The spectrum of laparoscopic surgery

Current Status of Robotic Gastrointestinal Surgery

Development of surgical support robots began in the 1980s as a navigation and auxiliary device for endoscopic surgery. For remote surgery on the battlefield, a master-slave-type surgical support robot was developed, in which a console surgeon operates the robot at will. The da Vinci surgical system, which currently dominates the global robotic surgery market, received United States Food and Drug Administration and regulatory approval in Japan in 2000 and 2009 respectively. The latest, fourth generation, da Vinci Xi has a good field of view via a three-dimensional monitor, highly operable forceps, a motion scale function, and a tremor-filtered articulated function. Gastroenterological tract robotic surgery is safe and minimally invasive when accessing and operating on the esophagus, stomach, colon, and rectum. The learning curve is said to be short, and robotic surgery will likely be standardized soon. Therefore, robotic surgery training should be systematized for young surgeons so that it can be further standardized and later adapted to a wider range of surgeries. This article reviews current trends and potential developments in robotic surgery.

A comparison of laparoscopic and robotic ergonomic risk

INTRODUCTION

Work related injuries in minimally invasive surgery (MIS) are common because of the strains placed on the surgeon's or assistant's body. The objective of this study was to compare specific ergonomic risks among surgeons and surgical trainees performing robotic and laparoscopic procedures.

MATERIALS AND METHODS

Ergonomic data and discomfort questionnaires were recorded from surgeons and trainees (fellows/residents) for both robotic and laparoscopic procedures. Perceived discomfort questionnaires were recorded pre/postoperatively. Intraoperatively, biomechanical loads were captured using motion tracking sensors and electromyography (EMG) sensors. Perceived discomfort, body position and muscle activity were compared between robotic and laparoscopic procedures using a linear regression model.

RESULTS

Twenty surgeons and surgical trainees performed 29 robotic and 48 laparoscopic procedures. Postoperatively, increases in right finger numbness and right shoulder stiffness and surgeon irritability were noted after laparoscopy and increased back stiffness after robotic surgery. Further, the laparoscopic group saw increases in right hand/shoulder pain (OR 0.8; p = 0.032) and left hand/shoulder pain (0.22; p < 0.001) compared to robotic. Right deltoid and trapezius excessive muscle activity were significantly higher in laparoscopic operations compared to robotic. Demanding and static positioning was similar between the two groups except there was significantly more static neck position required for robotic operations.

CONCLUSION

Robotic assisted surgeries led to lower postoperative discomfort and muscle strain in both upper extremities, particularly dominant side of the surgeon, but increased static neck positioning with subjective back stiffness compared with laparoscopy. These recognized ergonomic differences between the two platforms can be used to raise surgeon awareness of their intraoperative posture and to develop targeted physical and occupational therapy interventions to decrease surgeon WMSDs and increase surgeon longevity.

Is robotic surgery feasible at a safety net hospital?

BACKGROUND

Robotic surgery offers potential advantages of improved ability to complete procedures using a minimally invasive approach, recovery, and clinical outcomes. It has been previously established that safety net hospitals are outliers for surgical complications. As such, the adoption of new technology may not achieve the same outcomes as other institutions. We hypothesized that, compared to laparoscopic and open surgeries, robotic surgeries have fewer post-operative Clavien-Dindo complications at our safety net hospital.

METHODS

All robotic surgeries performed from 2017 to 2019 at a single, safety net hospital were reviewed. Cases were matched 1:3 to laparoscopic controls. Surgeries commonly performed open were additionally matched 1:3 to open counterparts. The primary outcome was Clavien-Dindo complications at 90 days post-operatively. Secondary outcomes included inadvertent enterotomy, conversion to open, operative duration, wound class, surgical site infection (SSI), surgical site occurrence (SSO), length of stay (LOS), reoperation, readmission, and recurrence.

RESULTS

A total of 160 robotic surgeries were included and matched to 480 laparoscopic surgeries and 108 open surgeries. Open surgeries were associated with greater risk of Clavien-Dindo complication (OR = 2.7, p = 0.040, 95% confidence interval 1.0-6.9) than either robotic or laparoscopic surgeries. Robotic cases had increased operative duration when compared to laparoscopic (p < 0.001) but not open cases (p = 0.093). No difference was seen in enterotomy, conversion to open, SSI, SSO, LOS, reoperation, readmission, or recurrence between robotic and laparoscopic, and robotic and open cases.

CONCLUSION

Robotic surgery is safe and feasible at a safety net hospital. Robotic and laparoscopic surgeries were associated with fewer Clavien-Dindo complications than open surgery, but no differences were seen between robotic and laparoscopic cases. Robotic surgery, compared to both laparoscopic and open surgery, had longer operative durations. Further studies are needed to assess the value of robotic as opposed to laparoscopic surgery in a safety net setting.

