Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome

BACKGROUND

The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate.

METHODS

In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. "Tension-free" repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis-Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction.

RESULTS

There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis-Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique.

CONCLUSIONS

To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis-Nissen procedure in such cases.

Randomized clinical trial of robot-assisted versus laparoscopic Nissen fundoplication

BACKGROUND

Several studies have shown the safety and feasibility of robot-assisted antireflux surgery but comparative data are lacking.

METHODS

Fifty consecutive patients scheduled for laparoscopic antireflux surgery were randomized into two groups. Twenty-five patients underwent robot-assisted surgery and 25 standard laparoscopic fundoplication. All robot-assisted procedures were performed with the da Vinci Surgical System.

RESULTS

There were no significant differences in age, sex, body mass or preoperative reflux pattern between the groups. Operating times were significantly longer for robot-assisted than standard laparoscopic operations (mean total operating time 131.3 versus 91.1 min, P < 0.001; skin-to-skin time 78.0 versus 63.5 min, P = 0.001). There was no conversion to open surgery. Conversion to standard laparoscopy was necessary in one of 25 robot-assisted procedures. The length of hospital stay was similar in both groups. Robot-assisted surgery was associated with significantly higher mean total costs (euro 3157 versus euro 1527; P < 0.001). There were no significant differences in clinical, endoscopic and functional outcomes between groups. There was no procedure-related mortality.

CONCLUSION

Robot-assisted laparoscopic fundoplication is comparable to the standard laparoscopic procedure in terms of feasibility and outcome, but costs are higher owing to longer operating times and the use of more expensive instruments.

Transanal endoscopic microsurgery in rectal adenomas: experience of six Italian centres

BACKGROUND/AIMS

Transanal endoscopic microsurgery is a minimally invasive technique that allows the excision of benign and selected malignant tumours. We present a study for evaluating surgical morbidity, mortality and local recurrence rate of patients with rectal adenomas treated with transanal endoscopic microsurgery in six different Italian centres following the same protocol.

METHODS

A total of 882 patients with rectal lesions (adenomas and early stage of carcinomas) underwent transanal endoscopic microsurgery in six different Surgical Departments from January 1993 to October 2004. Five hundred and ninety patients had preoperative diagnosis of adenomas but 588 patients were regularly followed up to determine treatment efficacy in terms of local recurrence rate.

RESULTS

The study involved 588 patients, with a median age of 66 years (25th percentile-75th percentile=58-71 years). No postoperative mortality was reported. Intraoperative complications were observed in three patients (0.5%). Minor complications occurred in 48 patients (8.2%) whereas major complications were found only in 7 patients (1.2%). Definitive histology confirmed adenomas in 530 cases (90.1%). Two patients (0.3%) were lost to follow-up so were not included in the paper. At median follow-up of 44 months (25th percentile-75th percentile=15-74 months), 23 (4.3%) adenomas recurred and were successfully retreated by transanal endoscopic microsurgery [20 cases (87%)] and by conventional surgery [3 patients (13%)]. No further recurrences were observed at subsequent follow-up. Thirty-one (5.3%) patients died during follow-up for old age, cardiac disease, etc.

CONCLUSIONS

Transanal endoscopic microsurgery is, in our experience, an effective method for local resection of benign rectal tumours with morbidity of 11.4%, no postoperative mortality and with a percentage of local recurrence of 4.3%.

Clinical Evaluation of Fibrin Glue in the Prevention of Anastomotic Leak and Internal Hernia after Laparoscopic Gastric Bypass: Preliminary Results of a Prospective, Randomized Multicenter Trial

BACKGROUND

Gastro-jejunal anastomotic leak and internal hernia can be life-threatening complications of laparoscopic Roux-en-Y gastric bypass (LRYGBP), ranging from 0.1-4.3% and from 0.8-4.5% respectively. The safety and efficacy of a fibrin glue (Tissucol) was assessed when placed around the anastomoses and over the mesenteric openings for prevention of anastomotic leaks and internal hernias after LRYGBP.

METHODS

A prospective, randomized, multicenter, clinical trial commenced in January 2004. Patients with BMI 40-59 kg/m2, aged 21-60 years, undergoing LRYGBP, were randomized into: 1) study group (fibrin glue applied on the gastro-jejunal and jejuno-jejunal anastomoses and the mesenteric openings); 2) control group (no fibrin glue, but suture of the mesenteric openings). 322 patients, 161 for each arm, will be enrolled for an estimated period of 24 months. Sex, age, operative time, time to postoperative oral diet and hospital stay, early and late complications rates are evaluated. An interim evaluation was conducted after 15 months.

