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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 39-43

Minimally invasive combined surgical procedures of digestive, gynecological, and urological disorders: Five-year experience from a developing country


1 Department of Health and Family Welfare, SDH Chadoora; Department of Surgery, New City Hospital, Tengpora, Jammu and Kashmir, India
2 Department of Surgery, New City Hospital, Tengpora; Department of General Surgery, SKIMS Medical College, Bemina, Jammu and Kashmir, India
3 Department of Surgery, New City Hospital, Tengpora; Department of General Surgery, GMC, Srinagar, Jammu and Kashmir, India
4 Department of Gynaecology and Obstetrics, SKIMS Medical College, Bemina, Jammu and Kashmir, India
5 Department of Urology, GMC, Srinagar, Jammu and Kashmir, India
6 Department of Health and Family Welfare, SDH Chadoora, Jammu and Kashmir, India
7 Department of Gynaecology and Obstetrics, Guru Multi-specialty Hospital, Sopore, Jammu and Kashmir, India

Date of Submission08-May-2019
Date of Acceptance12-May-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Majid Mushtaque
J3, Jeelanabad Colony, Peer Bagh, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_8_19

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  Abstract 

Context: With advancements in the field of minimally invasive surgery, a variety of general surgical, gynecological, and urological diseases are amenable to treatment by this approach. Combined procedures can be performed for treating coexisting abdominal pathologies.
Aims: The study aimed to evaluate our experience of combining multiple minimally invasive procedures in terms of its safety and efficacy.
Settings and Design: An observational study was conducted at three hospitals in Kashmir.
Materials and Methods: A total of 149 patients underwent combined laparoscopic or combined laparoscopic and endoscopic procedures for the treatment of coexisting abdominal diseases. The outcome was analyzed in terms of mean operative time, postoperative visual analog scale score (0–10), requirement of additional postoperative analgesics, complications, hospital stay, and patient satisfaction.
Statistical Analysis: Prospective sample survey analyzing the percentage and mean values.
Results: Of 149 patients, 48 (32.2%) were male and 101 (67.7%) were female. Age ranged between 18-58 years in females and 24–70 years in males. The mean operative time ranged between 27 and 115 min. It was the longest in patients who underwent laparoscopic cholecystectomy (LC) with laparoscopically assisted vaginal hysterectomy. The most common organ-specific procedures performed were LC, appendectomy, and ovarian cystectomy in 120, 34, and 15 patients, respectively. Urological procedures were done in 36 patients undergoing either LC or appendectomy. Additional parenteral postoperative analgesics were required in 128 (85.9%) patients. A total of five major and 32 minor complications were noted in 22 (14.7%) patients. Three (2.01%) patients required conversion to open surgery. Orals were started on the 1st postoperative day in the majority of the patients. The mean hospital stay was 2.4 days (range 1–6 days). Overall, 93.9% of the patients expressed satisfaction to the combined procedure.
Conclusions: Simultaneous minimally invasive procedures are feasible for coexisting abdominal pathologies in selected patients with the advantages of single anesthesia and hospital admission, low morbidity, and excellent patient satisfaction.

Keywords: Combined laparoscopic procedures, combined minimally invasive procedures, combined surgical procedures


How to cite this article:
Mushtaque M, Rather AA, Rashid A, Shah S, Iqbal T, Bacha UQ, Guru IR. Minimally invasive combined surgical procedures of digestive, gynecological, and urological disorders: Five-year experience from a developing country. Saudi J Laparosc 2019;4:39-43

How to cite this URL:
Mushtaque M, Rather AA, Rashid A, Shah S, Iqbal T, Bacha UQ, Guru IR. Minimally invasive combined surgical procedures of digestive, gynecological, and urological disorders: Five-year experience from a developing country. Saudi J Laparosc [serial online] 2019 [cited 2019 Nov 15];4:39-43. Available from: http://www.saudijl.org/text.asp?2019/4/1/39/267863


  Introduction Top


With the advancement in laparoscopic surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies. Simultaneous laparoscopic procedures have received good acceptance in the world literature.[1],[2],[3],[4],[5] The laparoscope provides an excellent view of the entire abdomen, opening up the possibility of combining >1 surgical procedure in a single sitting. Combining procedures result in longer operating time, longer anesthesia, and risk of increased blood loss. Minimal access surgery has the advantages of decreased hospital stay, less postoperative pain, lower morbidity, early return to work, and better cosmesis.[1] The present study evaluates our experience of combining multiple minimally invasive procedures in terms of its safety and efficacy.


