Feasibility and effectiveness of laparoscopic transgastric stapler-assisted circumferential esophageal mucosectomy and simultaneous fundoplication in a pig model.

Laparoscopic transgastric stapler-assisted mucosectomy (SAM) has been described for minimally invasive circumferential en bloc resection of Barrett's esophagus (BE). Conceivably long-term disease control might be achieved by adding antireflux surgery after resection of BE by SAM. The aim of this study was to assess the feasibility of combined SAM and fundoplication in one laparoscopic procedure in six pigs. Furthermore, the competence of the gastroesophageal junction (GEJ) was assessed at baseline, after SAM, and after subsequent laparoscopic fundoplication. At each measuring point reflux measurements were repeated 6 times in each pig. Blue-colored water was infused into the stomach to provoke reflux. Intragastric yield pressure and volume were recorded until drainage of blue solution (DBS) was noted. Time to reflux was measured by DBS and by multichannel intraluminal impedance (MII). In all animals SAM followed by laparoscopic fundoplication was feasible in a single session. A weakening of the GEJ was found after SAM, indicated by decreased yield pressure (11.5 mmHg vs. 8.5 mmHg; P < 0.001), time to DBS (90 seconds vs. 60 seconds; P = 0.008) and MII (80 seconds vs. 33 seconds; P < 0.001). After additional Nissen fundoplication the GEJ competence was restored, with measurements returning to baseline values (time to DBS 99 seconds; P = 0.15; MII 76 seconds; P = 0.84). The yield pressure increased from 11.5 mmHg at baseline to 19.7 mmHg after SAM and fundoplication (P < 0.001). Laparoscopic fundoplication and SAM may be combined in a single laparoscopic session. Although the GEJ was weakened after SAM, Nissen fundoplication restored the GEJ as an effective reflux barrier in this experiment. For clinical validation, the results need to be confirmed in a prospective human trial.

[Implementation of hybrid-NOTES sigmoidectomy for diverticular disease : In a center for minimally invasive surgery]. / Implementierung der Hybrid-NOTES-Sigmoidektomie bei Divertikelkrankheit : In einem Zentrum für minimalinvasive Chirurgie.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) describes surgical procedures through a natural orifice. In hybrid-NOTES small transabdominal trocars are combined with a NOTES access. OBJECTIVE: To evaluate hybrid-NOTES sigmoidectomy as a standard procedure for diverticulitis. MATERIAL AND METHODS: Elective laparoscopic sigmoidectomies performed between May 2011 and January 2016 were prospectively collated. Primary endpoint was the feasibility of hybrid-NOTES sigmoidectomy. The reasons for planning a laparoscopically-assisted sigmoidectomy (LAS), intraoperative change of treatment and reactive conversion were evaluated. Secondary endpoints were complications and operative time. RESULTS: Out of 130 laparoscopic sigmoidectomies 83% were planned for hybrid-NOTES and 8 out of 52 (15%) transvaginal (TVS) and 14 out of 56 (25%) transrectal (TRS) sigmoidectomies were intraoperatively changed to LAS. The reason for the change in 64% was that the specimen was too bulky and 80% of scheduled hybrid-NOTES procedures were carried out as planned. The operative time for TVS (146.8 ± 44.5 min) was shorter compared to LAS (173.2 ± 58.8 min, P = 0.016). The morbidities of TVS (15.3%) and TRS (14.9%) were not significantly different from LAS (23.9%, P = 0.501 and P = 0.537, respectively). CONCLUSION: Hybrid-NOTES for diverticular disease may be indicated in more than 80% of cases. In respect of intraoperative change of treatment, hybrid-NOTES is feasible in two thirds of patients. Given a high level of expertise, hybrid-NOTES can be provided as a standard procedure in sigmoidectomy for diverticular disease.

Hartmann's procedure and laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation.

