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A young male in his early 30s presented to us with increasing swelling at the umbilicus, and an umbilical hernia was diagnosed. At laparoscopic intraperitoneal onlay mesh (IPOM) repair, an unexpected finding of a thin innocuous-looking fibrous film over the small bowel was noted. This finding presented a dilemma as to the probable pathology of this material, and a decision had to be made on whether laparoscopic IPOM could be continued. It was prudently decided to abandon the plan of placing a mesh intraperitoneally and an open repair of the umbilical hernia was done. In retrospect this was a wise decision, as, after 7 months he had to have a laparotomy for intestinal obstruction, when the classic thick fibrous encapsulating abdominal cocoon was seen. Hence here we have followed the evolution of the abdominal cocoon from its original asymptomatic phase to the classic encapsulating sclerosing peritonitis with probably laparoscopic gas insufflation being the precipitating factor.

Perioperative management of implantable cardioverter-defibrillators is an important part of anesthetic care. Society recommendations and expert consensus statements exist to aid clinicians, and they have identified the umbilicus as an important landmark in decision-making. Implantable cardioverter-defibrillator antitachycardia therapy may not need to be deactivated for infraumbilical surgery because electromagnetic interference is unlikely to occur. The authors present two cases in which inappropriate antitachycardia therapy occurred intraoperatively with use of an underbody dispersive electrode, even though both surgeries were infraumbilical. The authors also present two cadaver models to demonstrate how monopolar electrosurgery below the umbilicus is sensed using both traditional and underbody dispersive electrosurgical return electrodes.

OBJECTIVE This prospective observational study aims to assess the association between maternal abdominal subcutaneous and visceral fat thickness measured with ultrasound scan during the first trimester and the risk of developing gestational diabetes mellitus (GDM). MATERIALS AND METHODS We recruited 43 non-diabetic women with singleton pregnancy between 11 and 14 weeks' gestation and evaluated ultrasonographic measurements of subcutaneous fat thickness (SFT) and preperitoneal fat (PF) above the umbilicus. During 2nd trimester, GDM screening was performed by 75g two-hour oral glucose tolerance test (OGTT) and diagnosis was made when one or more plasma glucose values meets or exceeds the values indicated by International Association of the Diabetes and Pregnancy Study Groups (IADPSG). RESULTS Among the 43 woman, 8 developed GDM (18.6%). Of these 37,5% (n=3) had been diagnosed with GDM during a previous pregnancy, with a statistically significant correlation (p = 0.035). Mean SFT for all patients was significantly higher in the GDM group compared to non GDM group (27.30±8.78 mm vs 18.56±9.99 mm; p value =0.049). Mean PF for all women showed a statistically significant correlation with GDM (13.27±9.07 mm for non GDM group vs 23.52±10.24 mm for GDM group; p value = 0.038). CONCLUSIONS Abdominal adiposity, both subcutaneous and visceral, seem to be suitable predictors of GDM in early pregnancy and can be easily assessed during a first trimester routine ultrasound, although further studies are needed to evaluate their role in the screening protocols.

Relatively little is known about allantois and urachal development in early humans. Serial sagittal histological sections from eight human embryos and fetuses were examined to determine allantois development. At gestational age 6-7 weeks, the primitive allantois consists of an enlarged tube located between the umbilical cord and abdominal cavity, whereas the urachus is not yet developed. At 8 weeks, the allantois gradually withdraws from the distal to the proximal end of the umbilical cord, and both the proximal allantois and the rectum (hindgut) start to develop into the cloaca. At 10 weeks, the allantois was located mostly in the abdominal cavity. The urachus forms from the distal end of the allantois and develops into a closed fibrous cord between the base of the urinary bladder and the umbilicus. The urogenital sinus forms from the proximal end of the allantois.

