Intraoperative laparoscopic complications. Are we getting better?

The effect of implant surgery experience on the learning curve of a dynamic navigation system: an in vitro study

BACKGROUND

Dynamic navigation systems have a broad application prospect in digital implanting field. This study aimed to explore and compare the dynamic navigation system learning curve of dentists with different implant surgery experience through dental models.

METHODS

The nine participants from the same hospital were divided equally into three groups. Group 1 (G1) and Group 2 (G2) were dentists who had more than 5 years of implant surgery experience. G1 also had more than 3 years of experience with dynamic navigation, while G2 had no experience with dynamic navigation. Group 3 (G3) consisted of dentists with no implant surgery experience and no experience with dynamic navigation. Each participant sequentially placed two implants (31 and 36) on dental models according to four practice courses (1-3, 4-6, 7-9, 10-12 exercises). Each dentist completed 1-3, 4-6 exercises in one day, and then 7-9 and 10-12 exercises 7 ± 1 days later. The preparation time, surgery time and related implant accuracy were analyzed.

RESULTS

Three groups placed 216 implants in four practice courses. The regressions for preparation time (F = 10.294, R² = 0.284), coronal deviation (F = 4.117, R² = 0.071), apical deviation (F = 13.016, R² = 0.194) and axial deviation (F = 30.736, R² = 0.363) were statistically significant in G2. The regressions for preparation time (F = 9.544, R² = 0.269), surgery time (F = 45.032, R² = 0.455), apical deviation (F = 4.295, R² = 0.074) and axial deviation (F = 21.656, R² = 0.286) were statistically significant in G3. Regarding preparation and surgery time, differences were found between G1 and G3, G2 and G3. Regarding implant accuracy, differences were found in the first two practice courses between G1 and G3.

CONCLUSIONS

The operation process of dynamic navigation system is relatively simple and easy to use. The linear regression analysis showed there is a dynamic navigation learning curve for dentists with or without implant experience and the learning curve of surgery time for dentists with implant experience fluctuates. However, dentists with implant experience learn more efficiently and have a shorter learning curve.

Post-operative morbidity following pancreatic duct occlusion without anastomosis after pancreaticoduodenectomy: a systematic review and meta-analysis

BACKGROUND

Pancreatic duct occlusion (PDO) without anastomosis is a technique proposed to mitigate the clinical consequences of postoperative pancreatic fistulas (POPF) after pancreaticoduodenectomy. The aim of this study was to appraise the morbidity following PDO through a systematic review and meta-analysis.

METHODS

A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of PDO following pancreaticoduodenectomy. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modeling. Meta-regression analyses were performed to examine the impact of moderators on the overall estimates.

RESULTS

Sixteen studies involving 1000 patients were included. Pooled postoperative mortality was 2.7%. A POPF was reported in 29.7% of the patients. Clinically relevant POPFs occurred in 13.5% of the patients, while intra-abdominal abscess and haemorrhages occurred in 6.7% and 5.5% of the patients, respectively. Re-operation was necessary in 7.6% of the patients. Postoperatively new onset diabetes occurred in 15.8% of patients, more frequently after the use of chemical substances for PDO (p = 0.003).

CONCLUSIONS

PDO is associated with significant morbidity including new onset of post-operative diabetes. The risk of new onset post-operative diabetes is associated with the use of chemical substance for PDO. Further evidence is needed to evaluate the potential benefits of PDO in patients at high risk of POPF.

The influence of dental experience on a dental implant navigation system

Background

This study evaluated the operating performance of an implant navigation system used by dental students and dentists of prosthodontic background with varying levels of experience. A surgical navigation system and optical tracking system were used, and dentists’ accuracies were evaluated in terms of differences between the positions of actually drilled holes and those of the holes planned using software before surgeries.

Methods

The study participants were 5 dental students or dentists who had studied in the same university and hospital but had different experience levels regarding implants. All participants were trained in operating the AqNavi system in the beginning of the study. Subsequently, using 5 pairs of dental models, each participant drilled 5 implant holes at 6 partially edentulous positions (11, 17, 26, 31, 36, and 47). In total, each participant conducted 30 drilling tests.

Results

In total, 150 tests among 5 dentists at 6 tooth positions (11, 17, 26, 31, 36, and 47) were conducted. Although a comparison of the tests revealed significant differences in the longitudinal error (P < .0001) and angular error (P = .0011), no significant difference was observed in the total error among the dentists.

Conclusions

A relatively long operating time was associated with relatively little implant experience. Through the dental navigation system, dental students can be introduced to dental implant surgery earlier than what was possible in the past. The results demonstrated that the operational accuracy of the dental implant navigation system is not restricted by participants’ implant experience levels. The implant navigation system assists the dentist in the ability to accurately insert the dental implant into the correct position without being affected by his/her own experience of implant surgery.

Learning curve for the management of recurrent and locally advanced primary rectal cancer: a single team's experience

AIM

The study aimed to define the learning curve required to gain satisfactory training to perform pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer.

METHOD

Consecutive patients undergoing exenterative pelvic surgery for recurrent and locally advanced primary rectal cancer, by one surgical team, between 2006 and 2011 were studied. They were divided into quartiles (Q1-Q4) according to the date of surgery. A risk-adjusted cumulative sum (RA-CUSUM) model was used to evaluate the learning curve. The chi-squared test with gamma ordinal was used to assess the change with time in the four quartiles.

RESULTS

One hundred patients (70 males; median age 61 (25-85) years; 55 primary cancers) were included in the study. Thirty patients underwent abdominosacral resection. The number of patients who underwent plastic reconstruction (n = 53) increased from 12 in Q1 to 15 in Q4 (P = 0.781). The median operation time, intra-operative blood loss and hospital stay were 8 (3-17) h, 1.5 (0.1-17) l and 15 (9-82) days respectively. There was no significant change with time. Complete resection (R0) was achieved in 78 patients. Microscopic (R1) or macroscopic (R2) residual disease was present in 15 and seven patients respectively. The number of major complications was 20, and minor 30. RA-CUSUM analysis demonstrated an improvement in any complications after 14, in major after 12 and in minor after 25 operations.

CONCLUSION

Pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer is complex and requires a minimum of 14 cases for an expert colorectal surgeon to gain the desirable training and experience to improve morbidity.

The learning curve of laparoscopic treatment of rectal cancer does not increase morbidity

INTRODUCTION

The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis.

OBJECTIVE

Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumour location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins.

RESULTS

Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins.

CONCLUSIONS

It is possible to learn this complex surgical technique without compromising the patient's safety and oncological outcome.

