Sleeve gastrectomy for morbid obesity

The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m2) seeking surgical treatments has led to the search for surgical techniques that provide adequate EWL with the least possible morbidity. Sleeve gastrectomy (SG) was initially added as a modification to the biliopancreatic diversion (BPD) and then combined with a duodenal switch (DS) in 1988. It was first performed laparoscopically in 1999 as part of a DS and subsequently done alone as a staged procedure in 2000. With the revelation that patients experienced weight loss after SG, interest in using this procedure as a bridge to more definitive surgical treatment has risen. Benefits of SG include the low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption and the ability to convert to multiple other operations. Reduction of the ghrelin-producing stomach mass may account for its superiority to other gastric restrictive procedures. SG should be in the armamentarium of all bariatric surgeons. Nonetheless, long-term studies are necessary to see if it is a durable procedure in the treatment of morbid obesity.

Changes in insulin resistance following bariatric surgery: role of caloric restriction and weight loss

The prevalence of type 2 diabetes mellitus (T2DM) and obesity in the western world is steadily increasing. Bariatric surgery is an effective treatment of T2DM in obese patients. The mechanism by which weight loss surgery improves glucose metabolism and insulin resistance remains controversial. In this review, we propose that two mechanisms participate in the improvement of glucose metabolism and insulin resistance observed following weight loss and bariatric surgery: caloric restriction and weight loss. Nutrients modulate insulin secretion through the entero-insular axis. Fat mass participates in glucose metabolism through the release of adipocytokines. T2DM improves after restrictive and bypass procedures, and combinations of restrictive and bypass procedures in morbidly obese patients. Restrictive procedures decrease caloric and nutrient intake, decreasing the stimulation of the entero-insular axis. Gastric bypass (GBP) operations may also affect the entero-insular axis by diverting nutrients away from the proximal GI tract and delivering incompletely digested nutrients to the distal GI tract. GBP and biliopancreatic diversion combine both restrictive and bypass mechanisms. All procedures lead to weight loss and decrease in the fat mass. Decrease in fat mass significantly affects circulating levels of adipocytokines, which favorably impact insulin resistance. The data reviewed here suggest that all forms of weight loss surgery lead to caloric restriction, weight loss, decrease in fat mass and improvement in T2DM. This suggests that improvements in glucose metabolism and insulin resistance following bariatric surgery result in the short-term from decreased stimulation of the entero-insular axis by decreased caloric intake and in the long-term by decreased fat mass and resulting changes in release of adipocytokines. Observed changes in glucose metabolism and insulin resistance following bariatric surgery do not require the posit of novel regulatory mechanisms.

Totally transumbilical laparoscopic cholecystectomy

A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass

BACKGROUND

Marginal ulceration (MU) is a well-known complication after gastrojejunostomy; however, its incidence has rarely been reported in bariatric studies. We present 16 cases of documented MU after laparoscopic gastric bypass (LGBP) that were successfully treated with proton pump inhibition (PPI).

METHODS

All patients undergoing LGBP from October 2002 to August 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with MU were analyzed. MU was diagnosed when patients presented postoperatively with mid-epigastric pain and/or upper gastrointestinal bleeding that responded to PPI or endoscopic intervention. Analysis of variance and Student's t test were used for the statistical analyses.

RESULTS

MU was diagnosed in 16 (4%) of 347 patients in whom LGBP was performed. An additional 10 patients had symptoms suggestive of MU, which raised the incidence as great as 7%. Of the 26 patients, 18 were women and 8 were men (age range 23-53 years), with a preoperative body mass index 37.1-63.9 kg/m2, similar to that of the patients who did not develop MU. Compared with the patients who did not develop MU, the operative times were longer in the MU group (180.5 versus 140.4 minutes, P <0.001). Of the 26 patients, 10 presented with abdominal pain and 16 with upper gastrointestinal bleeding. The mean interval between the initial LGBP and subsequent MU was 6.3 months (range 1-13). After an initial history and physical examination, upper endoscopy confirmed the diagnosis of MU in 16 patients. Three patients who developed MU were receiving chronic anticoagulation medication. All patients who developed MU began high-dose PPI, which resulted in 100% resolution of MU within 8 weeks. Since January 2005, 73 patients were given prophylactic PPI therapy postoperatively, with no patients subsequently developing MU (P = 0.006).