NASA-Task Load Index Differentiates Surgical Approach: Opportunities for Improvement in Colon and Rectal Surgery

OBJECTIVE

Surgeon workload, or human "cost" of performing a procedure, is not well understood in light of emerging surgical technologies. This pilot study quantified surgeon workload for colorectal procedures and identified patient, surgeon, and procedural factors impacting workload.

SUMMARY BACKGROUND DATA

Innovative technologies and procedures in surgery have generally been promoted for the advancement of patient care. The resulting surgeon workload is poorly studied with little knowledge of the contributing factors impacting workload.

METHODS

Surgeons completed NASA-Task Load Index (NASA-TLX) questionnaires to self-assess workload following abdominopelvic colon and rectal procedures. Corresponding patient data were retrieved from the medical record. Descriptive statistics, correlations, and ANOVA were performed to compare surgeon and patient factors, procedure type, and surgical approach on workload overall and by subscales.

RESULTS

Seven attending surgeons rated 238 surgeries, of which 218 (92%) had corresponding patient data. Surgeon experience and patient demographics had inconsistent effects on workload. A statistically significant 3-way interaction was identified among disease process, procedure type, and surgical approach on workload (F(9, 146) = 2.17, P = 0.027), but was limited to open procedures for neoplasia and inflammatory bowel disease patients. Proctectomy and colectomy procedures compared across open, laparoscopic, and robotic approaches showed significant differences in overall workload and subscales, where the robotic procedures required significantly less mental demand, physical demand, and effort, than open or laparoscopic (P < 0.05).

CONCLUSIONS

Patient characteristics, disease process, and surgical experience had inconsistent effects on surgeon workload. Major differences in workload were identified for procedure type and surgical approach, where robotic procedures required less mental demand, physical demand, and effort.

Minimally invasive surgery in gastrointestinal cancer: benefits, challenges, and solutions for underutilization

Background and Objectives:

After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused.

Methods:

We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field.

Results:

We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills.

Conclusions:

Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.

Magnetic Surgical Instruments for Robotic Abdominal Surgery

This review looks at the implementation of magnetic-based approaches in surgical instruments for abdominal surgeries. As abdominal surgical techniques advance toward minimizing surgical trauma, surgical instruments are enhanced to support such an objective through the exploration of magnetic-based systems. With this design approach, surgical devices are given the capabilities to be fully inserted intraabdominally to achieve access to all abdominal quadrants, without the conventional rigid link connection with the external unit. The variety of intraabdominal surgical devices are anchored, guided, and actuated by external units, with power and torque transmitted across the abdominal wall through magnetic linkage. This addresses many constraints encountered by conventional laparoscopic tools, such as loss of triangulation, fulcrum effect, and loss/lack of dexterity for surgical tasks. Design requirements of clinical considerations to aid the successful development of magnetic surgical instruments, are also discussed.

Laparoscopic Transversus Abdominis Release, a Novel Minimally Invasive Approach to Complex Abdominal Wall Reconstruction

Background. Open abdominal wall reconstruction is used to repair complex abdominal wall hernias with contour abnormalities. We present a novel minimally invasive approach to address these types of defects, completed entirely laparoscopically. Methods. Three patients underwent laparoscopic abdominal wall reconstruction for complex hernias in August and September of 2015. Operative approach consisted of laparoscopic transversus abdominis components separation, defect closure, and wide mesh implantation in the retromuscular space. Results. Two males and one female with mean age and body mass index of 70 and 30.1, respectively, underwent a mean operation room time of 329 minutes. Estimated blood loss and length of stay were 91.7 cc and 4.7 days, respectively. No subcutaneous flaps were raised avoiding the need for subcutaneous drains. There were no perioperative complications. All of the subfascial drains were removed prior to patient discharge. On initial follow-up visit at 3 weeks, there was no evidence of wound complications, bulging, or hernia recurrences. Conclusion. Laparoscopic abdominal wall reconstruction with transversus abdominis release is a unique and feasible approach to complex abdominal wall defects with the potential to reduce pain, facilitate recovery, and decrease length of hospital stay for patients.

Ergonomic considerations in endoscopic sinus surgery: lessons learned from laparoscopic surgeons

BACKGROUND

Endoscopic sinus procedures are increasingly common, and more technically difficult procedures are being undertaken to provide patients with minimally invasive alternatives to traditional open surgical techniques. However, such endoscopic approaches have increasing physical demands on the surgeon. The aim of this review is to summarize current literature on surgical ergonomic principles as they relate to endoscopic sinus and skull base surgery and focus on future needs for our specialty.

METHODS

Literature review was performed of surgical ergonomics and, particularly, laparoscopic ergonomic principles.