Attaining surgical competency and its implications in surgical clinical trial design: a systematic review of the learning curve in laparoscopic and robot-assisted laparoscopic colorectal cancer surgery

BACKGROUND

Laparoscopic surgery is increasingly used in the treatment of colorectal cancer and more recently robotic assistance has been advocated. However, the learning curve to achieve surgical proficiency in laparoscopic surgery is ill-defined and subject to many influences. The aim of this review was to comprehensively appraise the literature on the learning curve for laparoscopic and robotic colorectal cancer surgery, and to quantify attainment of surgical proficiency and its implications in surgical clinical trial design.

METHODS

A systematic review using a defined search strategy was performed. Included studies had to state an explicit numerical value of the learning curve evaluated by a single parameter or multiple parameters.

RESULTS

Thirty-four studies were included, 28 laparoscopic and 6 robot assisted. Of the laparoscopic studies, nine defined the learning curve on the basis of a single parameter. Nine studies used more than one parameter to define learning, and 11 used a cumulative sum (CUSUM) analysis. One study used both a multiparameter and CUSUM analysis. The definition of proficiency was subjective, and the number of operations to achieve it ranged from 5 to 310 cases for laparoscopic and 15-30 cases for robotic surgery.

CONCLUSIONS

The learning curve in laparoscopic colorectal surgery is multifaceted and often ill-defined, with poor descriptions of mentorship/supervision. Further, the quantification to attain proficiency is variable. The use of a single parameter to quantify this is simplistic. Multidimensional assessment is recommended; as part of this, the CUSUM model, which assesses trends in multiple surgical outcomes, is useful and appropriate when assessing the learning curve in a clinical setting.

The impact of obesity on learning laparoscopic surgery for colon cancer

OBJECTIVE

This study evaluated the impact of obesity on learning to perform laparoscopic surgery for colon cancer.

SUBJECTS AND METHODS

We compared the outcomes for 72 patients with colon cancer treated by a single surgeon between June 2005 and July 2008. The first 36 patients who underwent surgery were considered to be during the "early period," and the other 36 patients who underwent surgery as the "late period," and the patients with a body mass index (BMI) ≥25 kg/m(2) were defined as being obese.

RESULTS

During the early period, the tumor stages of obese patients were less advanced than those of nonobese patients, whereas the length of the operation, surgical blood loss, and wound diameter of obese patients were worse than those of nonobese patients. Furthermore, the tumor stages in the obese patients during the late period were more advanced than those in obese patients during the early period, whereas the length of the operation and number of dissected lymph nodes in the obese patients during the late period were better than those in obese patients during the early period.

CONCLUSIONS

We demonstrated that the differences of the surgical outcomes between obese and nonobese patients undergoing laparoscopic colon resection decreased as the surgeon's experience increased.

Evaluation of the learning curve in laparoscopic low anterior resection for rectal cancer

BACKGROUND

Laparoscopic low anterior resection for rectal cancer is considered to be more technically demanding than laparoscopic colectomy. This study aimed to analyze the learning curve for laparoscopic low anterior resection and to identify the factors that influence this learning curve.

METHODS

Data from 250 consecutive patients undergoing laparoscopic low anterior resection for rectal cancer, excluding patients with a combined resection such as cholecystectomy, hepatectomy, hysterectomy, or gastrectomy, between December 1996 and April 2010 were analyzed. For operative time, the learning curve was analyzed using the moving average method. The conversion rate and the postoperative complication rate were evaluated in five groups of up to 50 patients each based on the number of cases required for analysis of operative time. In addition, risk factors that influenced conversion to open surgery and postoperative complications were analyzed.

RESULTS

The learning curve analysis for operative time using the moving average method showed stabilization at 50 cases. The conversion rate decreased significantly by group 4 (151-200 cases). The postoperative complication rate decreased significantly by group 5 (201-250 cases). The significant factors for conversion to open surgery were male sex (odds ratio [OR], 2.6094; 95% confidence interval [CI], 1.1-6.4) and T stage (OR, 2.4793; 95% CI, 1.1-5.8). For postoperative complications, male sex (OR, 3.8590; 95% CI, 1.9-3.8) was significant. In addition, the risk factors for anastomotic leakage were male sex (OR, 15.7659, 95% CI, 3.2-284.8) and multiple firing (2 or more cartridges for rectal transection) (OR, 3.0589; 95% CI, 1.1-9.5).

CONCLUSIONS

The risk factors affecting the learning curve for laparoscopic low anterior resection were T stage and male sex. In laparoscopic low anterior resection, rectal transection in particular can be technically difficult, and standardization for accurate performance of the same technique for expanded indications is very important.

Laparoscopy improves short-term outcomes after surgery for diverticular disease

BACKGROUND & AIMS

Observational studies and small randomized controlled trials have shown that the use of laparoscopy in colon resection for diverticular disease is feasible and results in fewer complications. We analyzed data from a large, prospectively maintained, multicenter database (National Surgical Quality Initiative Program) to determine whether the use of laparoscopy in the elective treatment of diverticular disease decreases rates of complications compared with open surgery, independent of preoperative comorbid factors.

METHODS

The analysis included data from 6970 patients who underwent elective surgeries for diverticular disease from 2005 to 2008. Patients with diverticular disease were identified by International Classification of Diseases, 9th revision codes and then categorized into open or laparoscopic groups based on Current Procedural Terminology codes. Preoperative, intraoperative, and postoperative data were analyzed to determine factors associated with increased risk for postoperative complications.

RESULTS

Data were analyzed from 3468 patients who underwent open surgery and 3502 patients who underwent laparoscopic procedures. After correcting for probability of morbidity, American Society of Anesthesiology class, and ostomy creation, overall complications (including superficial surgical site infections, deep incisional surgical site infections, sepsis, and septic shock) occurred with significantly lower incidence among patients who underwent laparoscopic procedures compared with those who received open operations.

CONCLUSIONS

The use of laparoscopy for treating diverticular disease, in the absence of absolute contraindications, results in fewer postoperative complications compared with open surgery.

What is the definition of "conversion" in laparoscopic colorectal surgery?

BACKGROUND

A web-based survey was conducted among colorectal surgeons who represented members of both SAGES and ASCRS to find out how they define conversion for laparoscopic colorectal surgery.

METHODS

Questionnaires were designed based on MCQs, including three parts: surgeon information, different definitions for conversion, and four different clinical scenarios. Surgeons were asked to choose the best definition(s).

