Frits J. Berends

The "invisible cholecystectomy": A transumbilical laparoscopic operation without a scar.

BackgroundLooking to further reduce the operative trauma of laparoscopic cholecystectomy, we developed, in patients with no history of cholecystitis and a normal BMI, a scarless operation through the umbilicus. The operative technique, along with the results of the first 10 patients operated in this way, are fully described.Methods10 female patients underwent transumbilical scarless laparoscopic cholecystectomy.Through the umbilicus, two trocars of 5 mm were introduced parallel to another with a bridge of fascia between them (one for the 5-mm laparoscope and the other for the grasper). With the help of one 1-mm Kirschner wire, introduced at the subcostal line and bent with a special designed device, the gallbladder was pulled up and the triangle of Callot was dissected free, clipped, cut, and the gallbladder was subsequently resected. Finally the gallbladder was taken out through the umbilicus and the umbilicus reconstructed.Results10 female patients, mean age 36 years (range: 31–49), mean body mass index (BMI) 23 (range: 20–26), after one attack (six patients) or a second attack (four patients) and cholelithiasis confirmed by ultrasonography with no suspicion of inflammation were included in this preliminary study. Mean operative time was 70 minutes (range: 65–85) with no conversions; hospital stay was less than 24 hours with no complications.ConclusionLooking to reduce operative trauma and improve the cosmetic result following laparoscopic cholecystectomy, a transumbilical operative technique has been developed. Results of the operative procedure in a selected group of patients are encouraging with no signs of inflammation and normal BMI. The umbilicus can be developed as a natural port for performing various operative procedures with the help of the traction produced by thin Kirschner wires.

Technical considerations in laparoscopic liver surgery

BackgroundLaparoscopic solid organ surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. Laparoscopic liver surgery mainly comprizes diagnostic procedures and treatment of liver cysts. However, we believe there is room for a laparoscopic approach to the liver in selected cases, with the benefits that may be expected from laparoscopic solid organ surgery.MethodsBetween 1993 and 2000, 10 patients with various lesions of the liver underwent laparoscopic surgery. Indications consisted of cystic disease (n=2), hemangioma (n=2), focal nodular hyperplasia (n=2), liver abcess (n=1), and liver metastasis (n=3). Laparoscopic treatment varied from fenestration (n=3) to wedge resections (n=5), and formal left lateral hepatectomy (n=2).ResultsThe mean patient age was 54 years (range, 34–71 years). The mean operative time, including laparoscopic ultrasonography, measured 180 min (range, 80–240 min). Peroperative blood loss ranged from 200 to 450 ml. There was no mortality. In two patients, conversion to laparotomy was necessary. There were no postoperative complications. The mean hospital stay was 6 days (range, 4–11 days).ConclusionLaparoscopic treatment should be considered in selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver.

Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic-assisted and resection-facilitated techniques.

AbstractBackground: Because of the presence of significant inflammatory reaction, elective surgical laparoscopic-assisted treatment of complicated diverticular disease can be difficult, leading to a high conversion and complication rate. Laparoscopic alternatives to this assisted approach consist of the hand-assisted method and the more conventional facilitated laparoscopic sigmoid resection. Facilitated laparoscopic sigmoid resection implies laparoscopic mobilization of the sigmoid as much as possible and splenic flexure when called for. Through a Pfannenstiel incision, the difficult steps of the operation—such as the dissection of the inflammatory process and taking down the fistula, but also resection and manual anastomosis—can be performed. In this study, we compare the operating time, conversion rate, complications, and costs of both assisted and resection-facilitated techniques. Methods: We compared two consecutive series of 35 patients with diverticular disease who underwent a sigmoid resection by laparoscopy. Both groups were comparable in terms of age, gender, and kind of complicated diverticular disease. Results: The operating time, conversion rate, and costs were all less in the laparoscopic-facilitated group. The fact that there were no conversions in this group is the most important finding of this study. Not only was it possible to convert from the assisted laparoscopic approach to laparotomy (five patients of 35), it was also possible to convert from the assisted to the facilitated form (seven of 35 patients). Conclusions: Laparoscopic-facilitated sigmoid resection is a feasible intervention for all forms of complicated diverticular disease and yields marked reductions in operating time, conversion rate, and operative and general costs.

