Elie Capelluto

Feasibility of robotic laparoscopic surgery: 146 cases.

Theoretically, in laparoscopic surgery, a computer interface in command of a mechanical system (robot) allows the surgeon: (1) to recover a number a number of lost degrees of freedom, thanks to intra-abdominal articulations; (2) to obtain better visual control of instrument manipulation, thanks to three-dimensional vision; (3) to modulate the amplitude of surgical motions by downscaling and stabilization; (4) to work at a distance from the patient. These advances improve the quality of surgical tasks in a perfect ergonomic position. The purpose of this paper is to evaluate the feasibility of utilizing a robot in laparoscopic surgery. The first robot-assisted procedure in humans was performed in March 1997 by our team. One hundred forty-six patients underwent robot-assisted laparoscopic surgery. Between March 1997 and February 2001 a nonconsecutive series was performed of 39 antireflux procedures, 48 cholecystectomies, 28 tubal reanastomoses, 10 gastroplasties for obesity, 3 inguinal hernias, 3 intrarectal procedures, 2 hysterectomies, 2 cardiac procedures, 2 prostactectomies, 2 arteriovenous fistulas, 1 lumbar sympathectomy, 1 appendectomy, 1 laryngeal exploration, 1 varicocele ligation, 1 endometriosis cure, 1 neosalpingostomy, 1 deferent canal. The robot (Da Vinci system, Intuitive Surgical, Mountain View, CA), consists of a console and a cart with three articulated robot arms. The surgeon sits in front of the console, manipulating joysticklike handles while observing the operative field through binoculars that provide a three-dimensional picture. This computer is capable of modulating these data by eliminating physiologic tremor and by downscaling the amplitude of motions by a factor 5 or 3 to one. This study has demonstrated the feasibility of several laparoscopic robotic procedures. There is no morbidity related to the system. Operating time and the hospital stay were within acceptable limits. The system seems most beneficial in intra-abdominal microsurgery or for manipulations in a very small space. Optimized ergonomics and increased mobility of the instrument tips are beneficial in many steps of abdominal surgical procedures.

Surgical technique and complications during laparoscopic repair of diaphragmatic hernias

Diaphragmatic hernias can present as retrocostoxiphoid hernias (RCXH) or diaphragmatic dome hernias. The RCXH include the Larrey hernia (LH), the Morgagni hernia (MH), and the Larrey–Morgagni hernia (LMH). These congenital hernias are usually asymptomatic, and the diagnosis is simplified by two exams: chest X-ray, and thoraco-abdominal computed tomography (CT) scan. The potential risk in this condition is small-bowel incarceration in the hernia defect and subsequent obstruction. We report two cases of LH and one case of LMH treated by laparoscopy between February 2004 and October 2005, with a review of the surgical techniques. Two different laparoscopic techniques were used: the tension-free technique, and resection of the hernia sac with closure of the defect and reinforcement by prosthesis. One patient presented a postoperative cardiac tamponade due to a clip-induced bleeding of an epicardial artery at the inferior surface of the heart. Treatment by laparoscopy is feasible, but a consensus regarding the best laparoscopic repair is needed.

Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy.