RESULTS

325 (28.5%) of 1,140 surgeons, 28.5% responded; approximately half of them were part of private-based practices. Fifty-three percent had more than 10 years experience; 35.9% performed more than 50 laparoscopic colon cases per year, 12% performed more than 25 laparoscopic rectal cases per year, and 60% less than 10. The majority (68.4%) agreed that any incision made earlier than planned is conversion. Whereas 81.4% felt that incision >5 cm is not a conversion, only 53.4% considered incision >10 cm a conversion, and 37% did not. Neither extracorporeal vessel ligation (73.8%), bowel resection (81.2%), anastomosis (77%), or incision made for specimen retrieval (91.1%) was counted as conversion. In clinical case scenarios, 62% found an incision made to facilitate phlegmon dissection after laparoscopically mobilizing the left colon up to and around the splenic flexure to be laparoscopic-assisted. A 10-cm incision required for fistula take down after finishing laparoscopic dissection was defined as conversion (55.6%). A 10-cm incision made for the rectal dissection in rectopexy was described as conversion in 51% and laparoscopic-assisted in 48%. Increasing a 5-12-cm for specimen extraction, 49.3% was declared a laparoscopic-assisted case.

CONCLUSIONS

It was considered clear that any incision made earlier than planned a conversion, whereas extra corporeal vessel ligation, bowel resection and anastomosis were not. However, there seem to be many views of conversion regarding incision length, and some clinical situations that might influence outcome among different centers.

Multidimensional analysis of the learning curve for laparoscopic resection in rectal cancer

BACKGROUND

We attempted to assess the learning curve for laparoscopic resection for rectal cancer.

METHOD

We included 381 patients who underwent laparoscopic resection for rectal cancer between December 2002 and December 2007. The operative experience was divided into four periods according to numbers of operations and significant changes in main surgical results.

RESULTS

Operative time decreased significantly after 90 operations. The overall anastomotic leakage rate was 3.7%; 14.6% for the first 50 patients and 5.4% for the following 40 patients. The overall conversion rate was 2.9%, 4-6% during the first and second periods, but decreasing thereafter. The number of harvested lymph nodes and distal resection margin was within an acceptable range during the entire period. For the patients with stage I-III tumors, the local recurrence rate was 4.4% and the overall recurrence rate was 22.9%. The local recurrence rate was 8.9% initially and decreasing to 1.4% after the second period. The cumulative incidence of local recurrence decreased to less than 7% after 120 patients and to less than 5% after 180 cases.

CONCLUSION

The learning curve for laparoscopic surgery for rectal cancer changed over time. Moreover, the learning curve for oncological safety was longer than that for operative safety.

Multidimensional analysis of the learning curve for laparoscopic colorectal surgery: lessons from 1,000 cases of laparoscopic colorectal surgery

PURPOSE

We consider quality of surgery throughout the learning curve and attempt to determine the learning curve for competency in performing laparoscopic colorectal surgery.

METHODS

The study included 1,014 patients who underwent laparoscopic colorectal resection between June 1996 and December 2007. We categorized patients into nine periods according to number of cases performed.

RESULTS

Operative time continuously decreased for right hemicolectomy (216 versus 150 min) and anterior resection (214.8 versus 147.7 min), whereas for low anterior resection it did not change over many periods and then significantly decreased after the ninth period (221.3 versus 176.4 min). The proportion of patients who had undergone previous abdominal surgery increased after the second period. Anastomotic leakage rate was 6-9% for the first 200 cases, and then decreased to less than 2%. More than 10% of operations were converted to open surgery during the first period, after which this rate significantly decreased to 2%. Number of harvested lymph nodes stabilized to 35-40 for right hemicolectomy after 200 cases, whereas for anterior and low anterior resection it was consistently 15-20 after the initial 20 cases. Overall, disease recurrence rate was 16-25%. For rectal cancer, local recurrence rate was highest (12%) in the fourth period and decreased thereafter to about 3%.

CONCLUSION

Postoperative complications and local recurrence rate increased even after accumulation of experience because of expansion of indications for laparoscopic procedures.

Prophylactic ureteric catheters in laparoscopic colorectal surgery

BACKGROUND

The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure.

METHODS

Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed.

RESULTS

Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group.

CONCLUSION

Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Influence of learning curve on short-term results after laparoscopic resection for rectal cancer

BACKGROUND

Technical difficulties have been encountered in laparoscopic surgery for the treatment of rectal cancer. There are fewer studies about the learning curve for laparoscopic rectal resection.

METHODS

Between June 1995 and August 2007, 200 patients who were scheduled to undergo laparoscopic rectal resection for rectal cancer were enrolled in the study. Each surgeon's operative experience was divided into three groups: 1-20 cases, 21-40 cases, and 41 or more cases. Furthermore, patients were divided chronologically into four groups of 50 patients each. This report describes the association between the learning curves (surgeon's experience and team's experience) and short-term outcomes such as operating time, complication rate, and hospital stay in the case of laparoscopic resection for rectal cancer. We also analyzed how the learning curve influences several postoperative outcomes compared with other clinical factors.

RESULTS

The team's experience was not associated with short-term results except for surgical site infection (SSI). On the other hand, surgeon's experience was associated with mean operating time and SSI rate. The endpoints of the learning curve for reducing mean operating time and SSI rate were defined as 40 and 20 cases of laparoscopic rectal resection. In contrast, anastomotic leakage was not associated with surgeon's experience and showed the greatest correlation with total mesorectal excision (TME).

CONCLUSION

Surgeon's learning improved operating time and SSI. On the other hand, low level of anastomosis accompanied with TME was strongly related with leakage, and the association between leakage and surgeon's learning was not clearly demonstrated.

Effect of types of resection and manipulation on trocar site contamination after laparoscopic colectomy: An experimental study in rats with intraluminal radiotracer application

BACKGROUND

The etiology and incidence of port-site metastases after laparoscopic surgery for colorectal cancer remain unknown. The purpose of this experimental study was to detect and quantify the amount of contamination at the port-site by means of a method utilizing radiolabelled colloid particles following extra- or intracorporeal laporoscopic resection of cecum.

METHODS

Prior to experimental surgery, we obtained a high concentration of luminal colonic radiotracer activity by per anum application of sulphur colloid molecules labelled with Tc-99m pertechnetate. In three main groups of rats, we either resected a portion of cecum extracorporeally or intracorporeally, or did no resection. Each main group was further divided into two subgroups, in which the manipulations were either autraumatic or traumatic. We excised trocar sites as 2 cm doughnuts after completion of the surgical procedure. We used gamma camera imaging to quantify the amount of radioactive contamination at trocar sites. The background corrected trocar site activity for each rat was calculated. Activities exceeding the maximum background activity were accepted as trocar site contamination.

RESULTS

We detected an overall incidence of contamination in 44% of rats. This rate were 71% and 17% in traumatic and atraumatic subgroups. The resection itself increased the rate and intensity of contamination, as well (p = 0.04). The most intensive contamination was detected in the intracorporeal resection with traumatic manipulation subgroup (p = 0.0007).