RESULTS

To April 2005, 204 patients were randomized: 111 in the control group (mean age 39.0+/-11.6 years, BMI 46.4 +/- 8.2) and 93 in the fibrin glue group (mean age 42.9+/-11.7 years, BMI 46.9+/-6.4). There was no mortality or conversion in both groups; no differences in operative time and postoperative hospital stay were recorded. Time to postoperative oral diet was shorter for the fibrin glue group (P = 0.0044). Neither leaks nor internal hernias have occurred in the fibrin glue group. The incidence of leaks (2 cases, 1.8%) and the overall reoperation rate were higher in the control group (P=0.0165).

CONCLUSION

The preliminary results suggest that Tissucol application has no adverse effects, is not time-consuming, and may be effective in preventing leaks and internal hernias in morbidly obese patients undergoing LRYGBP.

Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study

BACKGROUND

The role of laparoscopic resection (LR) in the management of extraperitoneal rectal cancer still is unclear. This study aimed to compare perioperative and long-term results of laparoscopic and open resection (OR) for low and midrectal cancer.

METHODS

A prospective nonrandomized trial comparing patients submitted to OR or LR for low and midrectal cancer at a single institution was conducted.

RESULTS

The study included 191 consecutive patients: 98 patients who underwent LR and 93 who underwent OR. The mean follow-up period was 46.3 months for LR and 49.7 months for OR. The conversion rate for LR was 18.4%. With the use of LR, the mean time for complete patient mobilization was shorter (1.7 vs 3.3 days; p < 0.001) and patients were earlier in passing flatus (2.6 vs 3.9 days; p < 0.001) and stools (3.8 vs 4.7 days; p < 0.01), and in resuming oral intake (3.4 vs 4.8 days; p < 0.001). The mean hospital stay was shorter for LR, but the difference did not reach significance (11.4 vs 13 days). Morbidity and mortality rates were similar: LR (24.4% and 1%) and OR (23.6% and 2.2%). Laparoscopic patients presented a higher rate of anastomotic fistulas (13.5% vs 5.1%) and reoperations (6.1% vs 3.2%) but the difference was statistically nonsignificant. Laparoscopic resection presented a significantly lower local recurrence rate (3.2% vs 12.6%; p < 0.05). The cumulative survival and disease-free rates at 5 years were, respectively, 80% and 65.4% after LR and 68.9% and 58.9% after OR (nonsignificant difference). Stage-by-stage comparison showed prolonged cumulative survival for stages III and IV cancer in LR (82.5% vs 40.5%; p = 0.006 and 15.8% vs 0%; p = 0.013, respectively) and a reduced rate of cancer-related death for stage III in LR (11.4% vs 51.9%; p = 0.001).

CONCLUSIONS

As compared with conventional open surgery, LR for low and midrectal cancer is characterized by a faster recovery and similar overall morbidity (but a higher rate of anastomotic leakages), and does not present any adverse oncologic effect.

Laparoscopic total mesorectal excision-the Turin experience

Improved local control and survival rates in the treatment of rectal cancer have been reported after total mesorectal excision (TME). We performed an analysis of TME for rectal cancer by laparoscopic approach during a prospective nonrandomized trial. A prospective consecutive series of 98 laparoscopic total mesorectal excision (LTME) procedures for low and mid-rectal tumors. All patients had a sphincter-saving procedure. Case selection, surgical technique, and clinical and oncological results were reviewed. The distal limit of rectal neoplasm was on average 5.4 cm (range 3-12) from the anal verge. The mean operative time was 192.5 min (range 125-360). The conversion rate was 18.4%. The mean postoperative stay was 11.6 days (range 4-61). The 30-day mortality rate was 1% (1/98) and the overall postoperative morbidity was 18.4% including 10 anastomotic leakages. Concerning long-term oncological results, we evaluated 93 (94.8%) patients with a median follow-up of 46.3 months (range 12-132). During this period, 15.1% (14/93) died of cancer and 7.5% (7/93) are alive with metastatic disease. The port-site metastases rate was 2.1% (2/93). The locoregional pelvic recurrence rate was 2.1% (2/93): 1 stage II at 12 months and 1 stage III at 18 postoperative months, respectively. LTME is a feasible but technically demanding procedure (18.4% conversion rate). Our series confirms the safety of the procedure, while oncological results are at present comparable to the open published series with the limitation of a short follow-up period. Further studies and possibly randomized series will be necessary to evaluate long-term clinical outcome in cancer patients.