OBJECTIVE To assess whether Pfannenstiel skin incision compared with vertical skin incision was associated with postcesarean delivery wound complications in morbidly obese women. METHODS We assembled a retrospective cohort of patients with body mass index (BMI) of 40 or higher who delivered by cesarean between July 2012 and May 2019. The primary outcome was a composite wound morbidity (until 42 days postpartum) including wound separation, infection, and dehiscence. Secondary outcomes included individual composite components plus select maternal and neonatal outcomes. Comparisons of demographics and outcomes were made by χ2 and t test. Logistic regression was performed. Subgroup analysis was performed according to location of vertical skin incision in relation to the umbilicus. RESULTS A total of 3,901 patients were included. To account for imbalances in demographics between exposure groups, vertical and Pfannenstiel skin incision patients were matched in a 1:4 fashion for age, BMI, smoking status, and diabetes. The frequency of wound morbidity was 13.2% overall. There was no difference in the primary outcome when comparing Pfannenstiel with vertical skin incision (adjusted odds ratio [aOR] 1.5, 95% CI 0.8-2.8). Patients with a vertical skin incision were more likely to undergo vertical hysterotomy (aOR 138.7, 95% CI 46.9-410) and transfusion (aOR 5.4, 95% CI 1.8-16.5). When vertical skin incision was classified into supraumbilical and infraumbilical, and compared with Pfannenstiel skin incision, infraumbilical vertical skin incision was associated with increased wound morbidity (odds ratio [OR] 2.46, 95% CI 1.4-4.5) and wound infection (OR 2.5, 95% CI 1.4-4.6) compared with Pfannenstiel. Both types of vertical skin incision were associated with increased odds of vertical hysterotomy and transfusion when compared with Pfannenstiel. CONCLUSION In morbidly obese women who underwent cesarean delivery, the frequency of postoperative wound morbidity was similar after Pfannenstiel and vertical skin incisions.

Urachal carcinoma is a very rare tumor, commonly found in the urachal remnant connecting the bladder dome to the umbilicus. Diagnosis is often challenging due to the location of the tumor and its late presentation. We hereby report the case of a 49-year-old female where the diagnosis of urachal carcinoma was made and a robotic partial cystectomy associated with en bloc resection of the umbilicus was performed. We aim to present the clinical aspects, presentation, and diagnosis of this rare entity along with a review of the literature.

Background Gastrointestinal duplications are uncommon occurring in 1 in 5000 live births. Small intestine is commonly involved, while appendicular duplications are extremely rare. Vitelline duct anomalies arise due to failure of involution of the omphalomesenteric duct. Their spectrum ranges from a simple umbilical sinus to completely patent omphalomesenteric fistulae. We report here a rare association of complete appendico-cecal duplication with patent vitello-intestinal duct (PVID). Case presentation A 14-year-old girl who presented with complaints of scant, foul smelling, and feculent discharge from umbilicus intermittently since birth was evaluated and diagnosed to have a patent vitello-intestinal duct. At laparotomy, a patent vitello-intestinal tract opening unusually at the ileo-cecal junction was noted. In addition, an appendico-cecal duplication cyst bearing an appendix on the mesenteric side and a 4-cm long orthotopic appendix on the native cecum was found with the duplex cecum sharing a common wall and blood supply. The terminal ileum with the duplication and patent vitello-intestinal duct were excised in toto, and an end-to-end ileo-ascending anastomosis was done. The child is well at 1 year follow-up. Conclusion A complete appendico-cecal (Type C) duplication with ectopically inserted patent vitello-intestinal duct is reported here as an unusual association, discussing its management and the probable disarray in the embryological development.

Aim The prevalence and definition of diastasis recti abdominis (DRA) is under debate. This retrospective cross-sectional study evaluated the interrectal distance and the prevalence of DRA in computed tomography (CT) in an asymptomatic population. Materials and methods Patients undergoing CT scans for suspected appendicitis or kidney stones from 01/2016 to 12/2018 were screened retrospectively to participate. A study population with equal distribution according to gender and age (18–90 years) was generated (n = 329 patients) and the interrectal distance was measured at six reference points. Results DRA (defined as > 2 cm at 3 cm above the umbilicus) was present in 57% of the population. The 80th percentile of the interrectal distance was 10 mm at the xiphoid (median 3 mm, 95% confidence interval (CI) 0–19 mm), 27 mm halfway from xiphoid to umbilicus (median 17 mm, 95% CI 0–39 mm), 34 mm at 3 cm above the umbilicus (median 22 mm, 95% CI 0–50 mm), 32 mm at the umbilicus (median 25 mm, 95% CI 0–45 mm), 25 mm at 2 cm below the umbilicus (median 14 mm, 95% CI 0–39 mm), and 4 mm halfway from umbilicus to pubic symphysis (median 0 mm, 95% CI 0–19 mm). In the multivariate analysis, higher age (p = 0.001), increased body mass index (p p Conclusion The prevalence of DRA is much higher than commonly estimated (57%). The IRD 3 cm above the umbilicus may be considered normal up to 34 mm. To avoid over-treatment, the definition of DRA should be revised.

