The difficult laparoscopy

The Future in Standards of Care for Gynecologic Laparoscopic Surgery to Improve Training and Education

Standards of care offer doctors and patients the confidence that an established quality, evidence-based, care is provided, and represent a tool for optimal responding to the population’s needs. It is expected that they will increasingly express a multimodal relationship with gynecologic laparoscopy. Laparoscopy is, now, a standard procedure in operative gynecology, standards are embedded in many laparoscopic procedures, standardization of the skills/competency assessment has been progressively developed, and the proof of competency in laparoscopy may become a standard of care. A continuous development of surgical education includes standard equipment (that may bring value for future advance), standardized training, testing (and performance) assessment, educational process and outcome monitoring/evaluation, patients’ care, and protection, etc. Standards of care and training have a reciprocally sustaining relationship, as training is an essential component of standards of care while care is provided at higher standards after a structured training and as credentialing/certification reunites the two. It is envisaged that through development and implementation, the European wide standards of care in laparoscopic surgery (in close harmonization with personalized medicine) would lead to effective delivery of better clinical services and provide excellent training and education.

Prediction of Technical Difficulties in Laparoscopic Splenectomy and Analysis of Risk Factors for Postoperative Complications in 468 Cases

Prediction of intraoperative difficulties may be helpful in planning surgery; however, few studies explored this issue in laparoscopic splenectomy (LS). We performed retrospective analysis of consecutive 468 patients undergoing LS from 1998 to 2017 (295 women; median age 47 years). The patients were divided into difficult LS and control groups. The inclusion criteria for difficult LS were operative time ≥mean + 2SD; intraoperative blood loss ≥500 mL, intraoperative adverse events (IAE), conversion. Primary outcomes were risk factors for difficult splenectomy and secondary outcomes for perioperative morbidity. Fifty-six patients were included in the difficult LS group (12%). Spleens ≥19 cm and higher participation of younger surgeons in consecutive years were predictive for difficult splenectomy. Age ≥53 years and diagnosis other than idiopathic thrombocytopenic purpura (ITP) were independent risk factors of spleen ≥19 cm. The perioperative morbidity was 8.33%; its OR was increased only by blood loss and IAEs. Only blood loss significantly increased serious morbidity. Male sex, spleens ≥19 cm, and IAEs were independent risk factors for intraoperative hemorrhage. Spleen length ≥19 cm was a risk factor for difficult LS and intraoperative hemorrhage. Diagnoses other than ITP in patients aged ≥53 years with ≥19 cm spleens are predictive for intraoperative difficulties and perioperative complications.

Robotic-assisted paraesophageal hernia repair--a case-control study

AIMS

The da Vinci® telemanipulation system offers a wide range of precise movements and 3D visualization with depth perception and magnification effect. Such a system could be useful for improving minimally invasive procedures-as in the case of large hiatal hernia with paraesophageal involvement (PEH) repair. Studies reporting on the robotic-assisted PEH repair are scarce, and a comparison to the standard operation techniques is lacking. Therefore, we decided to investigate the feasibility and safety of robotic-assisted surgery (RAS) compared to conventional laparoscopic (CLS) and open surgery (OS) for the first time.

METHODS

We investigated 42 patients for the perioperative outcome after PEH repair. Twelve patients were operated on with RAS, 17 with CLS, and 13 with OS. Operating time, intraoperative blood loss, intra- and postoperative complications, mortality, and duration of hospital stay were analyzed in each method.

RESULTS

On average, operating time in the RAS group was 38 min longer, and the intraoperative blood was loss 217 ml lower compared to OS. Both results were similar to the CLS group. The intraoperative complication rate was similar in all groups. The postoperative complication rate in the RAS group was significantly lower than the OS group, though again similar to the CLS group. The hospital stay was 5 days shorter in the RAS group than the OS group and once again similar to the CLS group.

CONCLUSION

The results show that RAS is feasible and safe. It appears to be an alternative to OS due to lower intraoperative blood loss and potentially fewer postoperative complications, as well as shorter hospital stay. Though, RAS is not superior to CLS.

Laparoscopic lysis of adhesions

BACKGROUND

Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen.

METHODS

The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique.

RESULTS

The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%-93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%-2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4-6 days in most series.

CONCLUSIONS

Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.

Abdominal emergencies: diagnostic and therapeutic laparoscopy

BACKGROUND

Laparoscopy has been practiced in the management of emergencies resulting from inflammatory conditions, lumenal obstruction, perforation, vascular occlusion, and trauma. This article identifies and discusses controversial areas in the field, in particular surrounding the efficacy, cost effectiveness, and perceived advantages of laparoscopy in the evaluation and treatment of patients with acute abdominal conditions.

MATERIALS AND METHODS

Review and commentary on pertinent articles in the English language literature are presented.

RESULTS

Prospective randomized trials have been reported in the treatment of some disorders, but a lack of recommendations that are evidence-based has hindered more widespread usage of laparoscopy in an emergency setting. In addition, concerns have been raised that the creation of capnoperitoneum in the patient with established peritonitis may be detrimental with respect to potentiation of bacteremia and severe sepsis, and experimental studies have yielded conflicting data in this regard.

CONCLUSION

As such issues are resolved, utilization of laparoscopy is likely to increase substantially as expertise is acquired. A minimal-access approach carries less morbidity and may offer other practical advantages in terms of surgical technique and application. When surgical intervention is appropriate, laparoscopy is now preferred for acute biliary disease. Female patients of reproductive age with acute appendicitis may benefit, particularly if there is preoperative diagnostic uncertainty. Selected cases of intestinal obstruction and visceral perforation presenting soon after symptom onset and in whom shock is absent may also be amenable to laparoscopic repair. Its use in the treatment of most trauma patients and patients with generalized peritonitis or hemodynamic instability is not recommended at present.

Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.

Routine use of open laparoscopy: 1,006 consecutive cases

Blind insertion of the Veress needle and of the first trocar is a significant cause of laparoscopic surgery complications. Despite this risk, the closed technique is still more popular than the open one. The authors retrospectively evaluated 1006 consecutive laparoscopic operations in which Hasson's technique was routinely performed. The overall complication rate was 2.2%, but the vast majority of complications occurred during the first 50 cases (6% vs. 1.9%). They conclude that after a learning phase of about 50 cases, Hasson's technique is a quick and safe procedure.