  Materials and Methods Top


This prospective observational study included 149 patients undergoing combined laparoscopic general surgeries as well as those undergoing laparoscopic general surgery simultaneously with gynecological procedures or with laparoscopic or endoscopic urological procedures from February 2014 to January 2019. Patients with coexistent abdominal pathologies not included in the study were those with the American Society of Anesthesiologists Grade III and above, unfit for general anesthesia or prolonged CO2 pneumoperitoneum, associated cardiovascular or pulmonary illnesses, history of acute cholecystitis or appendicular lump within previous 8 weeks, gallbladder mass, suspected malignancy, recurrent concurrent disease, previous history of laparotomy, and those who refused combined procedure. Indication for cholecystectomy included symptomatic cholelithiasis in 103 patients and solitary large or multiple polyps in another 17 patients. Indication of an appendectomy was chronic right lower quadrant pain in 25 and previous history of documented appendicitis/appendicular lump in another nine patients. All the eligible patients were evaluated thoroughly with complete relevant history and examination, complete blood count, kidney function test, liver function test, international normalized ratio, chest X-ray, electrocardiogram, serology, ultrasound abdomen, and preanesthetic checkup. Additional investigations were done with relevance to the intraabdominal pathologies. Patients with gynecological diseases also had a thorough gynecological examination and relevant investigations such as contrast-enhanced computed tomography abdomen as well as serum CA-125 for ovarian mass and Papanicolaou tests before hysterectomy. CT urography was done in patients undergoing percutaneous nephrolithotomy (PCNL), ureteroscopic lithotripsy (URSL), or laparoscopic ureterolithotomy while those planned for Trans-urethral resection of prostate (TURP) underwent uroflowmetry and Prostate specific antigen (PSA) estimation. Patients with suspicion of common bile duct (CBD) stones underwent preoperative magnetic resonance cholangiopancreatography. Written and informed consent for combined procedures, including possibility of conversion, was obtained, and all patients were operated under general anesthesia.

Laparoscopic cholecystectomy (LC) as a primary procedure was performed using the standard four-port technique. Three ports (10mm umbilical, 5mm supra-pubic and 10mm left para-rectal midway between the previous ports) were used for laparoscopic appendectomy (LA). Additional ports after LC or LA were placed according to co-existing abdominal pathologies. Intraoperatively, CBD clearance was ensured by using semiflexible ureteroscope through the choledochotomy incision, which was then closed over a T-tube. In procedures that required working in the lower abdomen or pelvis, extra ports were used according to the principles of baseball diamond concept, thereby decreasing operative stress to the surgeon. PCNL, URSL, TURP, and Transurethral resection of bladder tumor (TURBT) were done as the second procedure in patients requiring them after appropriately adjusting the patient's position on the Operation table (OT) table. In all cases requiring concomitant LC, it was done first followed by the second procedure except in the cases where CBD exploration was planned. In cases requiring mesh repair of hernias (ventral/inguinal), the procedure was only done when there was no bile spillage whatsoever. Patients who underwent PCNL, URSL, TURP, TURBT, laparoscopically assisted vaginal hysterectomy (LAVH), and lap ureterolithotomy were routinely catheterized postoperatively.

The outcome of combined minimally invasive procedures was analyzed in terms of mean operative time, postoperative visual analog scale (VAS) score (0–10), the requirement of additional postoperative analgesics, complications, hospital stay, and overall patient satisfaction.


  Results Top


A total of 149 patients, including 48 males and 101 females (M: F = 1:2.1), underwent combined laparoscopic or combined laparoscopic and endoscopic procedures. Age ranged between 18–58 years in females and 24–70 years in males. The mean operative time in different combinations of minimally invasive procedures is shown in [Table 1]. The longest times were taken for the patients who underwent LC with LAVH (mean 115 min). The most common organ-specific procedures performed were LC, appendectomy, and ovarian cystectomy in 120, 34, and 15 patients, respectively. Urological procedures were done in 36 patients undergoing either LC or appendectomy. Additional parenteral analgesics were required (VAS ≥4) on the day of surgery and after 24 h postoperatively in 110 and 18 patients, respectively.
Table 1: Combination of minimally invasive procedures and their mean operative time

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A total of 37 complications (5 major and 32 minor) were noted in 22 (14.7%) patients [Table 2]. Three (2.01%) patients required conversion to open surgery. The reasons for conversion in one each of the patients included major vascular injury during LAVH, lateral rent in the CBD at laparoscopic choledocholithotomy, and colonic injury during laparoscopic ureterolithotomy. Orals were started on the 1st postoperative day (POD) in majority of the patients and on the 2nd POD in four patients with prolonged postoperative ileus. In two patients who had CBD or colonic injuries, orals were started on the 3rd and 5th POD, respectively. There was no mortality in our study group. The mean hospital stay was 2.4 days (range 1–6 days). Overall, 140 (93.9%) patients expressed satisfaction to the combined procedure.
Table 2: Complications of combined procedures