Transumbilical laparoscopic appendectomy (TULA) may be a feasible alternative to conventional laparoscopic appendectomy. However, a transumbilical incision may increase incisional surgical site infections (SSIs) compared to conventional laparoscopic appendectomy. This study aimed to investigate the relationship between the morphology of the umbilicus and the incidence of SSIs in patients who underwent TULA.This retrospective study analysed the medical records of consecutive patients who underwent surgery for acute appendicitis at our institution from June 2016 to October 2020. The patients were assigned to the SSI group (those with an SSI) or the non-SSI group. The morphology of the umbilicus was calculated by measuring its width and depth on preoperative computed tomography images and was compared between the SSI and non-SSI groups.The SSI group included 23 patients, while the non-SSI group included 252 patients. The width of the umbilicus was significantly shorter in the SSI group than in the non-SSI group (29 ± 10 mm vs. 34 ± 9 mm, P = 0.027). The umbilicus was slightly deeper in the SSI group than in the non-SSI group; however, the difference was not significant (16 mm vs. 15 mm, P = 0.384).This was the first study investigating the correlation between the morphology of the umbilicus and SSI development in TULA. SSIs tended to occur more commonly in a narrow and deep umbilicus. An extension of the umbilical incision may help prevent SSI in patients with this umbilical morphology.

Epidermoid Cysts are benign lesions that can occur anywhere on the body – most frequently on the face, neck, scalp and the trunk, but are rarely found in the umbilicus. Here, we report a case of umbilical epidermal cyst attached to an embryonic remnant in a 12-year-old boy, present since four years prior. Upon examination, the child had no complaints and the lesion had a round shape with no discharge or pain. During the operation, a tubular structure attached to the lesion was found. Both the lesion and attached structure were excised and the diagnosis of the former was confirmed by biopsy and histological examination. We report and discuss this case because the umbilicus is an uncommon site for epidermoid cysts in children and is rarely found attached to embryonic remnants. To the best of our knowledge, only three cases of umbilical epidermoid cysts in children have been reported in English literature.

Background: Patients with neurogenic bladder and bowel may benefit from combined urinary and fecal continence procedures. Few cases of robot-assisted (RA) Mitrofanoff appendicovesicostomy ...

Background: Appendectomy is one of the most commonly performed surgical procedures of the abdominal area. One of the recent innovations is single-port laparoscopic surgery (SPLS), which can insert multiple ports through a proprietary device with multiple channels. An incision is sited in the umbilicus to result in no visible scar. Objectives: The study aimed to evaluate the results of the treatment of acute appendicitis by applying single-port laparoscopic surgery. Methods: A clinical single-port laparoscopic appendectomy intervention of 122 patients, with the absence of a control group, was carried out by a sole surgeon at the Hue University of Medicine and Pharmacy Hospital, Hue, Vietnam, from August 2013 to December 2017. Research parameters included clinical history, physical examination, laboratory test, ultrasound imaging, intraoperative characteristics, and surgical outcomes. Results: We included 122 patients (64 males and 58 females) who met the inclusion criteria. The mean age was 31.28 ± 13.51 years (range, 16 - 73 years). The average BMI was 20.4 ± 1.39 kg/m2. All patients had abdominal pain, and the average duration of symptoms was 17.39 ± 5.41 hours (range, 6 - 31 hours). Five patients had a history of abdominal surgery. The mean diameter of appendicitis in ultrasound was 8.8 mm (range, 6 - 15 mm). Moreover, 89.3% of patients had an increase in white blood cells. The difficult location of appendicitis was 1.6% under the liver and 20.5% in the retrocecal region. In addition, 18.0% of retroperitoneal appendicitis and 6.6% of appendicitis were under cecalserosa. The mean operative time was 40.19 ± 14.67 mins (range, 23 - 150 min). Two cases (1.6%) required additional trocar insertion. Three cases (2.5%) had wound infection and no other complications. The median hospital stay was 3.64 ± 1.72 days (range, 2 - 13 days). Conclusions: Single-port laparoscopic surgery is the safe and effective treatment of acute appendicitis. This technique may be feasible for acute appendicitis with a difficult location.

