Curative treatment for recurrent tumour implantation after ruptured hepatocellular carcinoma.

Spontaneous rupture of hepatocellular carcinoma with intraperitoneal haemorrhage is a life-threatening condition. Intraperitoneal spread of the tumour after rupture occurs uncommonly. We report two cases of curative management for recurrent tumour implantation after ruptured hepatocellular carcinoma. The two patients presented with ruptured hepatocellular carcinoma and were treated with transarterial embolisation in the acute episode. Interval partial hepatectomy of the carcinoma was performed after the acute episodes. The first patient presented with a large epigastric mass 2 years after rupture. The mass was found to be adherent to the stomach and omentum. Distal gastrectomy was performed. The second patient presented with a right upper quadrant mass 4 months after rupture, and had a huge tumour attached to the ascending colon. Right hemicolectomy and omentectomy were performed. On histological examination, both tumours were confirmed to be recurrent hepatocellular carcinomas with clear surgical margins. After resection, both patients had no tumour recurrence at 1 year and 3 years, respectively.

Internal pancreatic ductal stenting to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a comparative study.

BACKGROUND/AIMS: This is a non-randomized comparative trial designed to compare the results of pancreaticoduodenectomy with internal pancreatic stenting versus no stenting for pancreaticojejunal (PJ) anastomosis after pancreaticoduodenectomy. METHODOLOGY: Between January 1999 and March 2008, a total of 49 consecutive patients undergoing pancreaticoduodenectomy with duct-to-mucosa PJ anastomosis with, or without an internal stent were evaluated. RESULTS: The 2 groups were comparable in demographic data, underlying pathologies, and pancreatic stump condition. Four patients (16.7%) in the stented group, and four patients (16%) in the non-stented anastomosis group had pancreatic fistula. There was no significant difference in pancreatic fistula rate between two groups. No surgical reintervention was necessary in all the patients with pancreatic fistulas. There were also no significant differences in operating time (mean, 270.5 minutes vs. 263.6 minutes), intra-operative blood loss (mean, 772.9 ml vs. 665.3 ml), overall morbidity (45.8% vs. 40%) and hospital mortality (4.2% vs. 4.0%). The mean hospital stay after surgery was 34 days in stented group and 21.5 days in non-stented group. CONCLUSIONS: Internal stenting of pancreatic duct could not reduce pancreatic fistula rate after pancreaticoduodenectomy.

Laparoscopic rectal cancer surgery with and without neoadjuvant chemo-irradiation: a comparative study.

OBJECTIVES: To evaluate the perioperative short-term outcomes of laparoscopic rectal cancer surgery in patients after neoadjuvant chemo-irradiation. PATIENTS AND METHODS: This is a comparative cohort study designed to compare the perioperative and short-term outcomes of laparoscopic rectal cancer surgery in patients with and without neoadjuvant therapy. Patients undergoing elective laparoscopic rectal cancer surgery after neoadjuvant chemo-irradiation formed the study group; those receiving surgery without neoadjuvant therapy and in whom the final histology confirmed either transmural or node-positive diseases were selected as controls. RESULTS: Fifty-two patients in the neoadjuvant group were compared with 138 patients in the control group. Both groups were comparable in terms of American Society of Anesthesiologists (ASA) grading and gender distribution. Median operating time was significantly longer in the neoadjuvant group (155 versus 135 mins, p = 0.09, Mann-Whitney U test). No significant difference was observed in terms of blood loss, conversion rates, postoperative morbidity, length of hospital stay or sphincter preservation rates. Overall 5-year survival rates in the two groups remained similar. CONCLUSIONS: Our data confirmed that, aside from a slightly longer operating time, laparoscopic rectal cancer surgery in patients with neoadjuvant chemo-irradiation is safe with no increased morbidity. Based on our experience, patients after neoadjuvant therapy should not be deterred from the minimally invasive approach.

Endo-laparoscopic colectomy without mini-laparotomy for left-sided colonic tumors.

