Israel L. Nudelman

A nickel–titanium memory-shape device for colonic anastomosis in laparoscopic surgery

BackgroundMinimally invasive surgery is used increasingly for colonic resection. With this procedure, the involved colon is dissected laparoscopically and exteriorized through a small incision, and the segment containing the tumor is resected. The anastomosis is performed extraperitoneally either by hand suture or with a stapler. This study was designed to evaluate the feasibility of using a memory-shape compression anastomosis clip (CAC) to perform laparoscopically assisted colonic anastomosis. The study was prompted by the authors’ successful experience with the CAC in an animal model and in 10 patients with diverse colonic cancers.MethodsThe sample consisted of 10 patients who underwent laparoscopic colonic surgery at the authors’ center. The anastomosis was performed with the CAC for five patients and with a stapler for five patients. To perform anastomosis with the CAC, the two edges of the resected colon are aligned. Two 5-mm incisions are made near the edges, through which the CAC, after cooling in ice water, is introduced in an open position using a special applier. In response to body temperature, the clip resumes its original (closed) position, thereby clamping the two bowel loops together. At the same time, the small scalpel incorporated in the applier makes a small incision through the clamped walls for the passage of gas and feces, and the clip is released into the intestine. The two 5-mm incisions are sutured. The clip is expelled with the stool within 5 to 7 days, creating a perfect uniform anastomosis.ResultsNeither group had complications, except one patient from the control group who experienced a small bowel obstruction attributable to a wound suture problem, which required laparotomy. His recovery was uneventful.ConclusionsThe use of the CAC for colonic laparoscopic surgery is simple and very efficient, shortening operation time. It creates a uniform anastomosis, approximating the no-touch concept in surgery, and may prevent infection. It also is lower in cost than the stapler.

Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation

AbstractBackground: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. Methods: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. Results: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 ± 7 min for unilateral hernia and 65 ± 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. Conclusions: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia.

Gallbladder inflammation is associated with increase in mucin expression and pigmented stone formation

Mucin is a high molecular weight glycoprotein that plays an important role in protecting the gallbladder epithelium from the detergent effect of bile. However, it also participates in gallstone formation. There is little information about a possible relationship between gallbladder inflammation and mucin expression or gallbladder stones’ characteristics. The aims of this study were to investigate stone characteristics and patterns of mucin expression in the gallbladder epithelium and bile of gallstone patients, in relation to inflammation. Gallbladder bile and tissue samples from 21 patients were obtained at surgery. Mucin content was evaluated by gel filtration on a Sepharose CL-4B column. Dot blot for bile mucin apoproteins and immunohistochemistry staining for gallbladder mucosal mucin apoproteins were performed with antibodies to MUC2, MUC3, MUC5AC, MUC5B and MUC6. Staining intensity score (0–3) was used for assessment of antigen expression and the level of inflammation. Gallstone cholesterol content was determined in 16 patients. MUC 5AC and MUC 5B were demonstrated in 95.4 and 100% of gallbladder bile samples, respectively. Immunohistochemistry staining with antibodies to MUC 2, MUC 3, MUC 5AC, MUC 5B and MUC 6 were positive in 0, 100, 85.7, 100 and 95.4% of the gallbladder mucosal samples, respectively. Pigmented brown stones were associated with a higher level of gallbladder inflammation. Mucin species expressed in gallbladder epithelium are MUC3, MUC5AC, MUC5B and MUC6. MUC5AC and MUC5B are secreted into bile. Inflammation of the gallbladder is accompanied by a higher level of MUC5AC expression and is associated with pigmented brown stones.

Minimally invasive surgery for axillary dissection

Abstract. Axillary dissection is the major cause of morbidity in breast cancer and primary cutaneous melanoma of the extremity. In the present study, we examine the potential benefits and advantages of endoscopic axillary lymph node dissection over conventional surgery. Twenty endoscopic axillary dissections and 10 lymph node samplings were performed in 10 cadavers (four male, six female). A preperitoneal distention balloon (PDB) system was used to dissect the axilla. In four of the cadavers, the procedure was followed by open surgery. The axillary contents were examined for lymphatic tissue by a pathologist. The endoscopic technique offered easy access to the axilla and clear visualization of the axillary vein, as well as the long thoracic and thoracodorsal nerves. Results were comparable to those achieved with the classic surgical dissection. Endoscopy is feasible for axillary lymph node dissection and sampling in cases of breast cancer and primary cutaneous melanoma of the extremity. Further studies in patients are needed to reach definitive conclusions.

Subtotal Colectomy for Inflammatory Disease of Bowel in a Patient with Hemophilia A

We report the rare case of a young patient with factor-VIII deficiency (hemophilia A) who developed severe inflammatory bowel disease ulcerative colitis with life-threatening gastrointestinal bleeding