Background:. Abdominoplasties are increasingly requested aesthetic, reconstructive surgical procedures that, in most cases, have shown the disadvantage of leaving an often-notorious periumbilical scar due to hypertrophy, keloid, or because it simply remains very visible over time, after surgery. The Alvarez technique (or nonscarring minimal-incision neo-omphaloplasty) is a completely new, unprecedented technique because it does not leave visible scars. This technique requires the generation of four small flaps and a purse-string suture system interacting with the aponeurosis of the rectus abdominis muscles, as well as the modification of the vertical abdominal plication, and management of the subcutaneous cellular tissue in the new umbilicus area, which, if executed correctly, provide adequate aesthetic results. Methods:. A multicentric case-series scientific study is presented with a total of 94 patients who underwent classical abdominoplasties and neo-omphaloplasties with the aforementioned technique from August 2018 to December 2020. Pre-surgical and postoperative photographic files were collected. Results:. Of the 94 patients, there were eight (8.5%) cases of seroma, which are not attributable to neo-omphaloplasty but inherent to the use of drains. There were five (5.3%) cases of umbilical dehiscence. In total, 89.2% (84 patients) showed a very high degree of long-term satisfaction, and 10.6% (10 patients) had a medium level of long-term satisfaction. Conclusions:. The Alvarez technique provides good aesthetic results that are well accepted among patients and surgeons, in the short and long term. It is useful for those patients who wish to undergo an abdominoplasty but cannot stand a scar in the umbilical region.

A 48-year-old man playing cards was accused of cheating. An assailant with a shotgun wounded the victim in the area of the right biceps muscle. When personnel from emergency medical services arrived, they applied a pressure dressing to the right arm to control profuse hemorrhage. The patient was awake and alert with a heart rate of 130 beats per minute and a systolic blood pressure of 110 mm Hg. The pressure dressing over the right arm was saturated with blood and was removed. Findings on examination included the following: a 20×12 cm cavity in the anterior right arm; absence of much of the right biceps muscle; absence of the brachial artery and venae comitantes; an intact median nerve; limited function of the right elbow; intact function of the right wrist and fingers; and absent right radial and ulnar pulses at the wrist. A pressure dressing was reapplied to the open wound in the right arm. As a blood specimen was drawn for type and cross-match, resuscitation with a crystalloid solution was initiated. An X-ray of the right arm documented that the shotgun pellets were all in the area of the right biceps muscle (figure 1). After administration of a cephalosporin antibiotic, the patient was moved to the operating room. Figure 1 X-ray of the right humerus documents no fracture and limited distribution of pellets. Skin preparation and draping included the chest and the entire right upper extremity from the left nipple to the right fingernails and from below the umbilicus to the toenails bilaterally. After the pressure dressing was removed, there was profuse venous hemorrhage from the open wound in the anterior right arm. Attempts at suture and metal clip control of multiple open veins had an only modest effect on controlling the hemorrhage. Based on the injuries described, your choice …

