Carmen Balagué

Splenomegaly should not be considered a contraindication for laparoscopic splenectomy.

OBJECTIVE To analyze the impact of spleen size on operative and immediate clinical outcome in a series of 74 laparoscopic splenectomies (LS). SUMMARY BACKGROUND DATA LS is gaining acceptance as an alternative to open splenectomy. However, splenomegaly hinders LS, and massive splenomegaly has been considered a contraindication. METHODS Between February 1993 and September 1997, 74 patients with a wide range of splenic disorders were treated by laparoscopy and prospectively recorded. They were classified into three groups according to spleen weight: group I, <400 g (n = 52); group II, 400 to 1000 g (n = 9); and group III, >1000 g (n = 13). Age, operative time, number of trocars required, need for perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia requirements, length of hospital stay, and morbidity rates were recorded. RESULTS LS was completed in 69 patients, and the conversion rate was thus 6.7%. Operative time was significantly longer in patients with larger spleens, and an accessory incision was more frequently required. However, there were no significant differences in transfusion rate, length of stay, severe morbidity, or conversion rate. CONCLUSIONS Preliminary evaluation of LS for patients with large spleens suggests that it requires a longer operative time, but it is feasible and may potentially offer the same advantages (shorter stay and faster recovery) as it does to those with smaller spleens.

Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy.

Objectives:The laparoscopic approach for colon resection is widely accepted but its definitive role in rectal tumors is controversial due to the technical difficulties associated with this procedure. Tumor size and volume, and pelvic dimensions may influence intraoperative and/or immediate outcome. This study aimed to evaluate the predictive value of anatomic and pathologic features on immediate outcome after laparoscopic rectal resection. Material and Methods:The study included a prospective series of 60 patients submitted to laparoscopic resection for rectal tumors. A preoperative computed tomography was performed in all patients. Three-dimension reconstruction of the pelvis, rectal tumor, and prostate was computed. Tumor and prostate volume and diameters were calculated, as were main pelvic diameters (subsacrum-retropubic, coccyx pubis, and promontorium coccyx), and lateral diameters, at the tumor level (3D Doctor Software package). Age, sex, body mass index (BMI), tumor height, previous radiotherapy treatment, and type of procedure (anterior resection, low anterior resection, and abdominoperineal resection) were recorded. Immediate outcome (morbidity, mortality, and stay) was also collected. Dependent variables were operative time, intraoperative difficulty, conversion, and postoperative morbidity. Univariate and multivariate analyses were performed (SPSS package). Results:The series included 36 men and 24 women, with a mean age of 72 years (range, 38–87). Surgical procedures were 10 anterior resections, 31 low anterior resections, and 19 abdominoperineal resections. Conversion rate was 9 of 60 (15%), operative time: 172 minutes (range, 90–360), morbidity: 31% and stay: 9 days (range, 6–43). Multivariate analysis showed tumor craniocaudal length was an independent predictive factor for conversion (P < 0.04, odds ratio [OR]: 1.5, confidence interval [CI]95%: 1–2.2). Pubic coccyx axis (P < 0.005) and sex (P < 0.009) showed independent values for operative time, and BMI (P < 0.02, OR: 1.2, CI 95%:1-1.5) was related to postoperative morbidity. When a subanalysis was performed in relation to sex, independent factors differed between males and females, with a predominance of anatomic and tumor measures in men. Conclusion:Local anatomy and pathologic features directly affect surgical outcome in the laparoscopic approach to the rectum. Sex, BMI, lower pelvis diameter, and tumor size are independent predictors for conversion, operative time, and morbidity. These data should be taken into account when planning this kind of procedure.

Energy Sources for Laparoscopic Colectomy: A Prospective Randomized Comparison of Conventional Electrosurgery, Bipolar Computer-Controlled Electrosurgery and Ultrasonic Dissection. Operative Outcome and Costs Analysis

The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small to medium-sized vessels. Bipolar computercontrolled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model.

NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen.