BackgroundOesophagectomy with extended lymphadenectomy carries considerable morbidity due to parietal trauma. It is also technically extremely demanding because the difficult access even through a large thoracotomy requires the use of long instruments to reach the deepest recess in the chest cavity. Since the first thoracoscopic oesophagectomy reported by Cuschieri et al. [1] in 1992, different minimally invasive approaches have been proposed [2–12]. The aim of this video is to show the accurate and relative ease of an entirely thoracoscopic and laparoscopic oesophagectomy with an extended lymph node dissection of mediastinum in prone position (thoracoscopically) and celiac trunk (laparoscopically).MethodsOesophagectomy by thoracoscopy, laparoscopy and cervicotomy was proposed in a 63-year-old man with a lower third oesophageal cancer. General anaesthesia was performed with a double-lumen endotracheal tube and the patient was placed in prone position. Surgeons were positioned at the right side of the patient. Only three trocars were needed. A 10 mm 30-degree angled scope was inserted in the 7th intercostal space on the posterior axillary line and the remaining two 5 mm trocars were inserted in the 5th and 9th intercostal spaces on the posterior axillary line. Prone position allows an excellent visibility of the operative field even in an only partially deflated lung. In order to achieve a good exposure, transitory pneumothorax with CO2 (14 mmHg) was performed. The mediastinal pleura overlying the oesophagus was incised and the arch of azygos vein was isolated, ligated and divided. The oesophagus was circumferentially mobilized from the thoracic inlet down to oesophageal hiatus. Para oesophageal and subcarinal lymph nodes were dissected so as to remain in block with the surgical specimen. A 28 F chest tube was inserted in the 8th intercostal space on the anterior axillary line. In the second stage the patient was placed in supine position and pneumoperitoneum was established. Five trocars were placed along an ideal semicircular line, with the concavity facing the subcostal margin and a 30-degree angled laparoscope was used. The lesser omentum was widely opened up the right pillar of the hiatus. Mobilization of the greater curvature of the stomach was performed preserving the right gastroepiploic artery. A wide Kocher maneuver was performed. Celiac lymphadenectomy started with skeletonization of the hepatic artery until the root of left gastric artery was reached. This artery and the left gastric vein were dissected, clipped and sectioned. All fatty tissue and lymph nodes along hepatic artery, left gastric artery and celiac trunk were resected in block with the surgical specimen. Multiple applications of a linear endoscopic stapler were used to create the gastric tube. Finally the distal oesophagus was dissected, until the thoracoscopic dissection field was joined. In the third stage a left lateral cervicotomy was performed and the cervical oesophagus was dissected down to the thoracoscopic dissection plane. Oesophagus and stomach were delivered through the cervical incision and an oesophagogastric anastomosis was created by a linear stapler technique. Cervical and abdominal drainages were installed.ResultsThe total operative time was 271 minutes (thoracoscopy: 106 minutes, laparoscopy 120 minutes and cervicotomy 45 minutes) and blood loss was about 100 ml. Histological examination demonstrated a squamous cell carcinoma. Both margins of resection were free of tumour and 29 lymph nodes were retrieved. The final stage was IIA (pT3N0Mx).ConclusionsThoracoscopic and laparoscopic oesophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopic oesophagectomy in prone position improves the quality of dissection because:The oesophagus and aorto-pulmonary window are reached under excellent visibility, despite a partially deflated lung, which because of gravity will always remain out of harm’s way. For the same reason small to moderate bleeding will not obscure the operative field.Dissection with the long endoscopic instruments is more accurate due to the support provided by the entrance site at the parietal level and the ergonomic position of surgeon.

Esophagectomy by thoracoscopy with patient in prone position, laparoscopy and cervicotomy (technique)