RESULTS

Existing ergonomic principles for laparoscopic surgery can be applied to endoscopic sinus and skull base surgery and can be expected to offer benefits in terms of surgeon fatigue, physical discomfort, and task efficiency.

CONCLUSION

Increasing surgeon awareness will allow for many basic ergonomic principles to be applied to endoscopic sinus and skull base surgery. Although many simple changes can be immediately made, there is a clear need for further study and abundant room for innovation.

Optimizing the technique of right laparoscopic adrenalectomy with a modified trocar arrangement and dynamic liver retraction: a comparative study with standard technique

OBJECTIVES

Right Laparoscopic adrenalectomy (LA) is technically more challenging than left LA, because of the anatomical position of the right adrenal gland and vein. We modified the technique for right LA to optimize the procedure, and compared the operative outcome with standard technique.

PATIENTS AND METHODS

The operative outcome of 13 cases of right adrenal mass treated with modified LA were compared retrospectively with 29 cases of standard right LA. For modified right LA, we used a 4-port transperitoneal laparoscopic approach that omitted the subxiphoid trocar (classically used for liver retraction), and instead, an assistant applied continuous, dynamic upward liver retraction in a plane perpendicular to the inferior vena cava (IVC).

RESULTS

Modified Right LA was done in 13 patients (3 men, 23.1%), without difficulty and with excellent direct exposure of the upper and medial aspect of the adrenal gland and adrenal vein. Mean operative time was significantly shorter compared with standard technique (122.3 ± 20.1 vs. 165 ± 33.6 min; P < 0.0001) There were no bleeding complication and open conversion in modified technique which was promising compared with 2 bleeding complications in our experience with 29 cases of right LA using standard technique.

CONCLUSION

Modified right LA with a 4-port approach and dynamic upward liver retraction in a plane perpendicular to IVC resulted in direct exposure of the upper and medial aspect of the adrenal gland and adrenal vein. This approach can be effective in challenging cases when the infrahepatic fossa is poorly exposed.

Laparoscopic and open splenectomy for splenomegaly secondary to liver cirrhosis: an evaluation of immunity

OBJECTIVE

We sought to investigate the perioperative inflammatory response and immunological function of patients with portal hypertension-induced splenomegaly who underwent laparoscopic (LS) or open splenectomy (OS).

METHODS

This prospective study investigated a total of 34 patients with splenomegaly due to portal hypertension who underwent either LS (n = 18) or OS (n = 16) between May 2009 and September 2010. Peripheral venous blood samples were taken from these patients prior to surgery and on postoperative days (POD) 1, 3, and 7. The perioperative clinical outcomes and immunological function results were analyzed and compared within each surgical group.

RESULTS

The demographics of the two groups did not differ. The patients in the LS group experienced longer operating time, less intraoperative blood loss, earlier resumption of diet, and shorter postoperative hospital stay. Both the open and laparoscopic groups exhibited statistically significant differences in interleukin -6 and C-reactive protein levels, and total lymphocyte, CD4 T, and natural killer cell numbers on POD 1 and 3 compared with pre splenectomy. The immune responses in the LS group were significantly lower than those in the OS group. The LS group exhibited better preserved cellular immune response and faster recovery than the OS group on POD 7.

CONCLUSIONS

An examination of the inflammatory reaction and cellular immune response after LS and OS demonstrated that there are significant differences in the immune responses observed in the two groups. Further human studies are required to determine the permanent effects of LS on immune function.

Laparoscopic-assisted versus open resection of right-sided colonic cancer--a prospective randomized controlled trial

PURPOSES

This study aims to compare the perioperative outcomes and survival between laparoscopic-assisted right hemicolectomy (LARH) and open right hemicolectomy (ORH) for right-sided colon cancer.

METHODS

Between July 1996 and October 2005, 145 patients were randomized to receive LARH (n = 71) or ORH (n = 74).

RESULTS

The median follow-up of living patients was 99.7 months. The demographic data of the two groups were similar. The time to resume diet (4 vs. 5 days, p = 0.045) and the hospital stay (7.8 vs. 10 days, p = 0.033) were significantly shorter in LARH group, but these benefits were at the expense of longer operating time (198 vs. 129 min, p = 0.002) and higher direct cost (USD8745 vs. USD6293, p < 0.001). The morbidity and mortality were comparable between the two groups. After curative resection, the probabilities of survival at 5 years of the LARH and ORH groups were 74.2% (SE 7.4%) and 75% (SE 7.1%), respectively. The probabilities of being disease free at 5 years were 82.3% (SE 6.9%) and 84.1% (SE 6.2%), respectively.