BACKGROUND: In performing "traditional" laparoscopic colectomy for left-sided colonic tumors, specimen retrieval necessitates a mini-laparotomy which often is the cause of postoperative pain, wound infection, and other pain-related complications. Here we describe a new technique of endo-laparoscopic anterior resection without mini-laparotomy, where specimen retrieval and colorectal anastomosis can be safely achieved with the use of the transanal endoscopic operation (TEO) device set-up. METHODS: This hybrid natural orifice transluminal endoscopic surgery (NOTES) technique involves insertion of the TEO device in the lower rectum and luminal extraction of the specimen via the device. The technique is applicable to patients with small tumors (4 cm or less) in the left-sided colon or upper rectum, where transanal construction of a stapled colorectal anastomosis is intended. RESULTS: The technique was attempted in ten patients (male:female 4:6) with median age of 66 years (range: 55-81 years). Five patients suffered from rectosigmoid tumors, whereas four patients had lesions in the sigmoid colon and one had a lesion in the descending colon. The median operating time was 127.5 min (range: 105-170 min) and the median blood loss was 20 ml (range: 20-50 ml). The median hospital stay was 7 days (range: 4-18 days), while the median maximum pain score (visual analog score) was 2 (range: 2-3) during in-hospital stay in this small series. CONCLUSIONS: Our preliminary experience indicates this new technique of endo-laparoscopic colectomy is feasible for selected patients with left-sided colonic tumors. Complications related to mini-laparotomy can be abolished entirely with this hybrid approach.

Minimally invasive surgical treatment of hepatocellular carcinoma: long-term outcome.

BACKGROUND: Laparoscopic liver resection for hepatocellular carcinoma (HCC) is still a matter of debate because of the uncertainty of the long-term results and the fear of compromising the oncological resection. Published findings on survival and outcome after laparoscopic liver resection for HCC are scarce still. The aim of the present study was to report the perioperative and long-term outcome of minimally invasive surgical treatment of HCC. METHODS: From January 1998 to November 2008, all patients with HCC who underwent laparoscopic liver resection in our unit were included. A prospectively collected database was analyzed retrospectively. Perioperative outcome included procedure-related morbidity and mortality. Long-term outcome included 5-year overall survival and disease-free survival. RESULTS: During the study period, 30 consecutive patients with HCC underwent laparoscopic liver resection (hand-assisted laparoscopic liver resection, n = 22; total laparoscopic liver resection, n = 7; converted to open approach, n = 1). The mean tumor size was 2.8 cm. The mean operating time was 139.4 min, and 90% of patients had R0 resection and 10% of patients had R1 resection. The hospital mortality and morbidity rates were 0 and 20%, respectively. The mean hospital stay was 7.4 days. For those patients (n = 22) with a minimal follow-up of 24 months, the 5-year overall and disease-free survival rates were 50 and 36%, respectively. No port site recurrence occurred. CONCLUSIONS: This study showed that laparoscopic liver resection for HCC was feasible and safe in selected patients. The long-term survival was also favorable.

Colonic injury from electric arcing: a significant complication of argon plasma coagulation.

Argon plasma coagulation is increasingly used in endoscopic haemostasis. This case report illustrates the potential for thermal injury at a staple line remote from the area of argon plasma coagulation treatment as a result of electrical arcing. Increasing numbers of colorectal anastomosis and reconstruction procedures are now being performed using stapling techniques and the use of argon plasma coagulation in these patients has become a common situation in clinical practice. Information about this potential danger should be well disseminated to endoscopists and surgeons to avoid preventable complications. The presence of a staple line nearby should be considered a contra-indication for argon plasma coagulation.

Bleeding pseudoaneurysms complicating upper abdominal surgery.

OBJECTIVE: To review the management of ruptured pseudoaneurysms following upper abdominal surgery. DESIGN: Retrospective study. SETTING: Minimal access surgery centre, Hong Kong. PATIENTS: Patients who were diagnosed to have a pseudoaneurysm after undergoing major upper abdominal surgery were recruited during the period of 1998 to 2006. MAIN OUTCOME MEASURES: Success rate of haemostasis, re-bleeding rate, re-intervention rate, and mortality. RESULTS: During the study period, a total of eight patients (median age, 61 years) were managed in our department for bleeding pseudoaneurysms following cholecystectomy, gastrectomy, or Whipple's operation. Five patients underwent upper endoscopy as the initial investigation. In four of these five patients, visceral artery pseudoaneurysms were identified by angiography and haemostasis was achieved without re-bleeding. The one for whom angiographic identification of the bleeding source failed, was successfully treated subsequently by open plication. In three other patients, open surgical haemostasis was resorted to and achieved in two of them. However, one of the latter had re-bleeding, which was successfully treated by embolisation. The one who failed open identification of the bleeding source, was eventually also treated successfully by embolisation. The overall success rates of embolisation and open surgery were 80% and 67%, respectively, and the re-bleeding rates were 0% and 33%, respectively. The corresponding mortality rates were 20% and 33%; both deaths were associated with multi-organ failure. There were no procedure-related complications following embolisation. CONCLUSIONS: Based on our experience, visceral angiography can enable the diagnosis and treatment of ruptured pseudoaneurysm in a single session. The procedure is safe, the re-bleeding rate is low, and it is as effective as alternative treatments, and should be considered a first-line intervention in patients with bleeding pseudoaneurysms complicating upper abdominal surgery.