CONCLUSION

We report 16 documented cases of MU occurring after LGBP. This underreported complication can be successfully treated with PPI, although MU complicated by gastrogastric fistula may require operative intervention. The institution of routine PPI therapy after LGBP lowered the short-term incidence of MU at our institution. Additionally, we recommend that all patients who undergo LGBP be given prophylactic PPI therapy postoperatively.

Evaluation of resident laparoscopic performance using global operative assessment of laparoscopic skills

BACKGROUND

The Global Operative Assessment of Laparoscopic Skills (GOALS), developed by Vassiliou and colleagues, has construct validity in the assessment of surgical residents' laparoscopic skills in dissection of the gallbladder from the liver bed. We hypothesized that GOALS would have construct validity for the entire laparoscopic cholecystectomy procedure and also for laparoscopic appendectomy.

METHODS

Using GOALS, attending surgeons evaluated PGY1 through PGY5 surgical resident performance during laparoscopic cholecystectomy (LC, n = 51) and laparoscopic appendectomy (LA, n = 43). Scores for five domains (depth perception, bimanual dexterity, efficiency, tissue handling, and autonomy) were recorded on a Web-based operative report generator at the conclusion of all cases. Domain scores were recorded using a 5-point Likert scale. Difficulty of the case was similarly rated on a 5-point scale. For analysis, residents were divided into two groups: novice (PGY1 to 3) and experienced (PGY4 to 5). Biostatistical analysis was performed using a two-sample t-test. Paired t-test was used to compare mean scores of residents who performed both LA and LC.

RESULTS

For both LC and LA, the experienced group scored higher than novices did in all five domains. The differences were significant in all domains. Using the mean of the scores from all 5 domains for both LC and LA, the experienced residents scored significantly better than novices did (LC 3.93 versus 2.76, p < 0.001) (LA 4.22 versus 2.75, p < 0.001). No significant differences were noted in difficulty of the cases (p = 0.060 for LC and p = 0.19 for LA).

CONCLUSIONS

This study provides additional evidence in support of GOALS as an assessment tool for objectively measuring technical skills in laparoscopic surgery.

Laparoscopic pancreatoduodenectomy: a review of 285 published cases

BACKGROUND

Given the difficulty level of minimally invasive pancreatoduodenectomy (MIPD), limited data exist for a comparison to open pancreatoduodenectomies. As the technique becomes more diffuse, issues regarding the adequacy of oncologic margins and lymph node retrieval need to be addressed.

METHODS

All published cases of MIPD were examined. Variables analyzed included conversion rates, operating room time, estimated blood loss, length of stay, follow-up, complications, mortality, lymph node retrieval, and margins.

RESULTS

Twenty-seven articles describing outcomes after MIPD were found, and a total of 285 cases were described. Main malignancy treated was pancreatic adenocarcinoma, accounting for 32% of all cases. Eighty-seven percent were performed totally laparoscopically, and 13% were performed with a hand-assisted approach to facilitate the reconstruction step of the procedure. The rate of conversion to an open procedure was 9%. Estimated blood loss had a weighted average (WA) of 189 mL. Average length of stay had a WA of 12 days, and average follow-up had a WA of 14 months. The overall complication rate was 48%, and the overall mortality rate was 2%. Average lymph nodes retrieved ranged from 7 to 36 nodes, with a WA of 15 nodes, and positive margins of resection were reported to be positive in 0.4% of patients with malignant disease.

CONCLUSIONS

This review found similar outcomes with respect to perioperative morbidity and mortality rates compared to open pancreatoduodenectomies. The oncologic goals of pancreatic resection may be able to be achieved by MIPD, but longer follow-up and larger series are still needed.

Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique

INTRODUCTION

Initial excitement for Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been partly tempered by the reality that a NOTES procedure without laparoscopic or needleoscopic-assistance has not been performed by most groups. After safely performing laparoscopically-assisted transvaginal cholecystectomy in an IACUC-approved porcine model, we embarked on an IRB-approved protocol to ultimately perform a pure NOTES cholecystectomy.

MATERIALS AND METHODS

We describe our experience with performing a true NOTES tansvaginal cholecystectomy after safely accomplishing 3 laparoscopically-assisted hybrid NOTES procedures in humans. To overcome the retracting limitations of currently available endoscopes, we used a 5-mm curved or articulating retractor that was placed into the abdomen via a separate colpotomy in the second and third patient. In a fourth patient, pneumoperitoneum to 15 torr was obtained via a transvaginal trocar placed through a colpotomy made under direct vision and endoscopically placed clips were used for both the cystic duct and artery, thus, obviating the need for any transabdominally placed instruments or needles.

RESULTS

This patient was the first patient to undergo a completely NOTES cholecystectomy at our institution and to our knowledge in the United States. She was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up.

CONCLUSION

Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans. Additional experience with this technique will be required before comparative studies to standard laparoscopy and hybrid techniques are appropriate.

Review of the clinical, histological, and molecular aspects of pancreatic endocrine neoplasms

Pancreatic endocrine neoplasms (PENs) are rare tumors, and little is known about their genetic and chromosomal alterations. Elucidation of the molecular events involved in PEN carcinogenesis has been hindered by the fact that PENs have been considered a single disease entity. The emergence of novel molecular characterization strategies has, however, made it apparent that these lesions exhibit diverse molecular fingerprints, which will facilitate the precise delineation of PEN prognosis, histopathology, and carcinogenesis.

Revisional bariatric surgery for inadequate weight loss

When behavioral or anatomic issues are not present, revisional surgery should be approached with a goal of treating malnutrition or enhancing excess weight loss. Unfortunately, no randomized controlled trials currently exist to help the practicing bariatric surgeon choose which revisional procedure to perform. A review of the available literature was undertaken and compared with our standard practices to see if any guidelines could be devised. At our institution, patients who have failed jejunal-ileal bypass are reversed in the setting of malnutrition and converted to a sleeve gastrectomy (SG) followed by duodenal switch (DS) as a second stage procedure in the setting of inadequate weight loss. After failed vertical banded gastroplasty (VBG), patients are converted to a Roux-en-Y gastric bypass (RYGBP). After failed adjustable gastric band (AGB) placement, we perform RYGBP. In the super-obese, we leave the band in place or convert to a DS with band removal. In patients with failed RYGBP, we convert our patients to DS, but placement of an AGB may be an acceptable option.

The open anterior paramedian retroperitoneal approach for spine procedures

HYPOTHESIS

With the advent of anterior lumbar interbody fusion and artificial disk replacement as common procedures for the treatment of many spinal problems, anterior exposure has become an increasingly popular procedure for general, thoracic, urologic, and vascular surgeons. Despite this, the body of literature describing this procedure, especially the general and vascular surgery literature, is lacking.

DESIGN

A retrospective review of medical records was performed for patients operated on from April 2002 to March 2004.

SETTING

Tertiary care university hospital.

PATIENTS

In total, 64 open retroperitoneal exposures for anterior spinal approaches were performed. Thirty-five (55%) were performed on men and 29 (45%) on women.

INTERVENTIONS

Fifty patients (78%) required lumbosacral approaches, and 14 (22%) required access to purely lumbar disk spaces. Forty-three patients underwent single-disk approaches, and 21 required access to either 2 or 3 levels. Forty patients (63%) underwent anterior lumbar interbody fusion, and 22 (34%) had a Prodisc disk replacement.

MAIN OUTCOME MEASURES

We analyzed intraoperative and early postoperative complications.

RESULTS

The average age was 43 years (range, 25-89 years), 42 and 44 years for men and women, respectively. Ninety-seven percent of all attempted retroperitoneal exposures were successful. Intraoperative complications occurred in 5 patients (8%) and included inability to mobilize the iliac veins, injury to the iliac vein, and ureteral tear. The postoperative course was complicated in 8 patients (14%) and included fever, urinary retention, spinal headache, Clostridium difficile colitis, and ileus.

