B. Schaeff

Tumor Seeding following Laparoscopy: International Survey

Abstract. The aim of the study was to determine if tumor seeding during laparoscopic surgery for cancer is a rare event or a typical complication of this procedure. Laparoscopic staging and treatment of intraabdominal tumors is increasing in gastroenterology, gynecology, and general surgery. A total of 1052 questionnaires were mailed to surgical department chairmen, members of the German Society of Surgery, Swiss Association for Laparoscopic and Thoracoscopic Surgery, and Austrian Society of Minimal Invasive Surgery asking them to list their departments experience with tumor seeding after laparoscopy for nonapparent or known malignancy. There were 607 (57.7%) surgeons who reported a total of 117,840 laparoscopic cholecystectomies, 409 incidental gallbladder carcinomas, and 412 laparoscopies on patients with colorectal carcinoma. Altogether 109 patients who developed tumor recurrence in connection with laparoscopic surgery have been reported. Port-site recurrence was identified in 70 of 409 patients (17.1%) with a median of 180 days following laparoscopic cholecystectomy for nonapparent gallbladder carcinoma. In 8 cases (11.5%) a protective plastic bag had been used for gallbladder retrieval. Six patients without port-site metastases were found to have a diffuse peritoneal carcinomatosis a median of 120 days after cholecystectomy. Of 412 laparoscopies for colorectal cancer, 19 cases (4.6%) of tumor seeding have been reported, 16 of which (3.9%) had documented port-site and scar recurrences a median of 196 days after laparoscopy. The tumor specimen was intact, and a plastic bag was used for extraction in seven cases. In 14 patients trocar-site metastases have been reported a median of 70 days after laparoscopy for different nonapparent or known malignancies. The probability of developing abdominal wall metastasis is higher after laparoscopy for cancer than after open surgery. An intact surgical specimen and the use of a plastic retrieval bag do not exclude the risk of port-site recurrences. These facts and the early appearance of peritoneal carcinosis in a few cases of intraabdominal malignancies seem to confirm a specific laparoscopic risk for intraperitoneal tumor cell seeding and implantation.

Gasless laparoscopy in abdominal surgery

Pneumoperitoneum, as a necessary precondition of laparoscopic procedures, represents a restriction of the surgeons freedom of movement and can lead to rare but typical complications. We describe our first experiences with laparoscopic surgery without using pneumoperitoneum. Under direct vision and digital control a fan-formed wall retractor, which is attached to an electric lift arm, is introduced into the abdominal cavity. After raising the abdominal wall, the scope is introduced through the same access and the laparoscopic procedure can be started without the technical and physiopathological problems which may occur using a pneumoperitoneum. In this gasless laparoscopic procedure, simple valveless trocars and instruments can be used. Furthermore, an unlimited suction can be obtained without a loss of exposure. During anesthesia, neither increased ventilation nor increased ventilation pressure is necessary, and the surgeon has increased freedom of action. Not only special laparoscopic instruments, but the conventional instruments, used in open surgery, can also be employed in gasless laparoscopy. In this way we performed gasless laparoscopic surgery on 54 patients: cholecystectomy (n=37), abdominal exploration for NSAP (n=5) or tumor staging (n=4), fenestration of liver cysts (n=5), and appendectomy (n=3). We did observe three wound infections as related complications. Six times, we had to change the surgical procedure. Compared to the traditional procedure with a CO2 pneumoperitoneum, the results of the first gasless procedures demonstrate potential advantages.

Laparoscopic surgery: The effects of insufflation gas on tumor-induced lethality in nude mice

OBJECTIVE The aim of the study was to examine the effect of helium (group 2), carbon dioxide (group 3), and heated carbon dioxide (group 4) pneumoperitoneum on survival in case of intraabdominal spread of tumor cells in nude mice. STUDY DESIGN The pneumoperitoneum was induced by a microhysteroflator with an intraperitoneal pressure of 8 mm Hg for 30 minutes. A washed tumor solution (0.4 ml) of a mesothelioma was injected intraperitoneally. RESULTS The survival rate of group 3 was significantly reduced compared with the controls (group 1) and group 4. The latter groups showed similar survival rates. In groups 2 and 3 no significant differences in survival rate were observed. CONCLUSION Clinical observations and the results of this animal study warn against the use of standard unheated carbon dioxide pneumoperitoneum in case of malignant tumors. Heated carbon dioxide seems to be advantageous.