CONCLUSIONS

Laparoscopic-assisted resection of right-sided colonic cancer has the advantage over open surgery in allowing earlier recovery. However this is at the expense of a longer operating time and higher direct cost (registration number: NCT00485316 ( http://www.clinicaltrials.gov )).

Ten Years of Laparoscopic Adrenalectomy: Lesson Learned from 104 Procedures

The purpose of this study was to evaluate the short- and long-term results of 104 consecutive laparoscopic adrenalectomies performed during a period of 10 years in two specialist centers. One hundred four patients underwent laparoscopic adrenalectomy in two specialist centers in Italy between 1994 and 2003. Indications to laparoscopic adrenalectomy were aldosterone-secreting adenoma (20%), pheochromocytoma (24%), cortisol-secreting adenoma (11.5%), incidentaloma (26.9%), multiple endocrine neoplasia (MEN) type 2A (2.8%), adrenal metastases from lung cancer (3.8%), adrenal cyst (6.7%), and angiomyolipoma (3.8%). Transperitoneal anterior and lateral approaches were adopted in 17 and 84 patients, respectively. Retroperitoneal approach was adopted in three patients. Mean operative time was 108 ± 39.1 minutes (range, 40–300 minutes). There was no correlation between adrenal tumor diameter and operative time. Mean intraoperative blood loss was 106 mL (range, 40–600 mL). Intraoperative complication rate and conversion rate were 4.8 per cent (5 cases). Laparoscopic adrenalectomy is a safe procedure. After a relatively short learning curve, it can be performed successfully by any surgeon with low operative morbidity and mortality. The size of the adrenal tumor should not be considered a contraindication to this procedure.

Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial

BACKGROUND

Although laparoscopic resection of colorectal carcinoma improves post-operative recovery, long-term survival and disease control are the determining factors for its application. We aimed to test the null hypothesis that there was no difference in survival after laparoscopic and open resection for rectosigmoid cancer.

METHODS

From Sept 21, 1993, to Oct 21, 2002, 403 patients with rectosigmoid carcinoma were randomised to receive either laparoscopic assisted (n=203) or conventional open (n=200) resection of the tumour. Survival and disease-free interval were the main endpoints. Patients were last followed-up in March, 2003. Perioperative data were recorded and direct cost of operation estimated. Data were analysed by intention to treat.

FINDINGS

The demographic data of the two groups were similar. After curative resection, the probabilities of survival at 5 years of the laparoscopic and open resection groups were 76.1% (SE 3.7%) and 72.9% (4.0%) respectively. The probabilities of being disease free at 5 years were 75.3% (3.7%) and 78.3% (3.7%), respectively. The operative time of the laparoscopic group was significantly longer, whereas postoperative recovery was significantly better than for the open resection group, but these benefits were at the expense of higher direct cost. The distal margin, the number of lymph nodes found in the resected specimen, overall morbidity and operative mortality did not differ between groups.

INTERPRETATION

Laparoscopic resection of rectosigmoid carcinoma does not jeopardise survival and disease control of patients. The justification for adoption of laparoscopic technique would depend on the perceived value of its effectiveness in improving short-term post-operative outcomes.

Minimally invasive surgery for ileo-colic Crohn's disease

OBJECTIVE: Patients requiring surgery for Crohn's disease are likely to undergo further surgery due to recurrent disease. A prospective study of laparoscopic-assisted surgery for ileo-colic Crohn's disease is reported. METHOD: Forty-one patients (26 female; median age 35 years) with ileo-colic Crohn's disease, without evidence of either fistula or abscess formation underwent laparoscopic-assisted surgery. All had medical therapy, including steroids, but had failed to respond or relapsed. Sixteen patients (39%) had previous surgery for Crohn's disease and 26 (63.4%) had previous abdominal surgery. Laparoscopic procedures (n=42) included ileocaecal/ileocolic resection (n=39), small bowel resection (n=1) and strictureplasty (n=2). RESULTS: The median operating time was 90 min (range 60-180). There were 6 conversions (14.6%). Of the 35 patients whose operation was completed laparoscopically, the median postoperative stay was 5 days (3-9) and the median time to full activity was 20 days (7-49). No major complications or death were recorded. The median follow up (34 out of 35) after surgery is 15.3 months (1-55). Twenty-four patients remain symptom free and 4 have minimal symptoms with no clinical or radiological evidence of recurrence of Crohn's disease. Six have however, developed recurrence requiring medical (n=5) and surgical (n=1) treatment. CONCLUSION: Laparoscopic-assisted surgery for Crohn's disease is feasible. It has the advantage of minimizing hospital stay and promoting early recovery in a group of patients who are likely to have further surgery due to the nature of the disease.

