J. M. Sackier

Robotically assisted laparoscopic surgery. From concept to development.

The evolution of laparoscopy from a monocular view to the video screen has enabled all in the operating room to see the procedure. This has meant the surgeon must rely on an assistant to hold the scope, which has many drawbacks. Robotic enhancement technology creates a symbiotic relationship between the surgeon and robot and leads to great improvement in the performance of the case.

Training in laparoscopic cholecystectomy. Quantifying the learning curve.

AbstractThere is no clear consensus on the best way to train general surgeons to perform laparoscopic cholecystectomy (LC). We attempted to quantify the “learning curve” for 86 surgeons attending eight consecutive 3-day, three-pig courses in LC. Each step of the operation was scored by the instructor for successful performance: Uncomplicated pneumoperitoneum (p), cystic duct and artery dissection (cd), artery and duct clipping (cc), operative cholangiography (oc), gallbladder dissection without holes (gd), liver bed hemostasis (h), gallbladder removal in one piece (i), and no abdominal organ injury (in). As well, operative time, method of dissection, and contact Nd: YAG or electrocautery were recorded. The percentage of students successfully completing each task for the first and third pigs on which they acted as surgeon was as follows: The operative time for the first and third pigs was 1.3±0.56 and 0.70±0.34 (mean±SD) h, respectively (P<0.01). When students were trained with the contact Nd: YAG laser there was more blood loss than with electrosurgery (P<0.001).Statistically significant improvement could only be demonstrated in the most difficult task, gallbladder dissection without perforation, but that task had not been mastered by the end of 3 days. The flat portion of the laparoscopic cholecystectomy “training curve” had not been reached by the end of the program.

Comparison of serum C-reactive protein concentrations for laparoscopic versus open cholecystectomy

In an attempt to quantify the difference in tissue damage between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC), we have compared in a prospective manner the pre- and postoperative concentrations of serum C-reactive protein (CRP) in 17 patients undergoing LC and 13 patients undergoing OC. In addition, we measured the pre- and postoperative white blood cell counts (WBC), the postoperative body temperature, and the postoperative duration of hospitalization. There were no differences in the preoperative serum CRP concentrations—5.9±2.62 mg/l (mean±SD) for the LC group and 6.12±2.38 mg/l for the OC group.Serum CRP rose markedly following OC compared to that of patients who underwent LC (128.6±45.1 mg/l vs 26.8±10.5 mg/l) (P<0.001). There were also significant differences in the postoperative WBC count (14,000±2,900 cells for the OC group vs 10,600±3,000 cells for the LC group), the postoperative body temperature (37.5±0.3°C vs 37.0±0.3°C), and the postoperative hospital stay (5.5±1.5 days vs 1.9±0.9 days). There was no correlation between serum CRP concentrations and the other postoperative parameters.These results provide us with biochemical evidence supporting the clinical observation that LC is far less traumatic to the patient than OC.

Laparoscopic cecopexy for cecal volvulus

SummaryA case of intermittent cecal volvulus in an immunocompromised patient is presented. This patient, whose bowel was viable, was managed successfully by laparoscopic cecopexy.As a clinical entity, cecal volvulus usually presents as either an unrelenting process, culminating in gangrenous bowel, or as an intermittent, recurrent condition with spontaneous resolution but which also may lead to loss of intestinal viability. Surgical management is required in almost every case; however, a review of the literature reveals considerable controversy as to what constitutes the best operation for cases in which the bowel is viable. The most appropriate operation is usually dictated by the clinical circumstances, and in many settings cecopexy is a satisfactory choice of procedure; resection is obviated, bowel need not be opened, and the operation can be performed laparoscopically relatively rapidly.

Complications of laparoscopy and thoracoscopy.

Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected.

Laparoscopic endocorporeal mobilization followed by extracorporeal sutureless anastomosis for the treatment of carcinoma of the left colon

Surgery has become progressively more reliant on technology. The technique of colonic anastomosis utilizing the biofragmentable anastomotic ring (BAR) is one such example. The benefits of therapeutic laparoscopy have been applied to the arena of colorectal surgery. A case is presented that combines these two modalities in a patient with colon cancer, laparoscopic mobilization of the large bowel, exteriorized resection, and BAR anastomosis.

Clinical and laboratory evaluation of an electrosurgical laparoscopic trocar

Electrosurgical energy may be utilized as an adjunct to mechanical force for insertion of laparoscopic trocars. The advantage of this approach may be better operator control of insertion, with less risk of intraperitoneal and retroperitoneal injury. To assess the safety and efficacy of electrosurgical trocars, we compared them to mechanical trocars in clinical and animal trials. During 100 trocar introductions in 25 laparoscopic cholecystectomies, insertion force was measured. In contrast to mechanical trocars, which required progressively more force to insert as size increased, electrosurgical trocars required the same low insertion force regardless of size. No wound complications occurred. In animal experiments, wound healing (measured histologically and by bursting strength) was normal and equivalent for mechanical and electrosurgical insertions.We conclude that electrosurgical trocars require less force for insertion and do not impair wound healing. Electrosurgical trocars may thus offer important safety advantages over mechanical trocars.

Biofragmentable anastomosis ring for laparoscopic bowel surgery

Laparoscopic surgery is now being applied for colonic resection, and one of the key challenges is fashioning a sound anastomosis. The biofragmentable anastomosis ring, a modern version of the Murphy Button, has been utilized in a series of experiments to develop and evaluate laparoscopic anatomotic techniques. A series of purpose-built devices were used to fashion left and right simulated colectomies as well as for a variety of other anastomoses. Survival animal experiments were performed and demonstrate the feasibility of this technique.

The rotary gallstone lithotrite to aid gallbladder extraction in laparoscopic cholecystectomy

SummaryDuring laparoscopic cholecystectomy, a large stone burden may cause difficulty when extracting the gallbladder through the abdominal wall. Currently, the alternatives available to the surgeon include increasing the incision, removing stones singly, or utilizing complex fragmentation techniques like the pulsed dye laser [1]. We have employed an electromechanical rotary gallstone lithotrite (RGL) to fragment stones to an aspiratable size.Initially, cholesterol spheres were pulverized in a latex balloon to demonstrate the efficacy of the device. Then, human gallstones were placed in the balloon and reduced to fragments less than or equal to 1 mm from initial sizes of 4–24 mm.Human stones were then inserted in ex vivo porcine gallbladders in a controlled experiment and treated with the device. Ten out of 12 tests were completed within 30 s; one test required 49 s and one 105 s to achieve complete fragmentation. Blinded histological evaluation demonstrated that tissue abrasion caused by use of the device would not interfere with the diagnosis of unsuspected malignancy. Clinical trials have now commenced under the auspices of the hospital ethical committee.

A purse-string device for laparoscopic surgery

ConclusionThis device offers the potential for totally intracorporeal bowel anastomoses.