Open versus closed establishment of pneumoperitoneum in laparoscopic surgery

Initial laparoscopic access using an optical trocar without pneumoperitoneum is safe and effective in the morbidly obese

Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in morbidly obese people. The aim of this study was to examine the safety and efficacy of accessing the peritoneal cavity using an optical, bladeless trocar without previous pneumoperitoneum in morbidly obese patients. The patients' characteristics and outcomes with consecutive and preferential use of an optical, bladeless, first trocar insertion without previous pneumoperitoneum in morbidly obese patients (body mass index > 35 kg/m2) was reviewed. A total of 208 morbidly obese patients were included. The trocar insertion technique was used in 196 patients. No bowel or major abdominal vessel injuries occurred. Ninety-eight patients (50%) had previous abdominal operations. Trocar-related injuries occurred in 3 patients: a superficial mesenteric laceration in 2 and a laceration of a greater omentum vessel in 1. The direct first trocar insertion technique provides safe entry into the peritoneal cavity in morbidly obese patients.

Laparoscopic entry: a review of techniques, technologies, and complications

OBJECTIVE

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.

OUTCOMES

Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.

EVIDENCE

English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT: 1. Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. The Veress intraperitoneal (VIP-pressure </= 10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B) 12. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars. (I-A) 13. The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B).

Medical liability insurance claims on entry-related complications in laparoscopy

BACKGROUND

Installation of the pneumoperitoneum is an essential part of laparoscopic surgery. Creation can be performed by either the open or a closed technique. The aim of this study was to assess the number of and contributing factors to entry-related complications in medical liability insurance claims in The Netherlands.

METHODS

A retrospective chart review was performed, including all malpractice claims filed at MediRisk, which is presently the largest medical liability mutual insurance company for institutions, mainly hospitals, in healthcare in The Netherlands.

RESULTS

From January 1993 to December 2005, 41 claims were identified as entry-related complications which comprised 18% of all laparoscopy-related complications leading to claims. Most were young (median age = 35 years) female patients who had routine, nonadvanced, laparoscopic procedures planned as short-stay or day-care procedures. The claims were equally divided between general surgery (n = 20) and gynecology (n = 21). A total of 51 structures were injured. There were 18 vascular structure injuries, 30 bowel injuries, and three other injuries. An open entry technique was used in only two (5%) patients. Vascular injury was exclusively associated with closed entry. In only 19 (46%) patients the entry-related complication was diagnosed peroperatively, consisting of 70% of the vascular and 25% of the bowel injuries. Twenty-six patients (64%) were admitted to the intensive care unit for a median of five days. There was no mortality. Besides conversion, the majority of the patients filed a claim to compensate for a longer hospital stay and related costs. A payment was made in 17 (57%) of the 30 settled claims.

CONCLUSIONS

Medical liability claims concerning laparoscopic entry-related complications comprised a fifth of all laparoscopy-related claims. Claims concerning entry-related complications occurred in young patients who had routine, nonadvanced procedures. In the investigated cases most claims involved the closed-entry technique.

Carbon dioxide embolism during laparoscopic cholecystectomy due to a patent paraumbilical vein

Carbon dioxide embolism is a rare but potentially fatal complication of laparoscopic surgery. The most common cause is inadvertent injection of carbon dioxide into a large vein or solid organ during initial peritoneal insufflation. We describe a case of carbon dioxide embolism in a 13-year-old boy during an elective laparoscopic cholecystectomy, caused by injection of carbon dioxide into a large paraumbilical vein. The clinical manifestations of carbon dioxide embolism were hypotension, bradycardia, and an abrupt drop in end-tidal CO2. He subsequently did well and had no sequelae. Carbon dioxide embolism is a recognized complication of laparoscopic surgery, although the risk to the patient may be minimized by the surgical team's awareness of the problem, continuous intraoperative monitoring of end-tidal CO2, and using an open technique for initial access to the peritoneum.

An open access technique to create pneumoperitoneum in laparoscopic surgery

BACKGROUND

An open access technique might reduce severe vascular and visceral injuries. An open access technique through the umbilical cicatrix tube has been developed as a routine method with the goal to be easy, safe and used by all surgeons in patients without a previous midline incision.

AIM

To evaluate the open technique in a prospective study in 100 consecutive laparoscopic operations regarding time for entrance, surgeons experience and BMI of the patients.

METHODS

A midline incision from the linea alba up into the inverted umbilicus was performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow into the abdominal cavity followed by a blunt trocar insertion.

RESULTS

Time for access was median 93 seconds. Entrance time in patients with BMI >30 (n=18) was 100 sec and with BMI <30 it was 90 sec (p = 0.71). The median time for consultants was 88 sec and for residents 120 sec (p = 0.003). No gas leakage was seen. Prolonged time for access was seen in three patients; two equipment failures and one obese patent.

CONCLUSION

The open access technique is applicable in all patients without a former midline incision. It is fast, easy to learn with very few associated problems.

Microdialysis of the bowel: the possibility of monitoring intestinal ischemia

Assessment of the intestinal circulation in a clinical setting still presents a significant diagnostic challenge. In patients suspected of having intestinal ischemia pre- or postoperatively, there is no clinically relevant marker which can determine whether the bowel is suffering from lack of oxygen or not. Microdialysis is a microinvasive technique that makes it possible to continuously detect tissue-specific metabolic changes. Recently, it has been demonstrated that intestinal ischemia can be detected and monitored continuously by the use of a microdialysis catheter placed in the proximity of the ischemic bowel. This review summarizes the clinical dilemma of intestinal ischemia and the latest experimental results using the microdialysis technique to detect critical perfusion in the small intestine. The possibility of using microdialysis in a clinical setting is outlined with the perspective of using it as a pre- or postoperative monitoring tool in relevant patients.

