D. Lomanto

Early experience with laparoscopic radical gastrectomy for advanced gastric cancer.

Use of the laparoscopic approach for the management of gastric cancer is still in the developmental phase. The authors present their experience with laparoscopic radical gastrectomy for advanced gastric cancer. Between September 1997 and August 1999, four laparoscopic gastrectomies for gastric carcinoma were performed on two male and two female patients (mean age, 61.5 years). One D2 total radical gastrectomy and three D2 subtotal distal gastrectomies were performed, using a totally laparoscopic approach. Mean operative time was 210 minutes. There were no intraoperative complications. All four patients recovered uneventfully from surgery and began oral feeding on the third postoperative day. Median postoperative stay was 7 days (range, 6–9). All patients were alive 8 months to 3 years after the operation, with no cancer recurrences. This series shows that laparoscopic radical gastrectomy for moderately advanced cancers can produce good results in terms of safety and oncologic adequacy.

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p<0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p<0.05). The surgeon’s experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.RésuméAlors que l’appendicectomie par laparoscopic pour appendicite non compliquée est faisable et sûre, son rôle dans l’appendicite perforée reste incertain. On a analysé rétrospectivement les résultats chez tous les patients traités pour appendicite perforée entre 1992 et 1999 dans un service de chirurgie d’un hôptial universitaire: 231 patients ont ainsi été inclus dans cette étude. Quatre-vingt-cinq patients ont eu une laparoscopic (LA): 40 patients (47%) ont nécessité une conversion à la voie tradtionnelle. Une appendicectomie par voie traditionnelle (OA) a été réalisée chez 146 patients. La durée de l’intervention était similaire entre les deux groupes. La reprise d’alimentation orale et solide a été plus rapide dans le groupe LA par rapport au groupe OA (p<0.01). On a noté des complications infectieuses, y compris des infections pariétales et des abcès intra-abdominaux chez 14% dans le groupe L, comparé à 26% pour le groupe O (p<0.05). L’expérience du chirurgien a été corrélée directement avec le taux de conversion. L’appendicectomie laparoscopique est associée à un taux élevé de conversion en raison de l’appendicite perforée. En cas de succès, la récupération est plus rapide et il y a moins de risque de complications infectieuses.ResumenMientras que la apendicectomía laparoscópica es posible y segura en las apendicitis no complicadas, el papel de la laparoscópia en el tratamiento de la apendicitis perforada está muy controvertido. En un hospital universitario se efectuó un estudio retrospectivo de todos aquellos casos de apendicitis perforada, intervenidos entre 1992 y 1999. 231 pacientes ftieron diagnosticados de perforación apendicular. 85 fueron tratados por laparoscópia (LA) pero 40 (47%) requirieron reconversión a cirugía abierta. Con apendicectomía abierta (OA) se trataron 146 enfermos. La duración de la operación fue similar en ambos grupos. La iniciación de la ingesta de líquidos y sólidos fue más precoz en el grupo LA que en el OA (p<0.01). Infección postoperatoria que comprende tanto la de la herida como abscesos abdominales, se constató en el 14% de los pacientes del grupo LA y en el 26% de los del grupo OA (p<0.05). La experiencia del cirujano se correlacionó directamente con la tasa de reconversión. Ésta es mucho más frecuente en el tratamiento laparoscópico de las apendicitis perforadas. Si la apendicectomía laparoscópica puede realizarse satisfactoriamente el paciente se recuperará con más rapidez y el riesgo de complicaciones infecciosas será menor.

Comparing T2 and T2-T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial

BackgroundThoracoscopic sympathectomy is a useful therapeutic option for palmar hyperhidrosis. Surgeons differ in the level of the sympathetic chain ablated. This study aimed to compare the blockade of the T2 with levels T2 and T3 to verify the effectiveness of different ablation levels in relieving hyperhidrosis symptoms.MethodsFor patients undergoing bilateral thoracoscopic sympathectomy for palmar hyperhidrosis, T2–T3 ablation is performed bilaterally. In our series, 25 consecutive patients were blindly randomized to undergo unilateral T2 and T3 ablation followed by contralateral ablation of level T2 only. The patients were followed up and analyzed for comparison of symptoms bilaterally, compensatory hyperhidrosis, and levels of satisfaction postoperatively.ResultsThe study group consisted of 25 patients with a male:female ratio of 3:2 and a mean age of 32 years (range, 19–50 years). The mean operative time was 35 min. The patients were followed up for a mean period of 23 months (range, 2–65 months). All 25 patients confirmed that their palmar sweating resolved postoperatively, with both palms equally dry. Of the 25 patients, 20 (80%) complained of compensatory hyperhidrosis, which also was bilaterally symmetric. The areas involved were trunk (80%), lower limbs (32%), and armpits (12%). Overall, 80% of the patients were very satisfied with the procedure. The remaining 20% experienced mild to moderate compensatory hyperhidrosis, which did not seem to affect their lifestyle.ConclusionThe findings show that T2 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis is as effective as T2–T3 ablation in terms of symptomatic relief, recurrence, compensatory hyperhidrosis, and patient satisfaction.