Study Objective To define vaginal cuff dehiscence, identify risk factors for dehiscence, understand steps needed for laparoscopic cuff revision, and review techniques for cuff closure. Design Vaginal cuff dehiscence, defined as a full thickness separation of the vaginal cuff, is a rare but morbid complication after hysterectomy. After a total laparoscopic hysterectomy, the incidence of vaginal cuff dehiscence is 0.7% (range 0.64 – 1.27%). Risk factors include poor vaginal cuff closure technique, smoking, low body mass index, conditions that cause poor wound healing such as infection, hematoma, prior radiation, or immunosuppression, and increased pressure on the vaginal incision line such as trauma, pelvic organ prolapse, or excessive valsalva. In this video we will demonstrate a laparoscopic repair of a vaginal cuff dehiscence. Setting Patients should be positioned in lithotomy position in the operating room. Standard GYN laparoscopic setup should be used. The authors prefer placing the camera via a 5mm trocar in the umbilicus, with 2 accessory 5mm ports laterally and a 5mm suprapubic port. Patients or Participants N/A. Interventions In this video we describe the 5 steps of a laparoscopic repair of a vaginal cuff dehiscence. We also discuss tips and tricks to optimize cuff closure. • Identify and normalize anatomy • Identify the vaginal cuff defect • Mobilize the cuff • Excise cuff edges • Close the cuff Measurements and Main Results N/A. Conclusion Although vaginal cuff dehiscence is rare, knowledge of safe and effective laparoscopic repair technique is crucial for the gynecologic surgeon, both for repair and for prevention of future cuff dehiscence.

Background Covered cloacal extrophy (CCE) is extremely rare condition. It requires a high index of suspicion for its diagnosis. External features are quite similar to that of common cloaca i.e. intact lower abdominal wall and single perineal opening whereas visceral features are similar to cloacal extrophy (CE). Case presentation 3 day old female neonate presented to the emergency department with single perineal opening and stool coming out of umbilicus as well as perineal opening. Abdominal wall was intact. After detailed workup, she underwent exploratory laparotomy and was diagnosed as covered cloacal extrophy. Conclusion Wide spectrum of cloacal malformation makes covered cloacal extrophy a diagnostic challenge and early diagnosis is helpful in strategizing future reconstructions.

Trans-umbilical extrusion of the distal ventriculoperitoneal shunt catheter is a rare complication of the VPS insertion. The objectives of this review were to analyze various variables like the age, sex, indication for VPS insertion, clinical presentation, the operative therapy offered for the management, and outcome of the cases published/managed for the trans-umbilical extrusion of the distal VPS shunt catheter. In 1973, the maiden case of trans-umbilical extrusion of the distal VPS catheter was published. Literature/case reports were retrieved from 1973 to October 31, 2021. A total of n=24 (12 males, 12 females) cases were recruited for this systematic review. All of them were children below the age of 13-years. In four-fifths (n=19) of children, the initial VPS catheter was inserted during the first 6-months of life. The median age of children at the time of diagnosis of the above-described VPS complication was 7.5 (42.21 SD) months, and it ranged from 2 months to 13 years of age. The median interval from the initial VPS insertion/last VPS revision to the diagnosis of complication was 4 (24.77 SD) months, and it ranged from 3 weeks to 8 years. The main complaint was the extrusion of the distal VPS catheter through the umbilicus. Surgical procedures performed for the management were (a) removal of the entire VPS catheter n=15, (b) removal of distal/part of distal VPS catheter n=5, and (C) others n=2. For VPS catheter revision; delayed re-VPS insertion was performed in n=10, immediate revision of the distal VPS catheter in n=3, and others. Three (12.5%) children died during the postoperative and follow-up period. The distal VPS catheter extrusion through the umbilicus is a rare complication of VPS insertion, and it occurred exclusively in children. In 70% (n=17) of children, it was documented ≤6 months afterward of the VPS insertion. Delayed re-VPS catheter insertion was preferred for 40% of the children for VPS revision procedures.