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery.

METHODS

A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued.

RECOMMENDATIONS

After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial

BACKGROUND

The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for disorders of the adrenal gland in terms of feasibility, safety, and length of hospitalization.

METHODS

Twenty consecutive patients with benign lesions of adrenal gland were randomized into two groups: Patients in the laparoscopic group underwent traditional laparoscopic adrenalectomy (LAP), whereas those in the robotic group underwent robot-assisted adrenalectomy (ROBOT) using the da Vinci robotic system.

RESULTS

There was no significant difference between the groups in terms of age, sex, body mass index, and size or locations of lesions. Operative times were significant longer in the ROBOT group (total operative time, 169.2 min [range, 136-215] vs 115.3 min (range, 95-155) p < 0.001. Skin-to-skin time was 107 m (range, 77-154) vs 82.1 min (range, 55-120) (p < 0.001). There were no conversions to open surgery. However, conversion to standard laparoscopic surgery was necessary in four of 10 ROBOT patients (40%; left, one right). Perioperative morbidity was higher in the ROBOT group (20% vs 0%). There was no difference in length of hospital stay. In the following ROBOT group, hospital stay was 5.7 days (range, 4-9) vs 5.4 days (range, 4-8) in the LAP group (p = NS). The total cost of the ROBOT procedure ($3,467) was significantly higher than that for LAP ($2,737) (p < 0.01).

CONCLUSION

Laparoscopic adrenalectomy is superior to robot-assisted adrenalectomy in terms of feasibility, morbidity, and cost.

Laparoscopic resection of colon Cancer: Consensus of the European Association of Endoscopic Surgery (EAES)

BACKGROUND

The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.

METHODS

A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.

RESULTS

Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.

CONCLUSION

Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

[Laparoscopic adrenalectomy in multiple endocrine tumors, in secreting and non-secreting lesions]

AIM

Personal experience in laparoscopic adrenalectomies (LA) for secreting and non-secreting tumors is presented.

METHODS

Between March 1995 and December 2001 a total of 111 LA (58 left, 49 right and 4 bilateral) were performed in 60 females and 51 males, mean age 47.5 (range 8-81) years, for: 38 Conn diseases, 24 incidentalomas, 15 pheochromocytomas, 13 Cushing diseases, 4 kysts, 3 angiomyolipomas, 1 adreno-genital syndrome, 1 hydatidosis, 1 hyperplasia, 1 ganglioneuroma, 1 oncocyte adenoma, 1 adrenal fibrous tumor, 4 cortical carcinomas and 4 metastases (from renal carcinoma, breast carcinoma, leiomyosarcoma and rabdoid sarcoma, respectively). In all cases LA was transabdominal with a lateral flank approach.

RESULTS

Mean global operative time was 88.6 minutes (range 35-240). Conversion rate was 1.8% (2/111). There was low postoperative pain. Mean hospital stay was 4.3 days (range 2-13). There were 0.9% (1/111) 30-day mortality and 4.5% (5/111) morbidity. During a mean follow-up of 41 months (range 1-81), the 67 secreting patients were disease-free. Concerning 8 malignant cases, mean follow-up was 40.5 months (range 9-72) with 3 cortical carcinomas disease-free and 1 dead for stroke, 2 metastases (1 leiomyosarcoma and 1 breast carcinoma) dead for disease and 2 disease-free. There was no port-site metastases.

CONCLUSIONS

LA seems safe and effective when performed in experienced Centers on endocrine surgery and laparoscopy.

Development of malignant glioma 15 months after anterior temporal lobectomy in a patient with temporal lobe epilepsy

We report a 36-year-old woman, who had previously undergone anterior temporal lobectomy for intractable temporal lobe seizures; fifteen months later, magnetic resonance (MR) images showed a space-occupying lesion in the temporal lobectomy cavity. After a second operation, a histopathological examination showed a grade III astrocytoma. The fortuitous co-occurrence of temporal lobe epilepsy and a tumour was suspected, but histopathological and immunohistochemical examination of original resected temporal lobe parenchyma did not show evidence of neoplasm. The patient had not undergone postoperative radiotherapy and had not experienced viral infections. We propose that two factors possibly associated with the development of glioma were chemical exposure from anticonvulsant agents and trauma from resection of the anterior temporal lobe during initial surgery.

