The E.A.E.S. Consensus Development Conferences on laparoscopic cholecystectomy, appendectomy, and hernia repair. Consensus statements--September 1994. The Educational Committee of the European Association for Endoscopic Surgery

Learning curve of laparoscopic appendectomy in a low-resource setting: a cumulative sum analysis of operative length

BACKGROUND

Cumulative sum (CUSUM) analysis is a valuable tool for quantifying the learning curve of surgical teams by detecting significant changes in operative length. However, there is limited research evaluating the learning curve of laparoscopic techniques in low-resource settings. The objective of this study is to evaluate the learning curve for laparoscopic appendectomy within a single surgical team in Senegal.

METHODS

This was a single-center prospective study conducted from May 1, 2018, to August 31, 2023 of patients who underwent laparoscopic appendectomy at a tertiary care institution in West Africa. The AAST classification was used to describe the severity of appendicitis. Parameters studied included age, sex, operative length, conversion rate, and postoperative outcomes. To quantify the learning curve, CUSUM analysis of operative length was performed.

RESULTS

A total of 81 patients were included. The mean age was 26.7 years (range 11-70 years) with a sex ratio of 1.9. Pre-operative severity according to AAST was Grade I in 75.4% (n = 61), Grade III in 7.4% (n = 6), Grade IV in 6.1% (n = 5), and Grade V in 11.1% (n = 9). Conversion occurred in 5 cases (6.1%). The average operative length was 76.8 min (range 30-180 min) and the average length of hospitalization was 2.7 days (range 1-13 days). Morbidity was observed in 3.7% (n = 3) and there were no deaths. The CUSUM analysis showed that a steady operative length was achieved after 28 procedures, with decreasing operative lengths thereafter.

CONCLUSION

Surgeons in our setting overcame the learning curve for laparoscopic appendectomy after performing 28 procedures. Moreover, laparoscopic appendectomy is safe and feasible throughout the learning curve. CUSUM analysis should be applied to other laparoscopic procedures and individualized by surgical teams to improve surgical performance and patient outcomes in low-resource settings.

Intra and Postoperative Advantages of Laparoscopy in the Treatment of Complicated Appendicitis

Aim: To determine and define the advantages of the laparoscopic appendectomy in the treatment of complicated appendicitis by comparing it with the open appendectomy. Material and Methods: In this prospective interventional clinical study we compared the intraoperative data and the postoperative outcome of 77 patients presented with complicated appendicitis, operated with open and laparoscopic appendectomy within a period of 20 months. One surgeon performed all of the laparoscopic procedures and two other senior surgeons performed the open procedures. Results: Operative time was shorter in the laparoscopic group (p = 0.033). Conversion rate was 2.3%. Overall postoperative morbidity was 25.97%. There was one operative revision due to postoperative small bowel obstruction in the laparoscopic group. Appendicular stump leakage occurred in one patient in the open group. One intra-abdominal abscess occurred in the laparoscopic group (p = 0.38). Wound infection occurred only in the open group (p = 0.018). Length of stay was shorter in the laparoscopic group (p = 0.0052). One patient from the laparoscopic group was readmitted. Conclusions: Laparoscopy is a reliable method in the treatment of complicated appendicitis. It offers a shorter operative time, low conversion rate, an acceptable rate of major postoperative complications and a shorter length of stay.

[Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]

OBJECTIVE

To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications.

MATERIAL AND METHODS

We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021.

RESULTS

There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses.

CONCLUSION

We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.

Mastering the learning curve significantly reduces operative time for laparoscopic treatment of complicated appendicitis

Laparoscopic appendectomy is the preferred operative method for acute appendicitistreatment. In terms of complicated appendicitis it can be effective in hands of an experiencedlaparoscopist that overwhelmed the learning curve for the method. Aim: Тhis retrospectivestudy examines whether the operative time for laparoscopic appendectomy for complicatedappendicitis is shortened after mastering the learning curve. Material and methods: A totalnumber of 196 patients were operated for the diagnosis of acute appendicitis, of whom 77were diagnosed with complicated appendicitis. They were subsequently divided in two groups(laparoscopic and open). Operative time in both groups was measured and the conversionand postoperative complications were noted. Results: Conversion rate was 2.3%. Operativetime was shorter in the laparoscopic group (67.4 ± 22.9 vs. 77.9 ± 17.9 minutes; p = 0.033).Overall postoperative morbidity was 25.97% with wound infection present only in the opengroup (p = 0.018). Intraabdominal abscess occurred in one patient from the laparoscopicgroup (0.38%). Length of hospital stay was shorter in the laparoscopic group (4.3 ± 2.2 vs. 5.7 ± 2.1, p = 0.0052).  

Deciphering the inflection points to achieve proficiency for each procedure step during training in laparoscopic appendicectomy

Background

Laparoscopic appendicectomy is a common procedure early in surgical training. A minimum number is usually required for certification in general surgery. However, data on proficiency are scarce. This study aimed to investigate steps towards proficiency in laparoscopic appendicectomy.

Methods

This was a prospective observational cohort study of laparoscopic appendicectomies performed by junior trainees under supervision scored on a six-point performance scale. Structured assessment was done within a defined programme. Procedures performed for uncomplicated appendicitis in adults were included. The procedures were evaluated with LOWESS graphs generated to investigate inflection points. Factors associated with proficiency rates were reported with odds ratios and 95 per cent confidence intervals.

Results

In total 142 laparoscopic procedures were included for 19 trainees (58 per cent female). The cumulative number of procedures during the study was a median of 20 (i.q.r. 8–33). For overall proficiency, an inflection point occurred at 30 procedures. Proficiency rate increased from 51 per cent for 30 or fewer procedures to 93 per cent for more than 30 procedures (odds ratio 11.9 (95 per cent c.i. 3.4 to 40.9); P < 0.001). Inflection points for proficiency for each procedure step varied considerably, with lowest numbers (fewer than 15 procedures) for removing the specimen, and highest for dividing the mesoappendix (more than 55 procedures). Operating time was significantly reduced by a median of 7 minutes after 30 procedures, from median 62 (i.q.r. 25–120) minutes to median 55 (i.q.r. 30–110) minutes for more than 30 procedures.

Conclusion

For junior trainees, variation in proficiency is related to specific procedure steps. Targeted training on specific procedure skills may reduce numbers needed to achieve proficiency in laparoscopic appendicectomy during training.

[Effectiveness of laparoscopic cholecystectomy for acute cholecystitis]

OBJECTIVE

To analyze the impact of laparoscopic cholecystectomy on in-hospital and postoperative mortality in patients with acute cholecystitis.