Hypothesis. Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option. Material and methods. We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally. Results. The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day. Conclusions. Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Minimally Invasive Treatment for Obstructive Tumors of the Left Colon: Endoluminal Self-Expanding Metal Stent and Laparoscopic Colectomy

Background: Obstruction of the left colon may be the first manifestation of colorectal cancer. Resection of the colonic segment involved and the construction of an end colostomy (Hartman’s procedure) is the most frequent treatment. Alternatives to the placement of a stoma are subtotal colectomy or intraoperative lavage of the colon and primary anastomosis, but their application depends on intraoperative findings and the availability of a skilled surgeon. The use of an expandable stent (SEMS) can enhance the feasibility of laparoscopic colectomy, avoiding the need for a colostomy and offering the advantages of a combination of two minimally invasive procedures. Study Design: Between 1997 and 2004, an SEMS was placed in 11 cases of left colonic obstruction due to cancer, the obstruction being successfully resolved in each case. Seven patients were approached by laparoscopy to attempt the definitive colectomy. We evaluated the location and pathological characteristics of the tumor, effectiveness and complications of SEMS insertion, time interval between the insertion of SEMS and laparoscopic surgery, and postoperative data. Results: The tumors were situated in the recto-sigma (1 case), sigma (3 cases) and descending colon (3 cases). Immediate relief of the obstruction was achieved in all cases after SEMS insertion of the stent, and oral diet was started at 24 h. The 7 patients were operated on an average of 8 days (range 6–14) after insertion of the stent. Conversion to open surgery was necessary in one case for reasons not related to the stent. Conclusions: Preliminary results of the combination of SEMS and elective laparoscopic surgery demonstrate that the procedure is feasible and that it presents all the clinical advantages of a minimally invasive approach. The procedure is a valid alternative to traditional major urgent surgery.

Single-Port Access: A Feasible Alternative to Conventional Laparoscopic Splenectomy

Hypothesis: The laparoscopic approach has become the gold standard for splenectomy despite the fact that the spleen is a solid organ located deep in the splenic fossa. There is currently a trend to reduce the invasiveness of minimally invasive procedures. Transabdominal or transumbilical single-incision laparoscopic (SILS) approaches are an alternative to natural orifice transluminal endoscopic surgery techniques, but no reports of their use have yet been published in relation to the spleen. Aim: To describe the SILS technique for splenectomy in 2 patients. Material and methods: Two patients were approached by SILS, a 26-year-old male diagnosed of autoimmune thrombocytopenia and a 45-year-old male with recurrent Hodgkin disease. In both cases 3 trocars (1 of 12 mm and 2 of 5 mm) were inserted through the umbilicus in one and in a left subcostal in the other, and a curved transanal endoscopic microsurgery instrument, a flexible-tip 10-mm scope, and the UltraCision were introduced. Visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transumbilicus stapling of the splenic hilum. The spleen was extracted through the umbilical incision, intact in one case and after morcellation in the other. Results: The postoperative course was uneventful. Both patients had minimal postoperative pain and scarring and were discharged on the second postoperative day. Conclusions: SILS access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Laparoscopic resection of clinically suspected gastric stromal tumors.

Gastrointestinal stromal tumors (GISTs) account for 5% of all gastric tumors. Preoperative diagnosis is relatively difficult because biopsy samples are rarely obtained during fibergastroscopy. Surgical radical resection is the gold standard treatment, allowing pathologic study for both diagnosis and prognosis. Laparoscopic resection has become an alternative to the open approach, but long-term results are not well known. The aim of this study is to report experience with laparoscopic resection, placing special emphasis on preoperative diagnosis and describing long-term results. A retrospective analysis was made of all patients undergoing a laparoscopic resection for clinically suspected gastrointestinal stromal tumors between November 1998 and August 2006 at 2 tertiary hospitals. The medical records of all participants were reviewed regarding surgical technique, clinicopathologic features, and postoperative long-term outcome. Laparoscopic gastric resection was attempted in 22 patients (13 women and 9 men) with a mean age of 66.7 years (range, 29-84 years). One patient had 2 gastric tumors. Tumor localization was upper gastric third in 6 patients, mid-gastric third in 7, and distal third in 10. Surgical techniques were transgastric submucosal excision (n = 1), wedge resection (n = 13), partial gastrectomy with Y-en-Roux reconstruction (n = 6), and total gastrectomy with Y-en-Roux reconstruction (n = 2). Two patients (9.1%) required conversion to the open procedure because of tumor size. Postoperative morbidity was delayed gastric emptying in 3 patients. Median postoperative stay was 6 days (range, 4-32 days). Pathologic and immunohistochemical study confirmed gastrointestinal stromal tumors in 18 cases. The other 4 cases were adenomyoma, hamartoma, plasmocytoma, and parasitic tumor (anisakis). Median tumor size was 5.6 cm (range, 2.5-12.5 cm) in cases of gastrointestinal stromal tumors. Malignant risk of gastrointestinal stromal tumors assessed according to mitotic index and size was low (n = 8), intermediate (n = 6), or high (n = 4). After a median follow-up of 32 months (range, 1-72 months), there was 1 case of recurrence of GIST. Definitive preoperative diagnosis of gastric submucosal tumors is frequently difficult. The laparoscopic approach to surgical treatment of these tumors seems safe and is associated with acceptable intermediate-term results, especially in cases of gastrointestinal stromal tumors.

