Aldo Fantini

Laparoscopic treatment of gastric stromal tumors.

AbstractBackground: The laparoscopic resection of gastric stromal tumors (GST) is being performed with increased frequency. Methods: Between November 1993 and October 1998, nine consecutive patients with benign and low-grade gastric stromal tumors underwent laparoscopic resection using intraoperative endoscopy. For lesions located on the anterior wall (three cases), a direct approach was utilized. Lesions located on the posterior wall were resected via a transgastric approach (four cases) or through a small opening on the omentum or on the gastrocolic ligament (two cases). Excision of the lesions was performed manually by means of electrocautery and scissors in eight cases; the gastric incisions were closed by manual running suture. An endoscopic stapler device was used in one case only. Results: All patients were successfully treated laparoscopically; there were no conversions to open surgery. Operative time ranged from 75 to 120 min. There was one bleeding from the suture line of the gastric wall postoperatively that was treated conservatively. The average postoperative hospital stay was 4 days (range, 2–6). Conclusions: In light of the results reported in the literature and on the basis of the present work, it seems that laparoscopic resection of GST should be considered as the treatment of choice. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. In our opinion the direct approach should be reserved for lesions located on the posterior wall of the body, which can be easily reached through the greater omentum, while the transgastric approach should be preferred for lesions located on the fundus and antrum. Manual excision allows a tailored operation; hand-sewn sutures are always feasible, and they are cheaper than stapled ones.

Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis

BACKGROUND A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.

Management of abdominal lymphoproliferative diseases in the era of laparoscopy

BACKGROUND The treatment of lymphoproliferative diseases requires extensive histological, immunohistochemical, and cytogenetic diagnosis. The aim of this study was to analyze the results of 66 laparoscopic procedures in the diagnosis, staging, and restaging of hematological malignancies localized in the abdominal cavity. METHODS Between July 1993 and March 1998, 64 consecutive patients (28 male and 36 female; mean age 46.6 years, range 7 to 69) with diagnosed or suspected lymphoproliferative diseases were referred for primary diagnosis or reassessment and for staging/restaging. RESULTS Sixty-two out of 66 procedures (93.9%) were completed laparoscopically. CONCLUSIONS The minimally invasive approach, in the management of lymphoproliferative diseases, is able not only to provide an adequate specimen for proper diagnostic techniques, but also, when compared with open surgery, to offer a large number of advantages.

Accuracy of Laparoscopy in the Diagnosis and Staging of Lymphoproliferative Diseases

Laparoscopy seems to be playing an emerging role in the management of lymphoproliferative diseases. The aim of this study was to prospectively analyze personal experience evaluating the role and limits of laparoscopy in the management of lymphomas. From July 1993 to December 2000, 131 consecutive patients were referred to our institution for primary diagnosis (group A, n = 70), suspected relapse (reassessment) (group B, n = 54), or staging/restaging of lymphoproliferative diseases (group C, n = 7). Diagnostic and/or operative laparoscopy was performed in all patients. To assess the accuracy of laparoscopy, the results were analyzed according to the indications for surgery. In all, 128 procedures were completed laparoscopically (95.5%). Conversion was required in 7 cases (5.1%). Causes of the conversions were severe obesity (body mass index 62.5), uncontrolled intraoperative bleeding (HIV+), nondiagnostic tissue sampling (2 cases), perisplenic inflammation and perisplenic abscesses (3 cases). The results of this study highlight the safety of diagnostic and staging laparoscopy and laparoscopic splenectomy in patients with lymphoproliferative diseases (major complications 2.9%, perioperative mortality 0%). In all, 96.4% of patients from group A and 100% of patients from group B were treated on the basis of laparoscopic findings. No false negative diagnosis occurred. Laparoscopy may become the “gold standard” in the management of lymphoproliferative disease in the following settings: for the differential diagnosis of hepatic and/or splenic focal lesions; when percutaneous needle biopsy fails and/or genetic analysis is needed for therapeutic decision; for the primary diagnosis and abdominal staging of patients with diffuse retroperitoneal lymphadenopathy in the absence of peripheral lymphadenopathy; for cases of abdominal restaging after concurrent chemoradiotherapy and in cases of suspected relapse when percutaneous biopsy is not technically possible; and for patients with lymphoproliferative disease when splenectomy is required. Marked splenomegaly with perisplenic inflammatory reaction and lymphadenopathy in HIV+ patients should be considered possible causes of failure of the laparoscopic approach.

Complications after laparoscopic cholecystectomy

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed.From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n=15), associated in six cases also with percutaneous cholangiography (PTC). “Minimally invasive” treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by “minimally invasive” techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n=4), ductal stricture by endoloop (n=1), iliac artery injury (n=1), and phlegmon of gallbladder bed (n=1).It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging. After a first diagnostic phase, complications should be managed by a multidisciplinary approach wherein the radiologist and the endoscopist strictly cooperate with the surgeon in order to obtain an immediate relief of the initial clinical problem, such as jaundice, bile leak, or infection, and then plan a definitive treatment which is tailored to each patients problem. Using this approach the whole event of LC and its complications can be managed within the field of minimally invasive therapy in most cases.

