Laparoscopic intracorporeal distal rectal transection with the CONTOUR(®) device.

Laparoscopic rectal resection is considered technically more demanding than laparoscopic colectomy. Rectal transection is a challenging part of laparoscopic low anterior rectal resection and restorative proctocolectomy. We describe our technique for laparoscopic rectal transection with a curved cutter, a device initially designed for open surgery, combined with the use of a ring-mounted sterile drape that allows maintenance of sufficient intra-abdominal gas pressure in a series of 34 patients.

Combining ultrasonic dissection and the Storz operation rectoscope.

BACKGROUND: Transanal endoscopic microsurgery (TEM) allows a precise, full-thickness resection of rectal tumors anywhere within the rectum. Unfortunately, the standard TEM technique needs complex and rather expensive equipment, demands high skill, and is attended by bleeding and oozing that may be challenging. A modified TEM procedure combining the new Storz operation rectoscope and ultrasonic dissection has been developed to overcome the limitations of the original technique. METHODS: The Storz operation rectoscope features a 5-mm telescope combined with a single-monitor display. Standard laparoscopic instruments and the LCSC5 Ultracision Maniple are used for dissection and coagulation. Full-thickness resection is performed most often. Closure of the defect is accomplished by interrupted 3-0 polydoxanone sutures secured by extracorporeal slipknots. RESULTS: Altogether, 18 TEMs have been performed according to the modified technique: 9 for malignant and 9 for benign lesions. The median operating time was 92.5 min for resection of malignant lesions and 40 min for resection of benign lesions. Two postoperative complications occurred: a bleeding and a partial dehiscence. The median follow-up periods were 35 months for malignant disease and 19.5 months for benign disease. No recurrence was observed. CONCLUSION: For tumors located up to 15 cm from the anal verge, TEM with the Storz rectoscope and ultrasonic dissection is indicated. Despite the complication described, coagulation is optimal and ultrasonic scissors allow working in a fairly bloodless field. The overall costs of the equipment are significantly lower.

Laparoscopic cholecystectomy by ultrasonic dissection without cystic duct and artery ligature.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, there are some pitfalls due to the limits of current technology and the use of inappropriate ligature material, with a relevant risk of injuries and postoperative, mainly biliary, complications. Ultrasonically activated scissors may divide both vessels and cystic duct, with no need of further ligature, and possibly reduce the risk of thermal injuries. METHODS: A prospective nonrandomized clinical trial was started in 1999 to test harmonic shears (Ultracision, Ethicon Endo-Surgery, Cincinnati, OH, USA) in 461 consecutive patients undergoing LC in order to evaluate the theoretical benefits of ultrasonic dissection and the possible reduction in intraoperative bile duct injuries (BDIs) and postoperative complications. Patients were divided in two groups: in group 1 (HS; 331 patients) the operation was performed by Ultracision (including coagulation-division of cystic duct and artery); in group 2 (LOOP; 130 patients) the cystic duct, after coagulation-division by harmonic scissors, was further secured with an endo-loop. Both groups were further divided into two subgroups: expert and surgeon-in-training. The following categories of data were collected and analyzed: individual patient data, indication for laparoscopic cholecystectomy, surgical procedure data (associated procedures, intraoperative cholangiography, intraoperative complications, length of surgery, and conversion to open), and postoperative course data (postoperative morbidity, postoperative mortality, reinterventions, and postoperative hospital stay). Furthermore, biliary complications were analyzed as a single parameter comparing the incidence within groups and subgroups. Cumulative complications (intraoperative and postoperative) were also analyzed as a single parameter comparing their incidence in the series of each surgeon within the surgeon-in-training subgroup to the average results of the expert subgroup. Finally, length of surgery, postoperative complication rate, and length of postoperative hospital stay within subgroups were analyzed to evaluate the learning curve. RESULTS: Overall conversion rate was 0.87%. The mean operating time was 76.8 min (median, 70 min) in group 1 and 97.5 min (median 90 min) in group 2. BDI occurred in 1 case (0.32%) in the surgeon-in-training subgroup. Overall BDI rate was 0.22% (1/461). The overall incidence of postoperative bile leak was 2.7% (9 patients of subgroup 1 and 1 patient of subgroup 2). Clinical observation with spontaneous resolution occurred in 4 patients, and in 1 case the management consisted in an endoscopic biliary drainage; surgery was requested in the remaining cases. A laparoscopic approach was successfully attempted in all cases. Overall morbidity rate was 8.76% in group 1 and 13.84% in group 2. Rates of major complications, overall biliary complication, and postoperative bile leaks within the expert and surgeon-in-training subgroup differ significantly (p = 0.026, p = 0.03, and p = 0.049, respectively). There was 1 death (0.22%) due to sepsis that resulted from a small bowel injury by trocar insertion. Mean postoperative stay was 4.28 days for group 1 and 5.05 days for group 2. CONCLUSION: No significant difference was found in both patient groups regarding postoperative mortality and complications, biliary complications, and especially cystic duct leaks. A retrospective comparison of literature data showed that use of ultrasonic dissection during LC seems to reduce the risk of BDI. Nevertheless, a learning curve in the use of ultrasonic-activated devices is required: a significant differences in postoperative major complications and biliary complications between the expert and the surgeon-in-training subgroups was shown. Furthermore, ultrasonic scissors misuse may cause bowel injuries in patients with severe adhesions, and this could represent a possible limitation for surgical safety.