Natural orifice transgastric endoscopic wedge hepatic resection in an experimental model using an intuitively controlled master and slave transluminal endoscopic robot (MASTER)

BackgroundThe lack of triangulation of standard endoscopic devices limits the degree of freedom for surgical maneuvers during natural orifice transluminal endoscopic surgery (NOTES). This study explored the feasibility of adapting an intuitively controlled master and slave transluminal endoscopic robot (MASTER) the authors developed to facilitate wedge hepatic resection in NOTES.MethodsThe MASTER consists of a master controller, a telesurgical workstation, and a slave manipulator that holds two end-effectors: a grasper, and a monopolar electrocautery hook. The master controller is attached to the wrist and fingers of the operator and connected to the manipulator by electrical and wire cables. Movements of the operator are detected and converted into control signals driving the slave manipulator via a tendon-sheath power transmission mechanism allowing nine degrees of freedom. Using this system, wedge hepatic resection was performed through the transgastric route on two female pigs under general anesthesia. Entry into the peritoneal cavity was via a 10-mm incision made on the anterior wall of the stomach by the electrocautery hook. Wedge hepatic resection was performed using the robotic grasper and hook. Hemostasis was achieved with the electrocautery hook. After the procedure, the resected liver tissue was retrieved through the mouth using the grasper.ResultsUsing the MASTER, transgastric wedge hepatic resection was successfully performed on two pigs with no laparoscopic assistance. The entire procedure took 9.4 min (range, 8.5–10.2 min), with 7.1 min (range, 6–8.2 min) spent on excision of the liver tissue. The robotics-controlled device was able to grasp, retract, and excise the liver specimen successfully in the desired plane.ConclusionThis study demonstrated for the first time that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures. With it, the triangulation of surgical tools and the manipulation of tissue became easy, and wedge hepatic resection could be accomplished successfully without the need for assistance using laparoscopic instruments.

Design of a master and slave transluminal endoscopic robot for natural orifice transluminal endoscopic surgery

Abstract Natural orifice transluminal endoscopic surgery (NOTES) is an endoscopic surgical intervention technique for treatment within the intraperitoneal cavity, which utilizes natural orifices (i.e. mouth, vagina, anus, etc.) as the entry point. In line with minimally invasive surgery (MIS), NOTES aims to perform surgical procedures without skin incisions, thus eliminating unsightly scars. In this article, a master—slave robotic system is proposed to enable the endoscopist to perform demanding NOTES procedures, which are currently performed by surgeons in an opened or keyhole surgery setting. The robotic system consists of a master console and slave manipulators driven by tendon—sheath actuation. Force prediction at the slave end is also introduced in this article to provide force feedback to the surgeon. Using the developed robotic system, liver wedge resection has been conducted in animal trials with promising results.

Two-trocar laparoscopic cholecystectomy: a reproducible technique.

Laparoscopic cholecystectomy is usually performed with a four-trocar technique. From December 1998 to March 1999, 25 of 42 admitted patients underwent a two-trocar laparoscopic cholecystectomy. In our technique, after establishing umbilical carbon dioxide pneumoperitoneum, a 30° scope was inserted, and a second 5-mm trocar was positioned below and to the left of the xiphoid process. Then two stitches with nonabsorbable sutures were passed: one at the fundus to pull up the gallbladder, and the second through the neck of the gallbladder to expose the structure of the Calot triangle. Intraoperative cholangiography was performed with a percutaneous catheter in 15 patients. Retrograde cholecystectomy was performed and the gallbladder was extracted through the umbilical port. Scars were closed with glue, and bupivacaine was injected to reduce pain. The technique was feasible in approximately 84% (25 of 30) of patients. The mean operative time was 42 minutes, and the mean hospital stay was 1.6 days. We conclude that this method is similar to four-port laparoscopic cholecystectomy in terms of safety and operation time. This technique seems to be well reproducible and offers better results in terms of postoperative pain, hospital stay without considering better cosmetic results, and cost-effectiveness.

Thoracolaparoscopic repair of traumatic diaphragmatic rupture.

Diaphragmatic rupture may occur after blunt or penetration trauma caused by the application of a powerful external force. Diaphragmatic rupture usually is repaired via laporotomy and/or thoracotomy, depending on the associated organ injury. The case of a 49-year-old man with traumatic rupture of the left hemidiaphragm is presented. Preoperatively, diaphragmatic rupture with herniation of the stomach into the left thoracic cavity was confirmed by computed tomography scan of the thorax. Under thoracoscopic guidance, the stomach, spleen, and omentum were repositioned in the abdominal cavity, and the rupture site (10 cm) was closed by nonabsorbable suture. A subsequent laparoscopy was performed to assess the efficacy of the repair and the absence of any abdominal organ injury. The patient was discharged from hospital without any respiratory or abdominal symptoms. Our report confirms that in the case of a patient with penetration injuries to the lower chest and upper abdomen, a combined thoracoscopic and laparoscopic approach may offer both diagnostic and therapeutic benefits with reduced surgical trauma. We conclude that thoracoscopic repair of traumatic diaphragmatic rupture can be used safely when no abdominal organ injuries are found.

Topic: Inguinal Hernia — Fixation

Needlescopic TEP hernioplasty has been shown to be a safe and feasible method for repair of unilateral inguinal hernia in selected patients. It is associated with significantly lower pain score when compared to conventional approach using 5mm ports. Though the mesh placement using tissue glue or tacker application can prevent migration and hence hernia recurrence, this may be technically challenging using needlescopic instruments and not feasible through 3mm working ports. A new design of laparoscopic self-fixating anatomical mesh can be used to attain the above result without increasing pain. We hereby illustrate a case of needlescopic TEP hernioplasty using laparoscopic self-fixating anatomical mesh.Needlescopic TEP hernioplasty has been shown to be a safe and feasible method for repair of unilateral inguinal hernia in selected patients. It is associated with significantly lower pain score when compared to conventional approach using 5mm ports. Though the mesh placement using tissue glue or tacker application can prevent migration and hence hernia recurrence, this may be technically challenging using needlescopic instruments and not feasible through 3mm working ports. A new design of laparoscopic self-fixating anatomical mesh can be used to attain the above result without increasing pain. We hereby illustrate a case of needlescopic TEP hernioplasty using laparoscopic self-fixating anatomical mesh.