilically without trocars. The cavity exploration showed a perforated gastric ulcer at the anterior surface of the prepyloric area. A suture repair, omentoplasty and lavage of the cavity was performed.

Results: No conversion to open surgery or additional trocars were necessary. Total operative time was 108 minutes and laparoscopic time 86 minutes. Final umbilical incision length was 15mm. The patient’s pain medication could be kept low and the patient was allowed to be discharged on the 5th postoperative day. After 6 months, the patient was well with no visible umbilical scar.

Conclusion: Transumbilical SAL can be proposed in selected patients for suspicion of perforated gastric ulcer, with the main advantage of cosmetic result.

Catégorie

single port, contribution

Mots-clés

Transumbilical, single access, perforated gastric ulcer

Type de vidéo

Vidéo chirurgicale

Durée

05'08''

Publication

2011-12

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3488.htm

Transumbilical single-access perforated gastric ulcer repair

1. Clinical case 00'17''

This 30 year-old lady presented with an acute abdomen. Decision was made to explore her to a single incision.

2. Trocar introduction 00'26''

A cut down was performed at the umbilicus and a purse-string was placed on the fascia. A reusable 11mm trocar was inserted and a 30-degree angled scope, 10mm, normal length, was introduced. The abdomen was inspected and the diagnosis of perforated stomach ulcer was made.

3. Curved instrument insertion 01'01''

In order to obtain a good exposure, a double-curved instrument was placed outside the purse-string and used at first to lift the liver, hereby exposing the perforated ulcer. It is also used for retracting the liver by driving a suture with a straight needle around the ligament of the liver, which was then pulled to the left of the patient. Thanks to this maneuver, the angle between the liver and the distal stomach opened up, exposing the pathologic area.

4. Curved needle holder insertion 01'57''

A suture material was inserted through the 11mm trocar and a single curved needle holder was inserted intra-abdominally within the purse-string. The needle holder has a 45-degree angle in the frontal plane, which helps tremendously in driving the needle and following the natural curve of this needle. The suture material in this example was 2/0 silk. This suture material has good memory and helps in knotting, which again is facilitated by the use of the double-curved grasper and the single curved needle holder.

5. Intracorporeal suture 02'50''

A flat knot was performed using a regular intracorporeal knotting technique and one can appreciate that thanks to the curved instruments there is no crowding or clashing, and the ergonomic conditions very much resemble the multi-trocar technique we usually use. For cutting, a single curved scissors is introduced again inside the purse-string, and the suture is cut. A second stitch was placed using a similar technique, again with the use of 2/0 silk, and a figure-of-eight stitch was performed. One can again appreciate the advantageous angle on the jaws of the curved needle holder. The same knotting technique is again used and again one can appreciate that both instruments are at a 90-degree angle both outside and inside the abdomen.

6. Omentoplasty 04'15''

An omentoplasty is then performed using the greater omentum, which is kept against the suture by driving the needle in a U fashion and again tying a knot intracorporeally. This secures the suture material.

7. Irrigation of abdominal cavity 04'46''

The abdomen is then generously irrigated with a special curved irrigating and suction device. The abdomen is totally rinsed in all quadrants until clear. The purse-string is tied after removal of the instruments and a final scar is measured at 15mm.