Laparoscopic resection of colon Cancer: consensus of the European Association of Endoscopic Surgery (EAES).

BACKGROUND: The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002. METHODS: A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer. RESULTS: Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery. CONCLUSION: Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

Randomized clinical trial of the costs of open and laparoscopic surgery for colonic cancer.

BACKGROUND: There has been no randomized clinical trial of the costs of laparoscopic colonic resection (LCR) compared with those of open colonic resection (OCR) in the treatment of colonic cancer. METHODS: A subset of Swedish patients included in the Colon Cancer Open Or Laparoscopic Resection (COLOR) trial was included in a prospective cost analysis; costs were calculated up to 12 weeks after surgery. All relevant costs to society were included. No effects of the procedures, such as quality of life or survival, were taken into account. RESULTS: Two hundred and ten patients were included in the primary analysis, 98 of whom had LCR and 112 OCR. Total costs to society did not differ significantly between groups (difference in means for LCR versus OCR euro1846; P = 0.104). The cost of operation was significantly higher for LCR than for OCR (difference in means euro1171; P < 0.001), as was the cost of the first admission (difference in means euro1556; P = 0.015) and the total cost to the healthcare system (difference in means euro2244; P = 0.018). CONCLUSION: Within 12 weeks of surgery for colonic cancer, there was no difference in total costs to society incurred by LCR and OCR. The LCR procedure, however, was more costly to the healthcare system.

Pneumoperitoneum versus abdominal wall lift: effects on central haemodynamics and intrathoracic pressure during laparoscopic cholecystectomy.

BACKGROUND: It has been shown repeatedly that laparoscopic cholecystectomy using pneumoperitoneum (CO2 insufflation) may be associated with increased cardiac filling pressures and an increase in blood pressure and systemic vascular resistance. In the present study, the effects on the central circulation during abdominal wall lift (a gasless method of laparoscopic cholecystectomy) were compared with those during pneumoperitoneum. The study was also aimed at elucidating the relationships between the central filling pressures and the intrathoracic pressure. METHODS: Twenty patients (ASA I), scheduled for laparoscopic cholecystectomy, were randomised into two groups, pneumoperitoneum or abdominal wall lift. Measurements were made by arterial and pulmonary arterial catheterization before and during pneumoperitoneum or abdominal wall lift with the patient in the horizontal position. Measurements were repeated after head-up tilting the patients as well as after 30 min head-up tilt. The intrathoracic pressure was monitored in the horizontal position before and during intervention using an intraesophageal balloon. RESULTS: After pneumoperitoneum or abdominal wall lifting there were significant differences between the two groups regarding MAP, SVR, CVP, CI, and SV. Analogous to previous studies, in the pneumoperitoneum group CVP, PCWP, MPAP, and MAP as well as SVR were increased after CO2 insufflation (P < 0.01), while CI and SV were not affected. In contrast, in the abdominal wall lift group, CI and SV were significantly increased (P < 0.01), as was MAP (P < 0.01), while CVP, PCWP, MPAP, and SVR were not significantly affected. There was a significant difference in intraesophageal pressure between the two groups. In the pneumoperitoneum group, the intraesophageal pressure was increased by insufflation (P < 0.01) while, in the abdominal wall lift group, it was unaffected. In the pneumoperitoneum group the mean increases in cardiac filling pressures were of the same magnitude as the mean increase in the intraesophageal pressure. CONCLUSIONS: In healthy patients, abdominal wall lift increased cardiac index while pneumoperitoneum did not. Cardiac filling pressures and systemic vascular resistance were increased by pneumoperitoneum but unaffected by abdominal wall lift. The recorded elevated cardiac filling pressures during pneumoperitoneum may be only a reflection of the increased intra-abdominal pressure.

Is a dissection balloon beneficial in bilateral, totally extraperitoneal, endoscopic hernioplasty? A randomized, prospective, multicenter study.

SUMMARY: Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to gain the initial working space in totally extraperitoneal endoscopic (TEP) hernioplasty, but this increases its cost. Forty-four men with bilateral, primary or recurrent inguinal hernias were randomized to undergo TEP with or without dissection balloon. There were two conversions to transabdominal preperitoneal hernioplasty, or open herniorrhaphy, in the group with balloon and four in the group without balloon. There was no difference in the postoperative morbidity or operation time between the two groups, and there were no major complications in either group. The recurrence rate was 4.3% in the group with the balloon and 7.1% in the group without the balloon. There were no statistically significant differences between the groups. Although our study population is too small to detect small differences between the groups, it seems that the use of a dissection balloon is not beneficial in a bilateral TEP.