CONCLUSIONS

Both the presence of resection and manipulative trauma seemed to be increasing the rate and intensity of the radioactive activity at the trocar site. When traumatic manipulatiun was exercised, the contamination was so intense that the type of resection did not differ. We concluded that our scintigraphic method would be useful in the intraoperative detection of port site contamination by the tumor cells, and that surgeons would take some preventive measures to prevent future port-site metastases.

Clinical evaluation of a new ultrasonic Doppler instrument (SonoDoppler) for the detection of blood flow during laparoscopic procedures

Complications may be avoided by exactly clarifying the structures in the operative field during laparoscopic surgery. We aimed to study the efficiency of a new ultrasonic Doppler device, SonoDoppler, which offers an easy and efficient way of mapping the anatomy. The design of the study was prospective, open observational and carried out on a sample of 51 patients who were operated on in four hospitals. The surgeons were asked to identify a common hepatic artery, cystic artery and portal vein during a laparoscopic cholecystectomy, and corresponding structures during other laparoscopic procedures using the SonoDoppler, instrument. Total operation time (skin-to-skin) and duration of the SonoDoppler, use were measured. The main outcome measures were gain of additional safety and clinical value. A number of evaluations concerning the ergonomics, functionality and interactions with other instruments were also carried out. The SonoDoppler, instrument has the potential to help to assess and clarify the anatomy during laparoscopic procedures. Its use can be advocated not only for inexperienced surgeons, to help them map the vessels during surgery, but also for experienced surgeons during complicated cases and advanced procedures.

Converted laparoscopic colectomy: what are the consequences?

BACKGROUND

The safety and benefits of laparoscopic colon resection are well documented. However, few reports have addressed the safety and comparative outcome of laparoscopic colon operations that necessitated conversion.

METHODS

All consecutive laparoscopic colon resections performed by a single surgeon from July 1996 to October 2003 were assessed. Data obtained from a prospective computerized database included demographics, diagnosis, reason and time to conversion, length of stay, morbidity, and mortality. Additionally, all laparoscopic-converted colectomies were then matched with open colectomies by diagnosis and severity of disease and analyzed with respect to morbidity, mortality, and clinical outcome.

RESULTS

A total of 143 laparoscopic colon resections were analyzed, 78 of which were left colon resections and 65 were right colon resections. The overall conversion rate was 19.6% (28 patients). The disease entities of the 28 converted patients were diverticulitis (16), polyps (four), Crohn's disease (three), metastatic cancer (three), and others (two). Conversion was higher in the left-sided (24 patients, 30.8%) versus right-sided (four patients, 6.1%) procedures. There were no differences regarding age, gender, and comorbidities among the laparoscopic, open, and converted groups; the median follow-up was 39 months. The median length of stay was 6, 8, and 12 days for the laparoscopic, open, and converted groups, respectively. Right-sided conversions were due to the size of the inflammatory mass in three patients and intraoperative bleeding in one patient. Left-sided conversions were due to the inflammatory process extending beyond the sigmoid colon in 12 patients, adhesions in five, obesity in four, pericolonic abscess in two, and fixed mass in one patient. Postoperative morbidity was significantly higher for laparoscopic procedures that were converted to open procedures more than 30 min into the operation. Preoperative predictors of conversion were extent of inflammatory process beyond the sigmoid colon and obesity, whereas intraoperative predictors were adhesions and bleeding.

CONCLUSIONS

Laparoscopic-converted colon resection is associated with significantly greater morbidity, particularly wound complications and greater length of hospital stay, compared to open or laparoscopic colectomies. Prompt conversion (<30 min) may reduce the overall morbidity associated with converted procedures. Furthermore, thoughtful patient selection may decrease the conversion rate and thereby prevent the inherent morbidity associated with converted procedures.

LAPAROSCOPIC AND OPEN COLORECTAL SURGERY IN EVERYDAY PRACTICE: RETROSPECTIVE STUDY

BACKGROUND

Most studies available on laparoscopic colorectal surgery focus on highly selected patient groups. The aim of the present study was to review short- and long-term outcome of everyday patients treated in a general surgery department.

METHODS

Retrospective review was carried out of a prospective database of all consecutive patients having undergone primary laparoscopic (LAP) or open colorectal surgery between March 1993 and December 1997. Follow-up data were completed via questionnaire.

RESULTS

A total of 187 patients underwent LAP resection and 215 patients underwent open surgery. Follow up was complete in 95% with a median of 59 months (range, 1-107 months) and 53 months (range, 1-104 months), respectively. There were 28 conversions (15%) in the LAP group and these remained in the LAP group in an intention-to-treat analysis. The LAP operations lasted significantly longer for all types of resections (205 vs 150 min, P < 0.001) and hospital stay was shorter (8 vs 13 days, P < 0.001). Recovery of intestinal function was faster in the LAP group, but only after left-sided procedures (3 vs 4 days, P < 0.01). However, preoperative patient selection (more emergency operations and patients with higher American Society of Anesthesiologists (ASA) score in the open group) had a major influence on these elements and favours the LAP group. Surprisingly, the overall surgical complication rate (including long-term complications such as wound hernia) was 20% in both groups with rates of individual complications also being comparable in both groups.

CONCLUSION

Despite a patient selection favourable to the laparoscopy group, only little advantage in postoperative outcome could be shown for the minimally invasive over the open approach in the everyday patient.

[Meta-analysis on minimally invasive surgical therapy of sigmoid diverticulitis]

The bowel diverticulitis is a complication of diverticulosis, occuring in 35% patients in 20 years after diagnosis. The study purpose was analysis of the results published in world literature.

METHOD

Double blind electronic search of several databases using key words: diverticulitis, laparoscopy.

RESULTS

11 studies with 415 patients that satisfy the criteria were selected. AGE: 62.7 + 14.2. Hinchey stadiums: I, IIa i IIb of these 44% I and 28% IIa i Iib each. Operative time: 197.4 +/- 49.6 min. Conversions: 11.7 +/- 10.1 (0 - 38.9%). Protective stoma: 5.5%. Bowel sounds: 2.3 - 3.2 postoperative day. Oral feeding: 2.6-5 postoperative day. Hospitalization: 6.1 2.1 dana. Anastomotic dehiscence: 2.8%, wound infection: 7.3%, iatrogen rectum perforation with stapler: 3.3%, bleeding: 3.5%, ileus: 4.4%, reoperation rate: 4.7%.

CONCLUSION

Sigmoid resection with or without a protective "loop" ileostomy is technically feasable by minimally invasive surgical technique, with an acceptable ratio of benefits and complications.

Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections

OBJECTIVE

To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections.

SUMMARY BACKGROUND DATA

The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment.