PURPOSE: Emergency surgical strategies for acute left-sided colonic perforation are evolving preferring primary anastomosis (PA) with ileostomy to Hartmann's procedure (HP) based on the morbidity and reversal rates. However, HP is still commonly performed. Hartmann's reversal is associated with considerable morbidity. It is of interest whether laparoscopic reversal results in a lower morbidity as retrospective data suggest. Here, we compared the combined morbidity rates for two surgical strategies: strategy A, HP followed by laparoscopic reversal, and strategy B, sigmoid resection with PA followed by ileostomy closure. METHODS: Prospectively collected data of all consecutive patients undergoing HP for benign left-sided colonic perforation between 2010 and 2014 were retrospectively compared to data of patients undergoing PA. Groups were matched for age and Charlson comorbidity index. Additionally, patients were analyzed for American Society of Anesthesiologists score, body mass index, and peritonitis stage. End points were morbidity, operation time, reversal rate, time to reversal, and length of hospital stay. RESULTS: The study included 32 patients for whom Hartmann's reversal was planned, along with 32 matched patients who underwent PA and diverting ileostomy. Median age was 75 and 72 years, Charlson score was 6 (4-9) and 6 (5-7), and patients classified by the American Society of Anesthesiologists (ASA) higher than III were 81 % in both groups. Combined major morbidity rates were 21 % for strategy A and 20 % for strategy B (p = 1.0). Combined comprehensive complication index was 16.4 ± 14.1 and 12.3 ± 19.1 (p = 0.08). HP reversal by laparoscopy was achieved in 71 %. The colostomy reversal rate was 75 % compared to ileostomy closure rate of 88 % (p = 0.34). CONCLUSIONS: Laparoscopic Hartmann's reversal is achievable in a high proportion of patients. Strategy B tends to have lower overall morbidity; meanwhile, major morbidity seems to be similar. Yet, in critically ill patients and in the absence of expertise of the surgeon on call, HP followed by elective laparoscopic reversal represents a viable alternative.

Transvaginal access for NOTES: a cohort study of microbiological colonization and contamination.

BACKGROUND AND STUDY AIMS: Animal data and limited clinical evidence suggest a low incidence of infection following transvaginal natural orifice transluminal endoscopic surgery (NOTES). However, a systematic microbiological evaluation has not yet been carried out. The aim of this prospective cohort study was to evaluate the extent of microbiological contamination of the peritoneal cavity caused by the transvaginal access for NOTES and the impact of preoperative vaginal disinfection on vaginal colonization. PATIENTS AND METHODS: Consecutive female patients with symptomatic cholecystolithiasis were offered either transvaginal rigid-hybrid cholecystectomy (tvCCE) or conventional laparoscopic cholecystectomy. Patients who opted for tvCCE were prospectively evaluated between February and June 2010. Disinfection in patients undergoing tvCCE included hexetidine tablets and octenidine applied vaginally. All patients received a single dose of perioperative cefuroxime. Swabs were obtained from the posterior fornix and the peritoneal cavity at different intervals. RESULTS: Of 32 patients, 27 (84 %) opted to undergo tvCCE. One patient (4 %; 95 % confidence interval [CI] 0.7 % - 18.3 %) had a positive bacterial culture in the Douglas pouch prior to transvaginal access compared with two patients (7 %; 95 %CI 2.1 % - 23.4 %) following colpotomy closure (P = 1.000). Vaginal disinfection significantly decreased vaginal bacterial load (P = 0.001) and bacterial growth in routine cultures (P < 0.001); in 16 patients (59 %; 95 %CI 40.7 % - 75.5 %) vaginal swabs were sterile after disinfection. No postoperative surgical site infections occurred (95 %CI 0 % - 12.5 %). CONCLUSIONS: In selected patients and following vaginal antisepsis, transvaginal access for NOTES is associated with microbiological contamination of the peritoneal cavity in a minority of patients, indicating a low risk of peritoneal contamination caused by the transvaginal access.

Transvaginal rigid-hybrid NOTES cholecystectomy: evaluation in routine clinical practice.