Parâmetros eficientes do posicionamento adequado da ponta da agulha de veress durante o estabelecimento de pneumoperitônio

OBJETIVO: Avaliar a possibilidade do estabelecimento de parâmetros fidedignos do adequado posicionamento da ponta da agulha de Veress no interior da cavidade peritoneal durante o estabelecimento do pneumoperitônio. MÉTODO: Em 100 pacientes selecionados a ponta da agulha de Veress foi introduzida na cavidade peritoneal e o insuflador foi programado para fluxo de 1,2L/min e pressão máxima final para 12mmHg. No início da insuflação e a cada 20 segundos a pressão intraperitoneal (PI) e o total do volume injetado até aquele momento (TVI) eram registrados. Os dados foram tratados por correlações estatísticas entre momentos e PI, e momentos e TVI. Também foi estabelecida a previsão dos valores de PI e TVI no final de cada um dos quatro primeiros minutos de insulflação, utilizando-se os modelo estimados: PI = 2,3083 + 0,0266 x tempo + 8,3x10-5 x tempo³ - 2,44x10-7 x tempo³ ; TVI = 0,813 + 0,0157 x tempo. RESULTADOS: A PI e o TVI mostraram correlação entre momentos pré-estabelecidos da criação do pneumoperitônio, sendo constatado um ajuste forte: PI = -2E - 07 x tempo³ + 8E - 05 x tempo² + 0,0266 x tempo + 2,3083, com coeficiente de explicação (R2) = 0,8011; TVI = 0,0157 x tempo + 0,1813, com R2 = 0,9604. A previsão de PI e TVI mostrou: PI(mmHg): 1min=4,15; 2min=6,27; 3min=8,36; 4min=10,10 e TVI(L): 1min=1,12; 2min=2,07; 3min=3,01; 4min=3,95. CONCLUSÕES: Parâmetros fidedignos para PI e TVI , quando a ponta da agullha de Veress se encontra na cavidade peritoneal, em dados momentos da insuflação podem ser estabelecidos durante a criação do penumoperitônio.

Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass

BACKGROUND

In laparoscopic surgery, serious complications caused by the blind insertion of trocars are well known. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming, especially in morbidly obese patients. Our aim was to determine whether the optical access trocar can be used to establish a safe and rapid entry during laparoscopic gastric bypass.

METHODS

The data on a single surgeon's experience with 370 laparoscopic gastric bypass procedures during a 4-year period were reviewed. The Optiview trocar was used for all except the initial 21 patients. The entry time for the optical trocar was measured in 10 patients.

RESULTS

Of the 370 patients undergoing laparoscopic gastric bypass from November 2000 to September 2004, the initial 21 were treated using the standard Veress needle to create the pneumoperitoneum. The next 22 were treated using the Veress needle to create the pneumoperitoneum, followed by insertion of the optical access trocar in the left upper quadrant as the initial trocar. From this point to the present, the optical access trocar has been inserted without the use of a Veress needle. There have been no trocar-related bowel or vascular injuries in the entire series. The mean optical trocar insertion time was 28 +/- 1.2 s.

CONCLUSIONS

This is the first laparoscopic gastric bypass series to report the results of its experience with the optical access trocar. This device provides a safe and rapid technique for placement of the initial trocar for laparoscopic gastric bypass. Insertion of the optical trocar with a 10-mm laparoscope into the left upper quadrant is our procedure of choice for obtaining the pneumoperitoneum in this patient population.

New technique of laparoscopic colectomy with the LAP DISC and a 5-mm flexible scope

PURPOSE

We devised a new method for the safe introduction of the first trocar and induction of pneumoperitoneum for laparoscopic excision of the large intestine.

METHODS

With this method, a small laparotomy is first conducted according to the size of the exposed affected intestinal tract or tumor size, prior to the application of a LAP DISC (LD) to the wound and introduction of a 12-mm trocar for the establishment of pneumoperitoneum. The method is advantageous in that organ injury and vessel injury are avoided when the small laparotomy is conducted first, and prompt transition to a conventional laparotomy is possible. The diaphragm of the iris bulb can be controlled in a non-stepwise manner. In addition, trocars, the stapler, and other instruments, can be inserted under the pneumoperitoneum. Furthermore, the use of a 5-mm flexible scope allows surgical maneuvers, except for application of LD, to be conducted via 5-mm trocars. In addition, the 5-mm scope can be inserted through any trocar, allowing multidirectional avoidance of dead space and intraperitoneal observation. When only 5-mm trocars are used, it is not necessary for the sites of trocar puncture to be closed by sutures, and this minimizes the risk of adhesions and port-site herniation. The method is also considered to be excellent from the point of view of esthetics.

RESULTS

We employed this surgical approach in 50 patients with colorectal cancer at our hospital. None of the patients developed any traumatic complications associated with the insertion of trocars, and none of the patients, even those with a past history of abdominal operation, required conversion to conventional laparotomy.

CONCLUSIONS

Based on these results, this method involving a small laparotomy prior to the application of an LD and introduction of a 12-mm trocar for establishing pneumoperitoneum, with the efficient use of a 5-mm flexible camera, is considered to be safe and useful for laparoscopic excision of the large intestine.

Prevention and management of complications in urological laparoscopic port site placement

OBJECTIVES

To review complications associated with urological laparoscopic port-site placement and outline techniques for their prevention and management.

METHODS

Review of the literature using Medline.

RESULTS

Laparoscopy now plays a key role in urological surgery. Its applications are expanding with experience and evolving data confirming equivalent long-term outcome. Although significant port-site complications are uncommon, their occurrence impacts significantly on perioperative morbidity and rate of recovery. The incidence of such complications is inversely related to surgeon experience. Ports now utilise bladeless tips to reduce the incidence of vascular and visceral injuries, and subsequently port-site herniation. Metastases occurring at the port site are preventable by adhering to certain measures.

CONCLUSIONS

Whether performing standard or robot-assisted laparoscopy, port-site creation and maintenance is critical in ensuring minimal invasiveness in laparoscopic urological surgery. Although patient factors can be optimised perioperatively and port design continues to improve, it is clear that adequate training is central in the prevention, early recognition, and treatment of complications related to laparoscopic access.