METHODS

This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections.

RESULTS

The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience.

CONCLUSIONS

Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.

Laparoscopic sigmoid colectomy for diverticular disease

Laparoscopic management of sigmoid diverticular disease has emerged as an important adjunct to the armamentarium of surgical options for this disease process. Although there are no prospective randomized studies directly comparing laparoscopic and open colectomy for diverticulitis, the comparative studies provide compelling data. The magnitude of benefits achieved with laparoscopic colectomy in the hands of experienced laparoscopic colon surgeons may soon be sufficient to make laparoscopic colectomy the standard of care.

Laparoscopic sigmoidectomy for fistulized diverticulitis

PURPOSE

Nowadays laparoscopic colorectal surgery has demonstrated its advantages, including reduced postoperative pain, decreased duration of ileus, and shorter hospital stay. Few studies report results of laparoscopic surgery in complicated diverticulitis. This study was designed to analyze the results of laparoscopic sigmoidectomy in patients with fistulized sigmoiditis.

METHODS

The authors retrospectively reviewed 16 patients who had laparoscopic sigmoidectomy for fistulized diverticulitis between 1992 and 2003 in a series of 247 laparoscopic colectomies. Eleven patients presented with colovesical, four with colovaginal, and one with colocutaneous fistulas; all were caused by sigmoiditis. The procedure always consisted of celioscopic sigmoidectomy with stapled transanal suture and, when indicated, closure of the cystic or vaginal fistula orifice.

RESULTS

Mean age was 60 (range, 39-78) years. Mean number of episodes of diverticulitis before operation was three (range, 1-5). Mean time between the last episode and operation was 46 (range, 2-250) weeks. In our first three years of experience, three cases (18.7 percent) were converted to laparotomy. Reasons for conversion were the necessity for intestinal resection, splenectomy, and a wound of the anterior rectum. The mean operative time was 172 (range, 100-280) minutes. Mean hospital stay was 5.7 (range, 3-12) days. There was no mortality. Postoperative morbidity (2 patients, 12.5 percent) consisted of one pulmonary infection and one splenectomy. Long-term follow-up revealed no recurrence of diverticulitis and one incisional hernia.

CONCLUSIONS

In experienced hands, laparoscopic sigmoidectomy may be a safe and effective procedure for fistulized sigmoiditis.

Iliac artery pseudoaneurysm as a complication of laparoscopic rectopexy

The occurrence of arterial pseudoaneurysms after laparoscopic cholecystectomy in the right hepatic artery, common hepatic artery, and cystic artery has been well documented. We describe a case of pseudoaneurysm of the common iliac artery presenting after laparoscopic stapled mesh rectopexy. As the benefits of minimal access surgery are extended to more and more procedures, surgeons should recognize the possibility of such a complication.

Laparoscopic surgery for colorectal carcinoma. an overnight victory?

Laparoscopic surgery became popular in the early 1990s. Cholecystectomy was the first 'victim' conquered by the new technique and laparoscopic cholecystectomy became the gold standard operation for gallbladder stones. Laparoscopic colorectal surgery was then attempted, for both benign and malignant disorders. After a short period of enthusiasm, alarming reports were published on laparoscopic surgery for malignant disease. The occurrence of so called 'port-site' metastases (PSM) led to a reduction in the use of the minimal invasive technique. In addition, the duration of the operations was criticised, as well as the limited beneficial effects (if any) and the possible violation of oncological surgical principles. The pros and cons of this new technique during its introduction are discussed, with focus on problem areas such as port-site metastases, surgical learning curve as well as beneficial effects. The current status of several comparative studies evaluating the laparoscopic technique is discussed leading to the conclusion that a basis for further research exists and therefore cautious progress is warranted.

Is obesity a high-risk factor for laparoscopic colorectal surgery?

BACKGROUND

The aim of this study was to assess the outcome of laparoscopic colorectal surgery in obese patients and compare it to that of a nonobese group of patients who underwent similar procedures.

METHODS

All 162 consecutive patients who underwent an elective laparoscopic or laparoscopic-assisted segmental colorectal resection between August 1991 and December 1997 were evaluated. Body mass index (BMI; kg/m2) was used as an objective index to indicate massive obesity. The parameters analyzed included BMI, age, gender, comorbid conditions, diagnosis, procedure, American Society of Anesthesiologists classification score, operative time, estimated blood loss, transfusion requirements, intraoperative complications, conversion to laparotomy, postoperative complications, length of hospitalization, and mortality.

RESULTS

Thirty-one patients (19.1%) were obese (23 males and 8 females). Conversion rates were significantly increased in the obese group (39 vs 13.5%, p = 0.01), with an overall conversion rate of 18%. The postoperative complication rate in the obese group was 78% versus 24% in the nonobese group (p <0.01). Specifically, rates of ileus and wound infections were significantly higher in the obese group [32.3 vs. 7.6% (p <0.01) and 12.9 vs 3.1%. (p = 0.03), respectively]. Furthermore, hospital stay in the obese group was longer (9.5 days) than in the nonobese group (6.9 days, p = 0.02).

CONCLUSION

Laparoscopic colorectal segmental resections are feasible in obese patients. However, increased rates of conversion to laparotomy should be anticipated and the risk of postoperative complications is significantly increased, prolonging the length of hospitalization when compared to that of nonobese patients.

Laparoscopically Assisted Hemicolectomy for Crohn's Disease: Are we Still Getting Better?

The most common indications for laparoscopic surgery in Crohn's disease include ileocolic resection and right hemicolectomy. The aim of this study was to compare the results of right hemicolectomy in an early phase versus a later phase. Between August 1992 and October 1998 all patients who underwent laparoscopic surgery for ileocolic resection and right hemicolectomy were divided into chronological groups: Group I = August 1992 to January 1996 and Group II = February 1996 to October 1998. Statistical analysis was performed using the Mann-Whitney test, Student t test, or Fisher's exact test. We identified 41 patients; 16 patients [eight females and eight males with an average age of 37.1 (range 20–59) years] were in Group I and 25 [16 females and nine males with an average age of 41.9 (range 15–74) years] were in Group II [ P = not significant (NS)]. Overall there were five (12%) intraoperative complications reported: two (12%) in Group I and three (12%) in Group II ( P = NS). Mean operative time was 149 (range 90–260) minutes in Group I versus 158 (range 100–285) minutes in Group II ( P = NS). Mean length of hospital stay was 7.4 (range 4–18) days in Group I and 6.6 (range 3–20) days in Group II ( P = NS). Four patients (25%) in Group I and seven (28%) in Group II had their procedures converted to laparotomy ( P = NS). In Group I four (25%) patients had surgery-related postoperative complications, one of which was wound related. One patient has an anastomotic leak whereas two had prolonged postoperative ileus. In Group II six (24%) patients had surgery-related complications, two of which were wound related, three were cases of prolonged postoperative ileus, and one was an anastomotic leak ( P = NS between Groups I and II). Perhaps as a result of the relative technical ease of right-sided resections or the nature of the disease the expected decrease in morbidity and conversion rate over time could not be shown.

