Laparoscopic splenectomy: optimal vascular control using the lateral approach and ultrasonic dissection

BACKGROUND

Intraoperative bleeding is the main complication and main cause of conversion to open surgery during laparoscopic splenectomy (LS). We present the advantages of the lateral approach and the use of the ultrasonic shears (US) for achieving a safer vascular control.

METHODS

We have performed a total of 48 LS using several approaches. In our initial experience 10 patients underwent surgery with an anterior approach. In the second series of 18 patients, we used a manually assisted procedure. In the last 20 patients, we employed a technique with a full lateral position. Only three ports have been used. The major part of the dissection was conducted from behind, thus allowing a safer vascular control. The division of short gastric vessels and lower pole vessels was performed using US. The main vascular pedicle was stapled. The spleen was removed through a short Pfannenstiel incision. There were 9 males and 11 females with a mean age of 36 years (range, 18-71 years). Fourteen had immune thrombocytopenic purpura (ITP); two had an HIV-infection-related purpura; two had an autoimmune hemolytic anemia; and two had a spherocytosis.

RESULTS

All the 20 LS were completed. The average splenic weight was 274 g (range, 162-1,400 g). In all but one patient, the intraoperative blood loss was less than 60 ml, and was none in six patients (average, 51 ml). In our initial series of 10 patients surgically treated with an anterior approach, the average blood loss was 180 ml, and it was 230 ml in the series of hand-assisted procedures. The average operative time was 127 min (range, 70-220 min), including the time required by the change of position and the Pfannenstiel incision. There was no mortality. All but one patient had an uneventful postoperative course. The HIV-infected patient had a severe postoperative pancreatitis. In those patients with an uncomplicated course, the average postoperative stay was 4.3 days (range, 2-8 days).

CONCLUSIONS

The lateral position with a posterior approach to splenic vessels allows for safe vascular control. The use of US results in a gain of time and safety. The average intraoperative bleeding of this series is much lower than that observed in our previous experience and in other published series.

Surgical endoscopic techniques in the diagnosis and follow-up of patients with lymphoma

BACKGROUND

In patients with lymphoma, tissue for histology can be obtained through image-guided techniques or by surgery. The aim of this study was to assess the efficacy of surgical endoscopic techniques in obtaining adequate tissue specimens.

METHODS

Ninety-two patients with suspected or confirmed lymphoma were referred for a surgical biopsy of a deeply located intrathoracic or intra-abdominal mass or lymph node. The 86 patients who had surgery using a surgical endoscopic technique were included in this study. There were 54 men and 32 women, of mean age 34 (range 15-78) years. Most were selected directly for surgery while five previously had a failed computed tomography-guided biopsy. A total of 89 procedures were performed in 86 patients: laparoscopy (15 patients), thoracoscopy (61) and mediastinoscopy (13).

RESULTS

No patient died. One intraoperative complication occurred during thoracoscopy (1 per cent). Two postoperative complications were noted (2 per cent). Three patients required conversion to open surgery (3 per cent). Adequate tissue for histology was obtained by surgical endoscopic procedures in 87 per cent. Twelve of 13 mediastinoscopies were successful. After thoracoscopy, the success rate was 92 per cent but only nine of 15 laparoscopies were considered successful.

CONCLUSION

In patients with lymphoma, surgical endoscopic techniques have a high diagnostic yield and a low morbidity rate. Barring exceptional circumstances these should be favoured rather than conventional open surgery.

Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation

BACKGROUND

Thoracoscopic sympathectomy is the most effective treatment for upper limb hyperhidrosis. However, this is offset by the occurrence of a high rate of side effects, such as embarrassing compensatory sweating. Anticipating that a technique that respects the sympathetic chain and divides only the rami communicantes may lead to fewer side effects, we assessed the technique described by R. Wittmoser, comparing it with conventional thoracoscopic sympathecomy.

METHODS

A total of 240 thoracoscopic sympathectomies were performed in 124 patients suffering from upper limb hyperhidrosis. Fifty-four patients underwent a conventional sympathectomy (group TS), 62 underwent division of the rami communicantes with respect to the main trunk (group SS), and 8 underwent both procedures (group TS/SS) because of accidental division of the chain during dissection. The mean follow-up is 8 months.

RESULTS

No recurrence was observed in group TS whereas six (5%) occurred in group SS (p < 0.05). The global rate of compensatory sweating was about the same in both groups: 72.2% in group TS and 70.9% in group SS. However, the rate of embarrassing or disabling compensatory sweating was significantly higher in group TS (50%) than in group SS (21%) (p < 0.001).

CONCLUSIONS

Although selective division of the rami communicantes results in a significant decrease in the rate of disturbing side effects, it also leads to recurrences that are usually not observed at that level in patients treated with the conventional technique. Therefore other means of achieving the ideal operation should be explored, that is, a technique associated with a high success rate but a minimal number of side effects.

[Thoracoscopic approach in pulmonary nodules: a prospective evaluation of a series of 120 patients]

More and more pulmonary nodules are currently approached via thoracoscopy. We have evaluated the results and the morbidity of a consecutive series of 120 patients operated on by a single surgeon.

PATIENTS AND METHODS

Hundred twenty-two nodules have been approached thoracoscopically in 120 patients. The average size of these nodules was 16 mm (3-30 mm). A pre-operative localisation technique has been used in 61 patients (50%). The procedures were as follows: biopsy (6 cases), wedge-resection (110 cases). A video-assisted lobectomy has been performed in 26 cases.