CONCLUSION

Open retroperitoneal exposure to the lumbar and lumbosacral vertebral bodies can be performed safely with a multidisciplinary approach that maximizes the various surgical skills of the orthopedic and vascular or general surgeon, reducing complication rates in anterior spinal surgery.

Minimally invasive approaches to extrapancreatic cholangiocarcinoma

BACKGROUND

Due to the perceived difficulty in dissecting gallbladder cancers and extrapancreatic cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques to remove these tumors. Furthermore, due to the relative rarity of these tumors when compared to hepatocellular carcinoma, only a few reports have focused on short- and long-term results.

METHODS

We performed a review by combining the experience of three international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database prospectively. All patients with gallbladder cancer and cholangiocarcinoma were analyzed; patients with distal cholangiocarcinomas who underwent laparoscopic pancreatoduodenectomies were excluded. Patients were divided according to if they had gallbladder cancer, hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma.

RESULTS

A total of 15 patients underwent laparoscopic resection for gallbladder cancer and 10 for preoperatively suspected gallbladder cancer, and 5 underwent laparoscopic completion procedures. An average of four lymph nodes (range = 1-11) were retrieved and all patients had an R0 resection. One patient (7 %) required conversion to an open procedure. No patients developed a biliary fistula, required percutaneous drainage, or had endoscopic stent placement. One patient had a recurrence at 3 months despite a negative final pathological margin, and a second patient had a distant recurrence at 20 months with a mean follow-up of 23 months. Nine patients underwent laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. All anastomoses were completed laparoscopically. Biliary fistula was seen in two patients, one of which died after a transhepatic percutaneous biliary drain resulted in uncontrollable intra-abdominal hemorrhage despite reoperation. A third patient developed a pulmonary embolism. Thus, the morbidity and mortality rates were 33 and 11 %, respectively. One patient was converted to open and six patients (66 %) are alive with a median follow-up of 22 months. Five patients underwent minimally invasive resection for hilar cholangiocarcinoma; of these, two also required laparoscopic major hepatectomy. The mean estimated blood loss (EBL) was 240 mL (range = 0-400 mL) and the median length of stay (LOS) was 15 days (range = 11-21 days). All patients are alive with a median follow-up of 11 months (range = 3-18 months). None of the 29 patients developed port site recurrences.

CONCLUSION

Minimally invasive approaches to gallbladder cancer and intrahepatic and extrahepatic cholangiocarcinoma seem feasible and safe in the short term. Larger series with longer follow-up are needed to see if there are any long-term disadvantages or advantages to laparoscopic resection of extrapancreatic cholangiocarcinoma.

Management of gastrogastric fistula after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Gastrogastric fistula (GGF) secondary to marginal ulceration (MU) is a reported complication of open Roux-en-Y gastric bypass; however, its frequency after laparoscopic gastric bypass (LGBP) is likely underreported. We present five cases of GGF and detail the management algorithm, including medical, endoscopic, and laparoscopic interventions.

METHODS

Data from 282 patients undergoing LGBP from October 2002 to January 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with GGF were analyzed. Patients who developed GGF were compared with those who did not using Student's t-test.

RESULTS

Five patients (1.8%) subsequently developed GGF. Upper gastrointestinal radiographic evaluation documented the presence of a GGF in these patients, and upper endoscopy confirmed the diagnosis of MU. The mean interval between initial LGBP and subsequent diagnosis of GGF was 8.8 months. Patients who developed GGF were significantly younger (32.4 years vs 41.2 years; P = .007) and had lost significantly more weight 1 year after surgery (82.7% excess weight loss vs 70.0% excess weight loss; P = .003). No difference was noted when comparing operative time (164 minutes vs 148 minutes) or preoperative BMI (45.6 kg/m2 vs 51.4 kg/m2). All MU/GGF patients were treated initially with high-dose proton pump inhibitor (PPI) therapy. In one patient, the GGF closed with PPI therapy alone. A second patient's GGF was successfully resolved with PPI therapy plus endoscopic injection of fibrin sealant. The remaining three cases were managed with laparoscopic division of the fistula after initial unsuccessful PPI therapy. In these patients, the GGF was of larger diameter than in those patients whose GGF closed with medical therapy alone.