[Simulator training in medicine and health care. A new pedagogic model for good patient safety]. / Simulatorträning inom medicinsk verksamhet. Ny pedagogisk modell för god patientsäkerhet.

Advanced simulation within medicine and health care is a rapidly growing field. Simulator based training can be applied in minimal invasive surgery, in endoscopic procedures as well as in anaesthesia and critical care management. At Huddinge University Hospital a center for advanced simulation of both endoscopic surgery and anaesthesia/critical care management is currently being set up. The objective is to focus on improved medical and health care training and thus improving patient safety by reducing medical errors.

Outpatient laparoscopic cholecystectomy. A prospective study with 100 consecutive patients.

One hundred patients with cholelithiasis were included in a prospective consecutive follow-up study to evaluate laparoscopic cholecystectomy in a day surgical setting. The median operating time was 70 min. In 96% of the patients, it was possible to perform peroperative cholangiography. The median time off work was 7 days and the median time to full recovery was 14 days. Five patients were admitted due to weakness/nausea. Six patients were admitted due to conversion to open surgery or choledocholithiasis. Eighty-nine patients were treated in ambulatory surgery. We conclude that laparoscopic outpatient cholecystectomy can be performed safely with a low unplanned admission rate.

Is a dissection balloon beneficial in totally extraperitoneal endoscopic hernioplasty (TEP)? A randomized prospective multicenter study.

BACKGROUND: Laparoscopic hernioplasty has been criticized because of its technical complexity and increased costs. Disposable dissection balloons can be used to facilitate the creation of the initial working space in totally extraperitoneal endoscopic hernioplasty (TEP), but their use adds to the cost of the operation. METHODS: A total of 322 men with unilateral, primary, or recurrent inguinal hernias were randomized to undergo TEP with or without a dissection balloon. RESULTS: In the group with the balloon, three of 161 patients (2.5%) required conversion to transabdominal preperitoneal hernioplasty (TAPP), or open herniorraphy, whereas 17 of 161 patients (10.6%) were converted to TAPP or open herniorraphy in the group without the balloon (p = 0.002). The mean operation time was 55 min in the group with the balloon and 63 min in the group without the balloon (p = 0.004). There was no difference between them in postoperative morbidity, and there were no major complications in either group. The recurrence rate was 3.1% in the group with the balloon and 3.7 % in the group without the balloon (p = 0.8). CONCLUSION: The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve.

Introduction of herniorraphy with mesh plug and patch.

OBJECTIVE: To evaluate the introduction of the Perfix mesh plug and patch system for inguinal hernia repair. DESIGN: Prospective consecutive follow-up study. SETTING: Teaching hospital, Sweden. SUBJECTS: 139 patients with 145 hernias who were operated on for inguinal hernia with the Perfix mesh plug and patch technique during 1997. MAIN OUTCOME MEASURES: Operating time, sick leave, time to full recovery, morbidity, recurrence rate. RESULTS: The median operating time was 35 minutes (range 15-105) and the mean follow-up was 9 months (range 4-13). Office workers required a mean of 7 days off work (range 0-43) and manual workers 15 days (range 0-90). Retired patients took 21 days (0-30) to recover fully, office workers 22 days (7-70), manual workers 30 days (7-90), students 34 days (0-60) and unemployed patients 60 days (21-150). There were 17 minor complications within 30 days and 2 recurrences during the follow up period. CONCLUSION: Herniorraphy with a mesh plug and patch can easily be introduced with good short-term results.

Laparoscopic hernia repair in patients with bilateral groin hernias.

OBJECTIVE: To compare outcome of unilateral and bilateral laparoscopic hernia repair. DESIGN: Prospective consecutive trial. SETTING: University hospital, Sweden. SUBJECTS: 380 patients who had unilateral hernias repaired laparoscopically and 64 patients who had bilateral hernias repaired. The median (range) age in the two groups was 56 (21-86) and 61 (30-85) years, respectively and the median (range) follow-up was 42 (24-58) months. MAIN OUTCOME MEASURES: Operating time, hospital stay, complications, and time to recovery. RESULTS: The median (range) operating time was 70 (25-240) minutes in the unilateral and in the bilateral group 113 (55-330) minutes. The complication rate, recurrence rate, and time to full recovery did not differ between the groups. CONCLUSION: The laparoscopic approach seems to be a good option for patients with bilateral inguinal hernias.

Cost-minimisation analysis of laparoscopic and open appendicectomy.