Laparoscopic vs open hepatic resection: a comparative study

BACKGROUND

Although the feasibility of minor laparoscopic liver resections (LLR) has been demonstrated, data comparing the open vs the laparoscopic approach to liver resection are lacking.

METHODS

We compared 30 LLR with 30 open liver resections (OLR) in a pair-matched analysis. The indications for resection were malignant disease in 47% of the LLR and 83% of the OLR. The average size of the lesions was 42 mm for LLR and 41 mm for OLR. Five wedge resections, 12 segmentectomies, and 13 bisegmentectomies were performed in each group.

RESULTS

The conversion rate for LLR was nil. The mean operative time was 148 min for LLR and 142 min for OLR. Mean blood loss was minimal in the LLR group (320 vs 479 ml; p < 0.05). Postoperative complications occurred in 6.6% of the patients in each group; there were no deaths. The mean postoperative hospital stay was shorter for LLR patients (6.4 vs 8.7 days; p < 0.05). In tumors, the resection margin was <1 cm in 43% of the LLR patients and 40% of the OLR patients ( p = NS).

CONCLUSIONS

Minor LLR of the anterior segments has the same rates of mortality and morbidity as OLR. However, the laparoscopic approach reduces blood loss and postoperative hospital stay.

Randomized clinical trial of ultrasonic versus electrocautery dissection of the gallbladder in laparoscopic cholecystectomy (Br J Surg 2003; 90: 799-803)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication

BACKGROUND

Barrett's esopagus (BE) is considered a risk factor for the development of esophageal carcinoma. Recently, partial restoration of squamous mucosa after ablation of BE with endoscopic techniques has been described.

METHODS

From November 1996 to November 1999, 23 patients with histologically proven BE have been treated by endoscopic argon plasma coagulation (APC) following suppression of gastro-esophageal reflux by laparoscopic fundoplication. Histological follow-up after completed ablation ranged from 16 to 45 months (mean, 31.9 months).

RESULTS

Histologically, complete squamous reepithelialization was observed in 20/23 patients, whereas a regrowth of a mixed squamous and gastric type mucosa was observed in 1 patient. Small islands of intestinal metaplasia were observed under the neosquamous epithelium in two patients (9%) during follow-up.

CONCLUSION

The success rate of APC ablation following laparoscopic antireflux surgery in our series may be as high as 91%. Nevertheless, small islands of intestinal metaplasia under the new squamous epithelium may persist in some patients. In these circumstances, the authors recommend that endoscopic ablation of BE should be confined to controlled clinical trials.

Laparoscopic liver resection of benign liver tumors

OBJECTIVE

The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting.

BACKGROUND

Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors.

METHODS

A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome.

RESULTS

From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD.

CONCLUSIONS

Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

Laparoscopic vertical banded gastroplasty for morbid obesity. Assessment of efficacy

BACKGROUND

The advantages of treating morbidly obese patients via the laparoscopic approach have been demonstrated, in particular, for adjustable silicone gastric banding, but this operation is associated with a high rate of late complications. Gastric bypass and malabsorbitive procedures are feasible via the laparoscopic approach, but they entail a prolonged operating time and a consistently high morbidity rate. Laparoscopic vertical banded gastroplasty represents an effective alternative.

METHODS

We performed 250 consecutive LVBG between November 1995 and February 2000. The procedure consisted of a personal technique designed to reproduce, by laparoscopy, MacLean's modification of the standard open Mason vertical-banded gastroplasty, with a calibrated transgastric window, a complete division between the staple lines, and a 5-cm-circumference polypropylene collar.

RESULTS

The operative time was 95 min and the conversion rate was 0.8%. Operative mortality was nil; early and late complications, respectively, were 4.4% and 4%; the reoperation rate was 2%. Global results at 4 years were as follows: excess weight loss (EWL) 61%, success rate (excess weight <50%) 76.9%, body mass index (BMI) 29.4 kg/m2. In morbidly obese patients, the EWL at 4 years was 62.2%, with a 77.4% success rate and a 28.4 kg/m2 BMI; in superobese patients, the EWL at 4 years was 54.9% with a 50% success rate and a 35.5 kg/m2 BMI. The overall follow-up rate was 92%.