Widening of the inter-rectus distance (IRD) is highly prevalent among postpartum women and can lead to dysfunction of abdominopelvic muscles. The aim of this study was to evaluate the differences in IRD and abdominopelvic function between nulliparous, primiparous and multiparous women. A cross-sectional study was conducted on 75 women (25 nulliparous, 25 primiparous and 25 multiparous at 6 months postpartum). The participants underwent ultrasound assessment under three conditions (at rest, abdominal draw-in maneuver (ADIM) and curl-up) at two locations (2 cm above and 2 cm below the umbilicus). Furthermore, abdominopelvic muscle function was determined by prone, supine and side bridge tests. In all conditions and locations, the IRD were significantly higher (p < 0.05) in the primiparous and multiparous women than in the nulliparous. The multiparous women presented greater (p > 0.05) IRD at rest and during ADIM compared to the primiparous women. Regarding abdominopelvic muscle function, differences were only significant (p < 0.05) between the nulliparous with primiparous women in prone and supine conditions. These findings suggest that parity influences IRD: women at 6 months postpartum present greater IRD compared to nulliparous women; multiparous women present greater IRD at rest and during the activation of deep abdominal muscles than primiparous women; and primiparous women exhibit worse abdominopelvic muscle function than nulliparous women.

Study Objective To review preoperative evaluation of a patient presenting with an abdominopelvic mass. To discuss methods of drainage and spill prevention during surgical management of large abdominopelvic masses and to demonstrate an efficient laparoscopic method for extraction of large adnexal masses. Design N/A Setting In the operating room with patient in dorsal lithotomy position with both arms tucked. Five-millimeter ports were placed in the umbilicus, the right lower quadrant and the left mid-abdomen. The specimen was extracted through an 8 mm port in the left lower quadrant. Patients or Participants 27-year-old female with a 15 × 13 cm abdominopelvic mass who presented with right lower quadrant and low back pain and mild right hydronephrosis. She had a benign appearing cyst on ultrasound and her tumor markers were negative. Interventions We employ a morcellation method we refer to as apple-peeling to cut the cyst into a long strip of 1 inch width to allow easy removal through an 8 mm laparoscopic port without spill or struggle. Measurements and Main Results N/A Conclusion Large abdominopelvic masses can be managed via laparoscopic approach with proper pre-operative work-up to ensure benign status. The apple-peeling morcellation technique demonstrated in this video allows efficient extraction of abominopelvic masses > 10 cm through small laparoscopic ports (8mm)

Study Objective Our objective is to review the anatomic course, sensory and motor functions, and approach to dissection of important pelvic nerves encountered during advanced gynecologic laparoscopy. Design Using annotated intraoperative footage, we illustrate surgical approaches to safe dissection of the following pelvic nerves: Ilioinguinal, iliohypogastric, lateral femoral cutaneous, femoral, genitofemoral, obturator, sciatic, hypogastric and pudendal nerves, lumbosacral trunk and sacral nerve roots. Setting Patients were placed in dorsal lithotomy position with legs in Yellowfin stirrups. The umbilicus was used for camera port placement, and three accessory ports were placed (in the bilateral lower quadrants and a second to the left of the umbilicus). Patients or Participants Patients requiring dissection of the aforementioned nerves for surgical treatment of deep infiltrating endometriosis, adhesiolysis, or treatment of pudendal neuralgia were selected. Interventions N/A. Measurements and Main Results N/A. Conclusion Surgeons must have a comprehensive understanding of pelvic anatomy and comfort operating in deep pelvic spaces in order to minimize risk of inadvertent nerve injury. A systematic approach to nerve dissection enables adequate exposure of the operative field and safe space for lysis of adhesions, excision of endometriosis, and surgical treatment of pelvic pain syndromes.

