Avraham Schlager

Single-incision laparoscopic cholecystectomy: lessons learned for success.

Since its introduction approximately 20 years ago, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis [1–3]. Conventional laparoscopic cholecystectomy generally is performed through four small incisions in the abdominal wall [4]. In recent years, a less invasive method has been sought in an effort to reduce postoperative pain and morbidities such as wound infection and trocar-site hernias while further enhancing the cosmetic results. Initial attempts to perform the procedure through three and then two ports or with reduced-diameter trocars (needlescopic surgery) [5–9] have since been superseded by even less invasive and more innovative techniques, namely, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) [10–13]. Single-incision laparoscopic surgery is an attractive technique for cholecystectomy due to its superior cosmetic results and potential to reduce the rate of wound complications such as infection, hematoma, and hernia. This technique, however, is not straightforward. The technical complexity of SILS naturally results in a steep learning curve and increased operating room time and requires specialized equipment. The primary technical obstacles of SILS currently include Collision of instruments both within and outside the abdomen as a result of their common entry point (“sword fighting”) Inadequate triangulation Compromised field of view due to obstruction by instruments entering the common port Inadequate exposure and retraction. Several techniques have since evolved to overcome these potential pitfalls [14–16]. By incorporating a number of these techniques, we have created a simplified technique that has proved successful with both animal and human subjects. We describe both our experience and what we have learned, which have allowed simplification of a technical complex procedure.

Providing more through less: current methods of retraction in SIMIS and NOTES cholecystectomy

BackgroundAs the field of minimally invasive surgery continues to develop, surgeons are confronted with the challenge of performing conventional laparoscopic surgeries through fewer incisions while maintaining the same degree of safety and surgical efficiency. Most of these methods involve elimination of the ports previously designated for retraction. As a result, minimally invasive surgeons have been forced to develop minimally invasive and ingenious methods for providing adequate retraction for these procedures. Herein we present our experience using endoloops and internal retractors to provide retraction during Single Incision Minimally Invasive Surgery (SIMIS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy. We also present a review of the alternative retraction methods currently being employed for these surgeries.MethodsSIMIS was performed on 20 patients and NOTES was performed on 5 patients at our institution. Endoloops or internal retractors were used to provide retraction for all SIMIS procedures. Internal retractors provided retraction for all NOTES procedures.ResultsSuccessful cholecystectomy was accomplished in all cases. One SIMIS surgery required conversion to standard laparoscopy due to complex anatomy. There were no intraoperative complications. Although adequate retraction was accomplished in all cases, the internal retractors were found to provide superior and more versatile retraction compared to that of endoloops.ConclusionAdequate retraction greatly simplifies SIMIS and NOTES surgery. Endograb internal retractors were easy to use and were found to provide optimal retraction and exposure during these procedures without complications.

Malignant Appendiceal GIST: Case Report and Review of the Literature

IntroductionGastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only a handful has been described in the literature, all of which have been of the benign type.Case ReportWe present the first reported case of a malignant appendiceal GIST. The tumor was discovered when the patient presented with a peri-appendiceal abscess which appeared suspicious on CT. The abscess was drained and managed medically. The patient responded to antibiotic treatment but subsequent CT and biopsy confirmed the diagnosis of appendiceal GIST, and the patient was started on treatment with imatinab mesylate.DiscussionOne week after initiation of therapy, the patient returned with frank peritonitis necessitating surgery. Abdominal exploration revealed an appendiceal GIST locally invading and perforating adjacent bowel. We describe the complex presentation and course of the case as well as a literature review of the appendiceal GISTs and the current approach to treatment.

Miniature Camera for Enhanced Visualization for Single-Port Surgery and NOTES

OBJECTIVE Natural orifice translumenal endoscopic surgery (NOTES) and single-port surgery (SPS) have maximized the enhanced aesthetic profile of laparoscopic surgery. Nevertheless, these modalities also accentuate the inherent limitations of subvisibility and decreased instrument dexterity of motion. The goal of this study was to evaluate the utility of a miniature laparoscopic camera to alleviate these obstacles. MATERIALS AND METHODS A miniature laparoscopic camera was inserted via an endoscopic working channel or embedded into laparoscopic tools. Following laparoscopic trainer studies, operations were conducted on pigs using standard laparoscopic, SPS, and NOTES approaches. Additionally, the camera was used to perform colonoscopies on mice, rats, and pigs. RESULTS The camera enabled visualizing the dissection area behind the renal vessels during laparoscopic nephrectomy and in the Triangle of Calot in laparoscopic cholecystectomy while providing accurate and detailed visualization of the operative field. The camera was successfully passed through the working channel of a standard gastroscope and used during NOTES procedures. It was used during colonoscopy to evaluate the distal colon in pigs and allowed the diagnosis of small colonic polyps with good image quality. Additionally, it could be easily passed beyond colonic strictures created in a porcine model. Finally, its miniature size enabled performance of colonoscopies on rats serving as animal models for colonic polyps. CONCLUSIONS The miniature laparoscopic camera provides adequate images with enhanced visibility in conventional laparoscopic, SPS, and NOTES procedures. We believe that this device or similar miniature cameras may greatly aid the future development of NOTES and SPS by enhancing the safety and ease of performing these procedures. Further development is being conducted in order to integrate this camera into standard instruments and to allow an even better image quality.