Laparoscopic surgery in situs inversus: a literature review and a report of laparoscopic sigmoidectomy for diverticulitis in situs inversus

BackgroundSitus inversus (SI) is a rare autosomal recessive congenital defect in which the position of abdominal and/or thoracic organs is a “mirror image” of the normal one, in the sagittal plain. In 25% of these cases, SI is part of the Kartagener syndrome, together with bronchiectasis and chronic sinusitis.MethodsWe present a case of a patient with Kartagener syndrome and complete SI that was laparoscopically operated on for diverticulitis. We also review the published English information available on this rare condition.ResultsA review of the literature revealed another single case of laparoscopic sigmoidectomy and 27 cases of other laparoscopic interventions in the presence of SI. Those laparoscopic procedures included basic procedures such as explorations and cholecystectomies, as well as advanced procedures such as gastrectomy and gastric bypass.ConclusionThe laparoscopic approach is feasible in cases of SI, although technically more complicated because of the different position of the organs and the different laparoscopic view of the anatomy.

Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura

BackgroundLaparoscopic splenectomy (LS) offers better short-term results than open surgery for the treatment of immune thrombocytopenic purpura (ITP), but long-term follow-up is required to ensure its efficacy. The remission rate after splenectomy ranges from 49 to 86% and the factors that predict a successful response to surgical management have not been clearly defined. The goal of this study was to determine the preoperative factors that predict a successful outcome following LS.MethodsFrom February 1993 to December 2003, LS was consecutively performed in a series of 119 nonselected patients diagnosed with ITP (34 men and 85 women; mean age, 41 years), and clinical results were prospectively recorded. Postoperative follow-up was based on clinical records, follow-up data provided by the referring hematologist, and a phone interview with the patient and/or relative. Univariate and multivariate analyses were performed for clinical preoperative variables to identify predictive factors of success following LS.ResultsOver a mean period of 33 months, 103 patients (84%) were available for follow-up with a remission rate of 89% (92 patients, 77 with complete remission with platelet count >150,000). Eleven patients did not respond to surgery (platelet count <50,000). Mortality during follow-up was 2.5% (two cases not related to hematological pathology and one case without response to splenectomy). Preoperative clinical variables evaluated to identify predictive factors of response to surgery were sex, age, treatment (corticoids alone or associated with Ig or chemotherapy), other immune pathology, duration of disease, and preoperative platelet count. In a subgroup of 52 patients, we also evaluated the type of autoantibodies and corticoid doses required to maintain a platelet count >50,000. Multivariate analysis showed that none of the variables evaluated could be considered as predictive factors of response to LS due to the high standard error.ConclusionLong-term clinical results show that LS is a safe and effective therapy for ITP. However, a higher number of nonresponders is needed to determine which variables predict response to LS for ITP.

Laparoscopic treatment for intussusception of the small intestine in the adult.

The term intussusception refers to a spontaneous invagination of a portion of the intestine into another bowel loop. Its incidence is higher in children, but in adults it causes 1% to 5% of intestinal obstructions. The diagnosis of intussusception in the adult is difficult due to the variability of the symptoms. The condition may be chronic, intermittent, or acute. Surgical intervention is necessary in all cases and in up to 90% of cases an organic lesion inside the invaginated part of the bowel is found to be the lead point. The laparoscopic approach offers both a diagnostic and therapeutic option. Laparoscopy may be used as the final diagnostic or therapeutic tool for intussusception in the adult.