George P.C. Yang

Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy

BACKGROUNDnThis study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC).nnnMETHODSnFrom November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27).nnnRESULTSnMean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6).nnnCONCLUSIONSnSILC was feasible and safe for properly selected patients in experienced hands.

Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy – A comparative study

BACKGROUNDnTraditionally, pancreatic surgery is considered as one of the most complex surgeries. The recently developed robotic technology allows surgeons to perform pancreaticoduodenectomy. A comparative study was undertaken to study outcomes between robotic approach and open approach.nnnMETHODSnA consecutive patients underwent pancreaticoduodenectomy (robotic approach, n=20; open approach=67) between January 2000 and February 2012 at a single institution were analyzed.nnnRESULTSnThe robotic group had a significantly longer operative time (mean, 491.5 vs. 264.9 min), reduced blood loss (mean, 247 vs. 774.8 ml), and shorter hospital stay (mean, 13.7 vs. 25.8 days) compared to the open group. Open conversion rate was 5%. There was no significant difference between the two groups in terms of overall complication rates, mortality rates, R0 resection rate and harvested lymph node numbers.nnnCONCLUSIONSnThis study showed that robot-assisted laparoscopic pancreaticoduodenectomy was safe and feasible in appropriately selected patients. However, it is too early to draw definitive conclusions about the value of robot-assisted laparoscopic pancreaticoduodenectomy. In light of remaining uncertainties regarding short-term and long-term outcome, caution should be exercised in the assessment of the appropriateness of this operation for individual patient.

Robotic hepatobiliary and pancreatic surgery: a cohort study

BackgroundRobotic surgery has emerged as one of the most promising surgical advances since its launch at the turn of the millennium. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary and pancreatic (HBP) surgery remains relatively unexplored. This article aims to evaluate the efficacy and outcomes of robotic HBP surgery in a single surgical center.MethodsBetween May 2009 and December 2010, all patients admitted to our unit for robotic HBP surgery were evaluated. A retrospective analysis of a prospectively maintained database on clinical outcomes was performed.ResultsThere were 55 robotic HBP operations performed during the study period. There were 27 robotic liver resections (left lateral sectionectomies nxa0=xa017, left hepatectomy nxa0=xa01, other segmentectomies nxa0=xa02 and wedge resections nxa0=xa07), 12 robotic pancreatic procedures (Whipple’s operations nxa0=xa08, spleen-preserving distal pancreatectomies nxa0=xa02, double bypass nxa0=xa01 and cystojejunostomy nxa0=xa01) and 16 biliary procedures (biliary enteric bypass nxa0=xa09, bile duct exploration and related procedures nxa0=xa07). The median postoperative hospital stays for robotic liver resections, biliary procedures and pancreatic operations were 5.5xa0days (range 3–11xa0days), 6xa0days (range 4–11xa0days) and 12xa0days (range 6–21xa0days), respectively. Morbidities for liver resection, biliary procedures and pancreatic operations were 7.4, 18 and 33%, respectively. There was no mortality in our series.ConclusionsRobotic surgery is feasible and can be safely performed in patients with complicated HBP pathologies. Further evaluation with clinical trials is required to validate its real benefits.

Robot-assisted laparoscopic liver resection for hepatocellular carcinoma: short-term outcome.

BACKGROUNDnThis study aimed at analyzing the perioperative and early survival outcomes of robotic liver resection of hepatocellular carcinoma (HCC).nnnMETHODSnThe study population included a consecutive series of patients with HCC who underwent robotic liver resection at a single center.nnnRESULTSnDuring the study period, 41 consecutive patients with HCC underwent 42 robotic liver resections. Five resections (11.9%) were carried out for recurrent HCC, and 23.8% (n = 10) were hemihepatectomy procedures. The mean operating time and blood loss was 229.4 minutes and 412.6 mL, respectively. The R0 resection rate was 93%. The hospital mortality and morbidity rates were 0% and 7.1%, respectively. The mean hospital stay was 6.2 days. The 2-year overall and disease-free survival rates were 94% and 74%, respectively. In the subgroup analysis of minor liver resection, when compared with the conventional laparoscopic approach, the robotic group had similar blood loss (mean, 373.4 mL vs 347.7 mL), morbidity rate (3% vs 9%), mortality rate (0% vs 0%), and R0 resection rate (90.9% vs 90.9%). However, the robotic group had a significantly longer operative time (202.7 mins vs 133.4 mins).nnnCONCLUSIONSnThis study demonstrated the feasibility and safety of robotic surgery for HCC, with favorable short-term outcome. However, the long-term oncologic results remain uncertain.