Patient selection and surgical technique may reduce major complications of laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE

To study the clinical outcome of patients who underwent laparoscopic-assisted vaginal hysterectomy especially with regard to early postoperative complications.

DESIGN

Retrospective study (Canadian Task Force classification II-3).

SETTING

Private hospital in Hamilton, New Zealand.

PATIENTS

Four hundred eighteen women.

INTERVENTION

Laparoscopic-assisted vaginal hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Primary indication for surgery, operating time, hospital stay, and major complications were analyzed. Major complications were defined as life-threatening injuries, unintended major surgical procedures, and conversions to laparotomy that occurred under duress (eg, intraoperative hemorrhage). Complications were reported up to 6 weeks of postoperative time. The total early postoperative complication rate was 11.24%. No patient had damage to the bowel, ureter, or bladder. There were no deaths. Major complications were three cases of partial vault dehiscence and one case of partial small bowel obstruction. The operation was performed successfully in 412 cases. Six patients needed laparotomy.

CONCLUSIONS

This retrospective study shows that laparoscopic-assisted vaginal hysterectomy is a safe surgical procedure. The possible reasons for the low complication rate reported are the surgical technique of ureteral dissection, the use of suitable instruments to expose the vaginal fornices, a consistent team approach, and the selection of patients.

Optical trocars - types, indications, clinical experiences

Since blind insertion of the Veress needle or the first trocar may cause serious complications, many surgeons prefer to perform a minilaparotomy to safely create the pneumoperitoneum. Optical trocars provide a third option, combining the advantages of the Veress needle with those of the Hasson trocar. We describe the optical trocars provided by two major producers of disposable laparoscopic instruments and report on our experience in using one of those trocars in over 500 operations without a single complication. In our opinion, optical trocars are safe and easy to handle, and offer several advantages over the use of the Veress needle and the minilaparotomy.

Visceral sliding technique is useful for detecting abdominal adhesion and preventing laparoscopic surgical complications

STUDY OBJECTIVE

Introduce a non-invasive method preoperatively to prevent bowel injury by the Veres needle and trocar during laparoscopy.

DESIGN

Case-controlled study.

SETTING

A hospital-based study.

PATIENTS

Five hundred and twelve patients who underwent laparoscopic surgery were prospectively enrolled.

INTERVENTION

A simple and non-invasive method to detect bowel adhesions preoperatively.

RESULTS

A total of 512 patients who underwent operative laparoscopy were prospectively enrolled for ultrasonographic visceral sliding evaluation. They were subdivided into two groups as follows: group I, 332 patients without previous abdominal surgery; group II, 180 patients with previous abdominal surgery. No bowel adhesion to the umbilicus was present in group I. In group II, only two cases with bowel adhered to the periumbilical area were found by visceral sliding technique. No patients suffered any bowel injury.

CONCLUSION

The proposed technique is useful and highly effective in guiding the insertion of the Veres needle and trocar to prevent bowel injury in laparoscopy.

Evaluation of the positioning of the tip of the Veress needle during creation of closed pneumoperitoneum in pigs

PURPOSE: Erroneous punctures and insufflations are frequent with the use of the Veress needle. Mistaken injections of gas in the preperitoneal space are not rare. The purpose of this research is to evaluate the correct positioning of the tip of the needle during creation of pneumoperitoneum. METHODS: The needle was inserted into the peritoneal cavity. Tests to assess the positioning of the needle tip were carried out. Pressure, flow rate and volume were periodically recorded and the needle was removed, being immediately reinserted into the right hypochondrium and placed in the preperitoneal space. RESULTS: The liquid flow test was always positive in the peritoneal cavity. No resistance to saline injection into the peritoneal cavity was observed, but increased resistance to saline injection into the preperitoneal space was observed in 45.5% of the cases. Some saline was recovered in 63.5% of the cases in the peritoneal cavity, and in 54.5% in the preperitoneal space. Saline drop test was positive in 66.6% of the cases in the peritoneal cavity and in 45.5% in the preperitoneal space. In the peritoneal cavity, initial pressure lower than 5 mm Hg was observed, and this pressure gradually increased during 123 seconds until reaching 15 mm Hg. In the preperitoneal space, initial pressure was 15 mm Hg. CONCLUSIONS: Aspiration, liquid flow and saline drop tests are important, whereas recovery test is inconclusive. Initial pressure of approximately 5 mm Hg indicates that the tip of the needle is in the peritoneal cavity. The peritoneal cavity should hold ten times as much volume of gas as the preperitoneal space. The increase in pressure and volume in the peritoneal cavity can be predicted by statistics.

[Open pneumoperitoneum for the sake of Quality Assurance]

The establishment of a pneumoperitoneum for coelioscopy is a maneuver which may have lethal consequences. The open or Hasson technique involves dissection of the abdominal wall layers and insertion of a blunt trocar under direct vision. The conclusions of a recent study comparing "open" and "blind" trocar insertion recommends that the "open" technique be routinely used as a measure of Quality Assurance. A programmed, standardized approach is the only way to prevent undesired complications. Surgeons often plead that the uniqueness of each patient argues against a rigidly standardized technique. But isn't this argument of patient variability just an alibi to avoid adherence to explicit and proven standards? When it comes to guaranteeing patient safety, shouldn't the demonstration that a technique diminishes risk be considered an adequate level of proof if there is no demonstrated benefit to the more dangerous approach? In laparoscopy, where are the proven benefits which would mitigate the undeniable increased risks of "blind" trocar insertion? Initial trocar insertion for laparoscopy by the "open" technique should be standard practice for reasons of safety. The calculus is simple. Given the innumerable laparoscopic surgeries performed every day, there are patients who die daily as a result of "blind" trocar insertion.