OBJECTIVE: To compare the direct and indirect costs of laparoscopic and open appendicectomy. DESIGN: Randomised study. SETTING: University hospital, Sweden. MAIN OUTCOME MEASURES: Total costs for a defined period of time for each option. RESULTS: 102 patients were randomised and 99 were included in the final analysis. All patients had completely recovered within two months of operation. Disposable extra material used for the laparoscopic operation and longer operating time raised its median cost by SEK 912 and 1785, respectively. The mean duration of hospital stay, period off work (indirect costs), and time to complete recovery did not differ between the groups. CONCLUSION: Laparoscopic appendicectomy has higher direct costs than open operation and is not as cost-effective when the longterm outcome is the same in both groups.

Prospective randomized multicentre study of laparoscopic versus open appendicectomy.

BACKGROUND: A prospective randomized multicentre study was performed to compare the outcome of laparoscopic and open appendicectomy in patients with suspected acute appendicitis. METHODS: A total of 523 patients was randomized, but because of 23 withdrawals the outcome in 500 patients is reported, 244 in the laparoscopic group and 256 in the open group. RESULTS: Patients having laparoscopic appendicectomy recovered more quickly than those having open surgery (13 versus 21 days, P < 0.001). There was no significant difference in duration of sick leave after operation (laparoscopic group 11 days versus open group 14 days). Postoperative pain (at 24 h, 7 days and 14 days) was less after laparoscopic operations and a functional index 1 week after operation was more favourable in these patients (P < 0.001). Operating time was significantly longer in the laparoscopic group (60 versus 35 min, P < 0.01). Hospital stay and complications did not differ between the groups. Thirty laparoscopic procedures (12 per cent) were converted to open appendicectomy. CONCLUSION: Laparoscopic appendicectomy is as safe as open appendicectomy and has the advantage of allowing a quicker recovery.

Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies.

OBJECTIVE: Analysis of reoperation and recurrence rates three years after repair of groin hernias. DESIGN: Prospective audit by questionnaire and selective follow-up. SETTING: Eight Swedish hospitals. SUBJECTS: All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years. MAIN OUTCOME MEASURES: Postoperative complications, reoperation for recurrence, and recurrence. RESULTS: During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence. CONCLUSIONS: The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

Hernia surgery in a defined population: a prospective three year audit.

OBJECTIVE: To establish a register of inguinal hernia surgery that allows audit and analyses of data from several centres. DESIGN: Prospective recording of data on a common protocol. SETTING: Eight Swedish hospitals. SUBJECTS: All groin hernia operations done for patients over 15 years old from January 1992 to December 1994. MAIN OUTCOME MEASURES: Methods of repair, postoperative complications including mortality, day surgery rate, and reoperations for recurrence. RESULTS: During the three years studied 4879 hernia operations were undertaken in 4474 patients. Postoperative mortality within 30 days of operation for emergency and elective hernia repairs was 3.5% and 0.07%, respectively. Of all herniorrhaphies 798 (16%) were done for recurrences, 142 of these after operations between 1992 and 1994. At 24 months 4% of all operations had been redone because of recurrences with highly significant variations among hospitals ranging from 1.5% to 6.7%. Postoperative complications within 30 days after operation, direct hernia, recurrent hernia, and the use of absorbable sutures were associated with an increased risk of reoperation. CONCLUSIONS: A quality register recorded voluntarily can identify significant interhospital differences in outcome as well as variables associated with an increased risk of reoperation, thereby raising quality awareness and facilitating the process of improvement.

Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up.

OBJECTIVE: To compare outcome and costs between laparoscopic and open hernia repair. DESIGN: Prospective randomised study. SETTING: One university and two district hospitals in Sweden. SUBJECTS: 200 men aged 25-75 years. MAIN OUTCOME MEASURES: Operating time, hospital stay, complications, and time to recovery. A cost-minimisation-analysis was used in which the total costs were calculated for a defined period of time for each option. RESULT: The one year follow-up rate was 98%. Mean (SD) operation times in the laparoscopic and open groups were 72 (30) and 62 (25) minutes, respectively (p = 0.009). Hospital stay and complication rates did not differ between the groups. Among employees the mean (SD) periods off work in the laparoscopic and open groups were 10 (8) and 23 (21) days, respectively (p = 0.0001). The mean direct costs of the laparoscopic operation were increased by SEK 4037 (US$ 483) but the savings in indirect costs resulting from earlier return to work were SEK 11392 (US$ 1364). CONCLUSIONS: Laparoscopic hernia repair gave the employed patients faster recovery and return to work, and was the most cost-effective strategy provided that both direct and indirect costs were included.

Laparoscopic bowel mobilization combined with intraoperative colonoscopic polypectomy in patients with an inaccessible polyp of the colon.