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  Discussion Top


Laparoscopy has come a long way since Erich Muhe performed the first LC in 1985.[6] Laparoscopic surgery, because of its well-known advantages, such as a faster return to daily activity and minor trauma on the abdominal wall, has expanded quickly in many surgical specialties. The innovations and availability of advanced laparoscopic and endoscopic equipment have enlarged the variety of general surgical, gynecological, and urological diseases amenable to a minimally invasive approach.[1],[2],[3],[4],[5],[7],[8] If two procedures are performed simultaneously not only do patients have the advantage of minimal access surgery but they also have a single hospital admission, single break from work, preoperative evaluation, and anesthesia exposure. The procedures when combined have proved equally safe and efficacious as when done singularly.[1],[2],[3],[5],[9]

Voitk and Lowry in their review of elective appendicectomies during cholecystectomies and abdominal hysterectomies found no increase in operative time, fever, or infectious complications.[10],[11] Wadhwa et al. reported 145 combined laparoscopic/endoscopic procedures and found that as long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery.[1] In our study, 149 patients underwent 298 procedures related to digestive, gynecological, and urological disorders. Sixty-three (42.2%) patients underwent combined laparoscopic general surgical procedures, 50 (33.5%) patients had combined laparoscopic general surgical and gynecological surgeries, and other 36 (24.1%) patients underwent combined laparoscopic general surgical and laparoscopic/endoscopic urological procedures. There was no significant increase in perioperative morbidity or duration of hospitalization. However, the mean duration of surgery, postoperative VAS scores, and the requirement of additional analgesics were higher when compared to a historical cohort of patients undergoing a single laparoscopic or endoscopic procedure.[12]

One-stage management of CBD stones with LC and laparoscopic CBD exploration is feasible, with lowest morbidity and mortality and is cost-effective with a short hospital stay.[13] Adding clean contaminated surgery to the inguinal transabdominal preperitoneal hernioplasty or laparoscopic intraperitoneal onlay mesh does not significantly alter the outcome of the procedure and is not associated with an increase in the infection of the mesh.[14],[15] Combined abdominal laparoscopic procedures of gynecologic and general surgery are safe and economic choices and benefit patients in many ways, including lesser pain, shorter hospital stays, and earlier recovery.[2],[3],[4] Recent reports even suggest that minimal access technique has been used as a safe option to simultaneously treat synchronous abdominal malignancies during a single operating room visit with acceptable intra- and post-operative morbidity apart from demonstrating general benefits of minimal access surgery.[16],[17]

The mean operative time in our study was more than that reported by Wadhwa et al. and Savita et al. in their respective studies when comparing similar combined procedures; however, the mean hospital stay was longer in their studies.[1],[2] Complication rate in our study was 14.7%. Five (3.35%) patients had major complications, of which three required conversion and management by open surgery. One patient had prolonged bile leak after laparoscopic hydatid cystectomy which required sphincterotomy and CBD stenting for resolution. Another patient who had retrograde stone migration during URSL also required additional extracorporeal shock wave lithotripsy postoperatively. No major complications were reported by Wang et al. and Savita et al., but the minor complication rates of 20.4% and 7.9% were seen in their respective studies.[2],[3] Our study demonstrates the benefits of combining multiple surgeries by minimal access technique with no additional morbidity and acceptable complication rates. However, it does increase the operative time and VAS pain scores, requiring additional doses of analgesics postoperatively. Ghidirim et al. also reported similar results in combined laparoscopic procedures as compared to cholecystectomy only patients.[18]

Minimal access procedures have evolved during the past three decades with continuous improvements in technical equipment and skills. The laparoscopic practice was initially restricted to academic centers and recently extended to become applicable in the general community practice.[8] Moreover, multiple combined minimal access procedures are being performed in low-risk patients with coexistent abdominal pathologies which not only reduce the morbidity of repeated admission and another surgery but also reduce the overall cost and patient anxiety.[1],[2],[3],[4],[5],[8],[9],[10]