BACKGROUND AND STUDY AIMS: Cholecystectomy using a rigid-hybrid transvaginal natural orifice transluminal endoscopic surgery (NOTES) approach (tvNCC) reduces abdominal wall incisions and might decrease surgical trauma by combining endoluminal access and laparoscopic techniques. We assessed the feasibility and safety of rigid-hybrid tvNCC in routine practice for symptomatic cholecystolithiasis or acute cholecystitis in a patient population with low selection. PATIENTS AND METHODS: From September 2008 to July 2009, all female patients with cholecystectomy indications were evaluated for tvNCC. Exclusion criteria were: refusal of tvNCC; inability to give informed consent; gynecological or urological contraindications; lack of preoperative gynecological examinations; need for cholangiography/choledochus revision; anesthesiological contraindications to pneumoperitoneum; liver failure; or coagulopathy. Age, obesity, previous surgery, or degree of gallbladder inflammation were not exclusion criteria. Preoperative and 2-weeks' postoperative gynecological examinations were performed. Sexual function was assessed preoperatively and at 6 weeks postoperatively. RESULTS: 102 of 137 consecutive patients (74.5 %) with symptomatic cholecystolithiasis (n = 74) or cholecystitis (n = 28) were scheduled for rigid-hybrid tvNCC with nine different surgeons. Patient mean age was 52.3 +/- 17.8 years (range 18 - 87) and mean body mass index 27.3 +/- 6.3 kg/m (2) (17.6 - 43.8). Two patients had conversion to conventional laparoscopic cholecystectomy. There were no intraoperative complications. Two major complications occurred: one stroke and one herniation within the transumbilical access. Minor complications were reported in 13 patients (12.7 %) and there were no serious postoperative gynecological findings. At 6 weeks postoperatively, there were fewer dyspareunia symptoms than preoperatively ( P = 0.049). CONCLUSIONS: Rigid-hybrid tvNCC is feasible and safe in routine practice for symptomatic cholecystolithiasis and acute cholecystitis.

Local excision and endoscopic posterior mesorectal resection versus low anterior resection in T1 rectal cancer.

BACKGROUND: Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer. METHODS: Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups. RESULTS: Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0.402 for major and P = 0.691 for minor complications). Median number of lymph nodes removed was 7 (range 1-22) for EPMR and 11 (range 2-36) for LAR (P = 0.132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence. CONCLUSION: EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.

Prospective study examining the impact of multichannel intraluminal impedance on antireflux surgery.

BACKGROUND: Reflux monitoring using combined multichannel intraluminal impedance (MII) and pH-metry increases the sensitivity for identifying gastroesophageal reflux episodes. The likelihood of a positive symptom index (SI) for patients with reflux disease (gastroesophageal reflux disease [GERD] or nonerosive reflux disease [NERD]) receiving proton pump inhibitor (PPI) treatment has been used to select candidates for antireflux surgery. Little is known about the advantages of MII-pH monitoring compared with pH monitoring alone for evaluating GERD/NERD patients off PPI treatment considered as candidates for antireflux surgery or for assessing changes in MII-pH-detected reflux episodes after antireflux surgery. This study aimed to determine the additional value of MII over pH-metry alone for patients off PPI treatment before and after antireflux surgery. METHODS: For this study 12 patients (4 women and 8 men; mean age, 45 years; range, 27-74 years) were evaluated using ambulatory MII-pH monitoring before and 3 months after mesh-augmented hiatoplasty. Reflux events were identified by MII-pH (A) and pH-metry (B) as patients recorded symptoms on a data logger. For each symptom, a symptom index was calculated for reflux events identified by MII-pH and by pH-monitoring alone. RESULTS: Preoperatively, MII-pH monitoring identified 71.9 +/- 8.4 reflux episodes, whereas pH monitoring identified only 51.0 +/- 7.8 (p < 0.05). Postoperatively, MII-pH monitoring identified 35.5 +/- 6.6 reflux episodes, whereas pH monitoring identified only 19.6 +/- 4.7 (p < 0.05). The pre- and postoperative symptom index for MII-pH monitoring was higher than pH monitoring (preoperative 91.7% vs 25%, p = 0.006; postoperative 50% vs 16.7%, p = 0.012). CONCLUSION: Combined MII-pH-metry improves the pre- and postoperative assessment of GERD patients off PPI and results in a higher symptom-reflux association.

[Medial mobilisation of the left hemicolon]. / Die Mobilisation des linken Hemikolons von medial.

