Surgical laparoscopy, endoscopy & percutaneous techniques

Publications in this journal

• Article: Retroperitoneal versus transperitoneal laparoscopic adrenalectomy in adrenal tumor: a meta-analysis.

  Wei Chen, Fei Li, Dingnan Chen, Yongtong Zhu, Chengwu He, Yuejun Du, Wanlong Tan
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  ABSTRACT: : The study aims to provide a pooled meta-analysis of existing studies that compare the outcomes of retroperitoneal laparoscopic adrenalectomy with transperitoneal approach for adrenal tumor. : A systematic search of electronic databases was performed and studies were selected based on specific inclusion and exclusion criteria. Data of interest were subjected to meta-analysis using randomized or fixed-effect model to calculate weight mean difference (WMD) or odds ratio (OR). The sensitivity analysis and publication bias test also be conducted. : Nine observational studies with 632 patients were identified (339 retroperitoneal vs. 293 transperitoneal). Retroperitoneal approach was associated with shorter operative time [WMD=-13.10; 95% confidence interval (CI), -23.83 to -2.36; P=0.02], less intraoperative blood loss (WMD=-40.60; 95% CI, -79.73 to -1.47; P=0.04), shorter duration of hospital stay (WMD=-1.25; 95% CI, -2.36 to -0.14; P=0.03), or time to first ambulation (WMD=-0.38; 95% CI, -0.47 to -0.28; P<0.001). Although the difference between number of convert to open management, time to first oral intake, and major postoperative complication rate was not significant (OR=0.53; 95% CI, 0.17 to 1.60; P=0.26; WMD=-0.31; 95% CI, -1.14 to 0.52; P=0.47; OR=0.41; 95% CI, 0.06 to 1.06; P=0.07). : The present evidence demonstrates that retroperitoneal adrenalectomy is better than transperitoneal approach for patients with adrenal tumor in short-term outcomes. However, extended follow-ups and further randomized controlled trials should be required to analysis.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):121-7.
• Article: Laparoscopic management of a small bowel herniation from an ileal conduit: report of a case and review of the literature.

  Lisa M Coughlin, Dennis P Orr
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  ABSTRACT: Bladder carcinoma can be treated with cystectomy and urinary diversion. Ileal conduit is a popular technique, originally performed with closure of all mesenteric and peritoneal defects to minimize internal herniation. Recent advances in laparoscopic and robotic techniques often leave these defects open. We present a case of a 75-year-old gentleman with a small bowel entrapment underneath an intraperitoneal ileal conduit and ureter causing obstruction. This internal hernia occurred 2 months after undergoing a DaVinci robotic-assisted laparoscopic cystoprostatectomy with an ileal conduit. Bowel obstruction is an important complication associated with the need for reoperation and patient mortality. Historical review shows a precedent for closure of the mesenteric defect, obliterating the peritoneal defect in the right lumbar gutter, and suturing the ileal conduit to the posterior peritoneum to prevent potential internal hernias. The literature involving ileal conduits is examined for consensus on the preferred method of treating these potential spaces.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e81-3.
• Article: Hepatoportal fistula in an 83-year-old male, presenting with hematemesis 52 years after blunt trauma.

  Gideon A Blecher, Robert Bohmer
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  ABSTRACT: Hepatoportal arteriovenous fistulae are a rare cause of portal hypertension, which can have significant clinical manifestations. They have multiple etiologies, one of which includes hepatic trauma. We present a case of hepatoportal fistula presenting with bleeding esophageal varices in an 83-year-old man. The exact cause of fistula in this case is not entirely clear; however, hepatic trauma was noted in the patients' history, some 52 years before presentation. We also present a literature review on this rare and interesting phenomenon.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e84-6.
• Article: Laparoscopic Transumbilical Single-Port Appendectomy: Initial Experience and Comparison With 3-port Appendectomy.

  Jie Ding, Guo-Qing Liao, Zhong-Min Zhang, Yang Pan, Sheng Liu, Zhong-Shu Yan
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):233-4.
• Article: Laparoscopic ultrasound for hepatocellular carcinoma and colorectal liver metastasis: an overview.

