C. N. Gutt

Fewer adhesions induced by laparoscopic surgery

BackgroundLaparoscopic surgery has potential theoretical advantages over open surgery in reducing the rate of adhesion formation, but very few comparative studies are available to prove this.MethodsA literature search was performed within Medline and Cochrane databases using the key words: adhesion*, adhesiolysis, laparoscop*, laparotomy, open surgery. Further articles were identified from the reference lists of retrieved literature. Both clinical and experimental studies comparing laparoscopy and laparotomy with regard to adhesion formation were retained. In each article, the rates of adhesion formation were identified or deduced for the operative site, access wound site, and distant sites.ResultsFifteen studies from 1987 to 2001 were identified. Most studies assessed the operative site. Thus, three clinical studies and six experimental ones found fewer adhesions following laparoscopy than laparotomy, while other five experimental studies found similar adhesion rates for the two surgical methods. There were fewer adhesions to trocar wounds than to the laparotomy wounds in seven studies and equal rates of adhesion in one study. The problem of distant adhesions is poorly represented in literature; three studies favored laparoscopy as being followed by fewer adhesions. Because of the important differences between studies with regard to the design, end points, and statistical calculations, a metaanalysis could not be achieved. The conclusion is based on the prevalence of evidence.ConclusionsAll clinical studies and most of the experimental studies found a reduction of adhesion formation after laparoscopic surgery compared to open surgery.

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.

Portal venous flow during CO2 pneumoperitoneum in the rat

AbstractBackround: CO2 gas insufflation is routinely used to extend the abdominal wall. The resulting pneumoperitoneum has a number of local and systemic effects on the organism. Portal blood flow, which plays an important role in hepatic function and cell-conveyed immune response, is one of the affected parameters. Methods: An established animal model (rat) of laparoscopic surgery was modified by implanting a perivascular flow probe. Hemodynamics in the portal vein were then measured during increasing intraabdominal pressure generated by carbon dioxide insufflation. Results: Using this technique, an adequate flowmetry of the portal vein was achieved in all animals. The creation of a CO2 pneumoperitoneum with increasing intraabdominal pressure led to a linear decrease in portal venous flow. Conclusions: Elevated intraabdominal pressure caused by carbon dioxide insufflation may compromise hepatic function and cell-conveyed immune response during laparoscopic surgery.

The phagocytosis activity during conventional and laparoscopic operations in the rat : A preliminary study

AbstractBackground: Numerous experimental and clinical investigations indicate that the mononuclear phagocyte system (MPS) has a relevant function in terms of physiological defense against tumor metastasis and bacterial infection. Consequently, a point of major interest is the influence of surgical techniques on the MPS function. Method: The model investigation examines the phagocytosis activity of the rats MPS during conventional fundoplication (group 1, n= 10), laparoscopic fundoplication using a pneumoperitoneum (group 2, n= 10), and gasless laparoscopic fundoplication (group 3, n= 10). The MPS function is evaluated by an intravascular carbon clearance test (G. Biozzi). Results: The fastest carbon elimination half-life was found in group 3. By way of contrast, there was a significant increase of carbon half-life in group 2 (p < 0.005). Even group 1 caused less MPS depression (p < 0.1) than group 2. Conclusion: Gasless laparoscopic procedures have a favorable effect on phagocytosis activity. The CO2 pneumoperitoneum seems to be the main reason for a decreased antigen elimination in laparoscopic treatments.

Effect of insufflation gas and intraabdominal pressure on portal venous flow during pneumoperitoneum in the rat

BackgroundCarbon dioxide, the primary gas used to establish a pneumoperitoneum, causes numerous systemic effects related to cardiovascular function and acid-base balance. Therefore, the use of other gases, such as helium, has been proposed. Furthermore, the pneumoperitoneum itself, with the concomitant elevation of intraabdominal pressure, causes local and systemic effects that have been only partly elucidated. Portal blood flow, which plays an important role in hepatic function and cell-conveyed immune response, is one of the affected parameters.MethodsAn established animal model (rat) of laparoscopic surgery was extended by implanting a periportal flow probe. Hemodynamics in the portal vein were then measured by transit-time ultrasonic flowmetry during increasing intraabdominal pressure (2–12 mmHg) caused by gas insufflation (carbon dioxide vs helium).ResultsThe installation of the pneumoperitoneum with increasing intraperitoneal pressure led to a significant linear decrease in portal venous flow for both carbon dioxide and helium. At higher pressure levels (8–12 mmHg), portal blood flow was significantly lower (1.5–2.5-fold) during carbon dioxide pneumoperitoneum. An intraabdominal pressure of 8 mmHg caused a decrease to 38.2% of the initial flow (helium, 59.7%); whereas at 12 mmHg, portal flow was decreased to 16% (helium, 40.5%).ConclusionElevated intraabdominal pressure generated by the pneumoperitoneum results in a reduction of portal venous flow. This effect is significantly stronger during carbon dioxide insufflation. Portal flow reduction may compromise hepatic function and cell-conveyed immune response during laparoscopic surgery.

Totally endoscopic Nissen fundoplication with a robotic system in a child.

A 67-year-old woman presented with severe cardiopulmonary insufficiency 17 days after an uneventful laparoscopic cholecystectomy. Pulmonary thromboembolism was demonstrated by transthoracic echocardiogram and later confirmed at surgery. With the aid of a cardiopulmonary bypass, a thrombectomy of the right atrium and the pulmonary artery was accomplished. The patient could not be weaned off cardiopulmonary bypass and ultimately died. We therefore recommend antithromboembolism therapy with low-molecular-weight heparin in selected cases of laparoscopic cholecystectomy.