Multimodality laparoscopic liver resection for hepatic malignancy – From conventional total laparoscopic approach to robot-assisted laparoscopic approach

INTRODUCTIONnLaparoscopic liver resection can either be total laparoscopic or hand-assisted laparoscopic approach. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. The role of robotic system in laparoscopic surgery was not well evaluated yet. The aim of this cohort study was to evaluate the outcome of multimodality approach of laparoscopic liver resection for hepatic malignancynnnMETHODSnFrom January 1998 to August 2010, all patients with hepatic malignancy underwent laparoscopic liver resection were included. A prospectively collected data was analyzed retrospectively.nnnRESULTSnDuring the study period, a total of 56 patients with hepatic malignancies (hepatocellular carcinoma, HCC, n = 42; colorectal liver metastases, CLM, n = 14) underwent laparoscopic liver resection in our surgical unit. The majority of cases were performed by hand-assisted laparoscopic approach, n = 31 (55.3%) and the remainder were with total laparoscopic approach, n = 10 (17.9%) and robot-assisted laparoscopic approach, n = 15 (26.8%). The median operation time was 150 min (range, 75-307 min). The median blood loss during surgery was 175 ml (range, 5-2000 ml). Two patients (3.6%) needed open conversion and one patient (1.8%) needed to be converted to hand-assisted laparoscopic approach. The morbidity rate was 14.3%. There was no procedure-related death. 89.3% of patients had R0 resection and 10.7% of patients had R1 resection. The median hospital stay was 6.5 days (range, 2-13 days). The 1-year, 3-year, and 5-year disease-free survival rates for HCC were 85%, 47%, and 38%, respectively. The 1-year, 3-year, and 5-year overall survival rates for HCC were 96%, 67%, and 52%, respectively. The 1-year, and 3-year disease-free survival rates for CLM were 92% and 72%. The 1-year, and 3-year overall survival rates for CLM were 100% and 88%, respectively.nnnCONCLUSIONSnMultimodality approach of laparoscopic liver resection of hepatic malignancy was feasible, and safe in selected patients. It was associated with a low complications rate. The mid-term and long-term survival outcome was favorable also.

Laparoscopic approach of surgical treatment for primary hepatolithiasis: a cohort study

BACKGROUNDnThe aim of the current study was to evaluate the perioperative and long-term outcome of a laparoscopic approach for management of primary hepatolithiasis.nnnMETHODSnFrom January 1995 to June 2008, 55 consecutive patients with primary hepatolithiasis who underwent laparoscopic partial hepatectomy and laparoscopic bile duct exploration were analyzed. Immediate outcomes included stone clearance rate, operative morbidity, and mortality. Long-term outcomes included stone recurrence rate and hepatolithiasis-related mortality.nnnRESULTSnNineteen patients underwent laparoscopic left lateral sectionectomy and 36 patients underwent laparoscopic bile duct exploration. Twenty-five patients also underwent concomitant laparoscopic choledochoduodenostomy bypass. The operative morbidity and mortality rates were 25.5% and 1.8%, respectively. Four procedures needed open conversion. The immediate stone clearance rate was 90.9%, and the final stone clearance rate was 94.5% after subsequent choledochoscopic treatment. With a mean follow-up of 59 +/- 30 months, recurrent stones developed in 3 patients. One patient died of advanced cholangiocarcinoma.nnnCONCLUSIONSnIn selected patients with primary hepatolithiasis, a laparoscopic approach of definitive treatment is safe and effective with good immediate and long-term outcomes.

Minimally invasive surgical treatment of hepatocellular carcinoma: long-term outcome.

BackgroundLaparoscopic liver resection for hepatocellular carcinoma (HCC) is still a matter of debate because of the uncertainty of the long-term results and the fear of compromising the oncological resection. Published findings on survival and outcome after laparoscopic liver resection for HCC are scarce still. The aim of the present study was to report the perioperative and long-term outcome of minimally invasive surgical treatment of HCC.MethodsFrom January 1998 to November 2008, all patients with HCC who underwent laparoscopic liver resection in our unit were included. A prospectively collected database was analyzed retrospectively. Perioperative outcome included procedure-related morbidity and mortality. Long-term outcome included 5-year overall survival and disease-free survival.ResultsDuring the study period, 30 consecutive patients with HCC underwent laparoscopic liver resection (hand-assisted laparoscopic liver resection, nxa0=xa022; total laparoscopic liver resection, nxa0=xa07; converted to open approach, nxa0=xa01). The mean tumor size was 2.8xa0cm. The mean operating time was 139.4xa0min, and 90% of patients had R0 resection and 10% of patients had R1 resection. The hospital mortality and morbidity rates were 0 and 20%, respectively. The mean hospital stay was 7.4xa0days. For those patients (nxa0=xa022) with a minimal follow-up of 24xa0months, the 5-year overall and disease-free survival rates were 50 and 36%, respectively. No port site recurrence occurred.ConclusionsThis study showed that laparoscopic liver resection for HCC was feasible and safe in selected patients. The long-term survival was also favorable.

Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus

BackgroundConventional preoperative staging for esophageal carcinoma could be inaccurate. Laparoscopy has been applied for the staging of various upper gastrointestinal malignancies. It can identify peritoneal and liver deposits not shown by imaging, and could reduce the number of nontherapeutic laparotomies. This study aimed to evaluate the efficacy of laparoscopic staging for the management of squamous cell carcinoma involving the mid and distal esophagus.MethodsA retrospective review was performed for all patients with esophageal cancer evaluated for surgical resection from January 1998 to January 2004. Laparoscopy was performed for all the patients with mid and distal esophageal cancer immediately before open gastric mobilization. The efficacy of laparoscopy for the management of squamous cell carcinoma of the esophagus was evaluated.ResultsAmong the 63 patients with potentially resectable disease shown on conventional imaging, 54 (84%) underwent esophagectomy with curative intent after laparoscopic staging. Seven patients (11%) underwent laparoscopy alone because of abdominal metastases (n = 5) or other medical conditions (n = 2) that precluded esophagectomy. Two patients (3%) had exploratory right thoracotomy without esophagectomy despite normal laparoscopic findings. The sensitivity and specificity of laparoscopic staging were 100% in this series of patients (100% sensitivity and specificity means no false-positives or -negatives).ConclusionLaparoscopic staging is valuable for the management of patients with mid and distal squamous cell carcinoma of the esophagus. Patients with metastatic disease and those with prohibitive surgical risk can thus avoid unnecessary laparotomy and be offered other treatment methods.

Robot-assisted laparoscopic approach of management for Mirizzi syndrome.

Mirizzi syndrome is an uncommon cause of common hepatic duct obstruction resulting from gallstone impaction in the cystic duct or gallbladder neck. Mirizzi syndrome is traditionally considered as a contraindication to laparoscopic surgery mainly due to risk of bile duct injury during dissection. We present the surgical experience of 5 patients with Mirizzi syndrome who were diagnosed preoperatively and managed using minimally access surgical technique, either total laparoscopic or robotic-assisted laparoscopic approach. All patients had successful operations and recovered without complications. We concluded that with a correct preoperative diagnosis, careful operative strategy, increasing expertise with laparoscopic technique, and introduction of robotic surgical system, minimally invasive approach of management of Mirizzi syndrome becomes safe and feasible.

An Approach to EVAR Simulation Using Patient Specific Modeling

BACKGROUNDnThe Simbionix Angiomentor Procedure Rehearsal Studio (PRS) offers accurate virtual anatomy for measurement, stent graft selection, and deployment of endovascular aneurysm repair (EVAR) devices.nnnMETHODSnSelected Gore Excluder EVAR cases from our EVAR database were reviewed and DICOM data loaded into the Simbionix Angiomentor simulator using PRS software. Using centerline measurements created on PRS, neck diameter (D1), length from lowest renal artery to each iliac bifurcation (Ll and Lr), and common iliac artery diameter (Dl and Dr) were recorded. All measurements for device selection were made based on data recorded on the simulator. Simulated EVAR was then performed using PRS on a dual limb endovascular simulator. Changes in device selection based on intraoperative measurements and use of three-dimensional (3D) anatomic overlay made by the attending vascular surgeon performing the case were recorded. The devices actually used for successful repair were considered gold standard for comparison. At the completion of each virtual case, simulations were rated by an experienced vascular surgeon for realism, imaging quality, and final product on a 5-point scale.nnnRESULTSnTen cases with complete operative data and available computed tomography scans were chosen at random. Fifty percent of the cases (5/10) had changes in device length when using the inxa0vivo 3D volume filled model and angiographic measurements. Analysis of variance revealed no significant differences between the groups in any measurement-main body diameter Pxa0=xa00.960; main body length Pxa0=xa00.643; and contralateral limb length Pxa0=xa00.333. Review of simulation scoring showed ratings of diminished realism (average 2.3/5) due to unrealistic ease of wire passage and gate cannulation; however, simulation imaging and final product were scored favorably (3.7 and 3.4, respectively).nnnCONCLUSIONSnThe use of centerlines, angiographic measurements, and 3D modeling within the PRS software approaches real-life device selection and represents an opportunity for high fidelity patient-specific preoperative EVAR case rehearsal.