ZusammenfassungGRUNDLAGEN: Die Autoren beschreiben die Technik der thorakoskopischen Ösophagektomie in Bauchlage mit anschließender Laparoskopie und zervikalen Exstirpation in Rückenlage. METHODIK: Zwischen 20. Oktober 2002 und 31. August 2005 wurden an 15 Patienten (12 Männer und 3 Frauen) eine laparoskopische Ösophagusresektion durchgeführt. Das Durchschnittsalter der Patienten betrug 60,4 Jahre (37–86). Die Tumorlokalisation war bei einem Patienten zervikal, bei 3 Patienten im mittleren Abschnitt, bei 6 Patienten im distalen Abschnitt und bei 5 Patienten am ösophagogastralen Übergang. Die präoperative Histologie zeigte bei je 7 Patienten ein Plattenepithel- und Adenokarzinom und bei einem Patienten handelte es sich um eine hochgradige Dysplasie mit carcinoma in situ. Eine neoadjuvante Therapie wurde nicht durchgeführt. ERGEBNISSE: Die durchschnittliche Operationszeit betrug 377,1 Minuten (300–540). Die durchschnittliche perioperative Blutung betrug 889,3 ml (125–2400). Die perioperative Morbidität bestand aus einer Konversion in offene Thorakotomie bei einem Patienten und einer Splenektomie bei einem zweiten Patienten. Als allgemeinmedizinische postoperative Komplikationen traten eine respiratorische Insuffizienz, eine tiefe Beinvenenthrombose, eine Pneumonie, zwei Trachealnekrosen und drei passagäre laryngeale Paralysen auf. Vier ösophagogastrale und eine ösophagocolische Anastomoseninsuffizienzen und zwei sehr große Hiatushernien waren die chirurgischpostoperativen Komplikationen. Histologisch waren die Resektionsränder alle im Gesunden. Die Zahl der entfernten Lymphknoten betrug periosophageal und mediastinal 5,1 (2–13), am Trunkus coeliakus und perigastral 12,2 (3–22). Die frühpostoperative Mortalität betrug 0. Nach einer mittleren follow-up Zeit von 19,1 Monaten (8–34) ist die Gesamtüberlebensrate 61,5 %. Von diesen Patienten sind 87,5 % tumorfrei und 37,5 % erhalten eine adjuvante Therapie. Es trat bei keinem Patienten ein gastro-ösophagealer Reflux auf und bei 4 Patienten kam es zu einer Stenose an der ösophagogastralen Anastomose. SCHLUSSFOLGERUNGEN: Die kombinierte thorakoskopisch-laparoskopische Ösophagektomie mit einer erweiterten Lymphadenektomie ist technisch durchführbar und sie stellt eine sichere Methode dar. Die Thorakoskopie in Bauchlage erhöht sowohl die Qualität der Ösophagusmobilisation als auch der mediastinalen Lymphadenektomie.SummaryBACKGROUND: Authors describe the technique of esophagectomy by thoracoscopy with the patient in the prone position, followed by laparoscopy and cervicotomy in supine position. METHODS: Between October 30, 2002 and August 31 2005, 15 patients (12 males and 3 females) underwent this procedure for esophageal cancer. The median age was 60.4 years (37–86). At the preoperative work-up the tumor was localized at the cervical esophagus in 1 patient, at the mid-esophagus in 3 patients, at the lower esophagus in 6 patients, and at the eso-gastric junction in 5 patients. Preoperative histological examination demonstrated squamous cell carcinoma in 7 patients, adenocarcinoma in 7 patients, and high-grade dysplasia with carcinoma in situ in 1 patient. None of the patients underwent neo-adjuvant therapy. RESULTS: Average total operative time was 377.1 minutes (300–540). Average total perioperative bleeding was 889.3 ml (125–2400). Perioperative complications comprised a conversion to thoracotomy in one patient and an associate splenectomy in another. Postoperative medical morbidity was 1 respiratory failure, 1 deep venous thrombosis, 1 pneumonia, 2 tracheal necroses, and 3 temporary laryngeal paralysis. Postoperative surgical morbidity included 4 leaks at esophagogastrostomy, 1 colic leak, 2 giant hiatal hernias. The median intensive care stay was 5 days and the median total hospital stay was 14 days. Upon histological examination, the margins of all specimens were free and the average number of lymph nodes identified was: 5,1 mediastinal/periesophageal (2–13), 12.2 celiac/perigastric (3–22). Early mortality was 0 %. After a mean follow-up of 19.1 months (8–34), total survival rate is 61.5 % of patients, whom 87.5 % free of disease and 37.5 % on adjuvant therapy. No gastroesophageal reflux was registered and in 4 patients we observed stenosis of the esophagogastrostomy. CONCLUSIONS: Thoracoscopic and laparoscopic esophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopy performed with the patient in the prone position improves the quality of the esophageal dissection and the mediastinal lymphadenectomy.

A laparoscopic approach to left diaphragmatic rupture after blunt trauma.

Abstract Diaphragmatic rupture after blunt trauma is rare, but indicates a powerful external impact. Associated lesions are often life-threatening and require a rapid diagnosis and management. We report a case of a 24-year-old man, admitted to the emergency department after a serious car accident. He complained of a left sided thoraco-abdominal pain with breathing difficulties. Chest X-ray showed a left diaphragmatic elevation. Computed tomography demonstrated a left haemo-pneumothorax, herniation of the stomach in the chest and a haemoperitonium. Laparoscopically, herniated organs were re-integrated in the abdominal cavity; the diaphragmatic tear was repaired by both direct suture and synthetic prosthesis. Closure of a small bowel perforation found during the laparoscopic exploration was also performed. We consider this therapeutic modality to be an excellent approach in the management of acute left side diaphragmatic rupture in haemodynamically stable patients. Firstly, it permits an inspection of the thoracic cavity through the diaphragmatic tear and secondly, an easy repair of damaged structures in the abdominal cavity.

