Presurgical Identification of Primary Central Nervous System Lymphoma with Normalized Time-Intensity Curve: A Pilot Study of a New Method to Analyze DSC-PWI

BACKGROUND AND PURPOSE

DSC-PWI has demonstrated promising results in the presurgical diagnosis of brain tumors. While most studies analyze specific parameters derived from time-intensity curves, very few have directly analyzed the whole curves. The aims of this study were the following: 1) to design a new method of postprocessing time-intensity curves, which renders normalized curves, and 2) to test its feasibility and performance on the diagnosis of primary central nervous system lymphoma.

MATERIALS AND METHODS

Diagnostic MR imaging of patients with histologically confirmed primary central nervous system lymphoma were retrospectively reviewed. Correlative cases of glioblastoma, anaplastic astrocytoma, metastasis, and meningioma, matched by date and number, were retrieved for comparison. Time-intensity curves of enhancing tumor and normal-appearing white matter were obtained for each case. Enhancing tumor curves were normalized relative to normal-appearing white matter. We performed pair-wise comparisons for primary central nervous system lymphoma against the other tumor type. The best discriminatory time points of the curves were obtained through a stepwise selection. Logistic binary regression was applied to obtain prediction models. The generated algorithms were applied in a test subset.

RESULTS

A total of 233 patients were included in the study: 47 primary central nervous system lymphomas, 48 glioblastomas, 39 anaplastic astrocytomas, 49 metastases, and 50 meningiomas. The classifiers satisfactorily performed all bilateral comparisons in the test subset (primary central nervous system lymphoma versus glioblastoma, area under the curve = 0.96 and accuracy = 93%; versus anaplastic astrocytoma, 0.83 and 71%; versus metastases, 0.95 and 93%; versus meningioma, 0.93 and 96%).

CONCLUSIONS

The proposed method for DSC-PWI time-intensity curve normalization renders comparable curves beyond technical and patient variability. Normalized time-intensity curves performed satisfactorily for the presurgical identification of primary central nervous system lymphoma.

Genome-Wide Association Studies for Methane Production in Dairy Cattle

Genomic selection has been proposed for the mitigation of methane (CH₄) emissions by cattle because there is considerable variability in CH₄ emissions between individuals fed on the same diet. The genome-wide association study (GWAS) represents an important tool for the detection of candidate genes, haplotypes or single nucleotide polymorphisms (SNP) markers related to characteristics of economic interest. The present study included information for 280 cows in three dairy production systems in Mexico: 1) Dual Purpose (n = 100), 2) Specialized Tropical Dairy (n = 76), 3) Familiar Production System (n = 104). Concentrations of CH₄ in a breath of individual cows at the time of milking (MEIm) were estimated through a system of infrared sensors. After quality control analyses, 21,958 SNPs were included. Associations of markers were made using a linear regression model, corrected with principal component analyses. In total, 46 SNPs were identified as significant for CH₄ production. Several SNPs associated with CH₄ production were found at regions previously described for quantitative trait loci of composition characteristics of meat, milk fatty acids and characteristics related to feed intake. It was concluded that the SNPs identified could be used in genomic selection programs in developing countries and combined with other datasets for global selection.

Distributed detection of hydrogen and deuterium diffusion into a single-mode optical fiber with chirped-pulse phase-sensitive optical time-domain reflectometry

For some infrastructures such as oil and gas extraction boreholes or radioactive waste repositories, where distributed optical fiber sensors are employed to grant the safety of the facilities, the presence of gas species such as hydrogen or deuterium is one of the most relevant parameters to monitor. The possibility of employing the same kind of sensors for this purpose is of special interest, reducing the cost by employing a single interrogator, able to measure multiple parameters by simply employing adequate sensing fibers. To meet this goal, we present here a chemical sensor based on chirped-pulse phase-sensitive optical time-domain reflectometry (CP-φOTDR), which is able to detect these species while they diffuse into the silica fiber. The ability of chirped-pulse φOTDR to measure a change in refractive index with sensitivity around 10^-8 has allowed determining hydrogen concentration with accuracy on the order of 10^-3  mol/m³ and spatial resolution ∼6  m. Another experiment provides an indirect measurement of the solubility of deuterium in a standard telecom-grade optical fiber, which is found to be around 1.47×10²⁴  m³/bar.