Hepatic resections through the laparoscopic approach.

Hepatic surgery has been undergoing progressive modifications in surgical approach to liver, passing through tohraco-phrenolaparotomy to bilateral subcostal incision and current Makuuchi's. Laparoscopic liver surgery should not be considered a new surgery, but simply a new surgical approach, with difficulties but advantages too. Laparoscopic hepatic resections are feasible with low morbidity and mortality; the short and medium term results are comparable to those obtained with open surgery provided that the surgeon has a significant experience in open hepatic surgery, advanced laparoscopic surgery and the availability of all and pertinent instrumentation. The aim of this paper is to show the rationales formal of hepatic resections through the laparoscopic approach, focusing on the necessary instrumentation, the surgical technique and results.

[Reconstruction after pancreaticoduodenectomy for cancer: Whipple-Child vs Traverso-Longmire technique (a National questionnaire 1990 on data of 1,095 cases of surgery)]. / Ricostruzione dopo cefaloduodenopancreatectomia per cancro: Whipple-Child v.s. Traverso-Longmire (questionario nazionale 1990 per una raccolta di 1.095 esperienze).

The Authors report the results of a National multicentric experience in 1.095 cases of pancreaticoduodenectomy for cancer. In order to evaluate the reliability of pyloric preservation mortality, morbidity, and functional results are discussed.

Laparoscopic ultrasonography: limits and potential of present technologies.

During recent years, laparoscopic contact sonography has been introduced into clinical practice to remedy the limitations of minimal invasive surgery. The technology of laparoscopic ultrasound probes is described in this paper as well as the technique of US contact scanning via the laparoscopic approach. This method is a tool which allows the examination of tissues and non-palpable parenchymal organs in endoscopic surgery, thus permitting correct assessment of both anatomy and the spreading of neoplasms, with consequent impact upon surgical decision making.

Experimental development in colorectal surgery.

A one year research programme on endoscopic colorectal resections was carried out at the University of Tübingen. Two research lines were planned: the development of the required technologies and the development of the surgical procedure. During the research programme on technologies a new device provided with an air proof system for transanal insertion of the anvil of a divisible stapler and a new technique for closure of the colonic and rectal stumps (cable binding technique) were developed. Such technological innovations enabled the authors to accomplish a new combined laparoscopic-rectoscopic procedure which was performed according to four different variants in a series of 32 animals. The last 15 consecutive successful cases, performed according to the definitive procedure, represented a standardized animal trial before starting the clinical investigation.

The laparoscopic approach to modified Taylor's procedure in the treatment of chronic duodenal ulcer: an improved technique.

Laparoscopic modified Taylor's procedure for chronic duodenal ulcer was performed in three patients. A new, specially developed combination instrument allowed the operation to be performed easily, sometimes using only four introduction sites. Coagulation, suction, and rinsing can be performed at the same time, and the hook knife, scissors, or different forceps can be introduced through the operating channel of the instrument. An overcast seam to approximate the seromyotomy was done using the technique developed for transanal endoscopic microsurgery. Instead of the silver clips, specially handmade steel and titanium clips were used to fix the PDS suture. No major postoperative complications occurred. The gastric acid output under basal condition and stimulation showed a decrease ranging from 47% to 79%. Endoscopic examination performed on the 4th postoperative week showed complete recovery in all cases.

Elective endoscopy in portal hypertension.

Eighty-four cases of portal hypertension from cirrhosis assessed by oesophagogastroduodenoscopy before elective surgery are reported. The need for evaluation of both the associated gastrointestinal lesions and the varices in patients with cirrhosis is stressed, to avoid inappropriate medical or surgical treatment.

Laparoscopic liver resections.