A case of adrenocortical carcinoma associated with recurrence after laparoscopic surgery

Laparoscopic adrenalectomy has become increasingly popular because of its minimally invasive nature, but guidelines for selection of cases suitable for this surgical procedure have not been established. We report a 52-year-old woman with adrenocortical carcinoma, manifesting as Cushing's syndrome, treated with laparoscopic adrenalectomy. The tumour was removed in toto and had been histologically diagnosed as adrenocortical adenoma. However, the patient developed intra-abdominal peritoneal dissemination of carcinoma 15 months after surgery. Review of the histopathological findings of the resected adrenocortical tumour revealed that the neoplasm met five out of nine histological criteria for adrenocortical malignancy, and was diagnosed as adrenocortical carcinoma. Histopathological examination of the tumour was also consistent with adrenocortical carcinoma. The patient responded extremely well to chemotherapy, including carboplatin, etoposide and o,p'-DDD (1,1-dichlorodiphenyldichloroethane), and a subsequent CT (computed tomography) scan 12 months after the start of chemotherapy demonstrated no evidence of disease. However, the patient developed neurological impairment, including dysarthria, as a side-effect of o, p'-DDD. The patient died of aspiration pneumonia due to a decreased pharyngeal reflex. Postmortem examination revealed no foci of residual carcinoma. This case report emphasizes the importance of excluing possible adrenocortical malignancy in patients considered for laparoscopic adrenalectomy, histopathological diagnosis of adrenocortical malignancy and careful monitoring for neurotoxicity during o,p'-DDD treatment.

Systemic cytokine response after laparoscopic-assisted resection of rectosigmoid carcinoma: A prospective randomized trial

OBJECTIVE

To compare the systemic cytokine response in patients after laparoscopic-assisted resection with those after open resection of rectosigmoid carcinoma.

SUMMARY BACKGROUND DATA

Laparoscopic resection of colorectal carcinoma is technically feasible, but objective evidence of its benefit is scarce. Systemic cytokines are accepted as markers of postoperative tissue trauma and mediators of the host immune response.

METHODS

Thirty-four patients with rectosigmoid carcinoma, without evidence of metastatic disease and suitable for laparoscopic resection, were randomized to undergo either laparoscopic (n = 17) or conventional open (n = 17) resection of the tumor. Clinical parameters were recorded. Sera were collected before surgery and at appropriate time points afterward and assayed for interleukin-1beta, tumor necrosis factor-alpha, interleukin-6, and C-reactive protein. The primary end points were the cytokine and C-reactive protein levels. Data were analyzed by intention to treat.

RESULTS

The demographic data of the two groups were comparable. The clinical outcome of both groups was satisfactory, with no surgical deaths and a reasonable complication rate. Both interleukin-1beta and interleukin-6 levels peaked 2 hours after surgery, with the responses in the laparoscopic group significantly less than those in the open group. C-reactive protein levels peaked at 48 hours, and the difference was also statistically significant. Levels of tumor necrosis factor-alpha were not elevated after surgery, and there was no difference between the groups.

CONCLUSIONS

Tissue trauma, as reflected by systemic cytokine response, was less after laparoscopic resection than after open resection of rectosigmoid carcinoma. The difference in the systemic cytokine response may have implications on the long-term survival.

Laparoscopic-assisted resection of right-sided colonic carcinoma: a case-control study

BACKGROUND AND OBJECTIVES

Laparoscopic-assisted resection of colorectal carcinoma is technically feasible. Whether it is beneficial to patients is uncertain. This study reviewed the results of laparoscopic-assisted resection in patients with right-sided colonic adenocarcinoma.

METHODS

We attempted laparoscopic-assisted right to extended right hemicolectomy in 28 patients with right-sided colonic carcinoma (study group). The results were compared with 56 matched patients who underwent conventional open resection in the same period (comparative group).

RESULTS

The median follow-up times for the study and comparative groups were 21.4 and 23.5 months, respectively. The operating time was significantly longer (t-test, P < 0.001), whereas the time to resuming normal diet (Mann-Whitney U-test, P < 0.001) and the duration of hospital stay (Mann-Whitney U-test, P = 0.002) were significantly less in the study than in the comparative group. The oncological clearance, in terms of the number of lymph nodes removed and the resection margins, the complication rate, the disease-free rate, and the survival rate were comparable in the two groups.

CONCLUSIONS

We conclude that laparoscopic-assisted resection of right-sided colonic adenocarcinoma has the advantage over open surgery of allowing earlier recovery. However, this is at the expense of a longer operating time.

Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair

BACKGROUND

In 1975, researchers introduced the use of a large unsutured polyester mesh prosthesis placed in the preperitoneal space for inguinal hernia repair. Different stapling devices have been used to secure this mesh, and the most common complication of the procedure is nerve damage secondary to the staples. The necessity of stapling has never been demonstrated. We designed a prospective randomized study of the need for stapling in laparoscopic extraperitoneal repair of inguinal hernias with 1-year and 3-year followup.