Purpose/Objective(s) Despite being an integral part of stem cell transplant, the technical aspects of classical total body irradiation (TBI) remain relatively crude. In particular, the implementations of lung and cardiac shielding vary widely between institutions. We hypothesize that the block margins away from anatomical landmarks could substantially alter lung and cardiac dose parameters, and thus affecting the likelihood of TBI-related toxicities such as radiation pneumonitis and late cardiotoxicities. This work seeks to utilize a newly commissioned 3D TBI beam model to determine potential dosimetric effects caused by variations in the choice of shielding parameters to better understand the potential for such detrimental effects. Materials/Methods We commissioned a TBI beam model in a treatment planning system. CT scans of 3 anonymized patients without gross disease are contoured following typical clinical practice. Patients are planned in the classic standing AP/PA at extended distance technique for a total dose of 1200 cGy in 6 fractions to midline at umbilicus level, with 3/6 fractions delivered with lung blocks. Lung blocks are modeled using automated script in the treatment planning system, with varying superior (from clavicles), inferior (from diaphragms), and lateral margins from 0 to 2 cm, as well as cases for which the cardiac silhouette was blocked or unblocked for the study. Dose to lungs and heart were calculated and compared for the following metrics: mean dose, volume receiving 10 Gy (V10 Gy) and 12 Gy (V12 Gy), and point dose behind the blocks. Results The results showed that the point dose behind the blocks is approximately 75% of prescription dose for all patients, with insignificant changes with varying block margins. The dose off the block center increases rapidly that much of the tissue under the blocks receives 80% to 90% of prescription dose. Similar results are observed for mean lung dose. In contrast, the lung V10 Gy increases by nearly two-fold, from approximately 30% to 60% over the 0 to 2 cm block margin range. The mean heart dose increased by approximately 7.5% when the cardiac silhouette is unblocked, while the cardiac V12 Gy increased by approximately 25%. The mean dose to left anterior descending artery (LAD) increases significantly in the unblocked case, with as much as 43% difference. Conclusion This work has shown that margins of lung blocks could affect the dose to lungs and heart substantially, despite the indifference that the commonly used point dose parameter, point dose behind the blocks, indicates. A 3D TBI model could provide more dosimetry data to help future studies to correlate TBI-associated toxicity to the heart and lungs.

Study Objective The incidence of ureteral injury with laparoscopic hysterectomy reported in the literature is 0.78%. The objective of this study was to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. Design We performed a retrospective chart review, evaluating gynecologic surgery cases between January 2009 and May 2019 performed exclusively by fellowship-trained surgeons in the Minimally Invasive Gynecologic Surgery (MIGS) Department at Harvard Medical School teaching hospitals in Boston. The rate of ureteral injury was assessed. Setting Patients were positioned in dorsal lithotomy with legs in Allen stirrups. A central (typically umbilical) camera port was placed along with bilateral lower quadrant ports and a third ipsilateral port to the left of the umbilicus. Patients or Participants A total of 5,160 cases were performed by MIGS surgeons between 2009-2019 at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital. Patients undergoing laparoscopic hysterectomy were selected for this review. Interventions N/A. Measurements and Main Results Out of the 5,160 MIGS cases, 2,396 laparoscopic hysterectomies were performed. Only 1 ureteral injury was noted intraoperatively (0.04%). No additional delayed ureteral injuries were observed. Conclusion Ureteral injury is associated with significant patient morbidity and high economic burden. Despite taking on medically and surgically complex cases at our tertiary referral center, we observed very low rates of ureteral injury at the time of laparoscopic hysterectomy. Putting this into context given that approximately 600,000 hysterectomies are performed annually in the US; the literature-reported ureteral injury rate would result in approximately 4,680 injuries versus an estimated 240 injuries in a high-volume center. This study highlights the benefits of fellowship-training and high-volume practice on patient outcomes.

Study Objective To compare the perioperative outcomes of the robotic single-port myomectomy (RSPM) using the new da Vinci SP® surgical system with those of the robotic multi-site myomectomy (RM) using the da Vinci Xi® surgical system. Design Multicenter retrospective case-controlled study. Setting A university tertiary care hospital. Patients or Participants A total of 101 patients were enrolled. 67 patients underwent RSPM and 34 patients underwent RM at November 2018 to May 2020 were included. Interventions All patients underwent robotic myomectomy who diagnosed uterine myoma with target size that the instrument could operate by entering the umbilicus. The choice of surgical modality was not influenced by the patient's history of previous abdominal surgery, body mass index, uterus size, location or type of myoma, or myoma size. Measurements and Main Results RSPM vs. RM patients demographics had no difference significantly in mean age, BMI, maximal diameter of myoma and total number of myomas. In terms of surgical outcomes, RSPM and RM has comparable in EBL (50 mL vs. 150 mL, p Conclusion Robotic single-port myomectomy using new da Vinci SP® surgical system is feasible surgical modality as like as multi-site myomectomy. Further studies are needed to confirm these preliminary results and to determine the proper indications for the surgery.