The authors present the rationale of the laparoscopic approach to liver surgery, showing the technique of fully endoscopic and endoscopic-assisted formal and wedge hepatic resections and the early results of their experience. From 1993 to 1997, 38 liver resections have been attempted through the laparoscopic or the laparoscopic assisted approach. Out of these 38 resections, 5 were wedge resections, 11 were segmentectomies, 10 were left formal hepatectomies, 1 was an extended left hepatectomy, 5 were bisegmentectomies, 5 were right formal hepatectomies, and 1 was an extended right hepatectomy. In two cases, one segmentectomy and one bisegmentectomy, the procedures were converted to open surgery. Wedge, segmental, and left liver resections were usually performed through a fully endoscopic approach, whereas right liver resections were accomplished by a video-assisted approach. In all but six cases, the resections were attempted for malignancy. There were no intra-operative deaths. One patient died on postoperative day-1 because of liver failure and severe coagulopathy. The early results are comparable to those of conventional surgery, with the benefits derived from minimal access surgery. Laparoscopic liver resections are technically feasible with an acceptable morbidity and mortality rate, but extensive experience in conventional liver surgery, advanced laparoscopic surgery, and the availability of all requested technology are indispensable prerequisites.

Future trends in endoscopic suturing.

This paper deals with future aspects and developments in endoscopic sutures, needles, needle drivers, and sewing devices. Shape memory alloys such as superelastic nickel-titanium can be used for surgical needles and hingeless needle drivers. A sewing device consists of a T-Needle which can be shuttled between the jaws of specially designed instruments. The jaws possess small elements that grip the needle tips. The "Needle Rotor" facilitates intracorporeal swivelling and positioning of the needle because one jaw can be moved longitudinally over the other. A new "cutting knot pusher" permits immediate cutting of a slip knot subsequent to tightening.

New technique for sigmoid colectomy.

A combination of laparoscopic and rectoscopic procedures has enabled complete resection of the sigmoid colon and eliminated the need for minilaparotomy when constructing the anastomosis or withdrawing the specimen. This combined procedure was performed in different ways in a series of animal models until the definitive technique had been standardized. These techniques were then successfully used in 15 consecutive medium-sized pigs. Histological evaluation of the specimens, including the anastomosis (examined 2-3 weeks after operation) confirmed the efficacy and safety of the method.

Laparoscopic gastric resections.

The impressive breakthrough in laparoscopic surgery has pushed surgeons to perform gastric resection through such an approach. Laparoscopy reduces the surgical stress and the postoperative pain and has a positive impact on the rehabilitation time, the hospital stay, and return to work and social activities. Laparoscopic partial gastrectomy for benign diseases and for palliation has been accepted as an effective surgical option: they are reproducible operations performed worldwide at a more and more rapid pace. Laparoscopic gastric resections and laparoscopically assisted gastric resections for malignancy deserve a word of caution. Nevertheless, the investigators report their series of laparoscopic subtotal and distal gastrectomies for cancer with medium and long-term results comparable with those of open surgery. Furthermore, new and less invasive surgical options have been recently introduced. Full and partial thickness local resections may be accomplished through intragastric procedures, for treatment of small benign tumors and early stage gastric cancer.

Current position of advanced laparoscopic surgery of the liver.

With the improvement of laparoscopic techniques and the development of new and dedicated technologies, endoscopic liver surgery has become feasible. While wedge liver resections are performed more and more frequently, laparoscopic anatomical liver resections are still at an early stage of development and are somewhat controversial. In 1993 we initiated formal laparoscopic liver resections in selected patients. From 1993 to December 1995 20 patients underwent endoscopic formal resections: the procedures comprised six left hepatectomies, five right hepatectomies, one of which extended to the segment IV, three mesohepatectomy, five segmentectomies and one bisegmentectomy. The operation time ranged from 120 to 270 min (average 193 min). In 17 out of 20 cases a Pringle manoeuvre was performed (mean occlusion time 45 min). No intra-operative complications occurred and there were no conversions in the whole series. Average intra-operative blood loss was 397.5 mL and 35% of patients required intro-operative blood transfusions. Post-operative mortality rate was 5% and post-operative morbidity rate was 45% (one coagulopathy with severe trombocytopaenia, six pleural effusions, one bile collection and four hematomas of the trocar sites). Such preliminary data are comparable with those of a group of 65 patients who underwent open anatomical liver resections from 1992 and 1995. Far from being a routine technique in liver surgery, the laparoscopic approach to forma liver resections may be a promising procedure in selected patients.

Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum-related effects and needle and trocar injuries in laparoscopic surgery.

