Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy (FALCON): an international multicentre randomized controlled trial.

AIM: To assess the added value of Near InfraRed Fluorescence (NIRF) imaging during laparoscopic cholecystectomy. METHODS: This international multicentre randomized controlled trial included participants with an indication for elective laparoscopic cholecystectomy. Participants were randomised into a NIRF imaging assisted laparoscopic cholecystectomy (NIRF-LC) group and a conventional laparoscopic cholecystectomy (CLC) group. Primary end point was time to 'Critical View of Safety' (CVS). The follow-up period of this study was 90 postoperative days. An expert panel analysed the video recordings after surgery to confirm designated surgical time points. RESULTS: A total of 294 patients were included, of which 143 were randomized in the NIRF-LC and 151 in the CLC group. Baseline characteristics were equally distributed. Time to CVS was on average 19 min and 14 s for the NIRF-LC group and 23 min and 9 s for the CLC group (p 0.032). Time to identification of the CD was 6 min and 47 s and 13 min for NIRF-LC and CLC respectively (p < 0.001). Transition of the CD in the gallbladder was identified after an average of 9 min and 39 s with NIRF-LC, compared to 18 min and 7 s with CLC (p < 0.001). No difference in postoperative length of hospital stay nor occurrence of postoperative complications was found. ICG related complications were limited to one patient who developed a rash after injection of ICG. CONCLUSION: Use of NIRF imaging in laparoscopic cholecystectomy provides earlier identification of relevant extrahepatic biliary anatomy: earlier achievement of CVS, cystic duct visualisation and visualisation of both cystic duct and cystic artery transition into the gallbladder.

European Association for Endoscopic Surgery (EAES) consensus on Indocyanine Green (ICG) fluorescence-guided surgery.

BACKGROUND: In recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community. METHODS: An expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021. RESULTS: A total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications. CONCLUSIONS: Overall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.

[Intraoperative fluorescence angiography in colorectal surgery]. / Intraoperative Fluoreszenzangiographie in der kolorektalen Chirurgie.

BACKGROUND: Fluorescence angiography with indocyanine green (ICG-FA) is frequently used in colorectal surgery to assess the blood perfusion in the region of an anastomosis. Previous studies with ICG-FA in both open and laparoscopic surgery could show a low rate of anastomotic leakage, e.g. the PILLAR II study with a leakage rate of 1.4%. This article presents own results, the current status of ICG-FA and the fields of application. OBJECTIVE: The aim of the study was to analyze whether the results obtained so far with ICG-FA are sufficient to recommend an extended use of this relatively new method in colorectal surgery. MATERIAL AND METHODS: From July 2009 to June 2019 a total of 378 colorectal resections (280 colon resections and 98 rectal resections) with intraoperative examination of the anastomosis using ICG-FA were performed. In 13 patients (3.4%) there was reduced intraoperative perfusion, which led to a change in the operative procedure (resection of the anastomosis and new anastomosis, colostomy). RESULTS: The total anastomotic leakage rate was 3.7% with 8 leaks in the colon (2.9%) and 6 in the rectum (6.1%). Without the intraoperative change in 13 patients the rate of leakages could have increased to 7.1% (27/378). The use of ICG-FA in the group of patients studied potentially led to a reduction of the leakage rate by 48%. Current publications show similar results with a potential decrease in the rate of anastomotic leaks in colorectal surgery. CONCLUSION: The results show a very low rate of anastomotic leakage when using ICG-FA. These results are promising in colorectal surgery but controlled randomized studies are lacking and should be carried out before final recommendations can be given.

[CAMIC Recommendations for Surgical Laparoscopy in Non-Obstetric Indications during Pregnancy]. / CAMIC-Empfehlungen zur chirurgischen Laparoskopie aus nicht geburtshilflicher Indikation während der Schwangerschaft.

In the operative surgical primary care, the laparoscopic surgical technique has firmly established itself in recent years. Meanwhile, in the normal population over 90 % of all cholecystectomies and over 80 % of all appendectomies are performed in a minimally invasive manner. The proven benefits of the laparoscopic surgical technique, compared with conventional open surgery, are a comparatively rapid early postoperative recovery with early resumption of the general physical and occupational activity. As these benefits are equally applicable for necessary interventions during pregnancy, in recent years laparoscopy has become the preferred treatment for non-obstetric indications in the gravid patient. Overall, it can be assumed that such interventions have to be performed in approximately 2 % of all pregnant patients. Numerous studies have proven here that the use of laparoscopic techniques, in particular for the expectant mother, is safe and not associated with an increased risk. On the other hand, the current pregnancy makes necessary an adapted approach to the solution of surgical problems to ensure the protection of the unborn child. On the basis of currently available data situation, recommendations are formulated which can be used as a decision-making support for a variety of clinical situations.

[Single-port technique in laparoscopic surgery]. / Single-port-Technik in der laparoskopischen Chirurgie.

Laparoscopic operations using only one trocar (single-port technique) have the aim to further minimize the trauma of access incisions similar to NOTES. To carry this out special trocars and instruments are needed which are presented in this article with respect to application and function. The range of indications corresponds to the conventional laparoscopic surgery. Recent publications have shown that operations using a single-port technique are safe and efficient. Greater technical difficulties and higher costs must be considered. For the identification of significant advantages, randomized studies are still lacking.