CONCLUSIONS

MU/GGF should be considered in the differential diagnosis of all postoperative gastric bypass patients who present with abdominal pain. In our series, GGF was always associated with MU. Early diagnosis of GGF can be successfully treated with PPI therapy. Smaller-diameter tracts that do not resolve with medical therapy may respond to endoscopic therapy. Large-caliber fistula are less likely to respond to medical or endoscopic therapy but can be managed laparoscopically.

Totally laparoscopic extended left hepatectomy

This video will discuss the main steps necessary to perform a totally laparoscopic extended left hepatectomy including partial or complete resection of the middle hepatic vein and resection of segment I. Although totally laparoscopic extended liver resections are currently only being performed in several centers with experience in both minimally invasive and hepatobiliary surgery, it will likely become more common, as more surgeons gain expertise in both of these disciplines.

Totally laparoscopic central hepatectomy

This video will show the pertinent steps to perform a totally laparoscopic central hepatectomy. The main steps of this procedure include control of the hepatic inflow, mobilization of the right liver, control of the hepatic outflow, and specimen removal. This technique is feasible and safe via laparoscopic techniques, but should currently be performed at high volume centers by surgeons with expertise in both HPB surgery and minimally invasive techniques.

Obesity, pancreatitis, and pancreatic cancer

The only universally accepted risk factors for the development of pancreatic cancer are a positive family history or a history of smoking. Although the contribution of pancreatitis to pancreatic carcinogenesis has been debated for decades in the epidemiology literature, the actual mechanism is still unclear. With the rising epidemic of obesity, scientists have begun to focus on the contribution of chronic inflammatory state of morbidly obese patients in an effort to better understand the contribution of inflammation to the comorbidities of obesity. Notably, population studies are beginning to show that one of the most serious potential comorbidities of obesity is an increased lifetime risk of developing cancer. In this article, the current literature that exists supporting this Chronic Inflammatory Hypothesis as it pertains to obesity and pancreatic carcinogenesis is reviewed. To date, studies have focused on interleukin-6, a cytokine known to play a role in obesity, chronic pancreatitis and pancreatic cancer. The anti-inflammatory adipocytokine, adiponectin, has also shown promise as a key player in this mechanism and has recently been found to be more specific than standard tumor markers in differentiating pancreatic cancer from chronic pancreatitis. If the pathogenesis of pancreatic cancer is related to hormone levels associated with obesity, such as adipocytokines, and cytokines associated with chronic inflammation, this could potentially lead to the development of new pancreatic cancer tumor markers and ultimately new therapies and methods of prevention.

Artificial Intelligence Surgery: How Do We Get to Autonomous Actions in Surgery?

Most surgeons are skeptical as to the feasibility of autonomous actions in surgery. Interestingly, many examples of autonomous actions already exist and have been around for years. Since the beginning of this millennium, the field of artificial intelligence (AI) has grown exponentially with the development of machine learning (ML), deep learning (DL), computer vision (CV) and natural language processing (NLP). All of these facets of AI will be fundamental to the development of more autonomous actions in surgery, unfortunately, only a limited number of surgeons have or seek expertise in this rapidly evolving field. As opposed to AI in medicine, AI surgery (AIS) involves autonomous movements. Fortuitously, as the field of robotics in surgery has improved, more surgeons are becoming interested in technology and the potential of autonomous actions in procedures such as interventional radiology, endoscopy and surgery. The lack of haptics, or the sensation of touch, has hindered the wider adoption of robotics by many surgeons; however, now that the true potential of robotics can be comprehended, the embracing of AI by the surgical community is more important than ever before. Although current complete surgical systems are mainly only examples of tele-manipulation, for surgeons to get to more autonomously functioning robots, haptics is perhaps not the most important aspect. If the goal is for robots to ultimately become more and more independent, perhaps research should not focus on the concept of haptics as it is perceived by humans, and the focus should be on haptics as it is perceived by robots/computers. This article will discuss aspects of ML, DL, CV and NLP as they pertain to the modern practice of surgery, with a focus on current AI issues and advances that will enable us to get to more autonomous actions in surgery. Ultimately, there may be a paradigm shift that needs to occur in the surgical community as more surgeons with expertise in AI may be needed to fully unlock the potential of AIS in a safe, efficacious and timely manner.