BACKGROUND: Both pneumoperitoneum and blind needle and trocar insertion may cause complications: because of the well-known physiological effects, CO2 insufflation is not indicated in patients with impairment of cardiorespiratory function and high-risk patients; injuries to underlying viscera and vessels by needles and trocars have been reported even when the open technique is used. METHODS: A technique which combines abdominal wall suspension by a new subcutaneous lifter (LaparoTenser) and optical trocar (OptiView) insertion has been evaluated in a random series of 22 patients undergoing various laparoscopic procedures. The optic trocar was inserted without previous insufflation, but low-pressure (1-5 mmHg) pneumoperitoneum was associated during the course of the procedure in 16 cases. RESULTS: The exposure of the operating field was good or sufficient in 21 cases (95%), while the placement of the optical trocar was always safe. One complication related to the insertion of the subcutaneous needles of the wall lifter occurred (suprafascial hematoma). CONCLUSIONS: The subcutaneous retractor allows the use of conventional cannulae and the combination of abdominal wall suspension with or without low-pressure pneumoperitoneum, thus enhancing the quality of exposure with no effect on the hemodynamic and respiratory functions.

Ultrasound-guided alcoholization of celiac plexus for pain control in oncology.

BACKGROUND: Treatment of inoperable pancreatic cancer pain is of paramount importance. The ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. This procedure may be performed under either fluoroscopic or computed tomography (CT) guidance, or it may accompany laparotomy. The authors describe a modified sonographically (ultrasound-US)-guided technique for alcoholization of the celiac ganglions. METHODS: Twelve patients underwent the neurolytic procedure. Nine of 12 suffered from pancreatic cancer. The remaining three were affected by inoperable hepatic, gastric, or colon cancer, respectively, with multiple hepatic metastases. US-guided alcohol neurolysis was performed by an anterior approach. In the last four patients, PIA (percutaneous injection alcohol) needles, modified by the authors, replaced the spinal needles employed in the first eight patients to inject the alcohol. Pain and pain relief were rated according to a Simple Descriptive Scale (SDS), and treatment success was gauged by declining opiate doses and need for pharmacological therapy. Results after treatment performed using different needles were compared. RESULTS: Procedure-related mortality was zero. Complications of the neurolytic procedure included left pleural effusion in one patient and mild diarrhea in two other patients. Positive, negative, and indeterminant results were noted in nine (75%, p < 0.001), two, and one patient(s), respectively. CONCLUSIONS: The neurolytic technique, although far from being considered a routine procedure, appears to provide patients with safe and effective pain relief for pain unresponsive to conventional medical treatment.

Histologic effects of different technologies for dissection in endoscopic surgery: Nd:YAG laser, high frequency and water-jet.

Precise cutting combined with reliable coagulation of the margins of the lesion is an important requirement for dissection techniques in endoscopic surgery. These requirements are met by the two most common ancillary energy sources applied for endoscopic dissection today, electrosurgery and "thermal lasers", mostly the Nd:YAG. For the comparison of the histological effects of monopolar and bipolar high frequency with the Nd:YAG laser an experimental in vitro and in vivo study has been performed. In order to evaluate the advantages of non thermal dissection for endoscopic procedures, a water jet cutting system was included in the in vitro study. In parenchymatous tissue the water jet was found to be the least traumatic technique, followed by bipolar high frequency, laser and monopolar high frequency. The water jet was not applicable for intestinal dissection since uncontrolled bloating of the rectal wall with uncontrolled disruption of the tissue layers occurred. A general disadvantage is that secure haemostasis in the line of incision is hard to achieve. In the microscopic comparison of the shape of the incision, the Nd:YAG laser produced the smoothest lesions with well-defined margins. The monopolar technique was more often associated with irregular and sometimes fissured margins. These results were confirmed in the in vivo part of the study (Transanal Endoscopic Microsurgery).

LaparoLith. A new instrument for stone fragmentation in laparoscopic cholecystectomy.

Laparoscopic cholecystectomy can be performed with incisions of a maximum diameter of 10 mm. The removal of a stone-filled gallbladder at the end of an operation via the 10-mm port needs often-extensive tissue-consuming manipulations for stone removal or minilaparotomy. Stone fragmentation can be achieved by mechanical crushing and by ultrasound-, electrohydraulic-, and tunable dye laser lithotripsy. The clinical employment of the LaparoLith (Baxter Healthcare Corporation), an instrument which allows mechanical fragmentation of stones inside the gallbladder, is presented here. We have used the LaparoLith in nine patients and have been successful in stone fragmentation in seven of these. The LaparoLith seems to be helpful in laparoscopic cholecystectomy, preventing extension of the subnavel incision.