Transumbilical enterostomy for Hirschsprung’s disease with a two-stage laparoscopy-assisted pull-through procedure

BACKGROUND A one-stage laparoscopic operation has recently been considered a favorable option for the management of patients with Hirschsprung's disease(HD)due to its superior cosmetic results.One-stage transanal endorectal pull-through for the treatment of rectosigmoid HD has been widely used in newborns without complications.However,enterostomy is required in some HD cases for enterocolitis and dilated colon.Our transumbilical enterostomy(TUE)and twostage laparoscopy-assisted anorectoplasty were effective and achieved a similar cosmetic effect to one-stage laparoscopy on the abdominal wall in patients with anorectal malformation,but the effect in patients with HD is unclear.AIM To evaluate the safety,efficacy and cosmetic results of TUE in two-stage laparoscopy-assisted pull-through for HD.METHODS From June 2013 to June 2018,53 patients(40 boys,13 girls;mean age at enterostomy:5.5±2.2 mo)who underwent enterostomy and two-stage laparoscopy-assisted pull-through for HD with stoma closure were reviewed at our institution.Two enterostomy approaches were used:TUE in 24 patients,and conventional abdominal enterostomy(CAE)in 29 patients.Eleven patients with rectosigmoid HD had severe preoperative enterocolitis or a dilated colon.26 patients had long-segment HD,and 16 patients had total colonic aganglionosis(TCA).The patients with left-sided HD underwent the two-stage laparoscopic Soave procedure,and the patients with right-sided HD and TCA underwent the laparoscopic Duhamel procedure.Demographics,enterostomy operative time,complications and cosmetic results were respectively evaluated.RESULTS There were no differences between the groups with respect to gender,age at enterostomy,weight and clinical type(P>0.05).No conversion to open technique was required.Two patients experienced episodes of stomal mucosal prolapse in the TUE group and 1 patient in the CAE group(8.33%vs 3.45%,P>0.05).No parastomal hernia was observed in either of the two groups.Wound infection at the stoma was seen in 1 case in the TUE group,and 2 cases in the CAE group(4.17%vs 6.90%,P>0.05).No obstruction was noted in any of the patients in the TUE group,whereas obstruction was found in 1 patient in the CAE group.Enterocolitis was observed in 3 and 5 patients in the TUE and CAE group,respectively(12.50%vs 17.24%,P>0.05).There was no significant difference between the TUE group and CAE group in terms of the incidence of soiling and constipation(P>0.05).The cosmetic result using the scar score in the TUE group was better than that in the CAE group(6.83±0.96 vs 13.32±1.57,P<0.05).CONCLUSION TUE is a safe and feasible method for the treatment of HD,and the staged enterostomy and two-stage laparoscopy-assisted pull-through achieved a similar cosmetic effect to the one-stage laparoscopic procedure.

Transperitoneal Laparoscopic Ureterotomy: A Mini-Invasive Option for Ureteral Stones

Background and Objective: Laparoscopy can be an alternative modality in the management of ureteral stones. We herein present our experience with laparoscopic ureterolithotomy although most ureteral stones are managed using endourologic techniques, open surgery, or shockwave lithotripsy. Materials and Methods: This retrospective study was performed from January 2014 to December 2019 on 20 patients with ureteral stones who were treated using transperitoneal laparoscopic access. We collected data on patients’ ages, genders, clinical profiles, relevant medical history, sizes of the calculi, localisation of the calculi as confirmed by imaging, and outcome of lithotripsy. Continuous data were presented as mean values and standard deviations (for normally distributed data) and medians with interquartile ranges (for skewed data). Categorical data were presented as frequencies and percentages. Results: We included 20 patients (13 males and 7 females) with a mean age of 40.40 ± 13.25 years. The mean stone size was 18.5 ± 3.05 mm and all procedures were completed laparoscopically. The mean operative time was 96 ± 22.34 minutes. The mean estimated blood loss was less than 150 ml, and none of the patients received a blood transfusion. There was no intraoperative complication or postoperative complications, except for leakage of urine in the suture area. The mean hospital stay was 2.05 ± 0.69 days and the double J stent was removed after an average of 20 days post-operatively. The stone-free rate was 100% and after a mean follow-up period of 3 months, there was no stone recurrence. Conclusion: Laparoscopic ureterolithotomy is an effective and safe technique in the management of ureteric stones. The benefits of this technique include minimal postoperative morbidity, short postoperative hospitalization, a short convalescence period, and remarkable cosmetic results.

Comparison of cosmetic outcomes between remote-access and conventional thyroidectomy:A review of the current literature

Objective:The pursuit of an esthetically pleasing scar following open thyroid surgery has led to the development of endoscopic thyroidectomy through remote incisions placed in several locations outside the neck.The objective of this study is to review the recent literature and compare the incision site appearance and patient satisfaction with the cosmetic outcome after extracervical and conventional thyroidectomy.Methods:The English literature published since 2010 was searched through the PubMed/Medline database for studies comparing the cosmetic outcomes between remote-access endoscopic and conventional thyroidectomy using a form of scar assessment scale.Results:A total of 9 relevant papers fulfilled the eligibility criteria including 1486 patients.Among them,595 patients underwent endoscopic thyroidectomy through several remote-access approaches and 891 patients were assigned to the conventional group.Only one randomized-controlled trial was identified,whereas among the rest,four were prospective and four were retrospective nonrandomized cohorts.Regarding the extracervical modifications performed in the endoscopic groups,the axillary approach was performed in three studies and the breast approach in four studies,while the retroauricular facelift technique and the transoral vestibular method were applied in one study,respectively.Conclusions:Evaluation of the wound appearance and patient satisfaction with the cosmetic outcome at various time points during the follow-up highlighted the superiority of the extracervical approaches over the conventional cervicotomy.Considering these findings,remote-access techniques could possibly be the ideal surgical method for patients with high esthetic requirements,providing an excellent appearance of the thoroughly exposed neck.