Open anterior approaches for lumbar spine procedures

With the advent of anterior lumbar interbody fusion (ALIF) and artificial discs as common procedures for the treatment many spinal problems such as pseudoarthrosis, degenerative disc disease and internal disc disruption from trauma, anterior exposure has become an increasingly popular procedure for the general, thoracic, urologic and vascular surgeon. Despite this, the body of literature describing this procedure is lacking. Dividing the approach for anterior spinal surgery into the thoracolumbar, mid-lumbar, and lumbosacral regions, we describe the basic techniques and anatomy needed to perform these open approaches, specifically, repairs of disc spaces T12-L2, L2-5, and L5-S1, respectively. The technique for the retroperitoneal approach will be discussed in detail; however, issues involved with indications for transperitoneal approach and technical "pearls" will also be discussed.

Modified robotic lightweight endoscope (ViKY) validation in vivo in a porcine model

The added precision and steadiness of a robotically held camera enables the performance of more complex procedures laparoscopically. In contrast to typical laparoscope holders, the modified lightweight robotic endoscope, the ViKY system is particularly compact, simple to set up and use, and occupies no floor space. Ease and safety of setup was confirmed in a porcine model and several common general surgical procedures were performed. The sterilizable endoscope manipulator is sufficiently small to be placed directly on the operating room table without interfering with other handheld instruments during minimally invasive surgery. The endoscope manipulator and its user interface were tested and evaluated by several surgeons during a series of 5 minimally invasive surgical training procedures in a porcine model. The endoscope manipulator described has been shown to be a practical device with performance and functionality equivalent to those of commercially available models, yet with greatly reduced size, weight, and cost.

Revision open anterior approaches for spine procedures

BACKGROUND CONTEXT

Anterior exposure has become an increasingly popular procedure for the general and vascular surgeon due to the increased use of anterior lumbar interbody fusion and artificial disc replacement for the treatment of many spinal problems.

PURPOSE

Because of this increase, revision operations have become increasing necessary. Despite this, there is almost no literature dealing with the issues related to these complex revision operations.

STUDY DESIGN

A retrospective review of charts was performed on patients operated on from April 2002 until October 2004 in two tertiary care hospitals.

METHODS

In total, 218 open exposures for anterior lumbar spinal approaches were performed of which 9 patients required revision lumbar spinal operations. Seven patients were approached again anteriorly (78%), and 2 (22%) patients required a combined anterior and posterior approach.

RESULTS

The nine cases were the number of revision procedures performed over the 16-month period of this study. The average age was 44 overall (range, 25-89) and 53 (33-73) for the revision operations, p>.05. All revision operations attempted were successful. Seven (78%) of the secondary procedures could be approached retroperitoneally whereas 2 (22%) patients required transperitoneal approaches owing to the degree of adhesions. The average length until revision surgery was 13 months (range 6-24). No patients required early revision defined as surgery within 30 days from the primary surgery. Early complications occurred in 4 patients (44%), and included dural tear, median nerve dysthesia, left common femoral nerve palsy further complicated by prolonged postoperative ileus and retrograde ejaculation. Late complications occurred in one patient and consisted of a deep venous thrombosis and urinary tract infection. The average length of stay was 6 days (SD 2.7 days) (range 4-12) compared with 4 days (SD 2.3 days) (range 2-22) for the index operations, p>.05.

CONCLUSION

Revision anterior open exposure to the lumbar and lumbosacral vertebral bodies can be performed safely, but is associated with an increased rate of early complications. Nonetheless, these complications are self-limited and highlight the importance of a multidisciplinary approach in maximizing the various surgical skills of spine (orthopedic and neurosurgical) and exposure (vascular and general) surgeons in reducing serious complications in revision anterior lumbar spinal surgery.