  Anna Rethy, Thomas Langø, Ronald Mårvik
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  ABSTRACT: Laparoscopic ultrasound (LUS) increases patient safety by allowing the surgeon to see beyond surfaces of organs. LUS, however, is not in widespread use due to long learning curve and difficulties in interpreting the ultrasound images. In this paper, we highlight LUS's many advantages and its indispensable nature in laparoscopic liver procedures. The focus is the use of LUS in diagnosis and treatment of hepatocellular carcinoma and colorectal metastasis. The majority of patients have associated liver cirrhosis, and are terminally ill. Therefore, it is important to avoid unnecessary surgical trauma. LUS is sensitive in the detection of small liver lesions that are often missed by other preoperative imaging methods. This makes LUS an excellent tool for diagnostic and therapeutic purposes. Our overview focuses on procedures relating to hepatocellular carcinoma and colorectal metastasis where LUS is used and has been proven to benefit patient survival and potentially improve quality of life.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):135-44.
• Article: Is laboratory training essential for beginners in learning laparoscopic adrenalectomy?

  Qing Yang, Jun Du, Zhi-Hua Zhao, Xu-Sheng Chen, Lei Zhou, Xin Yao
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  ABSTRACT: The aim is to develop a staged clinical laparoscopic training program (without laboratory trainings) for beginners to perform laparoscopic adrenalectomy (LA) and to determine its safety and feasibility. Five beginners with no previous experience in adrenalectomy were randomly selected to receive the staged clinical laparoscopic training, including open retroperitoneal adrenalectomy or radical nephrectomy and mentor-initiated clinical laparoscopic training. The clinical data of the 15 LAs performed by each the trainees were collected and compared with the data from the initial 15 LAs of the mentor. All LAs were completed successfully, and no procedure required conversion to open surgery. The median operative time of the trainees was obviously less than the mentor's. The learning curve of the trainees was shorter compared with that of the mentor. The perioperative complication rate was similar between trainees and mentor. Beginners without laboratory trainings could perform LA safely and effectively after they participated in staged clinical laparoscopic training.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):184-8.
• Article: Endoscopic closure of postoperative anastomotic leakage with endoclips and detachable snares.

  Jung Yoon, Hong Sik Lee, Jong Jin Hyun, Chang Duck Kim, Ho Sang Ryu
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  ABSTRACT: Anastomotic leakage, although uncommon, is a life-threatening complication and requires prompt recognition and treatment. Surgical closure has been recommended for defects that are large and symptomatic. However, recent reports on successful endoscopic closure of anastomotic leakage suggest that endoscopic techniques may be a feasible alternative to surgical approaches in patients with comorbid conditions that are not suitable for undergoing second operation or for those who refuse to be reoperated. Herein, we describe a case of postoperative gastrojejunal anastomotic leakage that was successfully treated with endoscopic closure using endoclips and detachable snares.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e74-7.
• Article: Gastroduodenal Intussusception of a Gastrointestinal Stromal Tumor (GIST): Case Report and Review of the Literature.

  David W Rittenhouse, Pei-Wen Lim, Lawrence A Shirley, Karen A Chojnacki
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  ABSTRACT: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in adults. They frequently occur in the stomach. Gastric GISTs typically present as a gastrointestinal bleed but can sometimes cause obstructive symptoms such as nausea and vomiting. We present a patient with a gastric GIST and liver metastases who during treatment with iminitab therapy presented with an acute gastric outlet obstruction. A computed tomography scan revealed a gastroduodenal intussusception of the gastric GIST. The patient underwent a laparoscopic exploration and resection of the GIST. We reviewed the English language literature of GISTs that presented as a gastroduodenal intussusception and put our case in the context of the previously reported cases. We discuss the diagnostic and therapeutic challenges that arise when treating these patients.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e70-3.
• Article: Addition of ketamine to propofol-alfentanil anesthesia may reduce postoperative pain in laparoscopic cholecystectomy.