MATERIAL AND METHODS

Comparative analysis was based on primary statistical data presented in public available analytical collections «Surgical care in the Russian Federation» (Revishvili A.Sh. et al. 2019, 2020). Depending on introduction of laparoscopic surgery, all regions were divided into 4 groups. Between-group analysis of differences was carried out using χ2 test. Statistical processing was performed using SPSS Statistics software package for Windows.

RESULTS

According to 2-year follow-up data (2018, 2019), in-hospital mortality was 0.97 and 0.95% and postoperative mortality was 1.36 and 1.47%, respectively, in the regions with percentage of laparoscopic surgery for patients with acute cholecystitis was less than 25%. In the second group (percentage of laparoscopic surgery 25.01 - 50%), in-hospital mortality was 0.95 and 1.14%, postoperative mortality - 1.38 and 1.71%. In the third group (percentage of laparoscopic surgery 50.01 - 75%), in-hospital mortality was 0.92 and 0.99%, postoperative mortality - 1.27 and 1.38%. In the fourth group, percentage of laparoscopic surgery exceeded 75%. In-hospital mortality was 0.61 and 0.74%, postoperative mortality - 0.76 and 0.98%, respectively. Analysis of multi-field contingency tables revealed non-random between-group differences of in-hospital (p<0.001) and postoperative (p<0.001) mortality, as well as significant decrease of mortality following laparoscopic surgery. We also analyzed mortality after laparoscopic surgery considering technology maturity curve.

CONCLUSION

In-hospital and postoperative mortality in acute cholecystitis depend on availability of laparoscopic technologies.

[Randomized trials and progress in surgery]

It is very difficult to find certain surgical field in which surgeon's decision is absolutely evidence-based. The objective of evidence-based medicine (and surgery) is offering the best treatment for each patient that should encourage conducting the randomized trials (RT) as the highest level of evidence. The results of RTs often contradict the existing clinical experience, and experience per se does not always confirm the significance of the results obtained. One cannot make any conclusions based on RT data. Treatment strategy for a particular patient remains unclear. The authors have analyzed the results of large-scale RTs devoted to laparoscopic cholecystectomy, rectal surgery, lung cancer surgery, postoperative care, treatment of pulmonary emphysema. It was shown that RT data as the highest level of evidence are not always true for surgery. In most clinical situations, the decision is not based on RT results. The desire of surgeons to master a new technique is often more significant than patient care, while clinical experience and the laws of the market are more important than science. There is no doubt that knowledge of RT results are essential in training period, but this means quite a bit for a particular patient. The best decision can be made during discussion and conversation with colleagues, where an experience of each specialist will have the same value as the best evidence.

Insight into the methodology and uptake of EAES guidelines: a qualitative analysis and survey by the EAES Consensus & Guideline Subcommittee

BACKGROUND

Over the past 25 years, the European Association for Endoscopic Surgery (EAES) has been issuing clinical guidance documents to aid surgical practice. We aimed to investigate the awareness and use of such documents among EAES members. Additionally, we conceptually appraised the methodology used in their development in order to propose a bundle of actions for quality improvement and increased penetration of clinical practice guidelines among EAES members.

METHODS

We invited members of EAES to participate in a web-based survey on awareness and use of these documents. Post hoc analyses were performed to identify factors associated with poor awareness/use and the reported reasons for limited use. We further summarized and conceptually analyzed key methodological features of clinical guidance documents published by EAES.

RESULTS

Three distinct consecutive phases of methodological evolvement of clinical guidance documents were evident: a "consensus phase," a "guideline phase," and a "transitional phase". Out of a total of 254 surgeons who completed the survey, 72% percent were aware of EAES guidelines and 47% reported occasional use. Young age and trainee status were associated with poor awareness and use. Restriction by colleagues was the primary reason for limited use in these subgroups.

CONCLUSIONS

The methodology of EAES clinical guidance documents is evolving. Awareness among EAES members is fair, but use is limited. Dissemination actions should be directed to junior surgeons and trainees.

Resident Learning Curve for Laparoscopic Appendectomy According to Seniority

Purpose

This study sought to delineate the learning curve (LC) for laparoscopic appendectomy (LA) in surgical residency according to seniority and experience.

Methods

Between October 2015 and November 2016, 150 patients underwent LA performed by one of 3 residents (who were in their first [A], second [B], or third [C] year of training) under supervision. The patients were nonrandomly assigned to each resident. Data from a prospectively collected database were reviewed and analyzed retrospectively. Perioperative outcomes including operation time, complications, and conversion were compared among the 3 residents. The LC was evaluated using the moving average method and cumulative sum control chart (CUSUM) for operation time and surgical completion.

Results

Baseline characteristics and perioperative outcomes were similar among the 3 groups except for age and location of the appendix. The operation time did not vary among the 3 residents (43.9, 45.3, and 48.4 minutes for A, B, and C, respectively; P=0.392). The moving average method for operation time showed a decreasing tendency for all residents. CUSUM results for operation time revealed peak points achieved at the 24th, 18th, and 31st cases for residents A, B, and C, respectively. In terms of surgical failure, residents A, B, and C reached steady states after their 35th, 11th, and 16th cases, respectively. Perforation of the appendix base was the only risk factor for surgical failure.

Conclusion

The resident LC for LA was 11 to 35 cases according to multidimensional statistical analyses. The accumulation of surgical experience among residents might influence the LC for surgical completion but not that for operation time.

Fundus first as the standard technique for laparoscopic cholecystectomy

In previous studies the fundus first technique (FF) has been a cost-effective way to simplify the laparoscopic cholecystectomy (LC) and facilitate patient rehabilitation. The feasibility and safety profile when introducing FF as the standard technique were aimed in this study. Between 2004–2014, 29 surgeons performed 1425 LC with FF and 320 with a conventional technique. During the first year 56% were with FF and 98% during the last four years. More females, ultrasonic shears, urgent operations, daycare operations and a shorter operation time were found with FF. 63 (3.6%) complications occurred: 10 (0.6%) bleedings, 33 (1.9%) infections and 12 (0.7%) bile leakages. Leakage from cystic duct occurred in 4/112 (3.6%) when closed with ultrasonic shears and in 4/1633 (0.2%) with clips (p 0.008). A common bile duct lesion occurred in 1/1425 (0.07%) with FF and in 3/320 (0.9%) with the conventional approach (p 0.003). In a multivariate regression model, the conventional technique was a risk factor for bile duct injury with an odds ratio of 20.8 (95% CI 1.6–259.2). In conclusion FF was effectively established as the standard procedure and associated with lower rates of bile duct injuries. Clipless closure of the cystic duct increased the rate of leakage.

