Antonio Garcia-Ruiz

Endoscopic endocrine surgery in the neck-An initial report of endoscopic subtotal parathyroidectomy

AbstractBackground: The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties. Methods: After experimental success in an animal model, we recently performed our first case of endoscopic subtotal parathyroidectomy in a 37-year-old man. The patient, who had a history of severe pancreatitis and pancreatic calculi, was diagnosed as having hyperparathyroidism. The option of endoscopic parathyroidectomy was proposed and accepted. After placing the first trocar directly under the platysma, a space was created by bluntly dissecting with the tip of a 5-mm endoscopic camera. Four parathyroid glands were identified, and after a frozen-section diagnosis of parathyroid hyperplasia, three-and-one-half of the glands were resected. Results: The patient developed slight hypercarbia and subcutaneous emphysema during the procedure, but no other problems were noted. His postoperative course was otherwise unremarkable. Conclusions: This is the first case reported of an endoscopic parathyroidectomy. This experience makes us optimistic about the future of endoscopic neck surgery.

Perioperative tumor localization for laparoscopic colorectal surgery

AbstractBackground: Because of the inability to palpate colonic tumors during laparoscopy, their location must be precisely identified before resection is undertaken. Method: A retrospective study was performed of 58 patients in order to be able to describe our methods of tumor localization for laparoscopic colorectal operations and to review their effectiveness. Results: In all patients, the entire colon was examined preoperatively by colonoscopy. In one patient, preoperative colonoscopic localization was inaccurate. In 31 patients, tumors were easily detectable at surgery. In five patients with the tumor in the right colon, even though the lesion was not detectable at surgery, right colectomy was performed without marking because preoperative colonoscopy reliably identified the lesion adjacent to the ileocecal valve. Twenty-two patients required some type of procedure to localize the tumor. The procedures and their problems were as follows: preoperative tattoo (five)—tattoo not visualized (one); intraoperative colonoscopy alone (six), combined with intraoperative tattoo (four) or clip (three)—poor operative exposure due to bowel distension (nine), hard to see the clip (three), dislodged clip (two), inadequate resection margin (one); intraoperative proctoscopy alone (two), combined with laparoscopic stitch (two)—no problems. In no patient was tumor present at a resection line and in no patient was the wrong segment resected. Conclusions: Reliable preoperative identification of the tumor adjacent to the ileocecal valve can permit right colectomy without marking. Lesions in the upper rectum can be approached via intraoperative proctoscopy ± suture placement. If the surgeon anticipates intraoperative localization may be difficult, lesions other than rectal or cecal ones should probably be marked by preoperative tattooing. Further studies regarding the technique of tattooing are warranted.

Laparoscopic total abdominal colectomy with ileorectal anastomosis for familial adenomatous polyposis

PURPOSE: This study was undertaken to describe our results in a series of patients undergoing total abdominal colectomy with ileorectal anastomosis (TAC/IRA) using laparoscopic techniques in patients with familial adenomatous polyposis (FAP) and rectal-sparing. Young patients with FAP requiring TAC/IRA may be ideal candidates for minimally invasive surgery, because they are generally thin and have benign disease. They might benefit maximally from the theoretic advantages of these techniques. METHODS: We have performed laparoscopic TAC/IRA in 16 FAP patients (10 females; mean age, 18 years). Procedures were entirely intracorporeal, with a 3-cm to 6-cm specimen extraction incision. RESULTS: Median operative time was 232 (range, 156–285) minutes, and blood loss 175 (range, 50–675) ml. The only intraoperative complication, a twisted ileorectal anastomosis, was noted intraoperatively and revised. There were no conversions to conventional laparotomy. Median postoperative interval to passage of flatus was three days,1–4 and for bowel movements it was three days.1–4 Median hospital stay was five days.3–11 One case of early postoperative small-bowel obstruction was treated nonoperatively, and one case of brachial plexus neuropraxia resolved spontaneously. CONCLUSIONS: Based on this preliminary experience, we believe laparoscopic TAC/ IRA can be a safe and effective treatment for selected patients with FAP. As techniques and instrumentation for laparoscopic colon surgery are perfected, this procedure will likely become an appealing option in the management of patients with FAP.