Single-shot distributed temperature and strain tracking using direct detection phase-sensitive OTDR with chirped pulses

So far, the optical pulses used in phase-sensitive OTDR (ΦOTDR) were typically engineered so as to have a constant phase along the pulse. In this work, it is demonstrated that by acting on the phase profile of the optical pulses, it is possible to introduce important conceptual and practical changes to the traditional ΦOTDR operation, thus opening a door for new possibilities which are yet to be explored. Using a ΦOTDR with linearly chirped pulses and direct detection, the distributed measurement of temperature/strain changes from trace to trace, with 1mK/4nε resolution, is theoreticaly and experimentaly demonstrated. The measurand resolution and sensitivity can be tuned by acting on the pulse chirp profile. The technique does not require a frequency sweep, thus greatly decreasing the measurement time and complexity of the system, while maintaining the potential for metric spatial resolutions over tens of kilometers as in conventional ΦOTDR. The technique allows for measurements at kHz rates, while maintaining reliability over several hours.

Gastrointestinal transit and stress response after laparoscopic vs conventional distal pancreatectomy in the canine model

BACKGROUND

Several authors have presented the feasibility of laparoscopic pancreatic surgery. However, the pathophysiological effect of laparoscopic pancreatic surgery is not well known.

METHODS

Ten mongrel dogs were randomly operated for laparoscopic and conventional distal pancreatectomy. Fed state gastrointestinal transit times were assessed using radiopaque markers. To assess surgical stress, we determined serum IL-1 and cortisol.

RESULTS

Postoperative mouth-to-anus transit time in the laparoscopic group was not prolonged while it was significantly prolonged in the conventional group compared with the baseline study, but no significant differences between groups were detected. First defecation was observed significantly earlier in the laparoscopic group. Serum cortisol levels were elevated significantly at 4 h after skin incision in both groups and decreased thereafter. In the laparoscopic group, they returned close to the normal level at 8 h after incision, but were still significantly higher in the conventional group. The level of IL-1 was elevated significantly higher in conventional group at 24 h after the skin incision.

CONCLUSION

Thus, we conclude that laparoscopic distal pancreatectomy demonstrated faster recovery of the bowel transit and less stress than conventional distal pancreatectomy in dogs.

The significance of pH and manometric testing after laparoscopic fundoplication

Laparoscopic antireflux surgery has become the standard operation for gastroesophageal reflux disease (GERD). This study examined the outcomes of laparoscopic antireflux surgery, hypothesizing that both subjective symptoms and objective pH would correlate with manometric parameters to reflect the absence of reflux after fundoplication. We evaluated 56 patients who underwent laparoscopic antireflux surgery. Preoperative and postoperative symptoms were documented by chart reviews and confirmed by telephone interviews with the patient. Preoperative pH probe and esophageal manometry studies were compared with postoperative studies performed 3 to 6 months after fundoplication. Subjective symptoms were correlated with objective measurements of acid reflux and lower esophageal sphincter pressure (LESP). The follow-up period was 3 to 29 months. Symptomatic improvement was seen in 91% of patients, and good to excellent improvement in preoperative symptoms was cited. Postoperatively, there was significant improvement in percentages of upright supine times when esophageal pH was less than 4 (p <0.001). There was an increase in LESP from an average of 16.9 mmHg preoperatively to 22.7 mmHg postoperatively (p <0.001). There was no correlation between postoperative LESP and symptoms or LESP and 24-h pH results. However, there was a predictive correlation between LESP and postoperative heartburn symptoms (p <0.001). These findings imply that symptom follow-up evaluation is adequate in the asymptomatic patient after laparoscopic fundoplication, and that routine physiologic testing is not necessary.