[Impact of obesity on postoperative results of elective laparoscopic colectomy in sigmoid diverticulitis: a prospective study]

STUDY AIM

The aim of this prospective study was to assess the outcome of laparoscopic colectomy for sigmoid diverticulitis in normal weighted, overweighted and obese patients.

PATIENTS AND METHOD

From January 1995 to December 2000, all patients (n = 77) undergoing an elective colectomy for sigmoid diverticulitis were included in the study. The patients were divided into three groups: group 1 (n = 29): normal weighted patients (BMI: 18-24.9); group 2 (n = 27): overweighted patients (BMI: 25.0-29.9); group 3 (n = 21): obese patients (BMI: 30.0-39.9). Comparison between these three groups was only made during the per and postoperative period.

RESULTS

There were no differences in the three groups with regard to age, sex and ASA classification. Duration of operation did not differ between group 1 and 2 (187 vs 210 min, P = 0.6) but was shorter in group 1 than in group 3 (187 vs 247 min, P = 0.003). Conversion rate did not differ and was respectively in group 1, 2 and 3: 13.8, 14.8 and 14.3%. The postoperative period during which parenteral analgesics were required was not different for group 1 and 2 but was longer in group 3 than in group 1 (8.5 vs 5.7 days, p = 0.03). Morbidity rate was similar in group 1, 2 and 3: 15, 14 and 17%. There was no perioperative mortality. Duration of hospital stay was similar in the three groups.

CONCLUSION

Data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to overweighted and obese patients.

Converted laparoscopic colorectal surgery

BACKGROUND

Conversion rates following laparoscopic colorectal surgery vary widely between studies, and the outcome of converted patients remains controversial.

METHODS

A comprehensive search of the English-language literature was updated until May 1999.

RESULTS

Twenty-eight studies on 3232 patients were considered for analysis. The overall conversion rate was 15.38%. Seventy nine percent of the studies did not include a definition for conversion; in these studies, the conversion rate was significantly lower than in the series where a specific definition was considered (13.7% vs 18.9%, chi-square test, p < 0.001). Converted patients had a prolonged hospital stay (11.38 vs 7.41 days) and operative time (209 vs 189 min) in comparison with laparoscopically completed patients (95% confidence interval (CI), 1.70-4.00 and 35.90-37.10, respectively). The factors associated with an increased rate for conversion were left colectomy (Odds Ratio [OR] = 1.061), anterior resection of the rectum (OR = 1.088), diverticulitis (OR = 1.302), and cancer (OR = 2.944) (for each parameter, Wald chi-square value, p < 0.001).

CONCLUSIONS

In nonrandomized studies, the rate of laparoscopically completed colorectal resections is close to 85%. Because converted patients have a distinct outcome, a clear definition of conversion is required to compare the results of randomized trials. Such trials should also consider a 20% rate of conversion when estimating the sample size for the desired power level. It is likely that converted patients will have a significant impact on the results of future clinical research in laparoscopic colorectal surgery.

Laparoscopic-assisted coloscopic polypectomy

PURPOSE

Patients with colorectal polyps often display a large kink or distinct mucosal fold in the area where the polypectomy is to take place. As a result, there is a higher risk of perforation or partial ablation during an endoscopic polypectomy. Is it safer to perform an endoscopic polypectomy using the control and assistance of a laparoscope? Can a segment resection of the colon that would otherwise be necessary be avoided?

METHODS

An endoscopic polypectomy using a laparoscope was conducted on six patients whose colorectal polyps were in an anatomically unfavorable location. The need for an open or laparoscopic segment resection or colotomy was indicated in all cases. The growth was located in the rectosigmoidal transition in five patients and in the region of the left flexure in one patient. We decided that an endoscopic polypectomy using the assistance of a laparoscope would be the most comfortable and technically elegant method, as well as easy. Except the well-known risks of laparoscopy and endoscopic polypectomy, no other risks have been seen in our patients. The affected area of the colon, the sigma, and the left flexure were mobilized and stretched as much as possible to enable a simultaneous and low-risk endoscopic polypectomy. In one case, we had to conduct a fractionated ablation because of a very wide-based finding.

RESULTS

The operation averaged 57 minutes, and no operation-specific complications were observed. Postoperative recovery in the hospital was very short and averaged 2.5 days. The histopathologic findings were benign in all cases, but a serious dysplasia was diagnosed in one patient.

CONCLUSIONS

The laparoscopic-assisted polypectomy is a safe method to remove even complicated polyps in anatomically unfavorable locations.

Experience as a factor influencing the indications for laparoscopic colorectal surgery and the results

BACKGROUND

The influence of experience on the results of treatment with laparoscopic surgery is indisputable. The establishment of indications and contraindications is relative, and varies depending on the experience of the surgeon. Learning curves have been described for a number of laparoscopic interventions, in particular laparoscopic cholecystectomy. The current prospective multicenter study investigates, among other things, the interrelation between experience and the results of treatment using laparoscopic colorectal surgery. The study makes no pronouncements on the long-term results achieved in patients with colorectal carcinoma who underwent an operation with curative intent, although relevant data were indeed collected.

RESULTS

Between August 1, 1995 and February 1, 1999, a total of 1,658 patients were recruited to the prospective multicenter study initiated by the Laparoscopic Colorectal Surgery Study Group. To investigate the influence of surgical experience, two groups were formed. Group A comprised all the institutions and surgeons with experience of more than 100 laparoscopic colorectal operations. Group B contained institutions and surgeons with experience of fewer than 100 such interventions. The results of this study clearly show that in Group A, significantly more procedures involving the rectum were performed (26.7% vs 9.5%), and significantly more carcinomas were surgically managed (37.3% vs 17.3%). Despite this significantly higher level of technically difficult procedures in the patient population of group A, which was comparable in terms of age, gender, height, and weight with the patient in group B, the postoperative mortality and morbidity was, with the exception of urinary tract infections, identical between the two groups. Conversion to open surgery was significantly less frequent in group A (4.3% vs 6.9%), and, finally, the duration of the procedures performed by the more experienced surgeons of group A was appreciably shorter than in institutions with a smaller frequency of such operations.