Robotic Nissen Fundoplication

SummaryBackground: Laparoscopic surgery is beneficial to the patient but challenging for the surgeon. The visual axis is not the same as the operative axis. The surgeon must manipulate long, sharp instruments through a fixed opening under the control of a two-dimensional monitor and without the help of any tactile sensation. The body cavity is penetrated by cannulas, which cannot be interchanged, so that the surgeon is obliged to move around the patient in order to reach the best position for every step of the procedure. Methods: A computer interface in command of a mechanical system (robot) makes it possible: 1) To regain several lost degrees of freedom through intra-abdominal articulations; 2) to obtain better visual control of instrument manipulation thanks to three-dimensional vision; 3) to modulate amplitude of surgical motions by downscaling and stabilization; 4) to operate at distance from the patient.These possibilities lead to improved surgical performance. In addition, the surgeon operates in an ergonomically correct position. The robot (da Vinci™ System, Intuitive Surgical, Mountain View, CA, USA) consists of a console and a surgical cart, which supports three articulated robotic arms. The surgeon sits at the console where he or she manipulates joystick-like handles while observing the operating field through binoculars that provide a three-dimensional image. This computer is capable of modulating data by eliminating physiologic tremor and by downscaling the amplitude of motions by a factor of 5 or 3 to 1. Results: The first robot-assisted procedure in a human was performed in March 1997 by our team. Since then, we have used robot-assisted laparoscopic surgery for 147 procedures, including 39 anti-reflux operations. Our study demonstrates the feasibility of telesurgery on humans in a variety of procedures including robotic Nissen fundoplication, with no morbidity specifically related to the use of robotics, and with acceptable operative times. Conclusions: In its present embodiment, the system seems most efficient when involved in microsuturing within the abdomen or in very confined spaces. Improved ergonomic conditions and improved instrument mobility at the level of distal articulation seem beneficial in routine abdominal procedures. More research is necessary for further improvement in tool configuration and visualization. The robotic approach implies new operative strategies, including specific trocar placement.ZusammenfassungGrundlagen: Während das laparoskopische Vorgehen für den Patienten Vorteile mit sich bringt, überwiegen für den Chirurgen gewisse Nachteile. Blickrichtung und operative Ausführung liegen auf verschiedenen räumlichen Ebenen. Der Chirurg führt lange, scharfe — durch Trokare fix positionierte — Instrumente. Dabei kontrolliert er seine Bewegungen lediglich über ein zweidimensionales Monitorbild und verfügt über kein taktiles Feedback. Da das Wechseln der Trokare nicht ganz unproblematisch ist, muß der Chirurg seine Position dem jeweiligen Akt anpassen. Methodik: Durch ein Computer-gesteuertes mechanisches System (Roboter) wird folgendes ermöglicht: 1) Wettmachen der Bewegungseinschränkung durch intraabdominelle Gelenke; 2) bessere visuelle Kontrolle der Manipulationen durch dreidimensionale Darstellung des Operationsfeldes; 3) die Amplituden der Bewegungen der Hand des Chirurgen können moduliert und stabilisiert werden; 4) es kann abseits vom Patienten operiert werden.Die Performance und die ergonomischen Bedingungen für den Chirurgen wurden verbessert. Der Roboter (da Vinci™ System, Intuitive Surgical, Mountain View, CA, USA) besteht aus einer Konsole und einem Wagen mit drei Roboterarmen. Der Chirurg sitzt an der Konsole, bewegt Joystick-ähnliche Handgriffe und schaut in ein dreidimensionales Operationsfeld. Durch den Computer können Zitterbewegungen eliminiert und die Bewegungsamplituden um den Faktor 5 bzw. 3 zu 1 moduliert werden. Ergebnisse: Weltweit der erste roboter-assistierte Eingriff am Menschen erfolgte durch unser Team 1997. Seitdem haben wir insgesamt 147 Eingriffe, darunter 39 Antirefluxoperationen mit dem Roboter durchgeführt. Unsere Studie zeigt, daß verschiedene Eingriffe am Menschen, darunter auch Nissenfundoplikationen, ohne Roboter-assoziierte Morbidität bei akzeptablen Operationszeiten machbar sind. Schlußfolgerungen: In der jetzigen Ausstattung bietet sich der Roboter für feines Nähen im Abdomen oder in engen Räumen an. Die verbesserten ergonomischen Bedingungen sowie die bessere Beweglichkeit der Instrumente sind für den Allgemeinchirurgen von Nutzen. Weitere Anstrengungen zur Verbesserung von Instrumentenkonfiguration und Visualisierung sind notwendig. Das Arbeiten mit dem Roboter verlangt spezielle operative Strategien und angepaßte Trokarplazierungen.