Primary access-related complications with laparoscopy: comparison of blind and open techniques

BACKGROUND

Severe or fatal complications attributable to gas embolus, major vascular injury, or visceral injury are rare but have been reported after blind access to the abdominal cavity in laparoscopy. The open access technique has been introduced with the aim to reduce these injuries. This report evaluates access-related complications with both blind and open access techniques in a teaching hospital using standardized techniques for both methods.

METHODS

Two groups of patients at different times from a prospective database were compared. A retrospective analysis of 2,297 patients treated using blind access between 1992 and 1996 were compared with 2,066 patients treated using open step-by-step access between 1999 and 2001 regarding access-related complications. An accreditation program for both techniques was mandatory for the 67 surgeons involved.

RESULTS

No case of gas embolus or major vascular injury was seen in either group. Four cases of visceral injuries (0.17%) in the blind access group and one case (0.05%) in the open group were seen (p = 0.337). All the injuries were recognized and repaired intraoperatively with no further postoperative complications.

CONCLUSION

Our educational efforts to make both techniques as safe as possible were successful, as evidenced by a minimum of access-related complications. Because no evidence exists to show that the blind access technique is superior in any aspect, the open technique is recommended for access to the abdominal cavity in laparoscopy.

Laparoscopic surgery: pitfalls due to anesthesia, positioning, and pneumoperitoneum

BACKGROUND

Laparoscopic procedures are increasing in number and extensiveness. Many patients undergoing laparoscopic surgery have coexisting disease. Especially in patients with cardiopulmonary comorbidity, pneumoperitoneum and positioning can be deleterious. This article reviews possible pitfalls related to the combination of anesthesia, positioning of the patient, and the influence of pneumoperitoneum in the course of laparoscopic interventions.

METHODS

A literature search using Medline's MESH terms was used to identify recent key articles. Cross-references from these articles were used as well.

RESULTS

Patient positioning and pneumoperitoneum can induce hemodynamic, pulmonary, renal, splanchnic, and endocrine pathophysiological changes, which will affect the entire perioperative period of patients undergoing laparoscopic procedures.

CONCLUSION

Perioperative management for the estimation and reduction of risk of morbidity and mortality due to surgery and anesthesia in laparoscopic procedures must be based on knowledge of the pathophysiological disturbances induced by the combination of general anesthesia, pneumoperitoneum, and positioning of the patient.

Bleeding remains a major complication during laparoscopic surgery: analysis of the SALTS database

BACKGROUND AND AIMS

The aim of this study was to determine the incidence of bleeding complications from various laparoscopic procedures in a nationwide prospective multicentre study in Switzerland from 1995 to 2001 following an initial learning curve.

PATIENTS AND METHODS

Since 1989, the Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS) has prospectively collected data from patients undergoing laparoscopic or thoracoscopic surgery at 114 surgical institutions (university, county and district hospitals, private practice). More than 130 items of data, including indication for surgery, intraoperative course, local as well as general postoperative complications, mortality and follow-up were recorded on a computerised data sheet.

RESULTS

Some 43,028 procedures were assessed and analysed. Local morbidity (e.g. wound infections) occurred in 0.05% of the whole patient group, whereas 3.3% developed general postoperative complications. The overall mortality rate was 0.2%. In 1.7% of the cases, the intraoperative course was complicated by internal bleeding or haematoma of the abdominal wall. In the postoperative course, 1.5% of the patients presented with internal bleeding or bleeding of the abdominal wall. Major vascular injury occurred in 0.09%. This patient group with bleeding complications was analysed in the context of the operator's experience, instrumental lesions (Veress needle or trocar) and conversion incidence. Furthermore, a trend analysis of the complication rate from 1995 to 2001 was performed.

CONCLUSION

Although the initial learning curve of laparoscopic procedures is probably finished, the rate of bleeding complications is still substantial. These results demonstrate that the collection of data in the form of multicentre studies is essential for quality control. It permits recognition and understanding of the current problems in laparoscopic surgery in order to improve the quality of daily surgical practice. The fact that the operator's experience seems to play an important role shows that improvement in learning and teaching programmes is still necessary and should be coordinated on a national basis.

Vascular injuries during gynecological laparoscopy--the vascular surgeon's advice

CONTEXT

Iatrogenic vascular problems due to laparoscopy are a well recognized problem and lead to significant repercussions. In this context, a ten-year review of cases topic is presented, based on experience gained while heading two important vascular surgery services.

CASES

Five patients with vascular injuries during elective laparoscopy are described. These patients presented with seven lesions of iliac vessels. All cases were evaluated immediately and required laparotomy, provisional hemostasis and urgent attendance by a vascular surgeon. Direct suturing was performed in three cases. One aortoiliac bypass and one ilioiliac reversed venous graft were made. Venous lesions were sutured. One case of a point-like perforation of the small bowel was found. There were no deaths and no complications during the postoperative period.

DISCUSSION

Important points on this subject are made, and advice is given. There needs to be immediate recognition of the vascular injury, and expert repair by a vascular surgeon is recommended, in order to significantly reduce the degree of complications.

Avaliação do posicionamento da agulha de veress durante o estabelecimento do pneumoperitônio pela técnica fechada, em porcos