CONCLUSIONS

Laparoscopic colorectal surgery is very demanding, and can be performed with low morbidity and mortality rates only by a surgeon with above-average experience with this type of surgery and a large caseload of laparoscopic colorectal procedures. The learning curve for such procedures is appreciably longer than for other laparoscopic operations. With increasing experience, technically more demanding operations, including radical oncologic rectal laparoscopic procedures, can be performed with appreciably reduced operating times and conversion rates, but with no increase in morbidity or mortality.

Defining a learning curve for laparoscopic colorectal resections

PURPOSE

The purpose of this review was to define the learning curve for laparoscopic colorectal resections.

METHODS

A prospectively accumulated, computerized database of all laparoscopic colorectal resections performed by three surgeons between April 1991 and March 1999 was reviewed.

RESULTS

A total of 461 consecutive resections were evenly distributed among three surgeons (141, 155, and 165). Median operating time was 180 minutes for Cases 1 to 30 in each surgeon's experience and declined to a steady state (150-167.5 minutes) for Cases 31 and higher. Subsequently, Cases 1 to 30 were considered "early experience," whereas Cases 31 and higher were combined as "late experience" for statistical analysis. There were no significant differences between patients undergoing resections in the early experience and those undergoing resections in the late experience with respect to age, weight, or proportion of patients with malignancy, diverticulitis, or inflammatory bowel disease. There were greater proportions of males (42 vs. 54 percent, P = 0.046) and rectal resections performed (14 vs. 32 percent, P = 0.002) in the late experience. Trends toward declining rates of intraoperative complications (9 vs. 7 percent, P = 0.70) and conversion to open surgery (13.5 vs. 9.7 percent, P = 0.39) were observed with experience. Median operating time (180 vs. 160 minutes, P < 0.001) and overall length of postoperative hospital stay (6.5 vs. 5 days, P < 0.001) declined significantly with experience. There was no difference in the rate of postoperative complications between early and late experience (30 vs. 32 percent, P = 0.827).

CONCLUSIONS

The learning curve for performing colorectal resections was approximately 30 procedures in this study, based on a decline in operating time, intraoperative complications, and conversion rate. Learning was also extended to clinical care because it was appreciated that patients could be discharged to their homes more quickly.

Importance of conversion for results obtained with laparoscopic colorectal surgery

PURPOSE

The need for a conversion is a problem inherent in laparoscopic surgery. The present study points up the significance of conversion for the results obtained with laparoscopic colorectal surgery and identifies the risk factors that establish the need for conversion.

METHOD

The study took the form of a multicentric, prospective, observational study within the Laparoscopic Colorectal Surgery Study Group. A total of 33 institutions in Germany, Austria, and Switzerland participated. The study period was 3.5 years. Cases were documented with the aid of a standardized questionnaire.

RESULTS

Within the framework of the Laparoscopic Colorectal Surgery Study Group, a total of 1,658 patients were recruited to a multicenter study over a period of three and one-half years (from August 1, 1995 to February 1, 1999). The observed conversion rate was 5.2 percent (n = 86). The patients requiring a conversion were significantly heavier (body mass index, 26.5 vs. 24.9) than those undergoing pure laparoscopy. Resections of the rectum were associated with a higher risk for conversion (20.9 vs. 13 percent). Intraoperative complications occurred significantly more frequently in the conversion group (27.9 vs. 3.8 percent). The duration of the operation was significantly increased after conversion in a considerable proportion of the procedures performed. Postoperative morbidity (47.7 vs. 26.1 percent), mortality (3.5 vs. 1.5 percent), recovery time, and postoperative hospital stay were all negatively influenced by conversion, in part significantly. Institutions with experience of more than 100 laparoscopic colorectal procedures proved to have a significantly lower conversion rate than those with experience of fewer than 100 such interventions (4.3 vs. 6.9 percent).

CONCLUSION

Although, of itself, conversion is not considered to be a complication of laparoscopic surgery, it is true that the postoperative course after conversion is associated with appreciably poorer results in terms of morbidity, mortality, convalescence, blood transfusion requirement, and postoperative hospital stay. The importance of experience in laparoscopic surgery can be demonstrated on the basis of the conversion rates. Careful patient selection oriented to the experience of the surgeon is required if we are to keep the conversion, morbidity, and mortality rates of laparoscopic colorectal procedures as low as possible.

Laparoscopic abdominoperineal resection: early postoperative results of a prospective study involving 116 patients. The Laparoscopic Colorectal Surgery Study Group

PURPOSE

Although laparoscopic colorectal surgery is attracting ever more attention, its use for curative treatment of colorectal carcinoma in particular continues to be controversial. The present study was an attempt to analyze the results of the perioperative course, oncologic quality, and preliminary long-term results.

METHOD

The data considered here were collected within the framework of a prospective, observational study initiated on August 1, 1995, and involving a total of 18 institutions in Germany and Austria. At the end of three years, the results are now being presented selectively, i.e., focusing only on abdominoperineal resection.

RESULTS

A total of 116 patients underwent laparoscopic abdominoperineal resections, 98 (84.5 percent) of which were performed with curative intent. The mean operating time was 226 (confidence interval, 140-365) minutes. Seven patients (6 percent) experienced an intraoperative complication, which in more than one-half of the cases was a vascular injury involving the presacral venous plexus; the conversion rate was 3.4 percent. Postoperatively, 40 patients developed 97 complications--including those of a very minor nature--giving an overall morbidity rate of 34.4 percent. Reoperation in six patients (5.2 percent) had to be performed for an afterbleed in one-half of the cases and ileus in the other one-half. Postoperative mortality was a low 1.7 percent. In most of the curative resections, an oncologically radical operation with high transection of the inferior mesenteric artery and a complete dissection of the pelvis down to the floor was performed. The median number of lymph nodes investigated was 11.5, and there was wide fluctuation in the numbers among the individual institutions. Tumor cell dissemination occurred intraoperatively in five patients. In the meantime, 79 patients (81 percent) underwent at least one follow-up examination, the mean follow-up period being 491 days. Seven patients developed a local recurrence, and a further six patients developed distant metastases. For recurrence-free survival rate, the Kaplan-Meier estimation calculated a probability of 71 percent.

CONCLUSION

Not all of the reservations about laparoscopic abdominoperineal resection, in particular with regard to resection with curative intent, have yet been eliminated. The present study does, however, show that a laparoscopic approach can in principle meet oncologic requirements of radicality and, with regard to the postoperative course, is associated with considerable benefits to the patient.

Laparoscopic surgery and surgical infection

INTRODUCTION

It has been observed that the metabolic response to surgical injury is less after laparoscopic surgery than after open surgery. However, the effect of laparoscopic surgery on surgical infection has not been given much attention in the surgical literature, even though it may decrease the incidence of infectious complications. The objective of this study was to assess the influence that laparoscopic surgery has on surgical infection and to highlight certain controversial aspects.