Outcomes of Open and Laparoscopic Appendectomy With Single Endoloop Stump Closure

Background and Objectives:

Although laparoscopic appendectomy (LA) has been used for 35 years, the open approach (OA) is preferred worldwide. Widespread access to instrumentation in a number of centers has reduced economic and logistical obstacles. The aim of this work is to compare the results for patients with suspected appendicitis treated using an OA versus patients treated using LA.

Methods:

A retrospective study of all patients (N = 290) who underwent operation due to suspected appendicitis in the General Surgery Department from 2014 to 2017 was conducted. LA was performed in 91 patients, and OA was performed in 199 patients.

Results:

Average surgery duration was 67.8 minutes in the LA group and 62.9 minutes in the OA group (P =.082). It was necessary to perform 3 conversions (3.3%) from LA to OA. Wound infections occurred in 2.2% of patients in the LA group and in 12.6% of patients in the OA group (P = .007). A reduced duration of hospitalization was noted in the LA group (3.3 days) compared with the OA group (4.7 days) (P < .001).

Conclusion:

The duration of LA is not considerably longer than that of OA. LA in patients with suspected appendicitis reduces the number of operation site infections compared with OA. LA with single endoloop stump closure is a safe method and may be recommended for wider applications.

Safety and feasibility of single-port laparoscopic appendectomy as a training procedure for surgical residents

Background:

Single-port laparoscopic appendectomy (SPLA) is one of the most commonly performed single-port surgeries worldwide. This study aimed to determine whether the performance of SPLA by residents without sufficient experience as operators of conventional LA (CLA) is safe and feasible.

Patients and Methods:

Records of patients who underwent LA between March 2017 and February 2018 at a hospital in Korea were retrospectively analysed. Patients aged <18 years or >80 years were excluded from the study. SPLA and CLA were performed by two 2^nd-year residents (junior group) and three 3^rd-year residents (senior group). Demographic data, perioperative variables and surgical outcomes were compared.

Results:

During the study period, 154 patients underwent LA (104 SPLA and 50 CLA) performed by surgical residents. No differences were found between the SPLA and CLA groups in demographic data or perioperative variables, except for the drain insertion rate. The SPLA group had significantly shorter mean operation times than did the CLA group. No significant difference was observed between the junior and senior groups in the mean operation time for LA. Perioperative outcomes were not significantly different between groups. Fewer women underwent SPLA performed by 2^nd-year residents compared with SPLA performed by 3^rd-year residents. However, there were no differences in other general characteristics or perioperative outcomes.

Conclusions:

SPLA was safe and feasible when performed by junior residents. Surgical residents with sufficient experience as assistants during laparoscopic appendectomies could perform SPLA safely. Furthermore, SPLA could serve as a teaching procedure for surgical residents.

Learning curve after rapid introduction of laparoscopic appendectomy: are there any risks in surgical resident participation?

BACKGROUND

With the spread of the minimally invasive technique, laparoscopic appendectomy (LA) is performed with increasing frequency with excellent results. The method provides surgical residents with an excellent opportunity to learn basic laparoscopic skills and prepares them for more complex interventions.

METHODS

We evaluated the results of 600 laparoscopic appendectomies performed by 5 surgical residents (Group A) and 5 consultant surgeons (Group B) between 2006 and 2009. Comparing the two groups based on patient demographics, duration of surgery, operation time depending on the severity of inflammation, intraoperative blood loss, conversion rate, hospital stay in days, and postoperative complications. We also assessed the extent to which the minimum of 20 surgeries to be performed in the learning curve period as recommended by the EAES corresponds to our experience. SPPS 20 was used for the statistical analysis.

RESULTS

Six hundred laparoscopic appendectomies were performed in the study period (Group A: n = 319; Group B: n = 281). A significant difference was found between the two groups in duration of surgery during the learning curve period and when comparing the duration of LA surgeries in the learning curve period with the duration of later surgeries in both groups. The operation time in case of more severe inflammation also showed a significant difference when comparing with simple appendicitis operation time.

CONCLUSIONS

The rapid introduction of laparoscopy involves few risks, the surgery is also performed with sufficient safety by surgical residents, and it provides them with an excellent opportunity to learn the basic laparoscopy skills.

The role of non-technical skills in surgery

Non-technical skills are of increasing importance in surgery and surgical training. A traditional focus on technical skills acquisition and competence is no longer enough for the delivery of a modern, safe surgical practice. This review discusses the importance of non-technical skills and the values that underpin successful modern surgical practice. This narrative review used a number of sources including written and online, there was no specific search strategy of defined databases. Modern surgical practice requires; technical and non-technical skills, evidence-based practice, an emphasis on lifelong learning, monitoring of outcomes and a supportive institutional and health service framework. Finally these requirements need to be combined with a number of personal and professional values including integrity, professionalism and compassionate, patient-centred care.

Should appendectomy be performed laparoscopically? Clinical prospective randomized trial

OBJECTIVE

Laparoscopic appendectomy (LA) has been described in 1983, and its superiority over open appendectomy (OA) is still being debated. Currently, there is no agreement on the advantages of LA. Postoperative pain is reported to be lower along with a faster return to normal activities in LA. However, some studies do not support these findings. In our study, we aimed to compare the outcomes and cost effectiveness of LA and OA.

MATERIAL AND METHODS

Patients were prospectively randomized into LA (31 patients) and OA (32 patients) groups. Demographic data, pre- and postoperative C-reactive protein (CRP) levels, white blood cell (WBC) count, duration of surgery and hospitalization, complications, and pain scores (VAS) were recorded. Cost was calculated for both groups. Return to normal activities was evaluated by phone calls at the first and second week and 1 month after surgery.

RESULTS

There was a significant postoperative decrease in WBC count in the LA group (p<0.01). There were no differences between LA and OA groups in terms of postoperative CRP levels (p>0.05). The rates of wound infection and abscess were similar (p>0.05), while post-operative pain and time to return to normal activities were higher in the OA group (p<0.01). There was a positive correlation between BMI and operative time in the LA group (p<0.01), while BMI and operative time did not show a correlation in the OA group (p>0,05). The average cost in the LA and OA groups were 1960.5±339.05 and 687.115±159.5 TL, respectively.

CONCLUSION

LA is an effective method in the treatment of acute appendicitis due to less pain and faster recovery. LA can be the choice of treatment in acute appendicitis, with utilization of re-useable and cheaper vascular sealing devices.

State of the art in robotic hepatobiliary surgery

Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

On-table urethral catheterisation during laparoscopic appendicectomy: Is it necessary?

INTRODUCTION

Laparoscopic appendicectomy (LA) is the most commonly performed surgical emergency procedure. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention.

METHODS

A retrospective review was carried out of all LA performed in a university teaching hospital over a two year period 2012-2013. Iatrogenic visceral injuries were identified and operative notes examined.

