Evaluation of surgical performance with standard rigid and flexible-tip laparoscopes.

BACKGROUND: Flexible-tip laparoscopes have recently been introduced into clinical practice, with the goal of improving surgeon performance during complex laparoscopic procedures. We used objective and subjective performance parameters to compare standard rigid 0 degrees and 30 degrees lens laparoscopes two flexible-tip laparoscopes in an in vitro model. METHODS: Twenty-nine subjects with varied levels of surgical experience performed complex laparoscopic tasks in three different models simulating (a) prostate dissection from the rectum, (b) cystic duct clipping, and (c) distal posterior rectum dissection. Each task was performed using two Storz rigid laparoscopes (0 degrees and 30 degrees) and two flexible-tip laparoscopes, the Olympus LTF-V3 and the Fujinon EL2-TF310. The sequence of application of the two flexible-tip laparoscopes was randomized. In each case, an experienced laparoscopic camera driver controlled the field of vision. Time to complete each task, operative precision, and subjective surgeon rating scores were compared. Statistical analysis was performed with analysis of variance (ANOVA) and a two-sided fisher's exact test. RESULTS: In all three models, the flexible laparoscopes offered no advantage in terms of procedure time, surgical precision, or subjective surgeon rating score when compared with the 30 degrees lens rigid laparoscope. The 30 degrees rigid lens laparoscope and the two flexible-tip laparoscopes were superior to the 0 degrees lens rigid laparoscope for all parameters evaluated, with the exception of subjective rating in the cystic duct model and procedure time in the colorectal model. CONCLUSION: In this in vitro experimental model, the flexible-tip laparoscopes found to have no advantage over the standard rigid 30 degrees lens laparoscope. These models were validated, as the 0 degrees lens rigid laparoscope was surpassed by the 30 degrees lens rigid laparoscope and the flexible-tip laparoscopes. Both flexible-tip laparoscopes produced similar results and excellent image quality, but some experience is required before their smooth application can be achieved.

Results of laparoscopic Heller-Toupet operation for achalasia.

BACKGROUND: Laparoscopic myotomy has become the preferred treatment for achalasia. Controversy persists on the need for fundoplication and/or its type; when used, most series have utilized the Dor fundoplication. We report a large series of laparoscopic Heller-Toupet procedures. METHODS: All patients operated for achalasia were entered into a prospective database. Pre and postoperative esophageal symptoms, satisfaction scores, and SF-36 variables were compared. Surgical failures were defined as recurrent or persistent dysphagia leading to secondary treatment. Data are expressed as mean +/- S.D. RESULTS: One hundred consecutive cases were analyzed (61 men, 39 women, age 47 +/- 17 yr). Heller-Toupet was performed in 94, whereas six patients had a Dor fundoplication because of mucosal perforation (three) or technical difficulties performing a posterior wrap (three). Operative time was 148 +/- 21 min. There were 13 intraoperative adverse events managed laparoscopically, and no conversions. Minor postoperative complications were noted in two cases, whereas there were no major complications or deaths. Mean hospital stay was 1.2 +/- 0.5 days, (range 1-4). Follow-up was complete in 92% at 26 +/- 17 months. Failures leading to further treatment occurred in 4%. All symptom scores were significantly improved (p < 0.0001). Solid dysphagia score went from 6.4 to 1.0 postoperatively; regurgitation score went from 4.5 to 0.2 (combined frequency and severity, range 0-8). Postoperative global esophageal symptoms scale revealed improvement in 97%, and all domains of the SF-36 were improved. CONCLUSIONS: Although the best surgical approach to achalasia is yet to be determined, laparoscopic Heller-Toupet operation in experienced hands is a safe and effective procedure with low rates of morbidity and failure and high patient satisfaction.