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Background: In this study, we set out to precisely define two symmetrical points-a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or "floppy") 360 degrees fundoplication (FP).Methods: For the terms of this study, circumference = c; diameter = d; c/d = pi; pi = 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n = 5) and intraoperatively (n = 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c.Results: The smallest measured value for c was 7.5 cm (d = 2.39 cm); the largest value for c was 10.0 cm (d = 3.18 cm). The mean value was 8.35 cm (d = 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d = 2.66 cm. This technique creates a correctly oriented, symmetrical, "floppy," true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible.Conclusions: Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a "floppy" 360 degrees fundoplication. [ABSTRACT FROM AUTHOR]

Background: Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation.Methods: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation was performed in eight adult hydrocephalus patients from August 1996 to September 1998. All eight patients had undergone 1 to 18 prior shunt revisions. The procedures were performed with two 2-mm trocars. The instrumentation consisted of a 2-mm laparoscope, a 2-mm grasper, and 2-mm scissors. All shunts were placed in an area free of adhesions and checked for flow under direct vision. Four of the patients required a lysis of adhesions to create a space adequate for catheter placement.Results: All of the procedures were successful, with no operative complications. The operative times ranged from 29 to 99 min, (mean, 63 min). The blood loss in all of the procedures was minimal. At this writing, none of the patients have required subsequent distal shunt revisions. No conversions to larger instruments or an open procedure were required.Conclusions: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation is safe and effective, offering several advantages over the open procedure. This procedure is ideal for the use of 2-mm instruments. [ABSTRACT FROM AUTHOR]

Introduction: Single-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with "wristed" instruments could overcome this limitation but the "arms" collide when working coaxially. This video demonstrates a new technique of "chopstick surgery," which enables use of the robotic arms through a single incision without collision., Methods: Experiments were conducted utilizing the da Vinci S® robot (Sunnyvale, CA) in a porcine model with three laparoscopic ports (12 mm, 2-5 mm) introduced through a single "incision." Pilot work conducted while performing Fundamentals of Laparoscopic Surgery (FLS) tasks determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, an experienced robotic surgeon performed a cholecystectomy and nephrectomy in a porcine model utilizing the "chopstick" technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This arrangement prevents collision of the external robotic arms. To correct for the change in handedness, the robotic console is instructed to drive the "left" instrument with the right hand effector and the "right" instrument with the left., Results: Both procedures were satisfactorily completed with no external collision of the robotic arms, in acceptable times and with no technical complications. This is consistent with results obtained in the box trainer where the chopstick configuration enabled significantly improved times in all tasks and decreased number of errors and eliminated instrument collisions., Conclusion: Chopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery.

The long QT syndrome (LQTS) is a rare inherited cardiac disorder that may induce fatal cardiac arrhythmias. Patients diagnosed with this disorder generally have several treatment options, including beta-blockade, cardiac pacing, an implantable automatic defibrillator, or a high thoracic left sympathectomy. We report the case of a 6-year-old girl with the LQTS treated by left thoracoscopic sympathectomy and stellate ganglionectomy. The procedure was performed after an initial thorascopic attempt at another institution failed due to inadequate resection of the sympathetic chain. Operative time was 85 min and blood loss was minimal. There were no intraoperative or postoperative complications. The girl's QT interval decreased and she was discharged on the 4th postoperative day. After 9 months of follow-up, she remains asymptomatic. We conclude that the LQTS patients who fail medical treatment can be treated successfully with left thoracoscopic cervicothoracic sympathectomy. We recommend that the extent of sympathectomy for treating the LQTS be T1-T4 and either the entire stellate ganglion or at least the inferior one-third.