Laparoscopic hernia repair enhances early return of physical work capacity

Several researchers have documented less postoperative pain and a quicker return to daily activities after laparoscopic herniorrhaphy. However, little objective data that validates this hypothesis exists. This study compares the rate of postoperative physical work capacity with return to preoperative levels, which is measured by a standard treadmill test in patients who underwent laparoscopic and conventional open hernia repair. Patients completed a 6-minute walking test preoperatively and 1 week postoperatively using a nonmotorized treadmill. The distance walked was recorded. If the distance that a patient achieved at 1 week was not within 0.02 miles of the preoperative values of the patient, the patient was asked to return at 1 month for repeat testing. Patients were enrolled prospectively in this study from October 1997 to February 1999. Sixty-six patients participated in the study (27 laparoscopic herniorrhaphies and 39 open herniorrhaphies were performed). There was no significant difference in age, body mass index, or preoperative distance achieved among the two groups. At 1 week, patients who underwent laparoscopic repair demonstrated a mean increase of 18 meters from preoperative distance (P = 0.07). In the open group, patients demonstrated a mean decrease of 90 meters at 1 week (P = 0.001). The change in distance at 1 week between the laparoscopic and the open groups was statistically significant (P = 0.001). However, at 1 month, there was no significant difference among the two groups. Measured using treadmill walking, laparoscopic hernia repair seems to offer an early advantage to open repair in return-to-physical-work capacity.

Missed lipoma of the spermatic cord. A pitfall of transabdominal preperitoneal laparoscopic hernia repair

BACKGROUND

Missed lipoma of the spermatic cord is a pitfall unique to the transabdominal preperitoneal (TAPP) laparoscopic hernia repair. This problem occurs when a palpable inguinal mass is noted preoperatively, but no identifiable hernia defect is found at time of laparoscopy and the procedure is terminated.

METHODS

Our group encountered six patients without intraperitoneal defects that had large cord lipomas on preperitoneal exploration. Two of these patients had undergone previous intraabdominal laparoscopy for a proposed TAPP repair, which was aborted when no defect was seen.

RESULTS

Both patients were referred for continued symptomatic groin masses, which were subsequently treated by lipoma resection in conjunction with inguinal floor repair.

CONCLUSIONS

When patients present with a groin mass, exploration of the preperitoneal space and cord structures is indicated during TAPP repair, even in the presence of a normal-appearing abdominal floor. Abandoning a transabdominal approach without exploration of the preperitoneal structures may lead to a failure to identify symptomatic and/or palpable cord lipomas.

Hand-assisted laparoscopic digestive surgery provides safety and tactile sensation for malignancy or obesity

BACKGROUND

Some of the persistent problems associated with laparoscopic surgery stem from the inability of the surgeon to palpate the abdominal contents during the operation. This lack of tactile sensation can lead to poor abdominal exploration, difficulty in extracting the organs, and a relatively long operation time compared to conventional procedures. The Dexterity Pneumo Sleeve is a new device that allows the surgeon to insert his or her hand into the abdominal cavity through a small incision while preserving the pneumoperitoneum.

METHODS

Recently, 13 of our patients underwent hand-assisted advanced laparoscopic surgery using this device. In this series, we had two cases of gastrectomy, two cases of gastric bypass for morbid obesity, two Whipple cases for periampullary tumor, and seven cases of bowel resection. On the basis of this series, we were able to assess the utility of this device.

RESULTS

Satisfactory pneumoperitoneum was maintained in 12 of 13 cases. The length of the skin incision was 7.8 cm on average, which was almost the same size as surgeon's glove. The device proved to be very useful for tissue retraction and abdominal exploration in all cases and for intracorporeal knot tying in some cases.

CONCLUSIONS

We found that the device permitted an easier dissection, resection, and anastomosis. It also helped to decrease the operation time.

Full robotic assistance for laparoscopic tubal anastomosis: a case report

Optical magnification and long instrumentation significantly increase surgical tremor, which makes laparoscopic microsuturing difficult. Therefore, laparoscopic tubal anastomosis has not gained wide acceptance among gynecologic surgeons. Robotic assistance facilitates this type of procedure by filtering tremor, reducing the surgeon's fatigue, and scaling the maneuvers. The authors have successfully completed a case of laparoscopic tubal reanastomosis using a "master-slave" robot to perform the standard microsuturing technique. A 33-year-old woman, gravida 2, para 2, requested reversal of her previous tubal ligature. A right isthmic-isthmic tubal anastomosis was performed laparoscopically, with faithful adherence to the authors' standard technique applied at laparotomy. Full robotic assistance was used to anastomose the tube. A chromotubation test showed anastomotic patency without leak. The patient recovered uneventfully after surgery and was discharged within 24 h after the procedure. Laparoscopic microsurgical tubal anastomosis with full robotic assistance is feasible and safe in humans.

Manual vs robotically assisted laparoscopic surgery in the performance of basic manipulation and suturing tasks

OBJECTIVE

To compare the surgical performance of manual and robotically assisted laparoscopic instruments on basic maneuvers and intracorporeal suturing in inanimate models.