INTRODUCTION: Laparoscopic surgery of the colon is becoming more and more popular. However, regarding sigmoid resection, controversy remains concerning the extent of mobilisation, particularly regarding the splenic flexure. We developed a technique for anterior resection that meets all surgical standards: the anterior approach. MATERIALS AND METHODS: From October 1999 to March 2001, 50 patients with benign diseases of the colon underwent laparoscopically assisted sigmoid resection. A completely anterior approach for mobilisation of the left hemicolon was used in all cases. Positioning the patients in Trendelenburg position on the extreme right side enabled primary ligation of the inferior mesenteric vein and artery as well as complete mobilisation of the splenic flexure from the middle. A transanal circular stapling device was used to reanastomose the colon 10-12 cm from the anus. RESULTS: There were conversion and complication rates of 10% each, and three patients needed to be reoperated. The median operating time was 180 min. Patients could be dismissed on the 14th postoperative day. CONCLUSION: To establish an operative standard, this technique has so far been used only for benign colon diseases. According to our experience, we think that it meets all oncological standards. Use of this technique in the treatment of malignant diseases seems therefore justified.

[Laparoscopic latero-lateral pancreaticojejunostomy]. / Laparoskopische latero-laterale Pancreaticojejunostomie.

Side-to-side pancreatojejunostomy for patients with chronic pancreatitis and dilated pancreatic duct is an established procedure, but so far there has been no report of this operation being performed as minimally invasive surgery. A 23-year-old woman with a history of seven years of recurrent pancreatitis with pancreas divisum underwent a latero lateral pancreatojejunostomy with Braun anastomosis. For access, three ports were used; the anastomoses were produced with Endo-GIA staplers. The operation time was 115 min and the postoperative course was uneventful. During 8 months of follow-up no dilatation of the pancreatic duct or signs of recurrent pancreatitis were seen. The patient feels fine. Using improved and newly developed surgical devices (i.e., ultrasonic shears, endo-staplers) more difficult procedures can be done in a reasonable operation time. Under ideal conditions, patients will have full benefits with minimally invasive surgery.

[Dorso-posterior extraperitoneal pelviscopy (DEP). From experiment to initial clinical application]. / Die dorsoposteriore extraperitoneale Pelviskopie (DEP). Vom Experiment zur ersten klinischen Anwendung.

BACKGROUND: Dorsoposterior and/or perineal access to pelvic connective tissue spaces has lost its importance due to improved transabdominal techniques. Because of the development of minimally invasive surgery towards "soft-tissue endoscopy" we were interested in whether the video-assisted technique could give new impetus to the perineal approach. Successful experiments on corpses were followed by the first clinical application. METHODS: After the dilation of the retrorectal, rectovaginal and rectoprostatical spaces with a dissecting balloon, pneumoextraperitoneum was established and all extraperitoneal structures of the pelvis could be dissected. RESULTS: In the experimental and in the clinical situation the spaces could be perfectly surveyed. EXPERIMENTALLY: Complete, circular preparation of the rectum was achieved. Parts of the bladder, vagina and prostate were visualized ventrally. Laterally both ureters and the paraproctal and iliacal vessels could be dissected. In the clinical application the retrorectal space could be dilated without problems and it could be rinsed and drained. Postoperatively no complications were recorded. The patient could be discharged on the 17th postoperative day. CONCLUSION: The described method is suitable for clinical use. Besides the described indication, further surgical applications exists.

Laparoscopic appendectomy does not change the incidence of postoperative infectious complications.

BACKGROUND: It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy. METHODS: One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position. RESULTS: Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group (P = 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P = 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA (P = 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA (P = 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively. CONCLUSIONS: Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications.

[Role of the pulsatile organ perfusion surgical simulator in surgery education]. / Die Rolle des POP-Operationssimulators in der chirurgischen Ausbildung.

The operation simulator with pulsatile organ perfusion ("POP trainer") simulates the blood supply of organs or organ complexes and was developed for the training in both minimally invasive and conventional surgery. With the redesigned new POP-trainer, even complex operations, such as colorectal and antireflux procedures can be practised. Due to perfect quality of simulation, simple handling and economic aspects, the POP trainer serves to intensify the training of surgeons, simultaneously decreasing the number of animal experiments.

[Double balloon catheter for facilitating (laparoscopic) choledochus drainage]. / Doppelballonkatheter zur Erleichterung der (laparoskopischen) Choledochusdrainage.