Laparoscopic techniques for fecal diversion

Although the role of laparoscopic techniques in performing major colorectal resections is unclear, laparoscopy may be well suited for fecal diversion procedures because no resection and minimal tissue dissection is required. PURPOSE: This report reviews our initial experience with laparoscopic stoma procedures to assess safety and efficacy. METHODS: Using a simple two-cannula technique, 24 such procedures (16 loop ileostomies, 6 end sigmoid colostomies, 1 transverse, and 1 sigmoid loop colostomy) were attempted. Indications for diversion were rectovaginal fistula (7), perianal sepsis (7), incontinence (4), advanced rectal or colon carcinoma (4), and complicated pelvic infection (2). There were 15 females and 9 males with a median age of 44 (range, 25–88) years. RESULTS: Median operative time was 60 (range, 20–120) minutes, and median blood loss was 50 (range, 0–150) ml. There were no intraoperative complications. One case was converted to a laparotomy because of dense adhesions. Median time to passage of both flatus and stool was one (range, 1–3) day for ileostomy patients, two (range, 2–4) days for flatus, and 3 (range, 2–6) days for stool after colostomy. Median time to discharge was 6 (range, 2–28) days and was often delayed by the primary disease process or ostomy teaching. One major postoperative complication, a pulmonary embolism, occurred eight days after operation in a patient with near obstructing, widely metastatic colon carcinoma. This patient later died of pulmonary failure. All stomas have functioned well, with no revisions required. CONCLUSIONS: Laparoscopic fecal diversion procedures can be performed safely, simply, and effectively. Apparent advantages over standard techniques are avoidance of a laparotomy, while maintaining the ability to precisely identify and orient the pertinent bowel segment and rapid return of bowel function.

Robotically assisted laparoscopic microsurgical uterine horn anastomosis

OBJECTIVE To evaluate the feasibility, safety, and sterility issues with regard to the use of a robotic device to perform uterine horn anastomosis in a live porcine model. DESIGN Prospective animal study. SETTING Landrace-Yorkshire pigs in a conventional laboratory setting. INTERVENTION(S) Six female pigs underwent laparoscopic bipolar electrocoagulation of the distal uterine horns. Two weeks later, the uterine horns were reanastomosed laparoscopically with use of a robotic system for microsuturing. Necropsy was performed 4 weeks later to assess postoperative adhesions and anastomosis patency. MAIN OUTCOME MEASURE(S) Tubal patency; secondary measures were operative time, complications, and surgeon fatigue. RESULT(S) The mean (+/-SD) total operative time per animal was 170+/-34 minutes including setting up and dismantling the robotic arms. The robot functioned well with only minor technical problems. All pigs survived both surgeries with no perioperative complications related to the use of the robot. Patency was confirmed after completing each anastomosis (12 anastomoses; 100% patency). Four weeks later, necropsy showed that eight anastomoses were still patent (67%). Only one pig had bilateral occlusion. Surgeons fatigue was mild for each animal study. CONCLUSION(S) Robotic technology can be used safely in creating laparoscopic microsurgical anastomoses. The robot functioned properly in a sterile operating room environment. Adequate patency rates were achieved during the acute phase and at 4-week follow-up. Robotic technology has the potential to make laparoscopic microsuturing easier.

Right colonic arterial anatomy. Implications for laparoscopic surgery.

PURPOSE: Hemorrhagic complications can be a major cause of conversion and/or morbidity during laparoscopic intestinal surgery. The limited exposure currently provided in laparoscopic intestinal resection demands a precise knowledge of mesenteric vascular anatomy to avoid such complications and to expedite the procedure. Most surgical texts depict a “normal pattern” of arterial supply to the right colon consisting of three arterial branches (ileocolic artery, right colic artery, and middle colic artery) arising independently from the superior mesenteric artery (SMA). Based on previous reports and clinical observations, we hypothesized that the right colic artery arises infrequently from the SMA, and most commonly, there are only two colonic arteries arising independently from the SMA. METHODS: We performed detailed dissections of the SMA in 56 human cadavers. RESULTS: We found the ileocolic artery in all of our cases and the middle colic artery in 55 of 56 cadavers but only six cases of a right colic artery emanating directly from SMA. CONCLUSIONS: Our data, combined with review of published anatomic studies, lead us to conclude that in the vast majority of cases there are only two independent branches arising from SMA that supply the large intestine, the ileocolic and the middle colic arteries. The right colic artery directly arising from SMA is unusual (10.7 percent). This knowledge may help lower the risk of vascular complications during laparoscopic intestinal surgery.