DESIGN

A set of laparoscopic tasks was used to evaluate basic endoscopic movements and intracorporeal suturing: positioning a cylinder on a Peg-Board, dropping beads into receptacles, running a 25-cm rope, and capping a hypodermic needle. Intracorporeal knot tying and running a suture through predetermined points were evaluated separately. The sutures used for these tasks were 2-0 and 4-0 silk and 6-0 and 7-0 polypropylene.

PARTICIPANTS

Twenty surgeons completed the set of laparoscopic tasks manually and then with a robotically assisted system. None had used the robotic system before.

MAIN OUTCOME MEASURES

Time required to complete the tasks and the precision in performing them.

RESULTS

The robotic system accurately reproduced the movements of the surgeons and filtered their hand tremors efficiently. In the basic tasks, operative times were significantly longer for the robotic system (P<.001). In the suturing tasks, operative times were longer with the use of the robotic system for sutures sizes 2-0 and 4-0 (P<.001). However, time differences were not significant for suture sizes 6-0 and 7-0 (P> or =.07). Precision measurements were similar for all tasks using the manual instruments and the robotically assisted system. No significant differences were found between the performance of advanced laparoscopic surgeons and laparoscopic fellows.

CONCLUSIONS

Laparoscopic maneuvering and suturing is faster and just as precise when performed manually as when performed with the prototype robotic system. These differences in speed are inversely proportional to the size of the suture. Future generations of the robotic system may eliminate these differences.

Robotically assisted laparoscopic microsurgical uterine horn anastomosis

OBJECTIVE

To evaluate the feasibility, safety, and sterility issues with regard to the use of a robotic device to perform uterine horn anastomosis in a live porcine model.

DESIGN

Prospective animal study.

SETTING

Landrace-Yorkshire pigs in a conventional laboratory setting.

INTERVENTION(S)

Six female pigs underwent laparoscopic bipolar electrocoagulation of the distal uterine horns. Two weeks later, the uterine horns were reanastomosed laparoscopically with use of a robotic system for microsuturing. Necropsy was performed 4 weeks later to assess postoperative adhesions and anastomosis patency.

MAIN OUTCOME MEASURE(S)

Tubal patency; secondary measures were operative time, complications, and surgeon fatigue.

RESULT(S)

The mean (+/-SD) total operative time per animal was 170+/-34 minutes including setting up and dismantling the robotic arms. The robot functioned well with only minor technical problems. All pigs survived both surgeries with no perioperative complications related to the use of the robot. Patency was confirmed after completing each anastomosis (12 anastomoses; 100% patency). Four weeks later, necropsy showed that eight anastomoses were still patent (67%). Only one pig had bilateral occlusion. Surgeon's fatigue was mild for each animal study.

CONCLUSION(S)

Robotic technology can be used safely in creating laparoscopic microsurgical anastomoses. The robot functioned properly in a sterile operating room environment. Adequate patency rates were achieved during the acute phase and at 4-week follow-up. Robotic technology has the potential to make laparoscopic microsuturing easier.

Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments

Interest has grown in reducing the size of laparoscopic instruments. We define as "needlescopic" those instruments that have a diameter of < or =3 mm. We compared data from 60 needlescopic cholecystectomies with a matched group of laparoscopic procedures. No intraoperative complications occurred in either group. Operative time was 20% longer for the needlescopic operations. Hospital stay was similar for both groups. Postoperative analgesia requirements for the needlescopic group were 70% lower than for the laparoscopic group. From a scale (0, no scar visible, to 10, worst scar), patients scored their scars as 1 for the needlescopic cases and 5 for the laparoscopic group. Likewise, we have used needlescopic instruments to perform appendectomy, inguinal herniorrhaphy, adrenalectomy, splenectomy, and fundoplication. In conclusion, needlescopic procedures are safe and efficient. While they result in longer operative times, they decrease the need for postoperative analgesia, which may shorten convalescence and improve the cosmetic result.