A laparoscopic approach for incarcerated Spigelian hernia.

Incarcerated Spigelian hernia (SH) is an uncommon surgical emergency that demands immediate operative treatment. In the era of minimal access surgery, elective laparoscopic repair of uncomplicated SH is safe and feasible. Herein, we report a case of incarcerated Spigelian hernia that was successfully managed by laparoscopic hernioplasty on an emergent basis.

Comparison of needlescopic appendectomy versus conventional laparoscopic appendectomy: a randomized controlled trial.

Laparoscopic appendectomy has been shown to improve postoperative recovery when compared with open appendectomy. The present randomized trial was conducted to evaluate any further difference in outcome between needlescopic appendectomy (NA) and conventional laparoscopic appendectomy (CLA) in the management of acute appendicitis. Patients with the clinical diagnosis of acute appendicitis were randomized to either NA (instrument size < or = 3 mm) or CLA (instrument size > or = 5 mm). Standardized anesthetic technique and perioperative management were adopted. The primary end point was length of postoperative hospital stay. Other parameters such as conversion rate, postoperative pain score and analgesic requirement, return of bowel function, resumption of normal activities, complication rate, and length of the final scars were also assessed and compared. A total of 363 patients (NA: 174, CLA: 189) were recruited. Both approaches could accurately arrive at the diagnosis (NA: 98.3%; CLA: 100%). Compared with CLA, NA resulted in a significantly longer operation time (P = 0.015) and a higher conversion rate (P < 0.001). The final scars of the NA group were significantly shorter when compared with the CLA group (P < 0.001). Otherwise, there was no statistical difference between the 2 groups in terms of complication rate, postoperative pain score, length of postoperative stay, and other recovery parameters. NA resulted in a longer operation time and higher conversion rate. Except for a smaller scar, the present study was unable to demonstrate any other short-term benefits. Thus, the technique cannot be routinely recommended.

Comparative study of 2-D and bichanneled 3-D laparoscopic images: Is there a difference?

INTRODUCTION: Lack of depth perception and spatial orientation are drawbacks of laparoscopic surgery. The advent of the 3-D camera system enables surgeons to regain binocular vision. The aim of this study was to gain subjective and objective data to determine whether 3-D systems are superior to 2-D systems. MATERIALS AND METHODS: Our study consisted of two parts: a laparoscopic training model and an actual operation assessment. In the first part, we compared two groups of surgeon (specialists and trainees) performing a laparoscopic task using a 2-D and a 3-D camera system. In the second part, surgeons were assessed on their performance of standard laparoscopic cholecystectomies using the two different camera systems. At the end of each assessment, participants were required to complete a questionnaire on their impressions of the comparative ease of operation tasks under 2-D and 3-D vision. RESULT: In the laboratory training model, trainees' performance time was shorter with the 3-D camera system than with the 2-D camera, but no difference was observed in the specialists group. In the surgical (cholecystectomy) assessment, no significant difference was observed between the 2-D and 3-D camera systems in terms of operative time and precision. The questionnaire indicated that all participants did not significantly favor the 3-D system. CONCLUSION: We believe that the 3-D camera system can allow young surgeons to perform standard laparoscopic tasks safely and quickly, so as to accelerate the learning curve. However, new-generation 3-D systems will be essential to overcome surgeons' discomfort.

Pseudo-Bouveret's syndrome.

We report a patient with gastric outlet obstruction due to gallstone, with clinical and imaging features mimicking Bouveret's syndrome. However, the obstruction was simply due to extrinsic compression by a gallstone without cholecystoduodenal fistula formation. Laparoscopic cholecystectomy cured the patient.

Robot-assisted laparoscopic approach of management for Mirizzi syndrome.

Mirizzi syndrome is an uncommon cause of common hepatic duct obstruction resulting from gallstone impaction in the cystic duct or gallbladder neck. Mirizzi syndrome is traditionally considered as a contraindication to laparoscopic surgery mainly due to risk of bile duct injury during dissection. We present the surgical experience of 5 patients with Mirizzi syndrome who were diagnosed preoperatively and managed using minimally access surgical technique, either total laparoscopic or robotic-assisted laparoscopic approach. All patients had successful operations and recovered without complications. We concluded that with a correct preoperative diagnosis, careful operative strategy, increasing expertise with laparoscopic technique, and introduction of robotic surgical system, minimally invasive approach of management of Mirizzi syndrome becomes safe and feasible.

Laparoscopic reversal of Hartmann's procedure: safety and feasibility.