CONCLUSIONS

LVBG is an effective and safe operation in morbidly obese patients, providing good weight loss with a low morbidity rate, no mortality, and minimum discomfort. However, in superobese patients, the weight loss results are disappointing; in these patients, LVBG is questionable and more complex procedures should be considered.

Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy?

OBJECTIVES

To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma.

METHODS

A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearson's correlation coefficient, Fisher's exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results.

RESULTS

A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conn's adenoma, Cushing's adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters.

CONCLUSIONS

Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.

Laparoscopic liver resection of benign liver tumors

OBJECTIVE

The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting.

BACKGROUND

Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors.

METHODS

A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome.

RESULTS

From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD.

CONCLUSIONS

Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

[Use of the "flat mesh" T4r in the Trabucco inguinal hernioplasty. Technical note]

Many of the surgical techniques proposed over the years for inguinal hernia repair have been associated with a high number of recurrences due to the presence of great tension on the suture line and to a lack of consideration for the alteration of the collagen metabolism at the fascia trasversalis level. The advent of the new "tension-free" techniques, among which that described by Trabucco, has represented a turning point in inguinal hernia surgery. In this article, the characteristics, indications and use of the T4r "flat mesh" in this hernioplasty are described. The T4r is not a real "plug" but a "flat mesh", a 5 cm-diameter-round pre-shaped polypropylene mesh with an intermediate rigidity grade with a 1 cm diameter hole in an eccentric position for the passage of the elements of the spermatic funicle. To make its collocation inside the deep inguinal ring in the preperitoneal position easier, a Foley catheter (14 Ch) is used whose balloon is inflated with 20-30 cc of physiologic solution or air. One of the actual problems among the possible complications of prosthetic surgery of hernia is the "migration" of the plug and thus the use of "plugs" in the Trabucco inguinal hernioplasty has been reconsidered. The positioning of the T4r in place of a three-dimensional plug like T1 in particular is an elective choice to prevent the risk of compression of the loco-regional vascular structures.

A hypothesis of epiarachnoidal growth of vestibular schwannoma at the cerebello-pontine angle: surgical importance

AIMS

The purpose of this study is to clarify the rearrangement of the arachnoid membrane on the vestibular schwannoma during its growth in relation to adjacent neurovascular structures for a better understanding of dissecting plane of arachnoid during surgery.

METHODS

Arachnoid membrane over the tumour was investigated during surgery with suboccipital transmeatal approach in twenty-six tumours. All microsurgical procedures were recorded with a video and reviewed. The tumour growth was classified into five stages depending upon the tumour diameter in the cerebello-pontine (CP) angle: Stage 1; purely intracanalicular (2 cases), Stage 2; less than 5 mm (2 cases), Stage 3; > or = 5 and <15 mm (8 cases), Stage 4; > or = 15 and <25 mm (9 cases) and Stage 5; > or = 25 mm (5 cases). Rearrangement of the arachnoid on the tumour was conceptualised throughout all stages.

RESULTS

All tumours of Stage 1 and 2 were entirely located in the subarachnoid space of the cerebello-pontine cistern without arachnoidal rearrangement, while all tumours of Stages 3 to 5 were enveloped, in the CP angle, with invaginated arachnoid membrane consisting of cerebello-pontine cistern except two surfaces; the medial pole and the tumour surface under the facial and cochlear nerves near the porus.

CONCLUSION

The tumour originates subarachnoidally within the internal auditory meatus (IAM) and grows epiarachnoidally in the CP angle. Rearrangement of the arachnoid begins with its adhesion on the medial pole of the tumour along the porus, resulting in the arachnoidal invagination into the cerebello-pontine cistern with further growing of the tumour.

Malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic resections

BACKGROUND

Acute left-side colonic obstruction is a surgical emergency whose management is controversial. Recently metallic expandable stents have been used to relieve obstruction either to palliate the condition or to prepare for an elective surgical resection.

METHODS

We propose a new minimally invasive therapeutic strategy for the management of malignant colonic obstructions: emergency endoscopic stenting followed by elective laparoscopic one-stage resection. The first four cases are presented.

RESULTS

The stents were positioned successfully in all cases, and all the patients had an immediate restoration of bowel functions. After a period that varied from 4 to 5 days, they underwent a one-stage laparoscopic resection and were discharged 5 to 7 days after the operation. There were no postoperative complications.

CONCLUSIONS

Malignant colonic obstruction can be managed by a sequential minimally invasive endolaparoscopic approach with an excellent postoperative outcome, good patient comfort, and a short hospital stay without the need for diverting stomas. A study involving a larger number of patients is needed to determine whether this approach is superior to traditional open surgery in terms of morbidity, mortality, quality of life, and recurrences.