Exposure of the operative field in laparoscopic surgery

Abstract. Endoscopic surgery, as a result of over 90 years of investigation, has now become the most innovative part of general surgery; every procedure in the thoracic and abdominopelvic cavity, intraperitoneal or extraperitoneal, has been reviewed for feasibility. The basic principles in the management of surgical patients, however, have not changed: adequate exposure and good lighting remain important and may become more important with endoscopic techniques. Historical review shows the dependence of advances in laparoscopy upon technical development in the field of intraabdominal exposure as the result of two objectives: namely abdominal wall displacement and bowel retraction.

Systems and instruments for laparoscopic surgery without pneumoperitoneum

Abstract. The insufflation of carbon dioxide into the peritoneal cavity is a routine technique of abdominal exposure in laparoscopic surgery. Because of adverse physiological effects and technical disadvantages of the pneumoperitoneum, alternative methods of abdominal wall lifting have been explored recently. Two groups of retraction systems exist: intraabdominal lifting and subcutaneous lifting of the abdominal wall. Some systems require additional pneumoperitoneum, because the extent of intraabdominal exposure is not sufficient. Other systems are working completely without gas insufflation. Two systems combine abdominal wall lifting with pressure on the internal organs. Every method allows the use of standard laparoscopic instruments, which originally were designed for a regular pneumoperitoneum. The use of a low-pressure pneumoperitoneum in combination with mechanical augmentation of the peritoneal cavity reduces physiological disadvantages of laparoscopy. But technical advantages, such as combination of laparoscopic and open techniques, can be realized only without gas insufflation. Conventional instruments have been designed to fit the ergonomical needs of isopneumic laparoscopy and to be employed with simple valveless cannulae.

Gasless laparoscopy – why and how?

SummaryThe pneumoperitoneum, generally used for all laparoscopic procedures, can lead to specific disadvantages and result in complications, and represents a restriction of the surgeons freedom of movement. Alternative methods to create sufficient abdominal exposure without pneumoperitoneum have been proposed all over the world. After a description of the most popular solutions, we describe our first experiences with an electromechanical retractor system for laparoscopic surgery. A fan formed wall retractor, which is attached to an electric lift-arm, is introduced into the abdominal cavity. After raising the abdominal wall, the laparoscopic procedure can be started without the technical and physiopathological problems which may occur using a pneumoperitoneum. In this way we performed gasless laparoscopic surgery on 121 patients: cholecystectomy (n = 78), abdominal exploration for NSAP (n = 6) or tumour staging (n = 12), fenestration of liver cysts (n = 7) and appendectomy (n = 18). In this gasless laparo...

Auswirkungen intraperitonealer CO2 Applikation auf die intraperitoneale Metastasierung