METHODS

A review of the literature was undertaken to examine the relationship between laparoscopic surgery and surgical infection. This was achieved primarily by using PubMed Medline as a source of material.

RESULTS AND CONCLUSION

Laparoscopic surgery is associated with better preservation of the immune system than open surgery. This results in a decreased incidence of infectious complications. Although carbon dioxide pneumoperitoneum affects the peritoneal response to injury, it seems to have no harmful effect in terms of intra-abdominal infection. Nevertheless, at laparoscopic operation the virulence of intestinal micro-organisms should be recognized and, while knowing the advantages of minimally invasive surgery, the surgeon should consider the complexity of this technique. Furthermore, maintenance of laparoscopic instruments should be governed by the same norms as those used in open surgery; recommendations offered by the manufacturers should be respected.

[Elective laparoscopic colectomy for sigmoid diverticulitis. Prospective study of 56 cases]

OBJECTIVE

The aim of this prospective study was to assess the feasibility and postoperative advantages of the laparoscopic-assisted elective colectomy for diverticular disease.

PATIENTS AND METHODS

From january 1989 to december 1997, among the 114 patients electively operated on for diverticulitis, 56 patients were treated by laparoscopic approach. Evaluated parameters included: gender, age, weight, size, ASA score, operating time, duration of hospital stay, of analgesic treatment, and of postoperative ileus, morbidity and mortality rate.

RESULTS

The study group consisted of 35 women and 21 men. Mean age was 59 years (34-81 years); 29 patients were ASA 1 and 27 ASA 2. Overall postoperative mortality rate was 0% and morbidity rate 16% (n = 9). There were no complications directly related to laparoscopic technique. The conversion rate was 14% (n = 8). Mean operating time was 300 min (200-600 min). Mean duration of postoperative ileus was 2.4 days. Mean duration of hospital stay was 9.4 days.

CONCLUSION

This study demonstrates the feasibility of elective laparoscopic-assisted colonic resection for diverticular disease in more than 80% of cases with a postoperative morbidity and mortality rate comparable to those of conventional surgery.

Laparoscopic surgery for the cure of colorectal cancer: results of a German five-center study

PURPOSE

The aim of this study was to assess the feasibility and safety of laparoscopic surgery for the cure of colorectal cancer with emphasis on oncologic follow-up in particular.

METHODS

A study was performed of patients with colorectal cancer treated by laparoscopy in five German centers between May 1991 and September 1997. Surgical and pathologic data were recorded in an anonymous registry database and analyzed by type of resection. Standard procedures were sigmoid or left colectomy, anterior resection, abdominoperineal resection, and right hemicolectomy. Follow-up information included incidence of local, distant, and port site recurrence and cancer-related death.

RESULTS

A total of 399 patients (212 females) with a mean age of 66.6 years underwent laparoscopic curative resections (sigmoid resection, 89; left colectomy, 11; anterior resection, 157; abdominoperineal resection, 102; right hemicolectomy, 40). Conversion was necessary in 6.3 percent (n = 25). Complications requiring reoperation occurred in 9 percent (n = 35). Complications that were treated conservatively occurred in 27.6 percent (n = 110). Thirty-day mortality was 1.8 percent (n = 7). First bowel movements resumed on the third postoperative day; patients did not use analgesics after a mean of five days. Mean postoperative hospitalization was two weeks. According to International Union Against Cancer classification, 147 patients had Stage I cancer, 35 had Stage II cancer, and 217 underwent curative resection for Stage III cancer. Mean number of lymph nodes resected was 12.1. At a mean follow-up of 30 months, one port site recurrence was documented. No local recurrence was observed after curative resection of Stage I colorectal cancer. Of 399 patients, local recurrence occurred in 6 patients (Stage II, 2; Stage III, 4), and distant metastases were documented in 25 patients (Stage I, 3; Stage II, 3; Stage III, 19). The highest incidence of cancer-related death occurred after abdominoperineal resection (4.9 percent).

CONCLUSION

To assess the role of laparoscopic colorectal surgery for the cure of cancer objectively, prospective randomized trials are necessary.

Is the port site really at risk? Biology, mechanisms and prevention: a critical view

Early case reports of port site tumour implants led to debate regarding the appropriateness of laparoscopic techniques for abdominal malignancies. Review of clinical, animal and cell culture studies addresses the relationships between tumour staging and shed cell behaviour that contributes to the peri-operative spread of tumours. In addition, a porcine model was used to test tumour cell distribution after laparoscopic and open colonic resections. Clinical evidence indicate that wound recurrence rates are 0.60 and 0.85% for open and laparoscopic colon cancer operations, respectively. Tumour staging and operative techniques are the most important factors determining wound implantation. Port site and open wounds are at equal risk of tumour implantation.

Laparoscopic surgery complications associated with trocar tip design: review of literature and own results

In the last 10 years, there has not been an abdominal surgical procedure that has not been performed by laparoscopic means. The enthusiasm of surgeons active in this field often neglects problems, especially with basic instruments which are important vehicles for the laparoscopic technique. The purpose of this study was to focus on trocar-related problems with special respect to the tip design. On the basis of a prospective study of laparoscopic transperitoneal hernia repair (TAPP) and laparoscopic Nissen fundoplication, we evaluated our data concerning trocar-related complications at the abdominal wall. We compared two groups of patients treated in a nonrandomized design with either sharp cutting single-use trocars or cone-shaped non-cutting reuseable trocars. The evaluation of our own data showed an incisional hernia in 1.83% of patients treated with a sharp trocar tip, a complication which could be significantly lowered, to 0.17%, with a conic tip design. Similar results could be seen with trocar-related bleeding events at the insertion site in the abdominal wall. In most publications, trocar design and related complications are unmentioned. Our data demonstrate a reasonable benefit for a conic tip design, which enables atraumatic insertion through the abdominal wall. The reuseable steel version furthermore holds a considerable cost-saving potential.

Hand-assisted laparoscopic surgery (HALS): a useful technique for complex laparoscopic abdominal procedures

Advanced laparoscopic abdominal surgery is now being performed routinely. However, it can be extremely challenging and time-consuming, and it may be associated with increased intraoperative and postoperative complications, mainly due to the loss of tactile sensation with totally laparoscopic techniques. This article describes a technique of hand-assisted laparoscopic surgery for complex abdominal procedures that allows the surgeon to insert a nondominant hand into the abdominal cavity while preserving the pneumoperitoneum. Use of the hand allows for rapid exploration, methodical dissection, identification of crucial structures, and expeditious performance of a procedure because of the maintenance of the tactile sensation. Our experience with this approach has been favorable.