RESULTS

During the study period 1124 appendicectomies were performed. Four iatrogenic bladder injuries occurred related to secondary trocar insertion. No patient was catheterised preoperatively. One of the injuries was identified intra-operatively, another in the early postoperative period where as two re-presented acutely unwell post-discharge from hospital. Three were repaired by laparotomy and one laparoscopically.

CONCLUSION

Iatrogenic secondary trocar induced bladder injuries are a rare but preventable and potentially serious complication of LA. Urethral catheterisation during LA is a safe and simple method which can prevent this complication.

Short term and long term results after open vs. laparoscopic appendectomy in childhood and adolescence: a subgroup analysis

Background

A comparative study was performed to compare quality of life after laparoscopic and open appendectomy in children and adolescents in a German General Hospital. The same study population was re-evaluated regarding their quality of life several years after operation.

Methods

Children and adolescents (n = 158) who underwent appendectomy for acute appendicitis between 1999 and 2001 were retrospectively analysed. Seven years after surgery those patients were interviewed applying a SF-36 questionnaire regarding their quality of life.

Results

For short term outcomes there was a trend towards reduced specific postoperative complications in the laparoscopically operated group (9.3 vs. 10.7%). Significantly more patients in the laparoscopic group would recommend the operation procedure to family members or friends than in the open group. Among the evaluated patients there was a significantly higher satisfaction concerning size and appearance of their scars in the laparoscopic group. The results of the evaluation in the eight categories of the SF-36 showed similar results in both groups.

Conclusions

More patients with laparoscopic appendectomy appeared to be satisfied with their operation method as becomes evident by a higher recommendation rate and a higher satisfaction concerning their scars.

[Robotic hepatobiliary and gastric surgery]

Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).

Intra-abdominal collections following laparoscopic versus open appendicectomy: an experience of 516 consecutive cases at a district general hospital

BACKGROUND

The objective of this study is to evaluate the incidence of intra-abdominal collections (IACs) in all patients undergoing laparoscopic (LA) and open appendicectomy (OA) from April 2009 to October 2011 in a district general hospital with expertise in minimally invasive surgery (MIS).

METHODS

A retrospective review of all patients undergoing appendicectomy in the specified time period was carried out. IACs were identified from various in-hospital data resources. Severity of appendicitis was assessed from histology reports.

RESULTS

516 patients were identified, of whom 242 (47 %) underwent OA and 274 (53 %) LA. Twenty-six (5 %) patients were found to have IACs postoperatively. Fifteen (5.5 %) IACs were identified in the laparoscopic group and 11 (4.5 %) in the open group. There was no statistically significant difference in the risk of developing IACs in open versus laparoscopic groups [odds ratio (OR) 1.22, confidence interval (CI) 0.55-2.70, P = 0.63]. Patients were twelve times more likely to develop IACs with an appendix identified as being necrotic or perforated on histology (OR 12.24, CI 5.29-28.32, P < 0.0001). There was a trend towards shorter total hospital stay in the LA (3.58 days, CI 3.0-4.1 days) compared with OA (4.31 days, CI 3.7-4.9 days, P = 0.082) group, although this was not statistically significant.

CONCLUSIONS

Increased rates of IAC following LA have been identified in some studies. Our series shows that, in a centre with adequate MIS experience, the IAC rate following LA is comparable to that of the open approach and should not deter surgeons with adequate support and resources.

A comparison between volume-controlled ventilation and pressure-controlled ventilation in providing better oxygenation in obese patients undergoing laparoscopic cholecystectomy

Background:

The maintenance of oxygenation is a commonly encountered problem in obese patients undergoing laparoscopic cholecystectomy. There is no specific guideline on the ventilation modes for this group of patients. Although several studies have been performed to determine the optimal ventilatory settings in these patients, the answer is yet to be found. The aim of this study was to evaluate the efficacy of pressure-controlled ventilation (PCV) in comparison with volume-controlled ventilation (VCV) for maintaining oxygenation during laparoscopic cholecystectomy in obese patients.

Methods:

One hundred and two adult patients of ASA physical status I and II, Body Mass Index of 30–40 kg/m², scheduled for laparoscopic cholecystectomy were included in this prospective randomized open-label parallel group study. To start with, all patients received VCV. Fifteen minutes after creation of pneumoperitoneum, they were randomized to receive either VCV (Group V) or PCV (Group P). The ventilatory parameters were adjusted accordingly to maintain the end-tidal CO₂ between 35 and 40 mmHg. Respiratory rate, tidal volume, minute ventilation and peak airway pressure were noted. Arterial blood gas analyses were done 15 min after creation of pneumoperitoneum and at 20-min intervals thereafter till the end of the surgery. All data were analysed statistically.

Results:

Patients in Group P showed a statistically significant (P < 0.05) higher level of PaO₂ and lower value of PAO₂–PaO₂ than those in Group V.

Conclusion:

PCV is a more effective mode of ventilation in comparison with VCV regarding oxygenation in obese patients undergoing laparoscopic cholecystectomy.

A brief review of laparoscopic appendectomy: the issues and the evidence

Laparoscopic appendectomy was first performed more than 25 years ago. We performed a systematic literature search on laparoscopic appendectomy and selected related topics. The technique should be considered the gold standard for surgical removal of the appendix in women of childbearing age (level of evidence Ia). There is minor but consistent evidence that it should also be advocated for men (level of evidence III), obese (level of evidence III), and elderly (level of evidence IIb) patients, while there is some evidence of unfavorable results on pregnant women (level of evidence IIb). Studies reporting higher incidence of intra-abdominal abscesses after laparoscopic appendectomy are difficult to interpret due to a lack of standardization of the operative technique and lack of uniformity related to the different grades of disease (ranging from uninflamed appendix to diffuse peritonitis, gangrene, or perforation of the organ). As far as surgical technique, the three-port procedure is superior to needleoscopy and single port access (level of evidence Ia). Costly high-tech instruments for dissection are mostly unnecessary (level Ib). Mechanical closure of the stump might prove safer (level Ib). The quantity of peritoneal lavage fluid is generally scanty (level III), and abdominal drains are not useful (level Ia). Fast-track protocols should be implemented (level Ic). Training and technical standardization are the key to devising future trials on this topic.

Laparoscopic versus open appendectomy--quality of life 7 years after surgery

BACKGROUND

In spite of the widespread use of laparoscopic appendectomy, there is an ongoing debate on the advantages of this method when compared to open appendectomy. In the evaluation of a postoperative procedure, long-term quality of life is essential.