Multimedia article. Totally laparoscopic extended right hepatectomy

BACKGROUND

This video demonstrates the relevant technical maneuvers necessary for performing a totally laparoscopic extended right hepatectomy.

METHODS

The five principal steps of this procedure include mobilization of the liver, control of hepatic inflow, division of the hepatic parenchyma, control of the hepatic outflow, and removal of the specimen.

RESULTS

A total of five totally laparoscopic extended right hepatectomies have been performed successfully at our institution. Our short- and long-term results have been similar to those for our open historical control subjects. No mortalities have been observed.

CONCLUSION

The minimally invasive approach to hepatic resections is limited by the comfort level of the operator and not the technique itself.

Laparoscopic vs. open resection of noninvasive intraductal pancreatic mucinous neoplasms

Required resection margins for noninvasive intraductal papillary mucinous neoplasms (IPMNs) are a controversial issue. Over a 10-year period we have resected IPMNs from the entire pancreatic gland with minimally invasive techniques and compared our survival and complication rates with open controls to see if any difference in resection margins and outcomes could be observed. Data were collected retrospectively, including our first cases of advanced laparoscopic resections. Five-year Kaplan-Meier curves were calculated and statistical analysis was performed using the log rank and Student's T test for continuous variables. Chi square and Fisher's exact tests were used for analyzing categorical variables. From March 1997 to February 2006, we operated on 22 patients with noninvasive IPMNs, of which 9 (41%) were operated on laparoscopically and 13 (59%) using open techniques. Three patients underwent laparoscopic duodenopancreatectomy, compared to five in the open group. All resection margins were negative, but two patients required total pancreatectomy, both of which were performed laparoscopically. One of these was converted to open (11%) because of difficulty in reconstructing the biliary anastomosis. The overall complication rates were 56% for the laparoscopic group and 85% for the open group. Twenty-two percent of the laparoscopic group required reoperation and 11% required percutaneous drainage, compared to 15 and 23% in the open group, respectively. All patients are alive after a mean of 20 months (range = 2-43) in the laparoscopic group and 37 months (range = 1-121) in the open one (p > 0.05). Laparoscopic resection of noninvasive IPMNs of the entire pancreatic gland has similar complication and survival rates as open procedures. As a result, the laparoscopic approach is appropriate for noninvasive IPMNs of the entire pancreatic gland; however, larger cohorts are needed to see if any approach has superior outcomes. Because of these favorable results, studies are currently underway to see if the minimally invasive approach is also appropriate for invasive IPMNs.

Laparoscopic liver resection: when to use the laparoscopic stapler device

Minimally invasive hepatic resection was first described by Gagner et al. in the early 1990s and since then has become increasingly adopted by hepatobiliary and liver transplant surgeons. Several techniques exist to transect the hepatic parenchyma laparoscopically and include transection with stapler and/or energy devices, such as ultrasonic shears, radiofrequency ablation and bipolar devices. We believe that coagulative techniques allow for superior anatomic resections and ultimately permit for the performance of more complex hepatic resections. In the stapling technique, Glisson's capsule is usually incised with an energy device until the parenchyma is thinned out and multiple firings of the staplers are then used to transect the remaining parenchyma and larger bridging segmental vessels and ducts. Besides the economic constraints of using multiple stapler firings, the remaining staples have the disadvantage of hindering and even preventing additional hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during minimally invasive major hepatic resections. Techniques to safely perform major hepatic resection with the above techniques will be described with an emphasis on when and how laparoscopic vascular staplers should be used.

Video: the lateral laparoscopic approach to lesions in the posterior segments

Although some authors believe that laparoscopy is contraindicated for the posterior hepatic segments, we believe that lesions in these segments are actually an indication for the minimally invasive approach. This video will illustrate the pertinent issues regarding instrument selection, trochar placement, intraoperative monitoring and steps necessary to perform laparoscopic resection of the posterior hepatic segments using totally laparoscopic techniques.