RESULTS

The mortality rate was 0.08% (One case of ARDS in the post-operative course of a video-assisted lobectomy). Intra-operative morbidity rate was 1.6% (2 cases of haemorrhage requiring a thoracotomy and the post-operative morbidity rate was 5%. Six procedures were converted to thoracotomy 55%). The nodules have been localised in all cases but 2 (1.6%). The mean post-operative stay was 4.6 days in the whole series and 3.2 days in the series of patients with a simple biopsy or wedge-resection.

COMMENT

The morbidity rate of thoracoscopic resection of lung nodules is very low and decreases with surgeon's experience. Experience allows one not to use a localisation technique in many cases, but the later remains helpful in small size nodules. It allows for a safe, rapid and accurate procedure to be performed. The need for a mini-thoracotomy is very rare. Mastering the techniques of radiological localisation techniques, thoracoscopic biopsy and wedge resection as wall as video-assisted lobectomies should make it possible for thoracoscopic resection of lung nodules to fulfil the criteria of a minimally invasive operation.

[Can a reduction of morbidity of esophagectomy be expected with the thoracoscopic approach?]

OBJECTIVE

Oesophagectomies have a high morbidity rate, mainly related to pulmonary complications. The aim of this work was to assess whether the thoracoscopic approach could reduce this morbidity.

PATIENTS AND METHODS

We conducted a prospective study of the results of 26 attempts of esophagectomy using a right thoracoscopic approach. There were 17 males and 9 females having an average age of 47. The indication was a squamous cell carcinoma in 19 patients, an adenocarcinoma in 1 patient, a melanoma in 1 patient and a caustic stenosis in 5. The whole oesophagus was mobilized thoracoscopically, and the eosophagectomy was completed through the abdomen. The reconstruction was achieved using a gastric pull-through and a cervical anastomosis.

RESULTS

There were 5 failures for the following reasons: unresectable carcinoma (1 case), large tumour making a thoracoscopic dissection unsafe (1 case) and incomplete lung collapse making the exposure of the posterior mediastinum difficult (2 cases). The average time of the thoracoscopic procedure was 135 min. The post-operative course was uneventful in all but 5 patients who had a pulmonary complication: atelectasis (3 cases), right purulent pleural effusion (1 case), acute respiratory distress syndrome (1 case). The latter complication was lethal. Four out of 5 respiratory complications occurred in patients for whom the dissection was considered as difficult. Among the other complications, there were 5 anastomotic leakages and 3 laryngeal nerve palsy. The mortality rate was 3.8%.

CONCLUSION

These initial results do not show a real benefit of the thoracoscopic approach for eosophageal dissection, especially for difficult oesophagectomies. Further evaluation of the technique is needed.

[Protection of cervical anastomosis after retrosternal coloplasty by an resorbable collagen impregnated lattice]

One of the main problems of retrosternal oesophagoplasty is the frequent fistulization of the cervical anastomosis. In 27 consecutive patients we protected the cervical anastomosis by means of a new absorbable polyglactin 910 mesh impregnated with collagen. The mesh, which was 3 cm wide and 4 cm long, was applied on two-thirds of the circumference of the anastomosis. A comparison between these patients and a series of 27 consecutive patients with unprotected cervical anastomosis showed a fall in fistulization rate from 41% to 14%, the difference being significant (P less than 0.05). No complication due to the use of this material was observed.

[Esogastric lesions caused by ingestion of liquid chlorine bleach in adults]

A retrospective study of 193 adult patients who ingested liquid chlorine bleach is reported. This figure represents 37 p. 100 of caustic product ingestions treated in the authors' hospital unit, these being attempted suicides in 85 p. 100 of the cases. All patients had oesophagogastric fibroscopy on the day of the ingestion: serious, grade 2 or 3 lesions were present in 38 p. 100 of the cases. Emergency surgery was necessary in 10 patients for a complication that occurred within the first 3 weeks, and after 2 months in 6 patients to treat a digestive tract stenosis. Compared with the other caustic products, liquid chlorine bleach predominantly creates gastric lesions and may produce digestive tract perforations by secondary necrosis which occurs after a free interval ranging from 2 to 26 days.

[Peroperative circulatory arrest during excision of an unrecognized thoracic pheochromocytoma]

The authors present a case of thoracic phaeochromocytoma responsible for cardio-circulatory arrest during thoracotomy for mediastinal tumour. In such cases, hypertension must be controlled with phentolamine or sodium nitroprusside, cardiac arrhythmia with lignocaine, and collapse with volaemic expansion. The medical literature concerning thoracic phaeochromocytoma is briefly reviewed.

[Early surgical management of severe corrosive burns of the oesophagus (author's transl)]

The authors have treated, as an emergency, 120 adults with corrosive burns. Thet were 22 patients among them checked as severe burns, i. e. who underwent surgical operations. Most of them tried to kill themselves by swallowing great quantities of acid or lye. Subsequently, gastric associated burns were frequent. Critical analysis of these observations, compared with the findings of pathology and in the literature permit one to get through the early management: -- Total fiberendoscopy is a true emergency, but for the patients who actually swallowed a glass or more of strong acid and have to undergo an immediate laparotomy. -- The place ofmajor surgical operations is discussed in relation to further specialist investigations of the appearance of complications. -- The results are assessed in 13 patients who were followed up for a long period.

[Caustic burns of the oesophagus in the adult. Histopathological study of 12 cases (author's transl)]

A histopathological study of 12 cases of major caustic burns of the oesophagus serves as a basis for a description of the lesions and to demonstrate the inexorable progression to fibrosis. The lesions are most frequantly diffuse, regardless of the substance responsible. Four morphological stages may be distinguished, superimposed on the clinical picture.