PATIENTS AND METHODS

From 1999 to 2001, 493 patients diagnosed with acute appendicitis were operated in a German general district hospital and included in an observational study. In a median postoperative interval of 7 years, these patients were re-evaluated regarding their quality of life after surgery. A Short-Form 36 Health Survey (SF-36) questionnaire was applied to evaluate the general parameters of quality of life after surgery. This questionnaire was supplemented by an additional self-developed module referring to the appendectomy. The primary outcome was the recommendation of the experienced operating procedure to relatives and friends.

RESULTS

A total of 243 patients underwent a laparoscopic procedure: 132 patients were re-evaluated (recovery rate 54%). In the open group, 250 patients were operated: 121 patients were re-evaluated (recovery rate 48%). The median interval from operation to evaluation was 7 years in the laparoscopic group and 7.7 years in the open group. For the primary outcome, patients with laparoscopic appendectomy would significantly more often recommend the procedure than patients with the open operation method. For secondary outcomes, the cosmetic results were judged significantly more favourably in the laparoscopic group. The eight scaled scores of the SF-36 questionnaire did not differ significantly between the two groups. Four patients of the open group and nine patients of the laparoscopic group (including one converted procedure) needed a reoperation because of incisional hernia, adhesions and late infections.

CONCLUSION

Patients after laparoscopic appendectomy show a higher degree of satisfaction with their body and their scar than patients after open appendectomy.

Laparoscopic appendectomy by residents: evaluating outcomes and learning curve

BACKGROUND

Laparoscopic appendectomy is being performed increasingly, worldwide. To the resident, it provides a valuable opportunity to master basic laparoscopic skills. Studies have shown that laparoscopic appendectomy performed by residents is safe. However, to date, there is no clear evidence for the minimum number of these operations required to achieving proficiency and safety. The aim of this study is to assess the outcome of laparoscopic appendectomies performed by surgical residents and to evaluate the effect of learning curve on patient outcome.

METHODS

All patients undergoing laparoscopic appendectomies performed by six residents during the study period were reviewed. Data on patient demographics,clinical and histological diagnosis, and outcome variables including operative duration, conversion to open surgery, complications, and length of stay were analyzed. We evaluated the effect of the learning curve by dividing patients into two groups: a first group consisting of the initial 20 patients and a second group consisting of the next 20 patients operated upon independently by each resident. Variables were analyzed to determine any difference between the two groups.

RESULTS

Three hundred six patients with the clinical diagnosis of acute appendicitis underwent laparoscopic appendectomy by residents. Mean operative time was 83.8 min. Of patients, 14.6% required conversion to open surgery. Mean length of hospitalization was 2.82 days. Operative duration and complication rate were significantly reduced with increasing experience of residents. The length of hospital stay and conversion rate to open surgery remained unchanged.

CONCLUSION

Operative duration and complications can be reduced with increasing experience of a resident.

The "inside approach of the gallbladder" is an alternative to the classic Calot's triangle dissection for a safe operation in severe cholecystitis

BACKGROUND

External dissection of Calot's triangle and the gallbladder associated with complete cholecystectomy is considered the gold standard technique to achieve a safe cholecystectomy. However, in severe acute or chronic cholecystitis, the laparoscopic application of this standard technique may be technically difficult, with an increased risk of bile duct injury, even in the hands of an experienced surgeon.

METHODS

In a consecutive series of 552 cholecystectomies, 39 patients (7.1%) with difficult local conditions within Calot's triangle, such as gangrenous cholecystitis (three patients), severe scleroatrophic cholecystitis with or without anomalous right hepatic duct (24 and 10 patients, respectively), or Mirizzi syndrome (seven patients), underwent a routine exclusive "endovesicular approach" as an alternative to dissection of Calot's triangle prior to further subtotal cholecystectomy. All patients were examined by control cholangiography 3 months postoperatively to confirm the safety of the technique.

RESULTS

The operation was well tolerated by all patients with only 15.4% minor complications. Intraoperative cholangiography was feasible in 79.5%. There were no postoperative biliary or infectious complications. At 4.3 months follow-up, all patients were symptom-free, except for two patients (5.1%) with residual common bile duct stones which were successfully treated by endoscopic sphincterotomy.

CONCLUSIONS

An endovesicular approach for gallbladder dissection followed by subtotal cholecystectomy is a safe alternative to the classic Calot's dissection in the case of severe cholecystitis or difficult local conditions. This technique is recommended as an attractive solution to prevent bile duct injury, particularly when severe inflammation is associated to extrahepatic anatomic variants of the biliary tree.

Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews

BACKGROUND

Patients with symptomatic cholecystolithiasis are treated by three different techniques of cholecystectomy: open, small-incision, or laparoscopic. There is no overview on Cochrane systematic reviews on these three interventions.

OBJECTIVES

To summarise Cochrane reviews that assess the effects of different techniques of cholecystectomy for patients with symptomatic cholecystolithiasis.

METHODS

The Cochrane Database of Systematic Reviews (CDSR) was searched for all systematic reviews evaluating any interventions for the treatment of symptomatic cholecystolithiasis (Issue 4 2008).

MAIN RESULTS

Three systematic reviews that included a total of 56 randomised trials with 5246 patients are included in this overview of reviews. All three reviews used identical inclusion criteria for trials and participants, and identical methodological assessments.Laparoscopic versus small-incision cholecystectomy Thirteen trials with 2337 patients randomised studied this comparison. Bias risk was relatively low. There was no significant difference regarding mortality or complications. Total complications of laparoscopic and small-incision cholecystectomy were high, ie, 17.0% and 17.5%. Total complications (risk difference, random-effects model -0.01 (95% confidence interval (CI) -0.07 to 0.05)), hospital stay (mean difference (MD), random-effects -0.72 days (95% CI -1.48 to 0.04)), and convalescence were not significantly different. Trials with low risk of bias showed a quicker operative time for small-incision cholecystectomy (MD, low risk of bias considering 'blinding', random-effects model 16.4 minutes (95% CI 8.9 to 23.8)) while trials with high risk of bias showed no statistically significant difference.Laparoscopic versus open cholecystectomy Thirty-eight trials with 2338 patients randomised studied this comparison. Bias risk was high. Laparoscopic cholecystectomy patients had a shorter hospital stay (MD, random-effects model -3 days (95% CI -3.9 to -2.3)) and convalescence (MD, random-effects model -22.5 days (95% CI -36.9 to -8.1)) compared with open cholecystectomy but did not differ significantly regarding mortality, complications, and operative time.Small-incision versus open cholecystectomy Seven trials with 571 patients randomised studied this comparison. Bias risk was high. Small-incision cholecystectomy had a shorter hospital stay (MD, random-effects model -2.8 days (95% CI -4.9 to -0.6)) compared with open cholecystectomy but did not differ significantly regarding complications and operative time.