OBJETIVO: Estabelecer parâmetros fidedignos do posicionamento adequado da agulha de Veress na cavidade peritoneal durante o estabelecimento do pneumoperitônio pela técnica fechada. MÉTODO: Em 11 porcos a agulha foi introduzida na cavidade peritoneal através do hipocôndrio esquerdo. Provas de posicionamento da ponta do instrumento foram efetuadas. Insuflou-se CO2 e registraram-se periodicamente pressões, fluxos e volumes. A posição intraperitoneal da agulha foi confirmada e esta foi retirada, sendo re-introduzida no hipocôndrio direito e posicionada sob visão direta no espaço pré-peritoneal. Os mesmos parâmetros foram aferidos. RESULTADOS: A prova do escoamento foi sempre positiva no peritônio. Não se encontrou resistência à introdução de soro no peritônio em nenhum caso, mas sim em 45,5% dos casos no pré-peritônio. Soro algum foi recuperado em 63,5% no peritônio e em 54,5% no pré-peritônio. O gotejamento fluiu livremente em 66,6% das vezes no peritônio e em 45,5% dos casos no préperitônio. No peritônio, pressões iniciais de 5,20 mmHg aumentaram progressivamente durante 123 segundos até atingir 15 mmHg. No pré-peritônio a pressão inicial foi de 15,60 mmHg e oscilou entre 12 e 15,60 mmHg. O volume de gás injetado no peritônio foi de 1500 ml e de 100 ml no pré-peritônio. CONCLUSÕES: Aspiração e observação do escoamento e do gotejamento são importantes; recuperar ou não o soro é inconclusivo. Pressão inicial menor ou igual a 5 mmHg é indicativo da ponta da agulha no peritônio, onde devem caber dez vezes mais gás que no pré-peritônio. No peritônio os aumentos das pressões e dos volumes pode ser previstos mediante estatísticas.

A safe technique for the insertion of the Hasson cannula

BACKGROUND

Most techniques of Hasson cannula insertion still involve a significant risk of visceral or vascular damage. This is true even for the modified open techniques of cannulation.

METHODS

A technique of sequential clipping and elevation of abdominal wall layers is described, which permits safer Hasson cannulation at the umbilicus or at other sites on the abdomen even in the presence of underlying adhesions.

RESULTS

Eight hundred and seventy-six patients underwent laparoscopic cholecystectomy using this technique of Hasson cannulation. Forty-two of these patients had the cannula placed at other sites other than the umbilicus because of previous surgery and suspected adhesions. Using this technique there were no major complications. Specifically, this technique did not incur any cases of visceral or vascular damage.

CONCLUSIONS

The technique of sequential clipping and elevation of all layers of the abdominal wall during the insertion of the Hasson cannula allows for safer entry into the peritoneal cavity.

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.

Laparoscopically monitored percutaneous endoscopic gastrostomy (PEG) in children: a safer procedure

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has now become the preferred technique for facilitating enteral nutrition in children with inadequate caloric intake. Because many problems related to PEG insertion have recently been reported, we were motivated to reassess this established technique. We have therefore added a new step--laparoscopic monitoring--to the classic PEG procedure.

METHODS

Fifteen children who required PEG during the previous year were studied. Their ages ranged from 2 months to 18 years. Six children were < 1 year old at the time of operation. In 11 patients, the PEG was performed at the end of a laparoscopic Nissen fundoplication. In the others, it was done as a single procedure.

RESULTS

In all 15 children, the PEG was performed safely and quickly, without complications.

CONCLUSION

The addition of 'laparoscopic monitoring' to the classic PEG procedure introduced by Gauderer et al. changes the first and last parts of the procedure from an almost 'blind' undertaking to a well-controlled and safer procedure.

Complications of laparoscopy: an inquiry about closed- versus open-entry technique

OBJECTIVE

The purpose of this study was to determine the amount of complications and the incidence of open- versus closed-entry (either by Veress needle or first trocar) technique in gynecologic laparoscopy in The Netherlands.

STUDY DESIGN

Questionnaire analysis of members of the Dutch Society for Gynaecological Endoscopy and Minimal Invasive Surgery was combined with a Medline literature search. Data related to complications on entry from January 1,1997, through December 31, 2001, were collected by questionnaire and were separated into group I (Veress needle or first trocar) and group II (open-entry technique). The number of laparoscopy procedures, years of experience, and indications to perform the chosen entry technique were collected.

RESULTS

Response rate was 98%. The procedures were performed by 187 gynecologists in 74 hospitals (72%) in The Netherlands. Groups I and II were comparable to each other, with respect to type of clinic (teaching vs nonteaching hospital), the number of procedures, and the experience of gynecologists. One hundred six gynecologists (57%) used only the closed-entry technique. This group reported 31 complications (0.1%) in 31,532 procedures. Even in the case of patients who were at risk for entry-related complications (previous laparotomy, obesity), pneumoperitoneum was established by the closed-entry technique. However, most gynecologists used an alternative insufflation point (eg, Palmer's point). The remaining 81 gynecologists used both entry techniques. However, the open-entry technique was used on special indications and in only 2.0% of cases (range: 1-20%). These special indications were suspected adhesions or previous laparotomy (90%) and obese (7%) or very thin patients (3%). These 81 gynecologists reported 20,027 closed-entry procedures and 579 open-entry procedures and complication rates of 0.12% and 1.38%, respectively (P<.001). Significantly more visceral lesions were found (P<.001) at open-entry technique in group II. Our literature search showed a calculated average entry complication rate for the closed-entry technique for visceral and vascular lesions of 0.44 of 1000 procedures and 0.31 of 1000 procedures, respectively.

CONCLUSION

Although 43% of the gynecologists in this study performed the open-entry technique in laparoscopy, Dutch gynecologists seldom use this technique. When it is performed in selected patients, the number of complications is not reduced necessarily. In contrast to published data of general surgeons' findings, the number of entry-related complications in the open technique was significantly higher than the closed-entry technique. There is no evidence to abandon the closed-entry technique in laparoscopy. However, the selection of patients for an open- or alternative-entry procedure is still recommended.

Avoiding complications of laparoscopic surgery

No matter how skilled the surgeon, the risk of complications always exists. Complications of laparoscopic surgery include anesthesia difficulties, positioning and nerve injuries, injuries due to insertion of needles and trocars, and intraoperative vascular, bowel, and urinary tract injuries. Injuries from electrosurgical equipment may also result. This article focuses on preventing such complications.

Optical access trocar injuries in urological laparoscopic surgery

PURPOSE

Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution.

MATERIALS AND METHODS

From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed.

RESULTS

The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair.

CONCLUSIONS

Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar.

Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial

BACKGROUND

Laparoscopic adhesiolysis for chronic abdominal pain is controversial and is not evidence based. We aimed to test our hypothesis that laparoscopic adhesiolysis leads to substantial pain relief and improvement in quality of life in patients with adhesions and chronic abdominal pain.

METHODS

Patients had diagnostic laparoscopy for chronic abdominal pain attributed to adhesions; other causes for their pain had been excluded. If adhesions were confirmed during diagnostic laparoscopy, patients were randomly assigned either to laparoscopic adhesiolysis or no treatment. Treatment allocation was concealed from patients, and assessors were unaware of patients' treatment and outcome. Pain was assessed for 1 year by visual analogue score (VAS) score (scale 0-100), pain change score, use of analgesics, and quality of life score. Analysis was by intention to treat.

FINDINGS

Of 116 patients enrolled for diagnostic laparoscopy, 100 were randomly allocated either laparoscopic adhesiolysis (52) or no treatment (48). Both groups reported substantial pain relief and a significantly improved quality of life, but there was no difference between the groups (mean change from baseline of VAS score at 12 months: difference 3 points, p=0.53; 95% CI -7 to 13).

INTERPRETATION

Although laparoscopic adhesiolysis relieves chronic abdominal pain, it is not more beneficial than diagnostic laparoscopy alone. Therefore, laparoscopic adhesiolysis cannot be recommended as a treatment for adhesions in patients with chronic abdominal pain.

A prospective analysis of predictive factors on the results of laparoscopic adhesiolysis in patients with chronic abdominal pain

Laparoscopic adhesiolysis for chronic abdominal pain is subject for criticism. In this prospective study, we analyze factors that encourage or discourage the indication for therapeutic laparoscopic adhesiolysis. Two hundred twenty-four consecutive patients with chronic abdominal pain underwent diagnostic laparoscopy, and in case of adhesions, they underwent adhesiolysis. Pain relief was assessed, and the individual impact of variables on pain relief was determined. Laparoscopy was performed in 224 patients. Two hundred patients had only adhesions and underwent primary laparoscopic adhesiolysis. Three months after adhesiolysis, 74% of patients were pain-free or had less pain. The remaining 26% of the patients felt no change (22%) or had more pain (4%). Gender, age, and bowel perforation leading to a laparotomy appear to be individual factors significantly influencing pain relief. Laparoscopic adhesiolysis can be done (almost) completely in 92% of patients with adhesions. After laparoscopic adhesiolysis, 74% of patients had good results and 4% had more pain. The complication rate is high.

Bowel injury in gynecologic laparoscopy

STUDY OBJECTIVE

To review surveys of the last decade on bowel injuries to evaluate the prevalence, causes, management, and outcomes of these events occurring during or as a result of laparoscopy.

DESIGN

Retrospective evaluation (Canadian Task Force classification II-2).

SETTING

Surveys and databases.

PATIENTS

None.

INTERVENTION

Data analysis.

MEASUREMENTS AND MAIN RESULTS

Combined data show that diagnostic and minor operative laparoscopy are associated with a 0.08% risk of bowel injury, and in major operative laparoscopy the risk increases to 0.33%. Injuries occurring during access and operative procedure decrease significantly with experience, but even in experienced hands injury during access cannot be avoided. Delayed diagnosis remains a major problem. Up to 15% of these injuries are not diagnosed during laparoscopy, and one of five cases of delayed diagnosis results in death. Perioperative diagnosis and immediate repair by laparoscopy or laparotomy reduce the likelihood of severe complications and consequently medicolegal actions.

CONCLUSIONS

Several surveys on complications of gynecologic laparoscopy tend to underestimate the risk of bowel injury. Prevention starts by awareness that such injury is an inherent risk of the technique, even in hands of experienced surgeons.

Laparoscopic access: complications, technologies, and techniques

PURPOSE OF REVIEW

To review laparoscopic access systems, insertion techniques, and the risks of complications associated with their use.

RECENT FINDINGS

Access devices usually comprised an external cannula and a removable sharp pyramidal trocar for penetration of the abdominal wall, and were nearly universally positioned following establishment of a pneumoperitoneum. However, it is apparent that such devices and techniques contribute to patient morbidity through visceral and vascular injury, as well as incision-related complications such as dehiscence and hernia. There exist alternative approaches to positioning insufflation needles and the initial cannula, which may reduce the incidence of vascular and visceral injury particularly in the face of previous abdominal surgery. Inserting the initial cannula after minilaparotomy is associated with a reduced risk of vascular injury, but visceral complications still occur. Some new access instruments may reduce the risk of some complications associated with 'blind entry', and although not all seem to be effective in this regard, a set of blunt-tipped devices now exist, which are surprisingly easy to position and may limit the risk of injury while significantly reducing the size of the myofascial defect in the abdominal wall. Port site metastasis is a relatively newly recognized complication of oncological surgery and is a concern, but further investigation is required to determine whether such metastasis is related to a change in clinical outcome.

SUMMARY

The incidence and spectrum of access-related complications is greater than previously perceived. Newer devices and modifications in technique may reduce the incidence of such adverse events.

[Open laparoscopy: analysis of complications due to first trocar insertion]

OBJECTIVE

To evaluate the complications of open laparoscopy during the set-up of laparoscopy in gynecologic surgery.

DESIGN

Retrospective study performed between February 1994 and January 2001 in a University Centre.

PATIENTS AND METHODS

1,562 patients underwent open laparoscopies. Procedures were performed by 8 gynaecological surgeons. Peri- and postoperative complications were assessed and analysed.

RESULTS

Major injuries concerned gastrointestinal tract: 2 perforations with immediate diagnosis and one postoperative occlusion treated by delayed laparotomy (0.19%). No death occurred. No vascular injuries and no bladder complications were noted.

CONCLUSION

We recommend open laparoscopy because of its innocuity and easiness. Advantages concern decrease of major vascular injuries and early recognition of bowel injuries.