AIMS: The present study aimed to compare the surgical outcomes of patients receiving laparoscopic reversal of Hartmann's procedure (RHP) with those receiving open surgery. METHODS: Records of all patients with RHP performed in our unit (including laparoscopic and open surgery) between 2000 and 2012 were retrieved. Data were retrospectively reviewed and compared. RESULTS: Eighty-two RHPs were performed between 2000 and 2012. Thirty-five were performed with an open approach and 47 with a laparoscopic approach. Conversion rate was 28% in the laparoscopic group. There was no difference, between the two groups, in operation time or blood loss. The median length of stay was significantly shorter in the laparoscopic group (12 vs 14 days, P = 0.002) and fewer patients in the laparoscopic group had complications with post-operative paralytic ileus (2 vs 17%, P = 0.038). None of the patients in the laparoscopic group developed incisional hernia at the conclusion of follow-up, as opposed to five in the open group (0 vs 14%, P = 0.012). CONCLUSION: Laparoscopic RHP is safe and feasible, with more favorable surgical outcomes, when compared with open surgery. Conversion rate is acceptable. It should be the technique of choice for patients undergoing RHP.

Robot-assisted laparoscopic hemi-hepatectomy: technique and surgical outcomes.

BACKGROUND: Laparoscopic major hepatectomies remain a challenge for liver surgeons. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. The use of robotic system in laparoscopic major hepatectomy was not known yet. METHODS: Between December 2010 and July 2011, 6 right hemi-hepatectomies and 4 left hemi-hepatectomies were performed by robot-assisted laparoscopic approach. Prospectively collected data was analyzed retrospectively. RESULTS: Overall mean duration of the operation was 347.4 ± 85.9 (SD) minutes. Mean duration of the operation for right hemi-hepatectomy was 364.8 ± 98.1 ml, while mean duration of the operation for left hemi-hepatectomy was 321.3 ± 67.8 ml. Overall mean operative blood loss was 407 ± 286.8 ml. Mean operative blood loss for right hemi-hepatectomy was 500 ± 303.3 ml, while mean operative blood loss for left hemi-hepatectomy was 156.9 ± 40.7 ml. No open conversion was needed. Three patients (30%) had postoperative complications. There was no mortality. Mean hospital stay was 6.7 ± 3.5 days. CONCLUSIONS: Our series indicate that in experienced hands, robot-assisted laparoscopic approach for hemi-hepatectomy is feasible and safe. As experience grows, this procedure will be more common.

Conventional laparoscopic and robot-assisted laparoscopic liver resection for benign and malignant pathologies: a cohort study.

The aim of our study was to evaluate different minimally invasive surgical approaches for liver resection in a tertiary surgical center. The study cohort comprised 104 consecutive patients who underwent total laparoscopic liver resection (n = 17), hand-assisted laparoscopic liver resection (n = 55), or robot-assisted laparoscopic liver resection (n = 32) in our center between October 1998 and January 2011. Surgical complications, postoperative course, disease-free survival, and overall survival for malignancy were assessed. These 104 resections were performed on 55 men and 49 women with a mean age of 60.4 years; 43.3% of patients had liver cirrhosis. The liver pathologies comprised malignant tumors (64.4%) and benign lesions (35.6%). The most common laparoscopic liver resection was left lateral sectionectomy (53.9%), wedge resection (26.9%), segmentectomy (13.5%), right hepatectomy (3.8%), and left hepatectomy (1.9%). Conversion from laparoscopy to open approach and from laparoscopy to hand-assisted approach occurred in 1.9 and 1% of the cases, respectively. Overall mortality was 0%, and morbidity was 17.3%. The median follow-up period was 24 months. The 5-year overall survival for hepatocellular carcinoma (HCC) was 52%, and the 3-year overall survival for colorectal liver metastasis was 88%. Based on these results, we conclude that laparoscopic liver resection is feasible and safe in appropriately selected patients. In our patient cohort, it was associated with a low complications rate and favorable survival outcome.

Robotic hepatobiliary and pancreatic surgery: a cohort study.