BACKGROUND: The purpose of this report was to describe a simple technique suitable for polyps where circumstances of the bowel anatomy prevent complete access and control of the colonoscopic procedure. METHODS: By combining laparoscopic mobilization of the bowel with colonoscopic polypectomy, previously inaccessible polyps could be snared in two patients. RESULTS: Both patients had 3-cm large sessile adenomas in the sigmoid colon safely removed, and they returned home within a day. CONCLUSIONS: The described procedure increases the safety of the otherwise difficult polypectomy and also avoids laparotomy with enterotomy or bowel resection as the alternative.

Transperitoneal or totally extraperitoneal approach in laparoscopic hernia repair: results of 491 consecutive herniorrhaphies.

Laparoscopic hernia surgery was introduced in this unit in May 1992. Up to November 1995, 426 patients with 491 inguinal and femoral hernias have undergone surgery. A transabdominal preperitoneal (TAPP) approach was used in 339 patients with 393 hernias. After June 1994 a totally extraperitoneal (TEP) technique was used in 87 patients with 98 hernias. This prospective nonrandomized study deals with the learning curve, complications, and early results. The mean (SD) follow-up times in the TAPP and TEP groups were 23 (9) and 7 (4) months, respectively. Mean operating times and hospital stays did not differ between the TAPP and TEP patients, but the period off work was shorter in the TEP group. Fifteen major complications, including one postoperative death, two bowel obstructions, one severe neuralgia, three trocar hernias, one epigastric artery bleeding episode, and seven recurrences, were recorded; all except one was in the TAPP group. The TEP operation may be the method of choice in laparoscopic hernia surgery.

Management of bile duct stones in the era of laparoscopic cholecystectomy: appraisal of routine operative cholangiography and endoscopic treatment.

OBJECTIVE: To assess the value of preoperative or postoperative endoscopic treatment of bile duct stones and routine use of operative cholangiography (OC) for detection of unsuspected common bile duct (CBD) stones in conjunction with laparoscopic cholecystectomy. DESIGN: Prospective study. SETTING: University hospital, Sweden. MAIN OUTCOME MEASURES: Diagnostic and therapeutic yield of stones at endoscopic retrograde cholangiography (ERC) before or after laparoscopic cholecystectomy and routine operative cholangiography. RESULTS: Of 630 patients who underwent laparoscopic cholecystectomy, 84 had preoperative ERC. Of these 84, 47 (56%) had bile duct stones. Endoscopic sphincterotomy was done for all 47, of whom 3 (6%) had retained stones at OC. OC was done for 590 (94%) of the 630 patients, and 45 (7.6%) were found to have choledocholithiasis. At postoperative ERC, however, 10 of these patients were free of stones and there were two cases of false negative OC, which resulted in sensitivity and specificity of OC of 95% and 98%, respectively. Thus, 35 patients (6%) had bile duct stones discovered at OC, of whom 33 had "unsuspected" stones. Of these 35 patients, 29 were cleared endoscopically after cholecystectomy. The remaining 6 patients were cleared of stones either by open choledocholithotomy (n = 2) or by laparoscopic transcystic manipulation (n = 4). There was no mortality after diagnostic or therapeutic ERC, and morbidity was confined to two cases each of pancreatitis and cholangitis, which resulted in a complication rate of 3% (4/118). No complications resulted from IOC. CONCLUSIONS: Preoperative ERC should be done for patients with symptoms or findings indicating ductal calculi. In most patients undergoing laparoscopic cholecystectomy, OC is feasible and its routine use is strongly advocated. Bile duct stones diagnosed at OC can safely and successfully be treated endoscopically after laparoscopic cholecystectomy. Until laparoscopic bile duct exploration becomes routine and generally applicable, endoscopic management of bile duct stones both before and after cholecystectomy will be an important therapeutic option.

Value of routine intraoperative cholangiography in detecting aberrant bile ducts and bile duct injuries during laparoscopic cholecystectomy.

A prospective study was performed to determine the frequency and type of bile duct abnormalities, and to determine whether routine use of intraoperative cholangiography during laparoscopic cholecystectomy might aid in the prevention of bile duct injuries. Overall, anatomical aberrations of the bile ducts were found in 98 (19 per cent) of 513 cholangiograms. The most common anomalies were at the hepatic confluence and constituted different types of right hepatic subsegmental ducts draining separately into the biliary tree (n = 43, 8.4 per cent), either close to the cystic duct or directly into the cystic duct. Three bile duct injuries (0.5 per cent) occurred during the study period. These results show that routine intraoperative cholangiography is feasible and provides valuable information about the anatomy of the biliary tract, thereby improving the safety of laparoscopic cholecystectomy. If an injury to the biliary tract occurs early during operation, the cholangiogram allows the surgeon to detect the injury, to make a prompt repair and thereby reduce the morbidity associated with a delayed diagnosis. Routine use of intraoperative cholangiography is strongly recommended.