Im Rahmen des rasanten Fortschreitens der technischen Machbarkeit laparo kopischer Operationen verzeichnen wir in ihrem Gefolge eine deutliche Zunahme des Spektrums ihrer Indikationen. Auch maligne Erkrankungen stellen per se keine Kontraindikation dar, sondern sollen mit kurativer Intention laparoskopisch operiert werden. In der Literatur jedoch haufen sich die Berichte uber das fruhe, und zum Teil explosionsartige Auftreten intraperitonealer Metastasen laparoskopisch operierter Ovarialkarziome auf der einen Seite, und auf der anderen Seite findet sich in den letzten Jahren eine steigende Anzahl von Mitteilungen uber das Auftreten von Tumormetastasen in den Bergeinzisionen und den vormaligen Trokarkanalen [3]. Obgleich der pathogenetische Mechanismus, der diesem Geschehen zugrunde liegt bislang vollig unklar ist, wird eine unzureichende Operationstechnik, mit dadurch bedingter Kontamination von Instrumenten und Bauchhohle, dafur verantwortlich gemacht. Die Tatsache, das diese Rezidive nicht nur in den ehemaligen Bergeinzisionen auftreten, spricht dagegen, dies mit einer lediglich lokalen Verschleppung von Tumorzellen, bei der Entfernung des Tumors, hinreichend zu erklaren. Auf diesem Hintergrund stellt sich die Frage, inwieweit in der Anlage eines CO2, -Pneumoperitoneums, eine mogliche Ursache des vermehrten Tumorzellwachstums zu suchen ist. Tierexperimentell konnte gezeigt werden, das die Anlage eines langanhaltenden CO2-Peritoneums, zu zeitweise massiven Veranderungen des peritonealen Milieus, fuhrt [5]. Ob diesen beobachteten Veranderungen klinische Relevanz zukommt, last sich bislang noch nicht mit Sicherheit abschatzen. Im Rahmen der folgenden tierexperimentiellen Studie sollen daher die Auswirkungen eines CO2-Pneumoperitoneums auf die intraperitoneale Metastasierung untersucht werden.

Laparoskopische Hemifundoplicatio nach ThaI im Kindesalter unter Einsatz des Operationsroboters Da Vinci / Use of the Robotic System Da Vinci for Laparoscopic Hemifundoplication in Children

Um die Eignung des Robotersystems Da Vinci (Intuitive Surgical, California) fur die Kinderchirurgie zu uberprufen, fuhrten wir 5 Thal- und 3 Nissen-Operationen durch. Das Durchschnittsalter betrug 12 Jahre (7-16 J.). Alle Operationen wurden ohne Komplikationen und ohne Konversion zu offener Chirurgie durchgefuhrt. Die mittlere Operationszeit betrug 146 min. Die Vorteile des Robotereinsatzes liegen in einem echten hochqualitativen 3D-Bild, der hervorragenden Instrumentenbeweglichkeit mit intrakorporaler Artikulation und der ergonomischen Position des Operateurs, so das eine erhohte Prazision resultiert. Nach unserer Meinung ist das Robotersystem sicher und auch fur das Kindesalter geeignet, bezuglich der Instrumentenauswahl fur kleinere Altersgruppen aber noch entwicklungsfahig.

Die Technik der laparoskopischen Antireflux-Operation nach Thal

Die Thal Operation beinhaltet eine Hiatusplastik, sowie eine Hemifundoplikatio. Es werden vier 5 mm Trokare verwandt. Nach Darstellen des Hiatus erfolgt die re-troosophageale Hiatusplastik mit 2–3 nicht resorbierbaren Nahten, anschliesend wird die Milz mobilisiert und eine 2-reihige Hemifundoplikatio angeschlossen. Zur Vermeidung einer paraosophagealen Hernie wird dabei der Osophagus am Peritoneum fixiert.

The tensioKNOT instrument set for endoscopic ligation and suture-knot formation and application

SummaryIn minimally invasive surgery (MIS), intracorporal knot-tying becomes complicated due to the limited field of vision and depth perception. At the tip of the tensioKNOT instrument, there is a needle driver of 3 mm with a slipfit hollow knot pusher. The knot is extracorporally attached by the quick formation of three loops by hand. After intra-abdominal insertion, the stitch or ligation is performed under endoscopic vision. The knot is pushed onto the standing end of the thread, doubled in an additional loop, and tightened with the integrated knot pusher. This loop allows an increase in the reverse slipping force without troublesome instrument change. The feasibility of the instrument set and the strength of the knot were proved in pigs and in 48 cholecystectomies and hernia repairs in humans. The independent extracorporal formation of a knot on a second tensioKNOT instrument allows quick application of a secured slip knot, equivalent to the use of clips and staples. As a result, cost saving is high.