  Murat Karcioglu, Işil Davarci, Kasim Tuzcu, Yusuf B Bozdogan, Selim Turhanoglu, Akin Aydogan, Muhyittin Temiz
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  ABSTRACT: : The aim of this study was to assess whether intravenous anesthesia supplemented with ketamine reduces postoperative pain after elective laparoscopic cholecystectomy. : Forty patients were enrolled and randomized 1:1 into one of 2 groups: the propofol group (received propofol and alfentanil supplemented with saline) and the ketamine group (received propofol and alfentanil with ketamine). The study was double-blind. The number and amount of the intraoperative additional alfentanil doses were recorded. Pain assessments and cumulative analgesic consumption at postanesthesia care unit (PACU) admission, PACU discharge, postoperative 24th hour, and hospital discharge were recorded. : The visual analog scale scores at PACU admission, PACU discharge, postoperative 24th hour, and hospital discharge were significantly lower in the ketamine group than the propofol group. The pain visual analog scale ≥75 at the postoperative 24th hour for the propofol group was also significantly lower (P<0.035) than that of the ketamine group. The difference in analgesic consumption between groups was statistically significant (P<0.001). : Our study showed that ketamine supplemented with propofol and alfentanil produced better analgesia intraoperatively and postoperatively and decreased analgesic consumption compared with the propofol group after laparoscopic cholecystectomy.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):197-202.
• Article: Effects of combined therapy using partial splenic embolization and transjugular retrograde obliteration on systemic hemodynamics in patients with gastric varices and a splenorenal shunt.

  Fumio Chikamori, Hiroshi Okamoto, Nobutoshi Kuniyoshi, Yasuhiro Takase
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  ABSTRACT: : The purpose of this study was to investigate the effects of combined therapy using partial splenic embolization (PSE) and transjugular retrograde obliteration (TJO) on the systemic hemodynamics of gastric varices with a splenorenal shunt. : Eleven patients having gastric varices with a splenorenal shunt were included in this study. PSE was applied 2 weeks before TJO. Systemic hemodynamic studies were performed before and 22±12 months after the combined therapy. : Complete obliteration of the splenorenal shunt and gastric varices was revealed by retrograde shuntography and computed tomography after TJO in all cases. The cardiac index (1/min/m) before and after the combined therapy was 3.98±0.85 and 4.05±0.78, respectively. The systemic vascular resistance index (dynes s/cm/m) before and after the combined therapy was 1887±450 and 1837±4621, respectively. They showed no significant change. The arterio-venous oxygen content difference (vol%) before and after the combined therapy was 2.55±0.55 and 3.21±0.90, respectively, showing a significant change (P<0.05). The splenic venous flow volume before and after the combined therapy was 307±158 and 166±78 mL/min, respectively, showing a significant change (P<0.05). : We conclude that the combined therapy using PSE and TJO reduces the splenic venous flow and stops the splenorenal shunt flow, which improves the arterio-venous oxygen content difference.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):149-53.
• Article: PEG fixation of an upside-down stomach using a flexible endoscope: case report and review of the literature.

  Péter Lukovich, Ibolyka Dudás, Krisztina Tari, Attila Jónás, György Herczeg
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  ABSTRACT: : Upside-down stomach usually is asymptomatic in adults, but sometimes it can cause regurgitation, vomiting, and weight loss. This condition has an incidence increasing with age thus increasing the risk of surgical intervention. : A 90-year-old man was admitted with dysphagia, postprandial regurgitation, and an 18 kg weight loss in the past year. Gastroscopy revealed a significantly dilated, cranky esophagus and an upside-down stomach. The diagnosis was confirmed by a barium swallow and computed tomography. The stomach was repositioned with a gastroscope using insufflation and an α-loop maneuver under fluoroscopic guidance. A percutaneous endoscopic gastrostomy tube was then inserted to fix the stomach. The patient was discharged on the first postinterventional day. He gained 6 kg in the next 2 months. : High-risk patients with upside-down stomach can be managed by endoscopic repositioning of the stomach and percutaneous endoscopic gastrostomy fixation. This is a useful alternative therapeutic intervention. There have been 14 similar cases being reported in the literature.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e65-9.
• Article: A Prospective Randomized Study of Systemic Inflammation and Immune Response After Laparoscopic Nissen Fundoplication Performed With Standard and Low-pressure Pneumoperitoneum.