Robotically assisted laparoscopic tubal anastomosis in a porcine model: a pilot study

As with standard microsurgical procedures performed at laparotomy, laparoscopic tubal anastomosis requires great dexterity. Handling fine suture materials under magnification to anastomose tubal segments with lumens less than 3 mm in diameter while working with your hands at a distance from the tissue makes these fine movements even more difficult. This is exacerbated by the tremor induced by the fatigue caused by a prolonged laparoscopic procedure and the need for precise control. We conducted a pilot study to evaluate the feasibility of performing laparoscopic tubal anastomosis with robotic assistance in a live porcine model. Two anastomoses were performed on one uterine horn via each of the following techniques: laparoscopy, laparoscopy with robotic assistance, and open microsurgery. Immediate necropsy demonstrated all the anastomoses to be patent. There were no intraoperative complications. Laparoscopic tubal anastomosis was associated with surgeon fatigue and neck, shoulder, and back pain. The surgeons were more comfortable performing the procedure with robotic assistance. The device functioned well and without incident. This acute animal study suggests that robotic assistance in laparoscopic tubal anastomoses is safe and feasible. It enhances surgeons' dexterity and precision while reducing fatigue. It is promising for future use in chronic experimental studies.

Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy

BACKGROUND

The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties.

METHODS

After experimental success in an animal model, we recently performed our first case of endoscopic subtotal parathyroidectomy in a 37-year-old man. The patient, who had a history of severe pancreatitis and pancreatic calculi, was diagnosed as having hyperparathyroidism. The option of endoscopic parathyroidectomy was proposed and accepted. After placing the first trocar directly under the platysma, a space was created by bluntly dissecting with the tip of a 5-mm endoscopic camera. Four parathyroid glands were identified, and after a frozen-section diagnosis of parathyroid hyperplasia, three-and-one-half of the glands were resected.

RESULTS

The patient developed slight hypercarbia and subcutaneous emphysema during the procedure, but no other problems were noted. His postoperative course was otherwise unremarkable.

CONCLUSIONS

This is the first case reported of an endoscopic parathyroidectomy. This experience makes us optimistic about the future of endoscopic neck surgery.

A porcine model for laparoscopic ventral hernia repair

Ventral hernia repair is one of the most common abdominal operations. Recurrence rate remains high despite all preventive measures. "Tension-free" repair has been postulated as the surgical method of choice. A laparoscopic approach to ventral hernia repair has been described recently. Theoretical advantages of a laparoscopic repair include faster recovery, less postoperative pain, less morbidity, and a better cosmetic result. However, the approach requires advanced laparoscopic skills and familiarity with its technique. An animal model of ventral hernia, suitable for laparoscopic repair, was developed to be used for educational and experimental purposes. The model is simple, reliable, and reproducible in any minimally invasive surgery facility. We conclude that the pig can be used as an excellent model to learn the technique and evaluate a variety of endpoints for laparoscopic ventral hernia repair.

Robotic surgical instruments for dexterity enhancement in thoracoscopic coronary artery bypass graft

OBJECTIVES

Endoscopically sutured vascular anastomoses are complex, time consuming, and require great dexterity. We decided to evaluate performance enhancement using a robotic device to create sutured coronary artery bypass anastomoses with endoscopic techniques in a plastic model.

METHODS

Seven coronary artery bypass anastomoses were endoscopically created in a plastic model using a robotic enhancement technology (Computer Motion, Goleta, CA). Anastomoses were created with a single running suture (7-0 monofilament). Our endpoints were operative time, intraoperative incidents, stability and dexterity of the robotic system, surgeon's fatigue, and anastomotic patency.

RESULTS

Operative time was 46+/-12 min (mean+/-SD). There were no intraoperative incidents. Patency was confirmed in all anastomoses. The system's stability and dexterity were high. Surgeon's fatigue was mild.

CONCLUSION

The use of robotic enhancement technology leads to an efficient performance of sutured coronary artery bypass anastomoses in a plastic model. The robotic device enhances dexterity, precision, and reduces surgeon's fatigue while preserving the quality of hand suturing.

Perioperative tumor localization for laparoscopic colorectal surgery

BACKGROUND

Because of the inability to palpate colonic tumors during laparoscopy, their location must be precisely identified before resection is undertaken.

METHOD

A retrospective study was performed of 58 patients in order to be able to describe our methods of tumor localization for laparoscopic colorectal operations and to review their effectiveness.