Laparoscopic direct supragastric left adrenalectomy.

BACKGROUND In this paper a novel laparoscopic approach to the left adrenal gland by the transabdominal anterior route is presented. This approach avoids an extensive viscera dissection to gain access to the left adrenal gland. METHODS The first step of the procedure is the division of the gastrophrenic ligament and the section of 1 or 2 short gastric vessels in order to mobilize the gastric fundus. The gastric fundus is then pulled down, allowing a wide exposure of the left crus of the diaphragm, the perirenal fat, and the superior edge of the pancreatic body. The diaphragmatic-adrenal channel runs on the left crus, crosses the middle adrenal artery, and, usually, joins the left adrenal vein before its junction with the left renal vein. By pulling on the diaphragmatic vein, exposure of the adrenal vein is facilitated. The adrenal vein is then isolated and divided between clips. Using the monopolar electrocautery to control arteries and small veins, the mobilization of the gland is then completed. The adrenal gland is then placed in a plastic bag to prevent cell spillage and removed through an enlarged umbilical incision. RESULTS During a 20-month period, 6 consecutive patients with left adrenal gland neoplasms have been operated on with the above mentioned original approach. The diameter of the adrenal mass ranged from 3 cm to 6 cm. No conversion to open surgery or complications have been registered. The mean operative time was 126 minutes. The mean length of hospitalization was 4.1 days (range 3 to 6). CONCLUSIONS This approach offers a complete visualization of the left adrenal gland, avoiding mobilization of the spleen, pancreatic tail, and left flexure of the colon, and allows an early and easy control of the left adrenal vein so adrenalectomy can be safely performed.

A Time-Saving Technique for Specimen Extraction in Sleeve Gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG), first intended as the first step of biliopancreatic diversion with duodenal switch (BPD-DS), is gaining popularity as a per-se procedure because of its effectiveness on weight loss and comorbidity resolution. The extraction of the gastrectomy specimen could be challenging and time-consuming. Different techniques have been described for specimen withdrawal. In this article we report the technique adopted in more than 250 LSGs performed in our department.MethodsIn the first 90 LSGs performed in our department from October 2002, the specimen was extracted in a retrieval bag using an endoloop. In the following 160 cases the technique has been simplified: the grasped specimen is withdrawn through the 15-mm trocar site without any additional device.ResultsWe registered only two cases of wound infection (1.2%) with the simplified technique, both occurring in the initial cases. There were no cases of trocar site hernia formation.ConclusionThe technique described does not require any special devices and seems to be simpler, saves time, and is cost effective if compared with other techniques previously reported.

Palpatory method used to identify the recurrent laryngeal nerve during thyroidectomy.

Abstract. The major complication of thyroid surgery, occurring in 1% to 6% of cases, is injury to the recurrent laryngeal nerve (RLN). A simple method to identify the RLN during thyroid surgery is described by the authors. It consists in palpation of the nerve caudally to the inferior pole of the thyroid, after the nerve has been made taut by the upward and medial traction of the thyroid gland. This method was used on 47 human cadavers and 45 patients with benign thyroid diseases. It made it possible to identify the RLN in all of the cadavers and 52 of the 55 identifications during 45 thyroidectomies (in 10 total thyroidectomies the identification was bilateral). Laryngeal motility was normal in all patients at postoperative laryngoscopy. Using the palpation before dissection in the region of the inferior thyroid artery, the traditional viewing method became easier and safer, reducing the risk of injury where it is most likely to occur to the nerve.

Laparoscopic sleeve gastrectomy as revisional surgery in a vertical gastroplasty with gastrogastric fistula: a simplified technique.

Gastrogastric fistula is one of the complications that can occur after vertical gastroplasty surgery for weight loss. We describe a novel sleeve gastrectomy technique to treat a proximal gastrogastric fistula after vertical gastroplasty.

Laparoscopic sleeve gastrectomy and left adrenalectomy with supragastric approach

A female patient, 48-year-old, with morbid obesity (body mass index 42.5 kg/m2) complicated by hypertension, T2DM, and severe Ostructive Sleep Apnea Syndrome was candidated to bariatric surgery. During the preoperative work-up, an abdominal ultrasonography and an RMN showed an incidental left adrenal tumor with a diameter of 11 cm. The laboratory evaluation for the functional adrenal tumor was negative. A laparoscopic sleeve gastrectomy and left adrenalectomy with supragastric approach was successfully carried out. The minimally invasive treatment of coexisting abdominal pathologies such as morbid obesity and adrenal incidentalomas seem to be suitable and safe, providing several benefits in terms of surgical and anesthesiologic management and postoperative clinical outcomes. The supragastric approach may represent a valuable option for left adrenalectomy combined with laparoscopic sleeve gastrectomy.