Safe retroperitoneal endoscopic resection of pheochromocytomas

Although endoscopic adrenalectomy is advocated for small adrenocortical tumors, questions remain about the safety of endoscopic retroperitoneal resection of pheochromocytomas. In this study we evaluated the outcome of retroperitoneal endoscopic adrenalectomy for pheochromocytoma. Between June 1995 and September 1999 we performed 18 retroperitoneal endoscopic adrenalectomies for a pheochromocytoma or paraganglioma. All patients received adequate α-adrenergic blockade. The adrenal vein was ligated at the end of the procedure. Operative blood pressure values were recorded and evaluated. Altogether 15 patients (11 women, 4 men; mean age 47.2 years) were operated on for 17 pheochromocytomas and 1 extraadrenal tumor (4 right, 11 left, 3 bilateral). One female patient was operated on at 13 weeks’ gestation. Hypertensive episodes at operation were seen in 4 (26.7%) patients, and tachycardia occurred in 5 (33%). Hemodynamic changes could be corrected in all cases using simple measures without morbidity or detrimental effects. The mean operating time was 125 minutes (80–180 minutes), and the conversion rate was 5.6% (1/18). The median hospital stay was 5 days (3–28 days). Morbidity was 20% (3/15). Endoscopic retroperitoneal adrenalectomy for pheochromocytoma is safe and effective, and it is associated with limited morbidity.RésuméAlors que la surrénalectomie laparoscopique est recommandée pour les petites tumeurs de la corticosurrénale, la sécurité de l’ablation laparoscopique par voie rétropéritonéale des phéochromocytomes est discutée. Dans cette étude, on a évalué les résultats de l’ablation laparoscopique des phéochromocytomes par voie rétropéritonéale. Entre juin 1995 et septembre 1999 nous avons réalisé 18 surrénalectomies pour phéochromocytome ou paragangliome par voie laparoscopique rétropéritonéale. Tous les patients ont reçu des bloqueurs α-adrénergiques. La veine surrénalienne a été liée en dernier. On a enregistré et évalué la tension artérielle pendant l’intervention. Quinze patients (11 femmes et 4 hommes), âge moyen de 47.2 ans, ont été opérés pour 17 phéochromocytomes et une tumeur extra-surrénaîienne (4 à droite, lia gauche, et 3 bilatérale). Une femme a été opérée à la 13è semaine d’une grossesse. On a observé des épisodes hypertensifs pendant l’opération chez 4 (26.7%) patients et une tachycardie chez 5 (33%) patients. Des perturbations hémodynamiques ont pu tre corrigées dans tous les cas par des mesures simples, sans morbidité ou effets délétères. La durée moyenne d’intervention a été de 125 minutes (80–180), le taux de conversion, de 5.6% (1/18). La durée médiane du séjour hospitalier a été de 5 jours (3–28). La morbidité a été de 20% (3/15). La surrénaîectomie laparoscopique rétropéritonéale pour phéochromocytome est sure, efficiente et associée à une faible morbidité.ResumenAunque la adrenalectomía endoscópica es preconizada para todos los tumores adrenocorticales pequeños, persiste el debate sobre la seguridad de la resección retroperitoneal endoscópica de los feocromocitomas. En el presente estudio se evaluó el resultado de la adrenalectomía retroperitoneal endoscópica en pacientes con feocromocitoma: 18 procedimientos por feocromocitoma o paraganglioma fueron realizados entre junio de 1995 y septiembre de 1999. Todos los pacientes recibieron bloqueo alfa adrenérgico. La vena suprarrenal fue ligada al término del procedimiento. La presión arterial durante la operación fue registrada y evaluada. Quince pacientes (11 mujeres y 4 hombres) con edad media de 47.2 años fueron operados por 17 feocromocitomas y un tumor extra-adrena! (4 en el lado derecho, 11 en el izquierdo y 3 bilaterales). Una paciente fue operada en la decimotercera semana de embarazo. Se registraron episodios hipertensivos durante la operación en 4 (26.7%) pacientes y taquicardia en 5 (33%). Las alteraciones hemodinámicas pudieron ser corregidas en todos los casos con medidas simples, sin morbilidad o efectos nocivos. El tiempo operatorio medio fue 125 minutos (80–180), la tasa de conversión fue 5.6% (1/18). La estancia hospitalaria media fue 5 días (3–28). La tasa de morbilidad fue 20% (3/15). La adrenalectomía retroperitoneal endoscópica es un procedimiento seguro y efectivo que se asocia con una limitada morbilidad.