In laparoscopic management of choledocholithiasis the drains available for bile-duct drainage are problematic. Since November 1991 we have given priority to the laparoscopic management of common bile-duct stones (n = 97). In cooperation with industry (W. Rüsch/D-Waiblingen), we have developed a double-balloon catheter for laparoscopic application. In 15 cases we used this double-balloon catheter. There were no complications like dislocation, obstruction or leakage. This new catheter facilitates the procedure of laparoscopic bile-duct exploration in choledocholithiasis. The operating time is reduced and removal of residual concrements is easily possible.

[Laparoscopic versus conventional appendectomy: a prospective randomized study]. / Laparoskopische versus konventionelle Appendektomie: eine prospektive, randomisierte Studie.

The discussion about laparoscopic appendectomy has increased since the introduction of this method. Randomized comparisons are still feasible, whereas this cannot be stated for other laparoscopic procedures (e.g., laparoscopic cholecystectomy). This randomized controlled trial included 170 patients. Open appendectomy was employed in 83 patients, and 87 were treated laparoscopically. The treatment groups were comparable regarding age, sex, Broca index, ASA classification, preliminary operations, and preoperative leucocytes. No statistically significant differences could be found with respect to surgical and general complications, operating time, consumption of analgesics and antibiotics, and return to work. The analysis revealed a statistically significant shorter hospital stay, a shorter time until return to normal physical activity, and a shorter duration of complaints for the laparoscopic group. We were unable to demonstrate any statistically significant advantage in using the open procedure.

[Laparoscopic therapy of choledocholithiasis]. / Die laparoskopische Therapie der Choledocholithiasis.

The introduction of laparoscopic cholecystectomy has led to controversial discussions about the proceeding in case of coincident common bile duct stones. In our unit choledocholithiasis has been treated laparoscopically since November 1991. Basic requirement has been a routine intraoperative cholangiography. 67 patients with common bile duct stones were treated until January 1995. All patients underwent a follow up and the results were compared to other concepts. In 40 cases common bile duct stones were eliminated via cystic duct and in 27 cases by choledochotomy. The choledochus was drained routinely for postoperative x-ray control. In 9 cases we found residual concrements: 7 patients required postoperative endoscopic papillotomy and in 2 cases the calculi where eliminated with a dormia basket introduced via drainage tube. In one case surgical management was changed to laparotomy. Postoperative complications occurred in 8 cases. One patient suffering from bacterial peritonitis underwent laparotomy on the 9th postoperative day; one with bleeding from the cystic artery was treated by relaparoscopy. One patient developed a liver abscess and two patients a bilioma requiring ultrasound guided drainage. A superficial wound infection in one patient and a biliary leakage after removal of the drainage in two patients healed spontaneously. Due to an intact papilla with less stress to the patient, as well as a complication rate comparable with other published therapeutic concepts, this strategy can be recommended as a valuable alternative procedure.

[Educational opportunities in minimally invasive surgery]. / Ausbildungsmöglichkeiten in minimal invasiver Chirurgie.

Since minimally invasive surgery makes high demands on the skill, concentration and endurance of the surgeon, requisite training in this operating technique is of overriding importance. Basic training on pelvitrainers serves to enable the participant to become acquainted with the instruments and the video technique and to gain experience in handling the camera. A realistic simulation of intraoperative situations is not possible. With pulsatile organ perfusion (POP) nearly all abdominal, thoracic, vascular, urological and gynecological surgical procedures, as well as the encountered complications, can be imitated, widely replacing the need for animal experiments. Complex operations which are bound to anatomical structures, have to be practised on anaesthetized animals, as before.

Simulated operations by pulsatile organ-perfusion in minimally invasive surgery.

The rapid amplification of indications and areas of application of laparoscopic or thoracoscopic techniques leads to increasing problems and needs in surgical training. Pulsatile perfusion of organs (POP) and organ groups in laparoscopic training devices (pelvitrainers) aids in creating optimum conditions for the simulation of difficult intraoperative situations and complications. Simple applicability, low cost, and the possibility of a noticeable reduction of the currently required animal experiments render POP an ideal training method for minimally invasive surgery.