Laparoscopic Infrared Imaging—The Future Vascular Map

OBJECTIVE One of the most significant limitations of laparoscopic surgery is the inability to achieve tactile assessment of structures during surgical dissection. Because blood vessels are naturally warmer than their surroundings, infrared (IR) detection can be highly effective in identifying and mapping out their course. In recent years, IR detection has been used successfully for this purpose in open surgery. Nevertheless, this technology has to be yet employed in laparoscopic surgery, where its contribution would be greatest. METHODS We performed a feasibility study using this technology on live porcine models. After insertion of IR detectors into the insufflated abdomen, we performed a series of laparoscopic procedures. During these operations we evaluated the ability of the IR detector to identify blood vessels as well as the effects of local and systemic changes in temperature. RESULTS The IR detector successfully identified concealed blood vessels as well as acute bleeding. Cool lavage and insufflation with room-temperature CO(2) accentuated IR detection of blood vessels, whereas warm CO(2) and systemic temperature changes did not affect detection. Additionally, localized heating of tissue on the operative field using electrocautery did not interfere with IR sensitivity. CONCLUSION Laparoscopic IR imaging is a feasible method of blood vessel detection in laparoscopic procedures. Use of IR blood vessel detection in laparoscopy has a potential to enable safer surgery and reduce operative time. Fusion of IR imaging with the standard laparoscopic view is currently being developed to allow real-time vessel mapping during laparoscopic procedures.

Plasma Factor in Red Blood Cells Adhesion to Endothelial Cells: Humans and Rats

Erythrocyte adhesion to the vascular endothelium is one of the key determinants of microcirculatory blood flow. Adhesion is a complex process determined by the intricate interaction among red blood cells (RBC), plasma factors, and the vascular endothelium. Rats are commonly used as disease models to investigate the pathophysiology of various hematological disease processes occurring in humans and their response to prospective treatments. The aim of our study was to characterize the adhesion of RBC in adult blood from rat and human subjects, in order to test the validity of rat models for adhesion-related disease processes. We demonstrated that adhesion of RBC from rats (rRBC), to endothelial cells (EC) in plasma-free buffer, is stronger than from human subjects (hRBC). In addition, plasma proteins induced elevation of hRBC (eightfold) but depression of rRBC (threefold) adhesion to EC. It is thus suggested to be aware of the difference in RBC/EC interaction for human and rat subjects, when studying models of blood flow.

An Endoscopic Repair Option for Acquired Esophagorespiratory Fistulas

Benign acquired esophagorespiratory fistulas (BERFs) represent a broad spectrum of anatomic pathology presenting in a wide variety of clinical settings. These fistulas can lead to severe respiratory compromise and rarely close spontaneously. Surgical fistula closure has been the traditional therapeutic approach, but is associated with significant morbidity and mortality. The recent advent of endoscopic technologies suggests that minimally invasive procedures may offer a safe alternative to surgery for the treatment of esophagorespiratory fistulas. In this article, we present our experience in treating complex benign esophagorespiratory fistulas of diverse etiologies utilizing a primarily minimal invasive, endoscopic, or combined surgical and endoscopic approaches. Our experience demonstrates that an endoscopic-based approach is safe and technically feasible and can, potentially, spare a subset of patients from open surgery. A multidisciplinary decision-making process, based on individualized parameters, is a prerequisite for a successful outcome.

Revascularization of the celiac and superior mesenteric arteries after operative injury using both splenic artery and saphenous graft.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.

Renal clear cell carcinoma emerging in a transplanted kidney 3 years after return to dialysis. Case report and review of the literature

We present a female patient with end-stage renal disease who was referred to the emergency department with sudden, excruciating pain over the right lower abdomen and flank. Radiologic evaluation following admission revealed a mass, solid in nature, located at the upper pole of the transplanted kidney. The patient was treated with empiric antibiotics and analgesics, and her symptoms subsided over the course of the week. Based on the clinical course and radiological findings, a self-limiting, spontaneous haemorrhage was thought to be the cause of the patients symptoms. Nevertheless, background malignancy could not be ruled out. Therefore, an interval, elective graft nephrectomy was scheduled. Pathology confirmed the diagnosis of renal clear cell carcinoma.