Roboterassistierte laparoskopische Cholecystektomie und Fundoplicatio – erste Erfahrungen mit dem Da-Vinci-System

Abstract. We report on our first five robot-assisted laparoscopic cholecystectomies and one fundoplication (Da Vinci system). No postoperative complications were observed. For the cholecystectomies (three elective and two acute cases) mean operation time was 1 h 35 min, and mean hospital stay was 5 days; for fundoplication the operation time was 2 h 15 min. The main advantages seem to be improved visualization by using a stereo camera und ease of precise dissection by micromechanical instruments directed by masterslaves from a distant console. The main disadvantage is the high cost. To fully evaluate the benefit for the patient, prospective clinical trials are warranted.Zusammenfassung. Wir berichten über unsere ersten Erfahrungen mit der roboterassistierten laparoskopischen Cholecystektomie (n = 5) und Fundoplicatio (n = 1). Stereooptik und Instrumente, die von einer Konsole aus über Masterarme vom Operateur gesteuert werden, erlauben eine präzise und sichere Operation. Subjektiv ist die Kombination eines dreidimensionalen Sehens, gepaart mit der dimensionalen Erweiterung des Instrumenteneinsatzes, im Vergleich zur herkömmlichen laparoskopischen Technik der größte Vorteil. Da zur Zeit der Einsatz des Da-Vinci-Systems noch mit erheblichen Kosten verbunden ist, dürften der Verbreitung dieser Technik enge Grenzen gesetzt sein. Es ist aber absehbar, daß Entwicklungen der Computertechnik, der Mikro/Nanomechanik und haptischen Resonanz dazu führen werden, Robotiktechnologie auch im Bereich der Visceralchirurgie präsent zu machen.

Standardized Technique of Laparoscopic Surgery in the Rat

The evolution of advanced laparoscopic techniques requires animal models for instrument development, evaluation of the physiopathological correlation and physician training. Selection of surgical models is primarily based on cost, availability, anatomic and physiologic considerations, and housing and anesthetic methods. The use of large animals is becoming increasingly difficult due to restrictive legislation, public concern, and economic factors. A standardized technique of laparoscopic surgery in the rat has been developed to perform procedures in all abdominal regions including fundoplication, splenectomy, nephrectomy, liver resection, herniorraphy, colotomy, colectomy, and retroperitoneal exploration. The equipment consists of a specially designed small animal operating table, a standard arthroscope and micro-instruments. The rat model gives the opportunity to investigate the physiopathological relations and immune functions of laparoscopic procedures, to develop micro-instruments under realistic conditions of a live organism, and it is an excellent training model especially for pediatric and microsurgery. Besides low costs and easy availability, the rat model requires less logistic and financial efforts.

Experiences with Percutaneous Endoscopic Gastrostomy

Abstract. Today the procedure of choice for long-term enteral tube feeding in patients with prolonged swallowing difficulties or inabilities is percutaneous endoscopic gastrostomy (PEG). The primary indications are head and neck cancers, neurologic dysphagia, cancer cachexia, and obstruction of the esophagus and pharynx with enough space for an endoscopic procedure. This technique requires no general anesthesia and is possible in patients with contraindications to surgical gastrostomy. Between September 1994 and April 1995 a total of 115 patients underwent PEG placement attempts. We employed the pull-technique with 15-Freka PEG tubes. The average procedure time, including esophagogastroduodenoscopy, was 17 minutes. In nine cases PEG insertion was impossible owing to severe obstruction of the esophagus. In 46 (40%) patients local abdominal pains started on the first or second postoperative day; 7 of these patients required surgical consultation, and no further intervention was needed. In only one patient was there a serious complication that required surgical intervention: a presumed perforation that turned out to have no correlate upon review. All patients received single-shot antibiotic prophylaxis; and only in those patients with abdominal symptoms do we recommend a prolonged antibiosis. The abdominal symptoms reported were due to a slight leak of gastric fluid causing a topical peritonitis, which required no further treatment. In our experience PEG is a useful alternative to surgical gastrostomy. The simplicity of this procedure leads to low complication rates, short hospitalization, and is possible on an outpatient basis. It is cost-efficient and has a much better psychological tolerance than nasogastric tubes.

CO2 environment influences the growth of cultured human cancer cells dependent on insufflation pressure.

BackgroundExperimental and clinical studies, have suggested that the CO2 pneumoperitoneum influences the development of intraabdominal tumor dissemination and port site metastases. Previous experiments performed both in vitro and in vivo have proved that CO2 insufflation stimulates malignant cell growth. Therefore, we designed a study to investigate the influence of CO2 insufflation administered at different pressures on the growth of cultured human tumor cells.MethodsTwo human tumor cell lines (CX-2 colon adenocarcinoma, DAN-G pancreas adenocarcinoma) were exposed to a CO2 environment maintained at different pressures (0 mmHg, 6 mmHg, 12 mmHg). Tumor growth was determined at different times after exposure to CO2 using fluorescence photometry. Cytotoxity of the CO2 environment different pressures was investigated using flow cytometry.ResultsAt 1-4 days after exposure to CO2 insufflation, CX-2 and DAN-G tumor cell growth was decreased significantly (p < 0.01). Proliferation of pancreatic adenocarcinoma DAN-G increased significantly from day 5 to day 15 independent of the insufflation pressure (p < 0.01). Proliferation of colon adenocarcinoma CX-2 increased significantly from day 5 to day 15 but was found to be dependent on the insufflation pressure. CX-2 growth increased significantly with higher pressures (p < 0.05).ConclusionsCO2 insufflation influences the growth of cultured human tumor cells. After a short period of suppression, the CO2 environment stimulates malignant cell growth. The insufflation pressure may also have additional effects in promoting tumor growth.