AUTHORS' CONCLUSIONS

No statistically significant differences in the outcome measures of mortality and complications have been found among open, small-incision, and laparoscopic cholecystectomy. There were no data on symptom relief. Complications in elective cholecystectomy are high. The quicker recovery of both laparoscopic and small-incision cholecystectomy patients compared with patients on open cholecystectomy justifies the existing preferences for both minimal invasive techniques over open cholecystectomy. Laparoscopic and small-incision cholecystectomies seem to be comparable, but the latter has a significantly shorter operative time, and seems to be less costly.

Effects of carbon dioxide pneumoperitoneum on hepatic function in obstructive jaundice: an experimental study in a rat model

BACKGROUND AND AIMS

The physiology of the patient during laparoscopy differs from that of open surgery. Both pneumoperitoneum and obstructive jaundice impair the hepatic function, but the combined insult has not been previously examined. In this study, we aimed to investigate the effects of carbon dioxide (CO(2)) pneumoperitoneum on hepatic function in a rat model of obstructive jaundice.

METHODS

Forty-four male Sprague-Dawley rats were divided into four groups: group 1 (n = 10), sham-operated group; group 2 (n = 12), obstructive jaundice group; group 3 (n = 10), CO(2) pneumoperitoneum group; and group 4 (n = 12), obstructive jaundice and CO(2) pneumoperitoneum group. Common bile duct was ligated and divided in the obstructive jaundice groups. After 6 days, a 12-mmHg pneumoperitoneum was induced, maintained for 60 min, and released for 120 min. Blood samples were drawn for the measurement of white blood cell and platelet counts, serum liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], total bilirubin). Tissue samples were obtained for analyses of malondialdehyde (MDA), glutathione (GSH), and superoxide dismutase (SOD) levels. We evaluated the degree of liver injury on a grading scale from 0 to 4, histopathologically.

RESULTS

Pneumoperitoneum after biliary obstruction resulted in an increase in AST and ALT levels and a decrease in white blood cell and platelet counts. However, changes in liver tissue MDA, GSH, and SOD levels did not correlate with the changes in AST and ALT levels and white blood cell and platelet counts. After sham operation with pneumoperitoneum, the GSH levels in liver homogenate were significantly decreased in the group 3 when compared to the group 2. On the other hand, obstructive jaundice itself caused significant reduction in the SOD activity of liver homogenate in comparison to the group 3. Histopathologically, sinusoidal congestion and vacuolization were more severe in the group 3.

CONCLUSIONS

Alterations in hepatic function occur in pneumoperitoneum applied jaundiced subjects. However, there were no statistically significant differences between the groups 2 and 4 with regard to white blood cell and platelet counts, serum liver enzymes including AST, ALT, and total bilirubin values, MDA and GSH levels and SOD activity of liver homogenate, and histologic damage. These results indicate that there is no additional risk on liver function associated with pneumoperitoneum performed in obstructive jaundice.

Clinical role of gasless laparoscopic adrenalectomy

BACKGROUND

Several studies have demonstrated that the pneumoperitoneum (PNP) may have several hemodynamic, metabolic, neurologic, and humoral effects; in a limited number of patients, these effects represent a contraindication to the use of the PNP in the presence of glaucoma, cardiovascular insufficiency, advanced chronic obstructive bronchitis, and neurologic disease.

PATIENTS AND METHODS

Between May 2002 and July 2008, we performed 9 laparoscopic gasless adrenalectomies in 8 patients (5 male and 3 female): 4 left, 3 right, and 1 bilateral, treated in 2 different operations. Mean age was 54.8 years (range: 34 to 76 y). Preoperative diagnosis was Cushing in 5 cases, pheochromocytoma in 1 case, incidentaloma in 1 case, and Conn in 2 cases. Postoperative histologic findings were cortical adenoma in 6 cases, pheochromocytoma in 1 case, and cortical hyperplasia in 2 cases. Contraindication to PNP were vascular endocranicanic malformation, acute glaucoma, history of vascular cerebral accident and hypertensive retinopathy, and recent neurosurgical intervention. We performed laparoscopic adrenalectomy in lateral flank position, using the LaparoTenser, an abdominal wall retractor, with 2 curved needles (Aghi Pluriplan) placed in the subcutaneous tissue of the anterolateral abdominal wall that allows low-pressure PNP offering a better view without negative effects of intra-abdominal pressure.

RESULTS

The mean operative time was 73 minutes (range: 45 to 120 min): left average 71.2 minutes, right average 75.0 minutes. The mean postoperative hospital stay was 3.38 days (range: 3 to 5 d). There was no conversion to open surgery. There were no intraoperative or postoperative complications. All patients are alive and there were no recurrences.

CONCLUSIONS

The gasless technique is a valid alternative to PNP when patients present a contraindication to the PNP, as it makes it possible to avoid the risks of intra-abdominal pressure and to conserve the advantages of a mini-invasive access.

Laparoscopic versus open appendectomy: a prospective randomized comparison

BACKGROUND

Whether laparoscopy offers a benefit over open surgery in the management of acute appendicitis or not remains a subject of controversy despite the publication of numerous randomized studies. This study aimed to compare laparoscopic appendectomy (LA) with open appendectomy (OA) and to ascertain its therapeutic benefit.

METHODS

Adult patients older than 14 years presenting with signs and symptoms suggestive of acute appendicitis were randomized to undergo either LA or OA from January 2006 to December 2007. Comparisons were based on operating time, time until return to a general diet, time until return to normal activity and work, length of hospital stay, billed charges, and postoperative complications.

RESULTS

The study enrolled 220 patients: 108 to undergo OA and 112 to undergo LA. The groups were similar in terms of clinicopathologic characteristics. The operating time seemed to be shorter for the OA patients than for the LA patients, but the difference was not significant (LA, 30 +/- 15.2 min vs. OA, 28.7 +/- 16.3 min; p > 0.05). The hospital stay of 4.1 +/- 1.5 days for the LA group and 7.2 +/- 1.7 days for the OA group, and the difference was statistically significant (p < 0.05). Laparoscopic appendectomy remained associated with a shorter time until return to a general diet (LA, 20.2 +/- 12.4 h vs. OA, 36.5 +/- 10 h; p < 0.05), to normal activity (LA, 9.1 +/- 4.2 days vs. OA, 13.7 +/- 5.8 days; p < 0.05), and to work (LA, 21.2 +/- 3.5 days vs. OA, 27.7 +/- 4.9 days; p < 0.05). The billed charges appeared to be higher for LA (LA, 5,720.3 +/- 115.7 yuan vs. OA, 5,310 +/- 575.4 yuan), but this difference failed to be clinically important or statistically significant (p > 0.05). Wound infections were more common after OA (n = 14) than after LA (n = 0) (p < 0.05). Intraabdominal abscesses occurred for two patients in the LA group and nine patients in the OA group (p < 0.05). Postoperative ileus occurred with frequencies of 0% in the LA group and 7.4% in the OA group (p < 0.05). The rate for overall complications was significantly lower in the LA group.