STUDY DESIGN

Inclusion criteria of the study were men older than 18 years and first-time inguinal hernia repair. Patients with recurrence and previous abdominal operations were excluded to avoid confounding variables. Each patient's hernia was assigned a consecutive random number chosen by computer, with each number corresponding to an assigned group. The first group had stapled mesh and the second had unstapled mesh.

RESULTS

Data were collected over a 15-month period, with each procedure having a mean followup time of 8 months. A total of 100 procedures was performed in 92 patients. The two groups of patients were well matched for age and the type of hernia repaired. There were no recurrences in either group and no complications or deaths.

CONCLUSIONS

The initial 12-month followup showed no significant differences in recurrence or complication rates between the stapled and unstapled groups. Both groups returned to work within an average of 4 days. A net savings of $120 was realized for each hernia repair performed without stapled mesh. In addition, stapling presents an inherent risk of nerve damage.

Laparoscopic-assisted resection of colorectal carcinoma: five-year audit

INTRODUCTION

The place of laparoscopic-assisted colectomy for colorectal carcinoma is controversial. This study reviewed a consecutive series of patients who underwent laparoscopic-assisted resection of colorectal carcinoma in the past five years.

METHODS

Two hundred seventeen laparoscopic-assisted resections of colorectal carcinoma were attempted starting in April 1992. Initially, we only selected patients with metastatic disease or patients who were older than 65 years. Subsequently, both palliative and curative resections were attempted in patients with a suitable tumor, with no age limitation. Thus, all suitable patients were randomly assigned to received either laparoscopic-assisted or conventional open surgery.

RESULTS

Data collection was completed in 201 patients. In 22 patients open surgery was performed after a diagnostic laparoscopy. In the remaining 179 patients (90 males) in whom laparoscopic dissection was actually performed, the mean follow-up was 19.8 months, and the mean age was 66.3 years. The procedures performed included right hemicolectomy or extended right hemicolectomy (30 patients), transverse colectomy (2 patients), left hemicolectomy (3 patients), sigmoidectomy (48 patients), anterior resection (59 patients), and abdominoperineal resection (37 patients). Thirty-two (17.7 percent) procedures were converted to open surgery. The mean operation time was 203 minutes. The median blood loss was negligible, and the median requirement of transfusion was zero. The median number of postoperative parenteral analgesic injections was three. The median time to resume diet and hospital discharge were four and six days, respectively. The operative mortality was 1.7 percent. The survival rates at four years were 100, 88.3, and 64.5 percent for patients with Dukes A, B, and C disease, respectively. There was only one (0.65 percent) port-site recurrence.

CONCLUSION

Laparoscopic-assisted resection of colorectal carcinoma was technically feasible and safe. It allowed early postoperative recovery with satisfactory long-term survival. This is at the expense of a long operation. Its benefits over the conventional open technique await the results of the randomized trials.

Laparoscopic surgery and its potential for medical complications

Laparoscopic surgery is very popular among physicians and patients because this technique is associated with safety, shorter hospital stay, early return to normal activity, and cosmetic acceptance of the operative scar. Although the procedure involves minimal invasion and tissue damage, it has potentially serious complications, including cardiopulmonary effects that result mainly from hypercarbia and raised intraabdominal pressure caused by pneumoperitoneum. Absorbed carbon dioxide from the peritoneal cavity tends to cause acidosis. Leakage of the gas into tissue spaces may induce subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium. Cardiac effects include arrhythmias, hypotension, cardiac arrest, gas embolism, pulmonary edema, and myocardial ischemia or infarction. Some of these effects, though rare, are serious and potentially fatal. Physicians should anticipate these problems in their patients undergoing laparoscopic procedures. This review discusses the technique of and physiologic considerations in laparoscopic surgery as well as its potential complications.

The role of laparoscopy in chronic and recurrent abdominal pain

BACKGROUND

This study was designed to determine the efficacy of laparoscopy on patients with a history of recurrent and chronic abdominal pain longer than 3 months, of unknown origin.

METHODS

From September 1990 to May 1994, we performed 66 laparoscopic treatments on 59 patients. The assessment of life quality ensured the disability score, the McGill pain questionnaire, and the visual analogue pain scale, which were completed preoperatively, then on the day of discharge, and finally at a mean period follow-up of 75.3 weeks. Laparoscopy provided diagnosis on 53 of 59 patients (89.8%).

RESULTS

All 66 attempted laparoscopic procedures were completed successfully, no conversion to laparotomy was necessary, and no postoperative complication occurred. Five out of 59 patients (8.5%) revealed no improvement of pain postoperatively, and 6 out of 56 (10.7%) still suffer from pain at the time of the follow-up.