Hand-assisted laparoscopic digestive surgery provides safety and tactile sensation for malignancy or obesity

AbstractBackground: Some of the persistent problems associated with laparoscopic surgery stem from the inability of the surgeon to palpate the abdominal contents during the operation. This lack of tactile sensation can lead to poor abdominal exploration, difficulty in extracting the organs, and a relatively long operation time compared to conventional procedures. The Dexterity Pneumo Sleeve is a new device that allows the surgeon to insert his or her hand into the abdominal cavity through a small incision while preserving the pneumoperitoneum. Methods: Recently, 13 of our patients underwent hand-assisted advanced laparoscopic surgery using this device. In this series, we had two cases of gastrectomy, two cases of gastric bypass for morbid obesity, two Whipple cases for periampullary tumor, and seven cases of bowel resection. On the basis of this series, we were able to assess the utility of this device. Results: Satisfactory pneumoperitoneum was maintained in 12 of 13 cases. The length of the skin incision was 7.8 cm on average, which was almost the same size as surgeons glove. The device proved to be very useful for tissue retraction and abdominal exploration in all cases and for intracorporeal knot tying in some cases. Conclusions: We found that the device permitted an easier dissection, resection, and anastomosis. It also helped to decrease the operation time.

Gastrointestinal transit and stress response after laparoscopic vs conventional distal pancreatectomy in the canine model

AbstractsBackground: Several authors have presented the feasibility of laparoscopic pancreatic surgery. However, the pathophysiological effect of laparoscopic pancreatic surgery is not well known. Methods: Ten mongrel dogs were randomly operated for laparoscopic and conventional distal pancreatectomy. Fed state gastrointestinal transit times were assessed using radiopaque markers. To assess surgical stress, we determined serum IL-1 and cortisol. Results: Postoperative mouth-to-anus transit time in the laparoscopic group was not prolonged while it was significantly prolonged in the conventional group compared with the baseline study, but no significant differences between groups were detected. First defecation was observed significantly earlier in the laparoscopic group. Serum cortisol levels were elevated significantly at 4 h after skin incision in both groups and decreased thereafter. In the laparoscopic group, they returned close to the normal level at 8 h after incision, but were still significantly higher in the conventional group. The level of IL-1 was elevated significantly higher in conventional group at 24 h after the skin incision. Conclusion: Thus, we conclude that laparoscopic distal pancreatectomy demonstrated faster recovery of the bowel transit and less stress than conventional distal pancreatectomy in dogs.

Missed lipoma of the spermatic cord. A pitfall of transabdominal preperitoneal laparoscopic hernia repair.

AbstractBackground: Missed lipoma of the spermatic cord is a pitfall unique to the transabdominal preperitoneal (TAPP) laparoscopic hernia repair. This problem occurs when a palpable inguinal mass is noted preoperatively, but no identifiable hernia defect is found at time of laparoscopy and the procedure is terminated. Methods: Our group encountered six patients without intraperitoneal defects that had large cord lipomas on preperitoneal exploration. Two of these patients had undergone previous intraabdominal laparoscopy for a proposed TAPP repair, which was aborted when no defect was seen. Results: Both patients were referred for continued symptomatic groin masses, which were subsequently treated by lipoma resection in conjunction with inguinal floor repair. Conclusions: When patients present with a groin mass, exploration of the preperitoneal space and cord structures is indicated during TAPP repair, even in the presence of a normal-appearing abdominal floor. Abandoning a transabdominal approach without exploration of the preperitoneal structures may lead to a failure to identify symptomatic and/or palpable cord lipomas.

Laparoscopic hernia repair enhances early return of physical work capacity

Several researchers have documented less postoperative pain and a quicker return to daily activities after laparoscopic herniorrhaphy. However, little objective data that validates this hypothesis exists. This study compares the rate of postoperative physical work capacity with return to preoperative levels, which is measured by a standard treadmill test in patients who underwent laparoscopic and conventional open hernia repair. Patients completed a 6-minute walking test preoperatively and 1 week postoperatively using a nonmotorized treadmill. The distance walked was recorded. If the distance that a patient achieved at 1 week was not within 0.02 miles of the preoperative values of the patient, the patient was asked to return at 1 month for repeat testing. Patients were enrolled prospectively in this study from October 1997 to February 1999. Sixty-six patients participated in the study (27 laparoscopic herniorrhaphies and 39 open herniorrhaphies were performed). There was no significant difference in age, body mass index, or preoperative distance achieved among the two groups. At 1 week, patients who underwent laparoscopic repair demonstrated a mean increase of 18 meters from preoperative distance (P = 0.07). In the open group, patients demonstrated a mean decrease of 90 meters at 1 week (P = 0.001). The change in distance at 1 week between the laparoscopic and the open groups was statistically significant (P = 0.001). However, at 1 month, there was no significant difference among the two groups. Measured using treadmill walking, laparoscopic hernia repair seems to offer an early advantage to open repair in return-to-physical-work capacity.