  Conclusions Top


With the expanded use of minimally invasive surgery, the options for combined surgical procedures have also increased and can be a modality of choice for coexisting pathologies in the abdomen. Provided the basic surgical principles, techniques and indication for simultaneous procedures are adhered to, more patients with acceptable risks could enjoy the benefits of minimal access surgery with additional advantages of single anesthesia, single hospital stay, and low expenses as compared to two surgical procedures done separately.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wadhwa A, Chowbey PK, Sharma A, Khullar R, Soni V, Baijal M, et al. Combined procedures in laparoscopic surgery. Surg Laparosc Endosc Percutan Tech 2003;13:382-6.  Back to cited text no. 1
    
2.
Savita K, Khedkar I, Bhartia VK. Combined procedures with laparoscopic cholecystectomy. Indian J Surg 2010;72:377-80.  Back to cited text no. 2
    
3.
Wang H, Zhou A, Fan M, Li P, Qi S, Gao L, et al. Application of laparoscopy in the combined surgical procedures of gynecological and digestive disorders in obese women: A retrospective cohort study. Int J Surg 2015;16:83-7.  Back to cited text no. 3
    
4.
Nichitaĭlo ME, Skums VV, Diachenko AN, Litvinenko AN, Ogorodnik PV, Galochka IP, et al. Simultaneous operations during laparoscopic cholecystectomy. Klin Khir 2004;2:5-7.  Back to cited text no. 4
    
5.
Maurya K, Sivanandam SE, Sukumar S, Bhat S, Kumar G, Nair B. Concomitant laparoscopic urological procedures: Does it contribute to morbidity? J Minim Access Surg 2009;5:67-71.  Back to cited text no. 5
    
6.
Jani K, Rajan PS, Sendhilkumar K, Palanivelu C. Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy. J Minim Access Surg 2006;2:49-58.  Back to cited text no. 6
    
7.
Nobili C, Romano F, Ciravegna AL, Garancini M, Degrate L, Uggeri F, et al. Consecutive concomitant laparoscopic splenectomy and cholecystectomy: An Italian experience of 30 patients and proposition of a technique. J Laparoendosc Adv Surg Tech A 2011;21:313-7.  Back to cited text no. 7
    
8.
Al-Otaibi K. Complications of 411 laparoscopic urological procedures: A single surgeon experience. Urol Ann 2018;10:308-12.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Nychytaĭlo MIu, Zahriĭchuk MS, Bulyk II, Masiuk IuI, Homan AV, Kondratiuk VA. Simultant laparoscopic operations for biliary calculi disease and hernia of the anterior abdominal wall. Klin Khir 2013;5:21-3.  Back to cited text no. 9
    
10.
Voitk AJ, Lowry JB. Is incidental appendectomy a safe practice? Can J Surg 1988;31:448-51.  Back to cited text no. 10
    
11.
O'Malley VP, Finch DR, Powley PH. Wound sepsis after cholecystectomy. Influence of incidental appendectomy. J Clin Gastroenterol 1986;8:435-7.  Back to cited text no. 11
    
12.
Bisgaard T. Analgesic treatment after laparoscopic cholecystectomy: A critical assessment of the evidence. Anesthesiology 2006;104:835-46.  Back to cited text no. 12
    
13.
Chander J, Vindal A, Lal P, Gupta N, Ramteke VK. Laparoscopic management of CBD stones: An Indian experience. Surg Endosc 2011;25:172-81.  Back to cited text no. 13
    
14.
Quezada N, Maturana G, Pimentel E, Crovari F, Muñoz R, Jarufe N, et al. Simultaneous TAPP inguinal repair and laparoscopic cholecystectomy: Results of a case series. Hernia 2019;23:119-23.  Back to cited text no. 14
    
15.
Praveen Raj P, Ganesh MK, Senthilnathan P, Parthasarathi R, Rajapandian S, Palanivelu C, et al. Concomitant laparoscopic intraperitoneal onlay mesh repair with other clean contaminated procedures-study of feasibility and safety. J Laparoendosc Adv Surg Tech A 2015;25:33-6.  Back to cited text no. 15
    
16.
Cartapatti M, Machado RD, Muller RL, Magnabosco WJ, Santos AC, Chapin BF, et al. Synchronous abdominal tumors: Is combined laparoscopic surgery in a single approach a safe option? Int Braz J Urol 2018;44:483-90.  Back to cited text no. 16
    
17.
Guo P, Liao S, Li J, Zheng S. Clinical application of combined laparoscopic surgery in the treatment of primary hepatocellular carcinoma with portal hypertension: A report of 16 cases. Transl Cancer Res 2019;8:330-7.  Back to cited text no. 17
    
18.
Ghidirim GH, Gladun EV, Danch AV, Mishina E. Combined laparoscopic treatment of polycystic ovary disease and gallstones J Am Assoc Gynecol Laparosc 1996;3:S15.  Back to cited text no. 18
    



 
 
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