CONCLUSIONS

The pain assessment and disability score was statistically significant postoperatively and at the time of the follow-up in relation to the preoperative score.

Randomized trial of laparoscopic cholecystectomy and mini-cholecystectomy

Three hundred and ten patients having elective cholecystectomy were randomized to either laparoscopic cholecystectomy or mini-cholecystectomy. There were 155 patients in each group. Conversion to open cholecystectomy was significantly more common with laparoscopic cholecystectomy (13 versus 4 per cent) and complications were significantly more frequent with laparoscopic cholecystectomy (9 versus 3 per cent). If laparoscopic cholecystectomy was successful, hospital stay was significantly shorter than for mini-cholecystectomy (2 versus 3 days respectively), but overall the hospital stay was not significantly different. Postoperative analgesia requirements were reduced and return to normal activities and to work were faster after laparoscopic cholecystectomy. There was no significant cost difference between the two procedures.

Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial

OBJECTIVE

The purpose of this study was to determine if laparoscopic inguinal herniorrhaphy represents a viable alternative to the conventional repair and to assess whether a prospective randomized controlled trial comparing both procedures is warranted.

METHODS

Three types of laparoscopic inguinal herniorrhaphies (transabdominal preperitoneal [TAPP], intraperitoneal onlay mesh [IPOM], and totally extraperitoneal [EXTRA]) were studied in a phase II design. Twenty-one investigators from 19 institutions participated. Approval from the local human research committee was required at each institution before patients could be enrolled.

RESULTS

There were 686 patients with 869 hernias; 366 (42.1%) were direct, 414 (47.6%) were indirect, 22 (2.5%) were femoral, and 67 (7.7%) were combination hernias. The TAPP procedure was used for 562 hernias, the IPOM was used for 217 hernias, and the EXTRA was used for 87 hernias. Sixty-one patients had additional abdominal procedures performed at the time of laparoscopy without any adverse affects on their herniorrhaphies. The overall recurrence rate was 4.5%, with a minimum follow-up of 15 months. Complications were divided into the following three groups: 1) those related to laparoscopy, 2) those related to the patient, and 3) those related to the herniorrhaphy. Complications related to the laparoscopy occurred in 5.4% of patients; bleeding or abdominal wall hematomas occurred 31 times, (two patients required transfusion); one patient had bowel perforation, which was sutured laparoscopically; a bladder injury required laparotomy for management. Patient complications occurred in 6.7%. The majority involved the urinary tract (5.8%). Two patients required secondary abdominal procedures for adhesions, one for pain in the right lower quadrant and the other for adhesive small bowel obstruction. Postoperative myocardial infarction on day 5 resulted in the only operative mortality, for a rate of 0.1%. Complications related to the herniorrhaphy itself occurred in 17.1%. Most of these were minor, consisting of transient groin pain (3.5%), seroma (3.5%), transient leg pain (3.3%), hematoma (1.5%), or transient cord or testicular problems (0.9%). The incidence of leg pain decreased dramatically as surgeons became more familiar with the anatomy of the nerve supply to the groin when viewed laparoscopically. Ninety-three percent of patients were discharged within 24 hours of their operations.

CONCLUSIONS

Laparoscopic inguinal herniorrhaphy is an effective method to correct an inguinal hernia. It can be offered safely to patients undergoing other abdominal procedures. The TAPP, IPOM, and EXTRA procedures appear to be equally effective. A controlled randomized trial is needed to compare this procedure with conventional inguinal herniorrhaphy.

Diagnostic laparoscopy: a survey of 92 patients

From January 1991 to June 1993 the authors performed 92 diagnostic laparoscopies when physical examination, laboratory tests, and noninvasive imaging techniques failed to provide accurate diagnoses. Thirty-three patients (36%) underwent laparoscopy to ensure or exclude diagnosis in suspected intra-abdominal malignancy or to assess the operability in the cases of known cancer; 31 patients (34%) were evaluated for chronic abdominal pain; 15 patients (16%) were evaluated for acute abdominal pain; 9 trauma patients (10%) were evaluated to exclude or confirm penetration of the peritoneum or laceration of intra-abdominal organs; and 4 patients (4%) were operated on for miscellaneous conditions. Of the 92 patients, laparoscopy led to diagnosis in 80 patients (87%), a laparotomy was avoided in 78 patients (85%), and operative treatment was done laparoscopically in 65 patients (71%). Diagnostic laparoscopy will not replace laparotomy in every instance. However, in selected groups of patients, it may be used to yield diagnosis and help to avoid unnecessary laparotomy.