The influence of CO2 versus helium insufflationor the abdominal wall lifting technique on the systemic immuneresponse

Background: Both laparoscopic and conventional surgery result in activation of the systemic immune response; however, the influence of the laparoscopic approach, using CO2 insufflation, is significantly less. Little is known about the influence of alternative methods for performing laparoscopy, such as helium insufflation and the abdominal wall lifting technique (AWLT), and the systemic immune response. Methods: Thirty-three patients scheduled for elective cholecystectomy were randomly assigned to undergo laparoscopy using either CO2 or helium for abdominal insufflation or laparoscopy using only the AWLT. The postoperative inflammatory response was assessed by measuring the white blood cell count, C-reactive protein (CRP) and interleukin-6 (IL-6). The postoperative immune response was assessed by measuring monocyte HLA-DR expression. Results: CRP levels were significantly higher 1 day after helium insufflation when compared with CO2 insufflation; however, no differences were observed 2 days after surgery. The AWLT resulted in significantly higher levels of CRP both 1 and 2 days after surgery when compared with either CO2 or helium insufflation. A small increase in postoperative IL-6 levels was observed in all groups, but no significant differences were seen between the groups. After both helium insufflation and AWLT a significant decrease in HLA-DR expression was observed, in contrast to the CO2 group. Conclusion: Carbon dioxide used for abdominal insufflation seems to limit the postoperative inflammatory response and to preserve parameters reflecting the immune status. These findings may be of importance in determining the preferred method of laparoscopy in oncologic surgery.

Reply to: ‘Re: “The invisible cholecystectomy”’

Dear Editor, We would like to thank Dr. Navarra and co-authors for their interest in our article and their valuable comments and remarks regarding ‘the invisible cholecystectomy’ and trans-umbilical flexible endoscopic surgery (TUFES) technique. In our opinion, visualization with a 5-mm, 30° camera is sufficient for a safe procedure. This camera is stable, high quality, and gives a very good view of the anatomy of the Callot triangle, permitting us to dissect it according to the critical view of safety [1]. The suggested technique by Dr. Navarra of using three transabdominal sutures for retraction and stabilization of the gallbladder may be a good alternative, however we do not have any experience with this technique [2]. In our opinion, the Kirschner wire we use (sometimes we used two wires, infundibulum and fundus of the gallbladder, in order to visualize better the Callots triangle) has the advantage of being nonflexible. Therefore, turning movements and movements to and away from the laparoscope directly facilitate exposure of the medial and lateral aspects of the triangle of Callot. Using this traction method the exposure of the triangle of Callot is very good and we can change the orientation of the anatomy as much as we need [3]. We can imagine that fixation of the gallbladder by means of stitches is possible, however this may not permit the flag changes you need during the operation. Currently we are investigating the use of magnets in order to achieve the same exposure as with the Kirschner wire. Concerning the incidence of umbilical incisional hernias, in all our patients treated with our technique this complication has not been observed. The randomized study performed by his group, remarked upon by Dr. Navarra, is to our knowledge unpublished; we are not preparing this kind of study with our approach. Moreover, the hybrid technique Dr. Navarra describes using a combination of both the natural orifice transluminal endoscopic surgery (NOTES) technique transvaginally and a 5-mm trocar inserted at the umbilicus is an interesting approach, but in our opinion not practical. At this time, to reduce still more the operative trauma you have to choose between the NOTES and TUFES approaches. The problems of NOTES are caused by the use of natural orifices to introduce the flexible endoscope. This will, without doubt, introduce risks and produce complications. The umbilicus is a natural scar, localized in the middle of the abdomen, and from this position will facilitate, along with the use of the new endoscope, pushing the boundaries of endoscopic surgery. The development of the flexible endoscope is the real improvement awaited in the near future and not the use of natural orifices for its introduction. The image produced by current flexible endoscopes are not stable enough for high-quality surgery and the instruments to work with are not precise enough for surgery without risks. Developments in the future will yield greater precision and safety. Furthermore, other groups are developing more-rigid scopes with more effective work channels in order to fix these problems, giving more stable vision and more angulation with better instruments, as the surgeon is accustomed to. This is a promising development and modifications, such as that mentioned by Dr. Navarra, will help this goal. In our opinion, we would still prefer to develop the TUFES technique through the natural scar, the umbilicus, for all possible access to abdominal pathology. In this way, other healthy structures such as vagina and stomach used in NOTES can be spared, in this way avoiding possible collateral complications.