Laparoscopic pelvic and paraaortic lymph node dissection in the obese

OBJECTIVE

The aim of this study was to determine the utility of laparoscopic pelvic and paraaortic lymph node dissection in obese women.

METHODS

We performed a retrospective analysis from 1/8/96 to 1/14/01 at the University of Oklahoma Health Science Center, evaluating patients who had a Quetelet index (QI) > or =28 and had planned laparoscopic bilateral pelvic and paraaortic lymph node dissections (lnd) for their gynecologic cancer. This group was compared to a matched group of patients that had lnd done by laparotomy. Patients were identified by our institution's database and data were collected by review of their medical records. Data were collected regarding demographics, stage, histology, length of stay, and procedural information including completion rates, estimated blood loss (EBL), operating room (OR) time, lymph node count, assistant, and complications. Associations between variables were analyzed using Student t tests and chi(2) testing, Excel v9.0.

RESULTS

Fifty-five patients had planned laparoscopic lnd (Group 1) and 45 patients had lnd via laparotomy (Group 2). All patients had the diagnosis of endometrial cancer. The percentage of stage I patients did not differ between groups (42/55, 71.2% versus 37/45, 82.2%, P = n.s.). Age and QI were also similar between groups, (64.6 versus 58.4, 40.0 versus 39.3, P = n.s.). Laparoscopy was completed in 35/55 (63.6%) cases. Reasons for conversion included obesity (23.6%), adhesions (1.8%), intraperitoneal cancer (5.5%), and bleeding (5.5%). QI > or =35 was associated with a decreased success rate compared to QI <35 (44.4% versus 82.1%, P = 0.004). There was no difference in successful laparoscopy when the first assistant was a fellow or a community obstetrician/gynecologist (61.0% versus 50.0%, P = n.s.). The patients in Group 1 who had laparoscopy completed had a longer OR time compared to those in Group 2 (265.3 versus 140.7 min, P < 0.0001), EBL and transfusion rates were equivalent (361.8 versus 344.2 ml, 5.6% versus 6.7%, P = n.s.), and length of stay was shorter (2.8 versus 4.5 days, P = 0.0004). Group 1 had significantly fewer postoperative fevers (5.5% versus 31.1%, P = 0.0007), fewer postoperative ileus (0% versus 13.3%, P = 0.005), and a trend for fewer wound infections (9.0% versus 22.2%, P = 0.07).

CONCLUSIONS

Obesity is not a contraindication to laparoscopic pelvic and paraaortic lymph node dissection. The overall success rate was significantly higher in those patients with a QI <35. Advantages include shorter hospital stay, fewer postoperative fevers, fewer postoperative ileus, and possibly fewer wound infections.

Surgical management of early-stage endometrial cancer in the elderly: is laparoscopy feasible?

OBJECTIVE

To give insight into the utility of laparoscopic staging of endometrial cancer in the elderly population by reviewing the surgical management of clinically stage I endometrial cancer patients.

METHODS

A retrospective analysis evaluating patients that were > or =65 years old and had planned laparoscopic staging, traditional staging via a laparotomy, or a transvaginal hysterectomy as management of their early endometrial cancer. The laparoscopic group had complete staging with bilateral pelvic and paraaortic lymph node dissections and was compared to the group who had staging performed via laparotomy. Patients were identified by our institution's database and data were collected by review of their medical records. Data were collected on demographics, pathology, and procedural information including completion rates, operating room (OR) time, estimated blood loss (EBL), transfusions, lymph node count, complications, and length of stay. Associations between variables were analyzed by Student's t tests and chi(2) testing using Excel v. 9.0.

RESULTS

From February 25, 1994, through December 21, 2000, 125 elderly patients were identified. Sixty-seven patients had planned laparoscopic staging (Group 1), 45 patients had staging via planned laparotomy (Group 2), and 13 patients had a transvaginal hysterectomy (Group 3). Group 1 and Group 2 were compared regarding surgical and postoperative data. Age was not different between these groups (75.9 vs 74.7 years, P = NS). Quetelet index was also similar (29.4 vs 29.9, P = NS) 32.8% of Group 1 had > or =1 previous laparotomy compared to 51.1% in Group 2 (P = NS). In Group 1, 53/67 (79.1%) had stage I or II disease compared to 29/45 (64.4%) in Group 2 (P = NS). Laparoscopy was completed in 52/67 (77.6%) attempted procedures. The reasons for conversion to laparotomy were obesity 7/67 (10.4%), bleeding 4/67 (6.0%), intraperitoneal cancer 3/67 (4.5%), and adhesions 1/67 (1.5%). OR time was significantly longer in successful Group 1 patients compared to Group 2 patients (236 vs 148 min, p = 0.0001). EBL was similar between these groups (298 vs 336 ml, P = NS). Ten of 52 (19.2%) of successful Group 1 patients received a blood transfusion compared to 1/45 (2.2%) of Group 2 patients (P < 0.0001). Pelvic, common iliac, and paraaortic lymph node counts were similar between successful Group 1 patients and those in Group 2 combined with those that received a laparotomy in Group 1 (17.8, 5.2, 6.6 vs 19.1, 5.1, 5.2, P = NS). Length of stay (LOS) was significantly shorter in Group 1 versus Group 2 (3.0 vs 5.8 days, P < 0.0001). There were less fevers (6.0 vs 15.6%, P = 0.01), less postoperative ileus's (0 vs 15.6%, P < 0.001), and less wound complications (6.0 vs 26.7%, P = 0.002) in Group 1 compared to Group 2. Group 3 average age was 77.5 years. Concurrent medical comorbidities were the main reason for the transvaginal approach. OR time averaged 104.5 min. The average length of stay was 2.1 days with no procedural or postoperative complications.

CONCLUSIONS

The favorable results from this retrospective study refute the bias that age is a relative contraindication to laparoscopic surgery. Laparoscopic staging was associated with an increased OR time and an increased rate of transfusion but equivalent blood loss and lymph node counts. Possible advantages are decreased length of stay, less postoperative ileus, and less infections complications. Transvaginal hysterectomy still remains a proven option for women with serious comorbid medical problems with short OR times, minimal complications, and short lengths of stay.