CONCLUSION

Laparoscopic appendectomy is a useful tool in the treatment of acute appendicitis. Its advantages lie in its minimal invasiveness, its better cosmetic outcome, its lower rate of complications based on surgical expertise and state-of-the-art equipment. It can be recommended as an adoptable method for the routine patient with appendicitis.

Perceptions of surgical specialists in general surgery, orthopaedic surgery, urology and gynaecology on teaching endoscopic surgery in The Netherlands

BACKGROUND

Specific training in endoscopic skills and procedures has become a necessity for profession with embedded endoscopic techniques in their surgical palette. Previous research indicates endoscopic skills training to be inadequate, both from subjective (resident interviews) and objective (skills measurement) viewpoint. Surprisingly, possible shortcomings in endoscopic resident education have never been measured from the perspective of those individuals responsible for resident training, e.g. the program directors. Therefore, a nation-wide survey was conducted to inventory current endoscopic training initiatives and its possible shortcomings among all program directors of the surgical specialties in the Netherlands.

METHODS

Program directors for general surgery, orthopaedic surgery, gynaecology and urology were surveyed using a validated 25-item questionnaire.

RESULTS

A total of 113 program directors responded (79%). The respective response percentages were 73.6% for general surgeons, 75% for orthopaedic surgeon, 90.9% for urologists and 68.2% for gynaecologists. According to the findings, 35% of general surgeons were concerned about whether residents are properly skilled endoscopically upon completion of training. Among the respondents, 34.6% were unaware of endoscopic training initiatives. The general and orthopaedic surgeons who were aware of these initiatives estimated the number of training hours to be satisfactory, whereas the urologists and gynaecologists estimated training time to be unsatisfactory. Type and duration of endoscopic skill training appears to be heterogeneous, both within and between the specialties. Program directors all perceive virtual reality simulation to be a highly effective training method, and a multimodality training approach to be key. Respondents agree that endoscopic skills education should ideally be coordinated according to national consensus and guidelines.

CONCLUSIONS

A delicate balance exists between training hours and clinical working hours during residency. Primarily, a re-allocation of available training hours, aimed at core-endoscopic basic and advanced procedures, tailored to the needs of the resident and his or her phase of training is in place. The professions need to define which basic and advanced endoscopic procedures are to be trained, by whom, and by what outcome standards. According to the majority of program directors, virtual reality (VR) training needs to be integrated in procedural endoscopic training courses.

Laparoscopic Appendicectomy in Children: A Trainee’s Perspective

Introduction: The emergence of operative laparoscopy has brought a great demand for training surgical residents, but there are no clear guidelines regarding choice of procedure for training, proficiency assessment and accreditation. We aim to examine from a trainee’s point of view, the safety and efficacy of laparoscopic appendicectomy (LA) as a laparoscopic training procedure. Materials and Methods: A retrospective analysis of all the consecutive cases of LA done by a trainee in paediatric laparoscopic surgery from September 2003 to February 2005 was done. Results: A total of 70 consecutive patients (37 males and 33 females) aged 3 to 15 years (mean, 10.5 ± 2.5) with suspected appendicitis underwent LA. Twelve (17.1%) patients had acute appendicitis, 25 (35.7%) had acute suppurative appendicitis adherent to the caecum with localised and/or pelvic pus pocketing, 29 (41.4%) had perforated appendicitis with generalised peritonitis and 4 (5.7%) had normal appendix [mesenteric adenitis (1), omental infarct (1), torted Meckel’s diverticulum (1) and primary peritonitis (1)]. There were no operative complications and none required conversion to open surgery. The operative duration ranged from 25 to 110 minutes (mean, 55.6 ± 23.4). There were two complications; one had adhesive intestinal obstruction and underwent successful laparoscopic adhesiolysis and one had umbilical wound infection. Conclusions: LA is a safe and effective laparoscopic training procedure, in addition to being effective for all stages of appendicitis, as well as concurrent lesions encountered in children with suspected appendicitis. Key words: Appendicitis, Laparoscopy, Training

Videolaparoscopic appendectomy: the current outlook

BACKGROUND

Mini-invasive techniques have revolutionized surgery, but the superiority of laparoscopic access for appendectomy is widely debated. The authors analyze their monocentric experience with 1,347 laparoscopic appendectomies.

METHODS

Between October 1991 and December 2002, all the patients with an indication for appendectomy underwent surgery (301 emergency and 1,046 interval appendectomies) using the laparoscopic approach.

RESULTS

For 1,248 patients, appendectomy was performed laparoscopically, whereas for 99 patients (7.3%), it was converted to an open procedure because of technical reasons (90 patients, 6.7%) or intraoperative complications (9 patients, 0.6%). For 59 patients (4.4%), the appendectomy was associated with another procedure. Histology showed "acute" alterations in 261 of the 301 emergency surgeries and in 148 of the 1,046 elective operations. Postoperative complications arose in 37 patients (2.7%), with 5 patients (0.3%) requiring invasive treatment. The mean postoperative stay was 30 h.

CONCLUSIONS

Laparoscopic appendectomy offers unquestionable advantages, but it is not yet considered the "gold standard" for appendiceal pathology. Many centers reserve it for selected patients (e.g., obese patients and women suspected of having other pathologies). No randomized trials or metaanalyses have definitively proved its superiority.

Morbidity of laparoscopic surgery for complicated appendicitis: an international study

BACKGROUND

Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses.

METHODS

A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions.

RESULTS

One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days).

CONCLUSIONS

The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis

INTRODUCTION

Though ruptured appendicitis is not a contraindication to laparoscopic appendectomy (LA), most surgeons have not embraced LA as the first-line approach to ruptured appendicitis. In fact, in 2002, the Cochrane Database Review concluded: 1) the clinical effects of LA are "small and of limited clinical relevance," and 2) the effects of LA in perforated appendicitis require further study.

OBJECTIVE

To study the effects of LA vs open appendectomy (OA) among adults with appendicitis.

METHODS

In 2003, 272 adults underwent appendectomy at a large County hospital, and were enrolled in a prospective clinical pathway that detailed their hospital course from time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (LA vs. OA), operative diagnosis (acute vs perforated appendicitis) and post-operative length of stay (LOS).

RESULTS

Complete data was obtained for 264 (97%) patients. Patient demographics were similar in the LA and OA groups (p > 0.05). Patients with LA had a significantly shorter LOS than OA by 1.6 days (p < 0.05). This LOS was significantly shorter among those with ruptured appendicitis vs. non-ruptured appendicitis (2.0 days vs. 0.3 day reduction, p = 0.0357). Rank-order multiple regression analysis, controlling for all other factors, showed laparoscopy to have a significant effect on postoperative LOS in all appendicitis cases, especially ruptured appendicitis.

