C Moretto

Thrombosis in the portal venous system after elective laparoscopic splenectomy

BackgroundThe occurrence of thrombosis in the portal system is an underappreciated complication of splenectomy. Presenting symptoms are usually mild and nonspecific. The short hospital stay associated with the laparoscopic approach could delay the early diagnosis of this condition unless routine imaging controls are planned after discharge.MethodsThe records of 40 patients who underwent laparoscopic splenectomy at our institution were reviewed for clinical signs of thrombosis in the portal system and associated factors. All patients were also enrolled in a color Doppler ultrasound surveillance program.ResultsNine patients (22.5%) developed thrombosis of the splenic vein, progressing to the portal vein in five cases (12.5%). Six patients (15%) were symptomatic. Thrombosis occurred even as late as 4 months after splenectomy. Spleen weight was the only significant factor predictive of postoperative thrombosis. The combination of splenomegaly and an elevated preoperative platelet count was associated with a 75% incidence of this complication.ConclusionThe high risk of thrombosis after the laparoscopic resection of large spleens should prompt strict postoperative imaging surveillance, combined with a more aggressive anticoagulation prophyaxis.

Robotic suture of a large caval injury caused by endo-GIA stapler malfunction during laparoscopic wedge resection of liver segments VII and VIII en-bloc with the right hepatic vein

Primary endo-GIA stapler malfunction occurred during robotic wedge resection of liver segments VII and VIII en-bloc with the right hepatic vein, in an obese woman diagnosed with single liver metastasis from a previous carcinoid tumour. Haemorrhage was soon controlled by clamping the vena cava below the injury using two wristed forceps angled at 90°. With the two instruments locked in the holding position the ensuing operative strategy was discussed between surgeon and anaesthesia teams. Using the third robotic arm the caval injury was repaired laparoscopically with interrupted polypropylene sutures. The patient was transfused with two units of packed red blood cells, recovered uneventfully, and was discharged on post-operative day five. We conclude that even the most advanced technologies can fail and that surgeons should be fully aware of the consequences of these malfunctions and be prepared for repair. From this point of view, the da Vinci surgical system seems to have some advantages over classical laparoscopic methods including the ability to lock the wristed instruments in the holding position, the use of three arms by the same operating surgeon, and the extreme facilitation of intracorporeal suturing and knot-tying in deep and narrow spaces, extremely difficult if not impossible with conventional laparoscopic instruments.

Laparoscopic distal pancreatomy: are we ready for a standardized technique?

This paper describes and discusses the surgical steps needed to perform a laparoscopic distal pancreatectomy. The current lack of standardization of the operative technique can account for the limited diffusion of this procedure. The issue of spleen preservation, which cannot be overemphasized, always demands an accurate surgical technique that results from proficiency both in open pancreatic surgery and advanced laparoscopy. The preservation of the splenic vessels or short gastric-vessel salvage is feasible, yet with different indications. Also, the splenic-vessels preservation procedure has two distinct technical options. The technique of occlusion of the pancreatic stump is crucial for reducing the risk of a post-operative fistula and should be tailored to the structural features of the gland at the transection line. Finally, the hand-assisted approach can provide distinctive advantages over the pure laparoscopic technique in selected circumstances.

Laparoscopic and Hand-Assisted Laparoscopic Live Donor Nephrectomy

Renal grafts from living donors represent an important source of organs, particularly for young patients with chronic renal failure. Laparoscopic donor nephrectomy is a relatively new technique, which has the potential to increase the pool of available kidney grafts by removing some disincentives to live donation. The technique used for left kidney donation at our center, the first to introduce laparoscopic live donor nephrectomy in Italy, is described in this report. To further reduce warm ischemia time, the kidney is preloaded inside the extraction bag and 2 staplers are used to transect the renal artery and vein. The spread of the new technique in our country and in the rest of Europe is likely to raise the issue of training in laparoscopic surgery for transplant surgeons. Copyright

Total Duodenectomy with Enteric Duct Drainage: A Rescue Operation for Duodenal Complications Occurring after Pancreas Transplantation

Duodenal graft complications (DGC) occur frequently after pancreas transplantation but rarely cause graft loss. Graft pancreatectomy, however, may be required when DGC compromise recipients safety. We herein report on two patients with otherwise untreatable DGC in whom the entire pancreas was salvaged by means of total duodenectomy with enteric drainage of both pancreatic ducts. The first patient developed recurrent episodes of enteric bleeding, requiring hospitalization and blood transfusions, starting 21 months after transplantation. The disease causing hemorrhage could not be defined, despite extensive investigations, but the donor duodenum was eventually identified as the site of bleeding. The second patient was referred to us with a duodenal stump leak, 5 months after transplantation. Two previous surgeries had failed to seal the leak, despite opening a diverting stoma above the duodenal graft. Thirty‐nine and 16 months after total duodenectomy with dual duct drainage, respectively, both patients are insulin‐independent and free from abdominal complaints. Magnetic resonance pancreatography shows normal ducts both basal and after intravenous injection of secretin. The two cases presented herein show that when DGC jeopardize pancreas function or recipient safety, total duodenectomy with enteric duct drainage may become an option.