Minimal access gastroduodenal surgery

Considerable advances are occurring in the application of laparoscopic techniques to gastrointestinal and hepatobiliary disorders. Following studies in experimental animals, surgeons with an interest in gastroduodenal disease have now introduced laparoscopic techniques into current surgical practice. Elective intervention for peptic ulcer disease is currently being established, particularly in patients with proven negative Helicobacter pylori (HP) status, or when eradication has proved unsuccessful with various drug regimens. In addition, emergency laparoscopic intervention for perforation is gaining acceptance, with or without a definitive anti-ulcer procedure. Therapeutic endoscopy for bleeding peptic ulcer may well be followed by anti-ulcer laparoscopic surgery in selected patients. Laparoscopic techniques have been utilized for the treatment of Mallory Weiss tear, congenital hypertrophic pyloric stenosis, Dieulafoy's lesion, gastric trauma or volvulus and benign gastric tumours. More ergonomic instruments are required before laparoscopic gastric resection becomes more widely acceptable. It is essential that objective evaluation of variations on vagotomy themes be undertaken in prospective clinical trials and that the safety and efficacy of gastric resection procedures be substantiated if this renaissance is to revolutionize gastroduodenal surgical practice.

Esophageal disease in the elderly patient

Disorders of the esophagus in elderly patients are usually associated with the classic symptoms of dysphagia, regurgitation, chest pain, and heartburn. Pulmonary complaints as a result of undiagnosed esophageal disease are common in this age group. Diagnosis is often delayed because symptoms are attributed to underlying cardiac and pulmonary disease. Elderly patients are more susceptible to the complications of aspiration and malnutrition that often accompany inadequately treated esophageal disease; therefore, prompt and aggressive treatment is indicated. Criteria for surgical intervention in esophageal disease do not change with age. Properly selected elderly patients tolerate esophageal surgery well. Age alone should not constitute a contraindication to surgery of the esophagus.

Strategies in the surgical treatment of gastric carcinoma

Surgical therapy still represents the treatment of choice for patients with primary gastric adenocarcinoma, but surgery may have reached its limits concerning the rate of resectability, postoperative mortality and survival rates. Resectability is as high as 80%, mortality after resection ranges between 3% and 5% and the best survival data can be achieved if potentially curative tumor-free (R0-) resection including systematic lymphadenectomy can be performed. Significant prognostic benefits are to be expected in tumor stages II and IIIA. Most gastric carcinomas, however, are diagnosed in far advanced tumor stages (i.e., stage IIIB and IV) and the survival rates in these patients remain disappointing. Multimodality treatment, consisting of preoperative chemotherapy and surgery, may be an encouraging alternative strategy. By endoscopic ultrasonography and staging laparoscopy it may be possible to identify patients with locally advanced tumors, so that these patients should be subjected to multimodal therapy to improve their prognosis. Primary surgical treatment should be exclusively performed in patients with tumor stages up to IIIA and those who are not eligable for aggressive chemotherapeutic regimens, while the concept of multimodality therapy needs to be investigated in the other cases within controlled prospective clinical trials.

Laparoscopic antireflux surgery and repair of hiatal hernia

Laparoscopic mobilization of the esophagus and esophagogastric (O-G) junction enables the safe and effective performance of endoscopic antireflux surgery for intractable reflux esophagitis. The two antireflux procedures that we have evaluated in clinical practice at this institution are the ligamentum teres cardiopexy (n = 9) and partial posterior fundoplication (n = 5). More recently, laparoscopic repair of large symptomatic hiatal hernia (sliding, paraesophageal, and mixed) has also been introduced (n = 4). The procedure entails reduction of the hernia, mobilization of the O-G junction with crural repair by a continuous suture technique employing a special preformed jamming loop knot, followed by total fundoplication, which is fixed proximal to the anterior margin of the diaphragmatic hiatus and distal to the O-G junction. The early results (maximum follow-up 18 months) of this experience have been favorable, with minimal morbidity, early hospital discharge, and effective control of reflux symptoms without adverse sequelae. Laparoscopic antireflux surgery is an alternative to long-term medication in patients with intractable esophagitis, and laparoscopic repair of large hiatal hernias offers significant advantage over the conventional open surgical approach in terms of rapid convalescence.

Laparoscopic reduction, crural repair, and fundoplication of large hiatal hernia

A technique for laparoscopic reduction, crural repair, and total fundoplication for large symptomatic hiatal hernia is described. The procedure entails the mobilization of the esophagogastric junction with crural repair by a continuous suture technique employing a special pre-formed jamming loop knot, followed by total fundoplication that is fixed proximally to the anterior margin of the diaphragmatic hiatus and distally to the esophagogastric junction. The procedure has been performed in eight elderly patients with a good outcome and accelerated recovery to full activity.