BACKGROUND: Robotic surgery has emerged as one of the most promising surgical advances since its launch at the turn of the millennium. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary and pancreatic (HBP) surgery remains relatively unexplored. This article aims to evaluate the efficacy and outcomes of robotic HBP surgery in a single surgical center. METHODS: Between May 2009 and December 2010, all patients admitted to our unit for robotic HBP surgery were evaluated. A retrospective analysis of a prospectively maintained database on clinical outcomes was performed. RESULTS: There were 55 robotic HBP operations performed during the study period. There were 27 robotic liver resections (left lateral sectionectomies n = 17, left hepatectomy n = 1, other segmentectomies n = 2 and wedge resections n = 7), 12 robotic pancreatic procedures (Whipple's operations n = 8, spleen-preserving distal pancreatectomies n = 2, double bypass n = 1 and cystojejunostomy n = 1) and 16 biliary procedures (biliary enteric bypass n = 9, bile duct exploration and related procedures n = 7). The median postoperative hospital stays for robotic liver resections, biliary procedures and pancreatic operations were 5.5 days (range 3-11 days), 6 days (range 4-11 days) and 12 days (range 6-21 days), respectively. Morbidities for liver resection, biliary procedures and pancreatic operations were 7.4, 18 and 33%, respectively. There was no mortality in our series. CONCLUSIONS: Robotic surgery is feasible and can be safely performed in patients with complicated HBP pathologies. Further evaluation with clinical trials is required to validate its real benefits.

Approach to manage the complications of choledochoduodenostomy: robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy.

PURPOSE: To evaluate the technical feasibility and safety of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy, using the robotic surgical system. METHODS: This is a report of the use of robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy on 2 patients with recurrent pyogenic cholangitis. Both had past history of side-to-side choledochoduodenostomy with complications of Sump syndrome and benign biliary stricture, respectively. RESULTS: Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy was completed successfully in these 2 patients. Both patients recovered from the operation, except for 1 patient who had minor bile leakage over the anastomosis 4 days after operation, which subsided after conservative treatment. The mean operating time was 300 minutes and 400 minutes, respectively. The blood loss was 20 mL and 10 mL, respectively. They were able to tolerate liquids on the second postoperative day. They were discharged 6 and 11 days after the operation, respectively. CONCLUSIONS: Robot-assisted laparoscopic Roux-en-Y hepaticojejunostomy is a feasible and safe procedure. However, more large-scale studies with long-term follow-up results are needed.

Multimodality laparoscopic liver resection for hepatic malignancy--from conventional total laparoscopic approach to robot-assisted laparoscopic approach.

INTRODUCTION: Laparoscopic liver resection can either be total laparoscopic or hand-assisted laparoscopic approach. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. The role of robotic system in laparoscopic surgery was not well evaluated yet. The aim of this cohort study was to evaluate the outcome of multimodality approach of laparoscopic liver resection for hepatic malignancy METHODS: From January 1998 to August 2010, all patients with hepatic malignancy underwent laparoscopic liver resection were included. A prospectively collected data was analyzed retrospectively. RESULTS: During the study period, a total of 56 patients with hepatic malignancies (hepatocellular carcinoma, HCC, n = 42; colorectal liver metastases, CLM, n = 14) underwent laparoscopic liver resection in our surgical unit. The majority of cases were performed by hand-assisted laparoscopic approach, n = 31 (55.3%) and the remainder were with total laparoscopic approach, n = 10 (17.9%) and robot-assisted laparoscopic approach, n = 15 (26.8%). The median operation time was 150 min (range, 75-307 min). The median blood loss during surgery was 175 ml (range, 5-2000 ml). Two patients (3.6%) needed open conversion and one patient (1.8%) needed to be converted to hand-assisted laparoscopic approach. The morbidity rate was 14.3%. There was no procedure-related death. 89.3% of patients had R0 resection and 10.7% of patients had R1 resection. The median hospital stay was 6.5 days (range, 2-13 days). The 1-year, 3-year, and 5-year disease-free survival rates for HCC were 85%, 47%, and 38%, respectively. The 1-year, 3-year, and 5-year overall survival rates for HCC were 96%, 67%, and 52%, respectively. The 1-year, and 3-year disease-free survival rates for CLM were 92% and 72%. The 1-year, and 3-year overall survival rates for CLM were 100% and 88%, respectively. CONCLUSIONS: Multimodality approach of laparoscopic liver resection of hepatic malignancy was feasible, and safe in selected patients. It was associated with a low complications rate. The mid-term and long-term survival outcome was favorable also.

Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy.

BACKGROUND: This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC). METHODS: From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27). RESULTS: Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6). CONCLUSIONS: SILC was feasible and safe for properly selected patients in experienced hands.

Combined percutaneous and endoscopic approach in management of dropped gallstones following laparoscopic cholecystectomy.

Dropped gallstones due to accidental perforation of gallbladder wall during laparoscopic cholecystectomy are often encountered. However, dropped gallstones as nidus of infection with subsequent abscess formation is a rare complication of laparoscopic cholecystectomy (0.3%). Most of the reported cases of complicated dropped stones required open surgical drainage. Minimally invasive measures were less frequently employed. We report a case of dropped gallstones that were removed endoscopically through a percutaneous drainage tract.