  Mario Schietroma, Francesco Carlei, Emanuela M Cecilia, Federica Piccione, Federico Sista, Fabiola De Vita, Gianfranco Amicucci
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  ABSTRACT: : The aim of this study was to compare changes in the systemic inflammation and immune response in the early postoperative (p.o.) period after laparoscopic Nissen fundoplication (LNF) was performed with standard-preassure and low-pressure carbon dioxide pneumoperitoneum. : We studied 68 patients with documented gastroesophageal reflux disease and who underwent a LNF: 35 using standard-pressure (12 to 14 mmHg) and 33 low-pressure (6 to 8 mmHg) pneumoperitoneum. White blood cells, peripheral lymphocites subpopulation, human leukocyte antigen-DR, neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein were investigated. : A significantly higher concentration of neutrophil elastase, IL-6 and IL-1, and C-reactive protein was detected postoperatively in the standard-pressure group of patients in comparison with the low-pressure group (P<0.05). A statistically significant change in human leukocyte antigen-DR expression was recorded p.o. at 24 hours, as a reduction of this antigen expressed on monocyte surface in patients from standard group; no changes were noted in low-pressure group patients (P<0.05). : This study demonstrated that reducing the pressure of the pneumoperitoneum to 6 to 8 mm Hg during LNF is reduced p.o. inflammatory response and avoided p.o. immunosuppression.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):189-96.
• Article: Transumbilical Single-incision Laparoscopic Appendectomy Using Conventional Instruments: The Single Working Channel Technique.

  Zheng Pan, Xiao-Hua Jiang, Jia-Hua Zhou, Zhen-Ling Ji
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  ABSTRACT: : This study aimed to evaluate the feasibility, safety, and cosmetic results of a novel technique, transumbilical single-incision laparoscopic appendectomy (TSILA), using a single working channel with conventional instruments. : The study enrolled 84 consecutive patients undergoing laparoscopic appendectomy for acute appendicitis. To test the advantages of TSILA on the management of patients with acute appendicitis, a prospective randomized clinical trial was conducted. Surgical outcomes such as operation time, complication, and hospital stay of 42 patients undergoing TSILA were analyzed and compared with those of 42 patients undergoing classic 3-port appendectomy. All patients received a follow-up visit for 3 to 12 months. : The study consisted of 42 patients undergoing TSILA and 42 patients undergoing classic 3-port laparoscopic appendectomy with an average age of 34.1 and 34.9 years, respectively. The mean operative time of TSILA did not show any difference when compared with the classic procedure (84.8 vs. 77.9 min, P=0.271). No operative complications occurred in patients undergoing TSILA, whereas 2 patients undergoing the classic procedure showed incisional infection. The average postoperative hospital stay was 2.7 days in the TSILA group and 2.9 days in the classic procedure group with no difference (P=0.316). At the follow-up visit, no patient showed any evidence of incisional hernia. The transumbilical incisions were visible minimally, and the cosmetic scores given by patients undergoing TSILA was higher than that given by patients undergoing the classic procedure (4.5 vs. 3.9, P<0.001). : The results of the study demonstrate that laparoscopic appendectomy can be achieved through a single umbilical incision and a single working channel using conventional instruments and that this approach is successful, safe, economic, and esthetic.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):208-11.
• Article: Postoperative vision loss after colorectal laparoscopic surgery.

