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Although the majority of acute arterial complications after TKA and THA are diagnosed on the day of surgery, a high clinical awareness for acute arterial injury should also be present in the postoperative period. Although not always feasible, endovascular management is now our preferred treatment for injuries associated with TKA or THA. This offers substantially shorter time to vascular restoration, with less morbidity than open repair, and equivalent satisfactory outcomes.

Use of MT has led to shorter treatment duration and length of hospital stay. Limiting first rib resection to the anterior half of the rib shortened operative time. Patients requiring stents had excellent long-term patency rates.

IntroductionNatural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.MethodsThe patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.ResultsThe patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.ConclusionsThe repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection.

Background Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques. Methods A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min. Results The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics. Conclusions The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach.

IntroductionSurgery is moving towards less invasive and cosmetically superior approaches such as single incision laparoscopy (SIL). While trans-umbilical SIL is gaining popularity, incisions may lead to post-operative deformations of the umbilicus and the possibility of an increased rate of incisional hernias. Access within the pubic hairline allows preservation of the umbilicus and results in a scar which is concealed within the pubic hair.MethodsSupra-pubic single incision cholecystectomy was performed in a 30-year-old patient with symptomatic gallstones. A 2.5-cm transverse incision was placed within the pubic hairline and a subcutaneous tunnel was formed. Three 5-mm ports were introduced into the tunnel and perforated the anterior rectus sheath superior to the skin incision. The surgical procedure was then undertaken with conventional laparoscopic instrumentation. The adjacent 5-mm incisions were merged for gallbladder removal. The entry site was closed under direct vision.ResultsThe above procedure was technically feasible and without complication. Operative time was 45 min, and the patient was discharged 5 h post-operatively.ConclusionsSupra-pubic single incision laparoscopic cholecystectomy may offer a more cosmetically appealing result than standard umbilical access. The operation can be performed by surgeons skilled in single incision techniques with good result.Electronic supplementary materialThe online version of this article (doi:10.1007/s11605-009-1079-0) contains supplementary material, which is available to authorized users.

BACKGROUND: Single-incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology. METHODS: The da Vinci Standard and S System (Intuitive, Sunnyvale, USA) were used in human cadavers and pigs to perform single-incision transabdominal and transvaginal surgery. Robotic arms were crossed and control-switched to achieve intuitive control. RESULTS: It was possible to perform robotic single-incision laparoscopy in the typical, intuitive fashion. Transvaginal set-up, including docking of the system and introduction of instruments into the abdominal cavity, was possible but no useful manipulation could be performed. CONCLUSIONS: While robotic NOTES with the da Vinci surgical system was not successful, robotic single-incision surgery is feasible using the above set-up. This new approach seems to offer the advantages of single-incision surgery while maintaining the intuitive control of robotic surgery. Clinical application appears justified

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