Short-term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer.

BACKGROUND: Randomized trials in low-risk populations have failed to show any benefit for laparoscopic compared with open colorectal resection in terms of morbidity. Furthermore, it is not known whether laparoscopic colorectal resection would yield advantages if randomization were revealed during surgery after a diagnostic laparoscopy. METHODS: Patients with cancer of the colon or upper rectum were randomly assigned to laparoscopic or open resection. All patients underwent diagnostic laparoscopy to assess whether laparoscopic resection was feasible and the result of randomization was then revealed to the surgeon. Main endpoints were overall, general and surgical morbidity, and mortality. RESULTS: Some 679 patients underwent diagnostic laparoscopy which led to the exclusion of 207; 250 patients were allocated to laparoscopic and 222 to open resection. Conversion to laparotomy occurred in 28 patients (11.2 per cent). There were no differences in morbidity (overall 25.2 versus 23.9 per cent) or mortality (1.2 versus 0.9 per cent) between laparoscopic and open groups. Postoperative hospital stay was shorter after laparoscopic resection (median (range) 10 (1-123) versus 12 (4-109) days; P = 0.032). CONCLUSION: Laparoscopic resection of colorectal cancer is associated with increased operating time but does not decrease morbidity even in a moderate-risk population.

[Laparoscopic hand-assisted operation. Review of the literature and initial personal experiences with the HandPort System]. / Laparoskopische handassistierte Operationen. Literaturübersicht und erste eigene Erfahrungen mit dem HandPort-System.

BACKGROUND: During complex laparoscopic operations sometimes the situation of a "missing hand" will occur. Using a device for hand assistance, the surgeon can place one hand into the abdominal cavity to assist the laparoscopic procedures. METHOD: After a laparotomy of 7-8 cm length, the surgeon can bring one hand into the abdomen via a special device maintaining the pneumoperitoneum. This hand can be helpful, i.e. for exploration, for retraction of gut and organs or for extraction of the specimen. Indications are complex laparoscopic operations such as stomach or colonic resections or splenectomies. In obese patients or patients with extended adhesions, preparation can be facilitated. RESULTS: The literature review and the author's own results with 10 patients since 2000 show remarkable advantages in operative situations when the laparoscopic procedure is complicated or even impossible. In our 10 patients, all operations could be managed laparoscopically by using the HandPort device. CONCLUSIONS: Complicated operations can be performed laparoscopically without conversion to conventional laparotomy by using the hand assistance. These patients do not have to forgo to the benefit of minimally invasive operations.

[Laparoscopic appendectomy in advanced stages of appendicitis]. / Die laparoskopische Appendektomie bei fortgeschrittenen Stadien der Appendizitis.

The laparoscopic stapling appendectomy (LA) is a safe and efficient procedure for all forms of appendicitis. Overall, LA was performed in 51.8% of 280 patients with advanced appendicitis, in 1998 in more than 85%, due to increasing experience. In these cases, the appendix was dissected in double-staple technique and extracted in an endo-bag. The postoperative outcome was uncomplicated even in advanced appendicitis, a reoperation had to be done in 2 patients (1.4%). Wound infections occurred only in 3.5% of patients with LA compared to 8.2% with open appendectomy, the mortality was 0%.

[Laparoscopy in intra-abdominal infection. Its diagnostic value and therapeutic possibilities]. / Laparoskopie bei intraabdomineller Infektion. Diagnostischer Stellenwert und therapeutische Möglichkeiten.

In 550 patients with the clinical features of acute abdomen a surgical laparoscopy was performed. In 121 cases there was found an unspecific reason of the acute abdominal disease that did not require surgical therapy. In 349 cases a regional peritonitis was found, 80 times a diffuse peritonitis. The diagnostic validity of laparoscopy was 96% as compared to 42% for sonography. The laparoscopic access resulted in a complication rate of 0.2%. In 239 cases (43%) the disease could be managed laparoscopically, 190 cases (35%) required open surgery.

[Surgical laparoscopy in acute abdomen]. / Chirurgische Laparoskopie beim akuten Abdomen.

In 582 patients, laparoscopy was performed for acute abdominal pain and symptoms of acute abdomen. It allowed a clear diagnosis in 96% as compared to 42% by sonography and 25% by X-ray. In 134 cases (22%) laparotomy (i.e. unnecessary appendectomy) could be avoided. In 42% surgery could be performed laparoscopically, and 36% required surgery by laparotomy.

[Diagnosis and surgical therapy of right-sided colonic diverticulitis]. / Diagnose und operative Therapie der rechtsseitigen Kolondivertikulitis.

Diverticulosis of the colon is common in the descending and sigmoid part; the right colon is rarely involved. Inflammation of perforation of a cecal diverticulum is an uncommon condition that mimics acute appendicitis. The correct diagnosis is mostly made after operative exploration. Four cases were surgically treated between 1994 and 1995. Because of the severe inflammation, ileocecal resection or right hemicolectomy was necessary; in one case we performed a local excision. After removal of the inflamed mass the postoperative healing was uncomplicated. A malignancy could be histologically excluded in all cases. As in sigmoid diverticulitis, early resection seems to be a safe operative therapy. Laparoscopy can show the correct diagnosis before the laparotomy is carried out. Preoperative diagnostic measures, differential diagnosis and possible surgical procedures are discussed.