  Gautam Kumar, Prasad Vyakarnam
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  ABSTRACT: Postoperative loss of vision is a serious but under-appreciated complication after surgery. Although more commonly seen with cardiac and spinal surgery, we report a rare case where ischemic optic neuropathy is associated with laparoscopic surgery. An ASA-2 middle-aged man with hypertension and obesity underwent a laparoscopic resection of rectosigmoidal adenocarcinoma. Intraoperatively, no surgical complications were noted with minimal blood loss encountered. He was positioned in a steep Trendelenberg position for 5 continuous hours, and had a mean blood pressure of at least 75 mm Hg throughout. Postoperatively, he had obvious facial and periorbital swelling. Initial decreased visual acuity was noted immediately and this only partially improved over several days and weeks. Magnetic resonance imaging and angiography revealed no structural abnormality and after ophthalmology review, a diagnosis of ischemic optic neuropathy was made. We describe a case showing the association of postoperative loss of vision with laparoscopic surgery and prolonged Trendelenberg positioning.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e87-8.
• Article: Incidence of postoperative venous thromboembolism after laparoscopic versus open colorectal cancer surgery: a meta-analysis.

  Guoce Cui, Xiaofeng Wang, Weiwei Yao, Huashan Li
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  ABSTRACT: The objective of this study was to systematically compare the incidence of postoperative venous thromboembolism (VTE; deep vein thrombosis and/or pulmonary embolism) in patients with colorectal cancer after laparoscopic surgery and conventional open surgery. A systematic search of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted. Eleven randomized control trials involving 3058 individuals who reported VTE outcomes were identified, of whom 1677 were treated with laparoscopic therapy and 1381 underwent open surgery. The combined results of the individual trials showed no statistically significant difference in the odds ratio for overall VTE (odds ratio 0.64, 95% confidence interval, 0.33-1.23, P=0.18), as well as in subgroups of deep vein thrombosis and anticoagulant prophylaxis between these 2 approaches. In conclusion, laparoscopic resection could achieve similar outcomes in terms of the incidence of VTE, which are associated with long-term benefits of the patients.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):128-34.
• Article: Effect of laparoscopic surgery on oxidative stress response: systematic review.

  Eugenia Ch Yiannakopoulou, Nikolaos Nikiteas, Despina Perrea, Christos Tsigris
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  ABSTRACT: This systematic review aimed to investigate: (a) the impact of laparoscopic surgery on oxidative stress (OS) and (b) the effect of laparoscopic surgery on OS in comparison with open surgery. Eligible trials were clinical trials or retrospective studies with at least 1 arm for laparoscopic surgery with measurements of at least 1 marker of OS or of antioxidant defenses. Twenty-nine trials fulfilled inclusion criteria. There was a great heterogeneity on measured OS markers, methods, and time periods of measurement and on the type of investigated operations. Methodological issues were raised including heterogeneity on study design, lack of reliability, low sensitivity, low specificity of the applied assays, and the limitations of the statistical methods. However, results were highly discordant with some studies suggesting less pronounced OS after laparoscopic surgery, other studies suggesting potentiation of OS after laparoscopic surgery and some studies demonstrating no difference in OS between open and laparoscopic surgery.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):101-8.
• Article: Lesser curvature approach in laparoscopic distal pancreatectomy.

  On Suzuki, Fumitaka Nakamura, Yoshiyasu Ambo, Toru Nakamura, Akihiro Kishida, Nobuichi Kashimura
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  ABSTRACT: Laparoscopic distal pancreatectomy (LDP) has entailed ventrally retracting the stomach to afford adequate visualization. The retracted stomach commonly droops over the pancreas and obstructs the surgical field, thus forcing the assistant surgeon to repeatedly lift the stomach out of the way ventrally and cranially. We herein reported LDP using the "lesser curvature approach" in which the pancreas was approached cephalad to the lesser curvature of the stomach in underweight patients with a coincidental low hanging stomach. An excellent view of both the distal pancreas and the spleen could be afforded, enabling complete mobilization of these organs from the retroperitoneum and easy ligation of the splenic vessels, without needing to retract the stomach ventrally and cranially. The lesser curvature approach in LDP could be performed safely and efficiently as an alternative to the conventional greater curvature approach in underweight patients with a low hanging stomach.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e57-60.
• Article: Single-Trocar Transumbilical Laparoscopy-assisted Management of Complicated Jejunal Diverticula.