How does a surgeon’s brain buzz? An EEG coherence study on the interaction between humans and robot

IntroductionIn humans, both primary and non-primary motor areas are involved in the control of voluntary movements. However, the dynamics of functional coupling among different motor areas have not been fully clarified yet. There is to date no research looking to the functional dynamics in the brain of surgeons working in laparoscopy compared with those trained and working in robotic surgery.Experimental proceduresWe enrolled 16 right-handed trained surgeons and assessed changes in intra- and inter-hemispheric EEG coherence with a 32-channels device during the same motor task with either a robotic or a laparoscopic approach. Estimates of auto and coherence spectra were calculated by a fast Fourier transform algorithm implemented on Matlab 5.3.ResultsWe found increase of coherence in surgeons performing laparoscopy, especially in theta and lower alpha activity, in all experimental conditions (M1 vs. SMA, S1 vs. SMA, S1 vs. pre-SMA and M1 vs. S1; p < 0.001). Conversely, an increase in inter-hemispheric coherence in upper alpha and beta band was found in surgeons using the robotic procedure (right vs. left M1, right vs. left S1, right pre-SMA vs. left M1, left pre-SMA vs. right M1; p < 0.001).DiscussionOur data provide a semi-quantitative evaluation of dynamics in functional coupling among different cortical areas in skilled surgeons performing laparoscopy or robotic surgery. These results suggest that motor and non-motor areas are differently activated and coordinated in surgeons performing the same task with different approaches. To the best of our knowledge, this is the first study that tried to assess semi-quantitative differences during the interaction between normal human brain and robotic devices.

Grasping and dissecting instrument for hand-assisted laparoscopic surgery: development and early clinical experience.

BackgroundThe operative potential of hand-assisted laparoscopic surgery (HALS) could be enhanced by the introduction of a new generation of assisting instruments. These tools will have to meet specific requirements of shape, function, and safety of use.MethodsProblems related to the working environment of HALS and deriving projectual restrictions of HALS instruments were analyzed in order to develop and manufacture a working prototype with grasping and dissecting properties to assist during HALS procedures. The resulting instrument was mechanically and clinically tested in 22 HALS procedures.ResultsThe additional benefit of the new device was particularly appreciated during dissection and isolation of vascular pedicles (nephrectomies and splenectomies). It was shown to be safe and effective in providing the additional assistance it was designed for.ConclusionThe described grasping and dissecting instrument for HALS is of great value in assisting the surgeon during fine dissection, as required in selected procedures. New generation of HALS instruments should comply with the functional and safety issues analyzed in this report.

Role of color Doppler sonography in post-transplant surveillance of vascular complications involving pancreatic allografts

PURPOSE To evaluate the role of color Doppler ultrasonography in the postoperative surveillance of the vascular complications involving pancreas allografts. METHODS A retrospective analysis of a consecutive series of 223 pancreas transplantations was performed. All recipients received antithrombotic prophylaxis, which was tailored to the individuals estimated risk of thrombosis. All patients were monitored with daily color Doppler ultrasonography during the first post-transplant week and thereafter whenever clinically indicated. Vascular complications were defined as all thrombotic events requiring: increased anticoagulant therapy, angiography with fibrinolytic therapy, or repeat surgery. RESULTS The overall patient survival rates at one, three, and five years after transplantation were 94.7%, 93.3%, and 91%, respectively. The overall graft survival rates at the same time points were 87.4%, 79.6%, and 75.6%, respectively. In 28 of the 223 cases (12.5%) graft thromboses were diagnosed with Doppler ultrasound within the first 10 days after transplantation. In 3 cases, graft pancreatectomies were performed because of a complete loss of blood flow in the parenchyma. An attempt to rescue the graft was made in 18 patients. Fourteen of these grafts were saved and are still functioning (77.7%); and 4 rescue attempts failed and the grafts were subsequently explanted (32.3%). CONCLUSION Color Doppler ultrasound is a suitable tool for postoperative surveillance of pancreas transplant recipients. Its use can lead to early diagnosis and timely treatment of vascular complications.

PANCREAS TRANSPLANT ALONE IN TYPE 1 DIABETIC RECIPIENTS WITH OVERT DIABETIC NEPHROPATHY: RENAL FUNCTION OUTCOME: 2378

U. Boggi1, F. Vistoli1, C. Croce1, S. Signori1, C. Moretto1, M. Del Chiaro1, G. Amorese2, M. Barsotti3, P. Marchetti4 1Azienda Ospedaliero-universitaria Pisana, U.O. Chirurgia Generale e Trapianti, Pisa/ITALY, 2Azienda Ospedaliero-universitaria Pisana, U.O. Anestesia e Terapia Intensiva, Pisa/ITALY, 3Azienda Ospedalierouniversitaria Pisana, U.O. Nefrologia e Dialisi con Trapianti, Pisa/ITALY, 4Azienda Ospedaliero-universitaria Pisana, S.V.D. Endocrinologia e Metabolismo dei Trapianti d’Organo e Cellulari, Pisa/ ITALY

OUTCOME OF PANCREAS TRANSPLANTATION WITH 5 YEARS FOLLOW-UP OR MORE: 2312

F. Vistoli1, C. Croce1, S. Signori1, C. Moretto1, M. Del Chiaro1, G. Amorese2, M. Barsotti3, P. Marchetti4, U. Boggi1 1Azienda Ospedaliero-universitaria Pisana, U.O. Chirurgia Generale e Trapianti, Pisa/ITALY, 2Azienda Ospedaliero-universitaria Pisana, U.O. Anestesia e Terapia Intensiva, Pisa/ITALY, 3Azienda Ospedalierouniversitaria Pisana, U.O. Nefrologia e Dialisi con Trapianti, Pisa/ITALY, 4Azienda Ospedaliero-universitaria Pisana, S.V.D. Endocrinologia e Metabolismo dei Trapianti d’Organo e Cellulari, Pisa/ ITALY