CONCLUSIONS

The two-day reduction in LOS among those with ruptured appendicitis who underwent LA was significant enough to overcome the smaller benefit of LA in acute appendicitis. From a hospital utilization point of view, LA should be considered as the first-line approach for all patients with appendicitis.

Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis

Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.

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.

Possibilities and limitations of current stereo-endoscopy

BACKGROUND

Stereo-endoscopy has become a commonly used technology. In many comparative studies striking advantages of stereo-endoscopy over two-dimensional presentation could not be proven. To show the potential and fields for further improvement of this technology is the aim of this article.

METHOD

The physiological basis of three-dimensional vision limitations of current stereo-endoscopes is discussed and fields for further research are indicated. New developments in spatial picture acquisition and spatial picture presentation are discussed.

RESULTS

Current limitations of stereo-endoscopy that prevent a better ranking in comparative studies with two-dimensional presentation are mainly based on insufficient picture acquisition.

CONCLUSION

Devices for three-dimensional picture presentation are at a more advanced developmental stage than devices for three-dimensional picture acquisition. Further research should emphasize the development of new devices for three-dimensional picture acquisition.

Development of explicit criteria for cholecystectomy

OBJECTIVE

Consensus development techniques were used in the late 1980s to create explicit criteria for the appropriateness of cholecystectomy. New diagnostic and treatment techniques have been developed in the last decade, so an updated appropriateness of indications tool was developed for cholecystectomy in patients with non-malignant diseases. The validity and reliability of panel results using this tool were tested.

METHODS

Criteria were developed using a modified Delphi panel judgement process. The level of agreement between the panelists (six gastroenterologists and six surgeons) was analysed and the ratings were compared with those of a second different panel using weighted kappa statistics.

RESULTS

The results of the main panel were presented as a decision tree. Of the 210 scenarios evaluated by the main panel in the second round, 51% were found appropriate, 26% uncertain, and 23% inappropriate. Agreement was achieved in 54% of the scenarios and disagreement in 3%. Although the gastroenterologists tended to score fewer scenarios as appropriate, as a group they did not differ from the surgeons. Comparison of the ratings of the main panel with those of a second panel resulted in a weighted kappa statistic of 0.75.

CONCLUSIONS

The parameters tested showed acceptable validity and reliability results for an evaluation tool. These results support the use of this algorithm as a screening tool for assessing the appropriateness of cholecystectomy.

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p < 0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p < 0.05). The surgeon's experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.

Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study

OBJECTIVE

We assessed the value of sonography in predicting intraoperative difficulties for patients undergoing laparoscopic cholecystectomy and in identifying indicators for conversion to conventional cholecystectomy.

SUBJECTS AND METHODS

Upper abdominal sonography was performed (according to a checklist) in 75 consecutive patients before laparoscopic cholecystectomy. Sonographic findings were verified by the surgeon in the operating room.

RESULTS

Conversion from laparoscopic surgery to laparotomy was performed in five patients (6.7%). Of 75 patients, 19 had sonograms revealing gallbladder wall thickening (>4 mm); surgical preparation difficulties in 16 of these patients led to laparotomy in four patients. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of technical difficulties were 66.7%, 94.1%, 84.2%, and 85.3%, respectively. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of surgical conversion were 80.0%, 78.6%, 21.1%, and 78.7%, respectively. Technical difficulties at laparoscopy occurred in all five patients with pericholecystic fluid on sonography (sensitivity, 20.8%; specificity, 100%; positive predictive value, 100%; accuracy, 74.7%) and led to laparotomy in three patients (sensitivity 60.0%, specificity 97.1%, positive predictive value 60%, accuracy 94.7%). The accuracy of sonography for cholecystolithiasis was 100%.

CONCLUSION

On sonography, gallbladder wall thickening is the most sensitive indicator and pericholecystic fluid is the most specific indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to laparotomy.

Hepatobiliary surgery

The transformation of liver and biliary tract surgery into a full speciality began with the application of functional anatomy to segmental surgery in the 1950's, reinforced by ultrasound and new imaging techniques. The spectrum of gall-stone disease encountered by the hepatobiliary surgeon has changed with the laparoscopic approach to cholecystectomy. There is increased need for conservation techniques to repair the bile duct injuries that arise more often in the laparoscopic approach to cholecystectomy. These and other surgical interventions on the bile ducts should be selected as a function of risk versus benefit in relation to the patient's requirements and the institutional expertise. Bile duct cancers, including hilar cholangiocarcinoma, and gallbladder cancers have a dismal reputation, but evidence is accumulating for better survivals from aggressive approaches performed by specialist hepatobiliary surgeons. Hepatic surgery has increased in safety and effectiveness, largely due to the segmental approach, but also to experience with techniques for vascular control and exclusion used in liver transplantation. Techniques such as portal vein embolisation, which induces hypertrophy of the future remnant liver, percutaneous local tumour destruction using cryotherapy or radiofrequency tumour coagulation and more effective chemotherapy are beginning to increase the number of patients who can undergo curative resection. In liver transplantation, segmental surgery has been applied to graft reduction and to split liver grafts, and is opening new perspectives for living donor transplantation. Today the limitation to survival in primary and metastatic liver cancer lies not in the surgical technique but in the difficulty of dealing with microscopic and extrahepatic disease. Progress in these fields will enable the hepatobiliary surgeon to further extend the possibilities for proposing curative resections.

Laparoscopic cholecystectomy: a report on the community hospital experience in Hokkaido

We analyzed the outcome of 1408 patients who underwent laparoscopic cholecystectomy (LC) between February 1991 and October 1993 in affiliated community hospitals around Hokkaido, Japan. LC was performed for symptomatic gallstones (68%) and asymptomatic gallstones (29%) using the pneumoperitoneum (96%) or abdominal wall lift (4%) techniques. Intraoperative and postoperative complications occurred in 105 patients (10%), including bile duct injuries in 9 patients (0.9%). Conversion to open surgery or reoperation was required in 89 patients (8%) mainly because of unclear anatomy, difficulties with hemostasis, or bile duct injury. One patient died of congestive heart failure, resulting in a mortality rate of 0.07%. The patients were discharged after an average of 8 days, and returned to work after an average of 14 days. The complication and conversion rates were high; however, the incidences of reoperation, bile duct injuries, postoperative bile leaks, and deaths were low. In conclusion, LC was performed with acceptable safety in our community hospitals. The reason for this is most likely that conventional cholecystectomy was preferred to LC in difficult cases during this early period.