  Michail Pitiakoudis, Sotirios Botaitis, Konstantinos Romanidis, Dimitrios Charalampidis, Alexandros Polychronides, Constantinos Simopoulos
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  ABSTRACT: Small-intestinal nonmeckelian diverticula are very uncommon and are considered to be acquired pulsion diverticula. Most of these diverticula are asymptomatic and are simply incidental findings. Complicated-acquired diverticular disease of the jejunum and ileum is a diagnostic dilemma. Small-bowel diverticulum is diagnosed with the aid of radiography techniques, such as small-bowel contrast series or enteroclysis. Laparotomy remains the gold standard for a definite diagnosis of asymptomatic and complicated diverticula, but laparoscopy is also very useful in the diagnosis and treatment of this condition. A surgical approach is the best form of treatment for complicated jejunoileal diverticula. The current report is about a patient who presented with iron deficiency anemia caused by a complicated jejunal diverticulum and managed with single-trocar transumbilical laparoscopy.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e78-80.
• Article: Oncological 3-port laparoscopic colectomy by 1 surgeon and 1 camera operator: a preliminary report.

  Fumi Hasegawa, Yutaka J Kawamura, Junichi Sasaki, Shingo Tsujinaka, Fumio Konishi
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  ABSTRACT: This retrospective study analyzed the short-term outcomes of oncological reduced-port laparoscopic colectomy (RPLC) using 3 ports performed by 1 surgeon and 1 camera operator. Patients who underwent laparoscopic colectomy for colorectal carcinoma in 2010 and 2011 were divided into 2 groups: the CLC group, which included 62 patients who underwent a conventional laparoscopic colectomy and the RPLC group, which included 28 patients who underwent reduced-port laparoscopic colectomy, respectively. There were no significant differences between the groups with regard to TNM stage, estimated blood loss, complications, conversion rate, pain score, the length of postoperative stay, or the number of harvested lymph nodes. However, the prevalence of right-side colectomy was higher and the operative time was significantly shorter in the RPLC group. RPLC was technically feasible, providing that the appropriate patients were selected. Therefore, even though its surgical benefit might be subtle, we believe that RPLC definitively contributes to the reduction of equipment and manpower costs and will be considered as a standard procedure in the near future.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):176-9.
• Article: Pure laparoscopic subsegmentectomy of the liver using a puncture method for the target portal branch under percutaneous ultrasound with artificial ascites.

  Masahiko Sakoda, Shinichi Ueno, Satoshi Iino, Koji Minami, Kei Ando, Yota Kawasaki, Hiroshi Kurahara, Yukou Mataki, Kousei Maemura, Hiroyuki Shinchi, Shoji Natsugoe
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  ABSTRACT: : It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC) and, consequently, laparoscopic hepatic resection is widely performed. However, most anatomic resections, except left lateral sectionectomy, are still difficult technically and, as an alternative approach, laparoscopy-assisted procedures also have been introduced because of the safety and curative success of the operation. Herein, we describe pure laparoscopic subsegmentectomy of the liver using puncture of the portal branch under percutaneous ultrasound (US) with artificial ascites. : Pure laparoscopic subsegmentectomy of segment 6 (S6) was planned for a patient with HCC of S6 of the liver. The identification of the segment was performed by dye injection under percutaneous US guidance with artificial ascites. : The procedure was completed successfully in a minimally invasive manner with an operative time of 260 minutes and with intraoperative blood loss of 10 mL. The difference between the size of the resected specimen and that estimated by 3-dimensional computed tomography was very small. The postoperative course was uneventful and the patient was discharged 10 days after surgery. : Pure laparoscopic subsegmentectomy for HCC with a conventional puncture technique under percutaneous US with artificial ascites is considered to be a useful procedure featuring both low invasiveness and curative success.
  Surgical laparoscopy, endoscopy & percutaneous techniques 04/2013; 23(2):e45-8.