Radially expanding laparoscopic access for renal/adrenal surgery

OBJECTIVES

To use a radially expanding system (Step) and a modified port location for intra-abdominal access to decrease the access-related complications in renal and adrenal surgery. Access-related complications during laparoscopic renal surgery are frustrating and are more common in patients with previous abdominal surgery and associated adhesions.

METHODS

Laparoscopic upper tract procedures were performed in 62 patients using radially expanding trocars, and the results were reviewed with regard to access, port placement, and associated complications. For initial access, a Veress needle was placed subcostally in the midclavicular line. An expandable mesh sleeve trocar was used for trocar insertion after a pneumoperitoneum was established. A blunt-tipped fascial dilator was used to dilate to 10 or 12 mm. Additional ports were placed in an L shape (nephrectomy) or a subcostal configuration (adrenalectomy) under direct vision using the Step ports.

RESULTS

Of 62 patients, 24 had had prior abdominal surgery. Open insertion of the mesh sleeve was necessary in 20%, of whom 60% had had prior abdominal surgery. In 9% of cases, the liver was punctured with the initial pass of the Veress needle. Only minimal bleeding from the injury site was noticed. The liver punctures did not require cauterization and did not result in conversion to an open procedure. At a mean follow-up of 12 months, no access-related complications or port-site hernias were noted.

CONCLUSIONS

Placement of the initial access subcostally at the level of the midclavicular line helps to prevent visceral injury, especially in patients with previous abdominal surgery. The use of the radially expanding access system with the modification of port location allows safe and rapid laparoscopic access for upper urinary tract surgery. This trocar system is an excellent alternative to the standard laparoscopic trocars.

[Methods for laparoscopy: open laparoscopy or closed laparoscopy? Attitude of the French Central University Hospital]

Standard technique of insufflation of the pneumoperitoneum includes the use of the Veress needle followed by the blind insertion of the umbilical trocar. To avoid blind trocar insertion, numerous techniques for the creation of the pneumoperitoneum have been reported: open-laparoscopy and micro-laparoscopy are the two major alternative methods used in France. The aim of this study was to determine the incidence of open-laparoscopy in the French departments of Gynecology of the University Hospitals. With this purpose, we send to each chief of the department of Gynecology in a University Hospital a simple questionnaire about the methods used in his division for the creation of pneumoperitoneum. Sixty-three chiefs of department have answered to the questionnaire. Thirteen (21%) answered they only used conventional technique. Ten (16%) departments perfonned always open-laparoscopy, and 40 University Hospital mostly used conventional technique combined sometimes when the initial procedure of insufflation failed or seems to be too dangerous (Obesity, previous laparotomy...). Five surgeons used a lateral rather than umbilical insertion for the openlaparoscopy in case of previous laparatomy. Fifteen departments used micro-laparoscopy since 1995, and mostly since 1998. We conclude that no simple technique can claim to be overwhelmingly superior. It seems tous dangerous to impose or to condemn any methods. Keeping the choice of the technique, learning security and organizing the survey of our results remain our recommendations for the approaches of abdominal entry for laparoscopy.

Laparoscopic pelvic and paraaortic lymph node dissection: analysis of the first 100 cases

OBJECTIVE

The aim of this study was to analyze the first 100 cases of planned laparoscopic pelvic and paraaortic lymph node dissection (LND) done for staging of gynecologic cancers. The goal of the study was to assess prognostic factors for conversion to laparotomy and document complications.

METHODS

A retrospective review of patients who had planned laparoscopic bilateral pelvic and bilateral paraaortic LND for staging of their gynecologic cancer was performed. Patients were identified by our institutional database and data were collected by review of their medical records. Data were obtained regarding demographics, stage, histology, length of stay, and procedural information including completion rates, operating room time, estimated blood loss, assistant, lymph node count, and complications. Associations between variables were analyzed using Student t tests, analysis of variance, and chi(2) testing (Excel v7.0).

RESULTS

A total of 103 patients were identified from 12/15/95 to 8/28/00. Demographics included mean age of 66.2 (25-92) and mean Quetelet index (QI) of 30.8 (15.9-56.1). A total of 34/103 (33.0%) had > or =1 previous laparotomy. Ninety-five patients had endometrial cancer and 8 had ovarian cancer. Eighty-six of 103 (83.5%) were stage I or II. The length of stay was shorter for those who had laparoscopy than for those who needed conversion to laparotomy (2.8 vs 5.6 days, P < 0.0001). Laparoscopy was completed in 73/103 (70.9%) of the cases. Completion rates were 62/76 (81.6%) with QI < 35 vs 11/27 (40.7%) with QI > or = 35, P < 0.001. Significantly more patients had their laparoscopy completed when an attending gynecologic oncologist was the first assistant compared to a fellow or a community obstetrician/gynecologist (92.9%, 69.0%, 64.5%, P < 0.0001). The top three reasons for conversion to laparotomy were obesity, 12/30 (29.1%), adhesions, 5/30 (16.7%), and intraperitoneal disease, 5/30 (16.7%). Pelvic, common iliac, and paraaortic lymph node counts did not differ when compared to those of patients who had conversion to laparotomy (18.1, 5.1, 6.8 vs 17.3, 5.7, 6.8, P = ns). Complications included 2 urinary tract injuries, 2 pulmonary embolisms, and 6 wound infections (all in the laparotomy group). Two deaths occurred, 1 due to a vascular injury on initial trocar insertion and 1 due to a pulmonary embolism after a laparotomy for bowel herniation through a trocar incision.

CONCLUSION

Laparoscopic bilateral pelvic and paraaortic LND can be completed successfully in 70.9% of patients. Age, obesity, previous surgery, and the need to perform this procedure in the community were not contraindications. Advantages include a shorter hospital stay, similar nodal counts, and acceptable complications.