RESULTS

In all patients, the entire colon was examined preoperatively by colonoscopy. In one patient, preoperative colonoscopic localization was inaccurate. In 31 patients, tumors were easily detectable at surgery. In five patients with the tumor in the right colon, even though the lesion was not detectable at surgery, right colectomy was performed without marking because preoperative colonoscopy reliably identified the lesion adjacent to the ileocecal valve. Twenty-two patients required some type of procedure to localize the tumor. The procedures and their problems were as follows: preoperative tattoo (five)--tattoo not visualized (one); intraoperative colonoscopy alone (six), combined with intraoperative tattoo (four) or clip (three)--poor operative exposure due to bowel distension (nine), hard to see the clip (three), dislodged clip (two), inadequate resection margin (one); intraoperative proctoscopy alone (two), combined with laparoscopic stitch (two)--no problems. In no patient was tumor present at a resection line and in no patient was the wrong segment resected.

CONCLUSIONS

Reliable preoperative identification of the tumor adjacent to the ileocecal valve can permit right colectomy without marking. Lesions in the upper rectum can be approached via intraoperative proctoscopy +/- suture placement. If the surgeon anticipates intraoperative localization may be difficult, lesions other than rectal or cecal ones should probably be marked by preoperative tattooing. Further studies regarding the technique of tattooing are warranted.

Laparoscopic total abdominal colectomy with ileorectal anastomosis for familial adenomatous polyposis

PURPOSE

This study was undertaken to describe our results in a series of patients undergoing total abdominal colectomy with ileorectal anastomosis (TAC/IRA) using laparoscopic techniques in patients with familial adenomatous polyposis (FAP) and rectal-sparing. Young patients with FAP requiring TAC/IRA may be ideal candidates for minimally invasive surgery, because they are generally thin and have benign disease. They might benefit maximally from the theoretic advantages of these techniques.

METHODS

We have performed laparoscopic TAC/IRA in 16 FAP patients (10 females; mean age, 18 years). Procedures were entirely intracorporeal, with a 3-cm to 6-cm specimen extraction incision.

RESULTS

Median operative time was 232 (range, 156-285) minutes, and blood loss 175 (range, 50-675) ml. The only intraoperative complication, a twisted ileorectal anastomosis, was noted intraoperatively and revised. There were no conversions to conventional laparotomy. Median postoperative interval to passage of flatus was three days, and for bowel movements it was three days. Median hospital stay was five days. One case of early postoperative small-bowel obstruction was treated nonoperatively, and one case of brachial plexus neuropraxia resolved spontaneously.

CONCLUSIONS

Based on this preliminary experience, we believe laparoscopic TAC/IRA can be a safe and effective treatment for selected patients with FAP. As techniques and instrumentation for laparoscopic colon surgery are perfected, this procedure will likely become an appealing option in the management of patients with FAP.

Laparoscopic techniques for fecal diversion

Although the role of laparoscopic techniques in performing major colorectal resections is unclear, laparoscopy may be well suited for fecal diversion procedures because no resection and minimal tissue dissection is required.

PURPOSE

This report reviews our initial experience with laparoscopic stoma procedures to assess safety and efficacy.

METHODS

Using a simple two-cannula technique, 24 such procedures (16 loop ileostomies, 6 end sigmoid colostomies, 1 transverse, and 1 sigmoid loop colostomy) were attempted. Indications for diversion were rectovaginal fistula (7), perianal sepsis (7), incontinence (4), advanced rectal or colon carcinoma (4), and complicated pelvic infection (2). There were 15 females and 9 males with a median age of 44 (range, 25-88) years.

RESULTS

Median operative time was 60 (range, 20-120) minutes, and median blood loss was 50 (range, 0-150) ml. There were no intraoperative complications. One case was converted to a laparotomy because of dense adhesions. Median time to passage of both flatus and stool was one (range, 1-3) day for ileostomy patients, two (range, 2-4) for flatus, and 3 (range, 2-6) days for stool after colostomy. Median time to discharge was 6 (range, 2-28) days and was often delayed by the primary disease process or ostomy teaching. One major postoperative complication, a pulmonary embolism, occurred eight days after operation in a patient with near obstructing, widely metastatic colon carcinoma. This patient later died of pulmonary failure. All stomas have functioned well, with no revisions required.

CONCLUSIONS

Laparoscopic fecal diversion procedures can be performed safely, simply, and effectively. Apparent advantages over standard techniques are avoidance of a laparotomy, while maintaining the ability to precisely identify and orient the pertinent bowel segment and rapid return of bowel function.