Abdominal wall recurrences after colorectal resection for cancer: results of the Italian registry of laparoscopic colorectal surgery

PURPOSE

The purpose of the present study was to evaluate prospectively the abdominal wall recurrence rate after laparoscopic resection for colorectal cancer, to analyze the impact of the learning curve on abdominal wall recurrence, and to assess the outcome of those patients.

METHODS

The Italian Registry of Laparoscopic Colorectal Surgery database was analyzed to obtain data on cancer patients with abdominal wall recurrence, concomitant local or distant metastases, and interval between initial surgery and diagnosis of trocar site or minilaparotomy recurrences. The records of the initial procedures and the technique of specimen removal were reviewed.

RESULTS

From January 1992 to July 2000, 2,583 patients (1,753 cases of carcinomas and 830 cases of benign diseases) were recorded. The malignant lesions were located on the right colon in 19 percent, the left colon in 48.8 percent, and rectum in 32.2 percent. Sixteen patients with histologic evidence of colorectal adenocarcinoma recurrences at the abdominal wall were observed (0.9 percent). Ten patients presented an advanced stage (III for 7 patients and IV for 3 patients). Eleven cases occurred during the learning curve period (the first 50 consecutive cases). The median survival time after abdominal wall recurrence diagnosis was 16 (range, 12-60) months. By July 2000 only two patients were alive.

CONCLUSIONS

The results of the Italian prospective Registry of Laparoscopic Colorectal Surgery confirm that the incidence of abdominal wall recurrences is similar to that reported in open studies (<1 percent). Most abdominal wall recurrences occurred in the learning curve period, suggesting that surgical experience may play a role in the development of this outcome. The prognosis of these patients is very poor.

Gasless laparoscopy could avoid alterations in hepatic function

BACKGROUND

In a previous clinical study, we showed that the duration and level of pneumoperitoneum are responsible for changes in hepatic function during laparoscopic procedures. These findings encouraged us to evaluate hepatic function during laparoscopy with and without carbon dioxide (CO(2)) pneumoperitoneum in a clinical setting.

METHODS

We performed 63 laparoscopic cholecystectomies and 30 non-hepatobiliary laparoscopic procedures in 93 consecutive patients with normal preoperative liver function tests. The anesthesiologic protocol was uniform, using drugs at low hepatic metabolism. We performed laparoscopic cholecystectomies in 43 patients with a pneumoperitoneum; in the remaining 20, we used a gasless technique. We randomized the 43 laparoscopic cholecystectomies into 23 performed with pneumoperitoneum at 14 mmHg and 20 performed at 10 mmHg. All non-hepatobiliary laparoscopic procedures were performed with a pneumoperitoneum of 14 mmHg. The postoperative serologic levels of AST, ALT, and bilirubin, and the prothrombin time were measured at 6, 24, 48, and 72 h. The alterations in the serologic hepatic tests were then related to the type of procedure, its duration, and the level of pneumoperitoneum.

RESULTS

The study group was comprised of 93 patients, 39 male and 54 female, with a mean age of 50.5 years (range, 15-74). There were no deaths. There was no morbidity in the pneumoperitoneum group, but there was one case of accidental omental injury during the placement of the abdominal, wall retractor in the gasless group. All patients had postoperative changes in serologic hepatic tests. Slow return to normality occurred 48 or 72 h after the operation. The increase in AST and ALT was statistically significant and correlated to the level and duration of pneumoperitoneum. The serologic change in the gasless group were significantly lower than in the laparoscopic cholecystectomy group with pneumoperitoneum at 14 mmHg. There was no statistically significant difference between the gasless group and the laparoscopic cholecystectomy group with pneumoperitoneum at 10 mmHg. There was a statistically the significant increase in the non-hepatobiliary laparoscopy group over the gasless group, despite the absence of hepatobiliary injuries in the first group. No symptoms were related to these serologic hepatic changes.

CONCLUSIONS

The gasless technique causes smaller alterations in serological hepatic parameters than pneumoperitoneum at 14 mmHg. By contrast, the gasless technique and low-pressure pneumoperitoneum have the same effect on hepatic function. Therefore, the use of a subcutaneous abdominal wall retractor combined with a low-pressure pneumoperitoneum is recommended for patients with severe hepatic failure. Transaminases