J. P. E. N. Pierie

Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines

BackgroundWith minimally invasive surgery (MIS), a man–machine environment was brought into the operating room, which created mental and physical challenges for the operating team. The science of ergonomics analyzes these challenges and formulates guidelines for creating a work environment that is safe and comfortable for its operators while effectiveness and efficiency of the process are maintained. This review aimed to formulate the ergonomic challenges related to monitor positioning in MIS. Background and guidelines are formulated for optimal ergonomic monitor positioning within the possibilities of the modern MIS suite, using multiple monitors suspended from the ceiling.MethodsAll evidence-based experimental ergonomic studies conducted in the fields of laparoscopic surgery and applied ergonomics for other professions working with a display were identified by PubMed searches and selected for quality and applicability. Data from ergonomic studies were evaluated in terms of effectiveness and efficiency as well as comfort and safety aspects. Recommendations for individual monitor positioning are formulated to create a personal balance between these two ergonomic aspects.ResultsMisalignment in the eye–hand–target axis because of limited freedom in monitor positioning is recognized as an important ergonomic drawback during MIS. Realignment of the eye–hand–target axis improves personal values of comfort and safety as well as procedural values of effectiveness and efficiency.ConclusionsMonitor position is an important ergonomic factor during MIS. In the horizontal plain, the monitor should be straight in front of each person and aligned with the forearm–instrument motor axis to avoid axial rotation of the spine. In the sagittal plain, the monitor should be positioned lower than eye level to avoid neck extension.

Laparoscopic versus open total mesorectal excision for rectal cancer: An evaluation of the mesorectum’s macroscopic quality

BackgroundNext to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated.MethodsA series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum.ResultsA three-grade scoring system showed no differences between the LTME and OTME groups.ConclusionThe current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.

Healing of the cervical esophagogastrostomy.

Reconstruction of the upper digestive tract with the stomach or gastric tube after esophageal resection has proven to be a safe surgical procedure. But dehiscence, leakage, and stricture of the esophagogastrostomy are prevalent and have been reported in 0% to 4%, 5% to 44%, and 7% to 50% of patients respectively. These complication rates exclude esophageal resection for benign diseases and cast doubt in the case of palliation. Many surgeons prefer to resect the esophagus transhiatally with a cervical anastomosis, which circumvents the transthoracic route and avoids possibility of leakage of an intrathoracic anastomosis and its severe consequences, with mortality rates up to 58%. Anastomotic complications occur more frequently, however, after cervical anastomosis compared with the intrathoracic position when the stomach is used as a substitute for the esophagus. Currently, a narrow gastric tube as a neoesophagus is often preferred because of improved gastric emptying in comparison with wide gastric tubes and gastric pull-up. The extra length can be helpful in reaching the neck because a narrow gastric tube makes widening of the upper thorax aperture unnecessary. Despite these advantages, healing of the cervical esophagogastrostomy is often impaired, leading to nonfatal complications such as leakage and stricture formation. Among the factors that might affect anastomotic healing are: surgical technique and material, vascularization of the gastric tube at the level of the anastomosis, diameter of the gastric tube, position of the anastomosis, and reflux of the gastrointestinal contents.

Effect of proctoring on implementation and results of elective laparoscopic colon surgery

PurposeA steep learning curve exists for surgeons to become skilled in laparoscopic colon resection. Our institute offers a proctored training programme. The purpose of this descriptive study was to evaluate whether the course resulted in adoption of laparoscopic colorectal surgery into clinical practice, explore post-course practice patterns and analyse the outcome of surgical performance.MethodsBetween 2003 and 2008, 26 surgeons were trained by our institute. The course consisted of 24 elective laparoscopic resections under direct supervision. A questionnaire and a prospective post-course web-based registration were used to analyse the effect of the training and the outcome of surgical performance.ResultsThe response rate of the questionnaire was 85%. The majority had not performed any laparoscopic colon resections before attending the course. All 24 respondents successfully implemented laparoscopy into daily practice. After the course, 70% of all sigmoid resections were performed laparoscopically in contrast with 0% of all transverse colon resections. The results of the trainees after following the course are equal to results of other studies.ConclusionsA proctored training programme, consisting of 24 supervised cases, is safe and feasible. For adequate monitoring, participating in a post-course registry should be obligatory.

Psychophysiological assessment of sexual function in women after radiotherapy and total mesorectal excision for rectal cancer: a pilot study on four patients

INTRODUCTION The potential contribution of psychological and anatomical changes to sexual dysfunction in female patients following short-term preoperative radiotherapy (5 x 5 Gy) and total mesorectal excision (TME) is not clear. Aim. In this study we assessed female sexual dysfunction in patients who underwent radiotherapy and TME for rectal cancer. MAIN OUTCOME MEASURES Genital arousal was assessed using vaginal videoplethysmography. METHODS Sexual functioning was examined in four patients who had rectal cancer and underwent radiotherapy and TME. All investigations were done at least 15 months after treatment. The results were compared with an age-matched group of 18 healthy women. RESULTS The patients and healthy controls showed comparable changes in vaginal vasocongestion during sexual arousal, though three out of four patients showed a lower mean spectral tension (MST) of the vaginal pulse compared with healthy controls. Subjective sexual arousal was equivalent between the two groups. CONCLUSIONS In this study the changes of genital and subjective sexual arousal after erotic stimulus condition between patients and healthy controls were not different, though lower MST of the vaginal pulse was found in three out of four patients compared with healthy women. Additional work, however, must be performed to clarify the mechanisms of sexual dysfunction following treatment of rectal cancer.

Technique for laparoscopic autonomic nerve preserving total mesorectal excision

With the introduction of total mesorectal excision (TME) for treatment of rectal cancer, the prognosis of patients with rectal cancer is improved. With this better prognosis, there is a growing awareness about the quality of life of patients after rectal carcinoma. Laparoscopic total mesorectal excision (LTME) for rectal cancer offers several advantages in comparison with open total mesorectal excision (OTME), including greater patient comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure. Moreover, laparoscopy allows good exposure of the pelvic cavity because of magnification and good illumination. The laparoscope seems to facilitate pelvic dissection including identification and preservation of critical structures such as the autonomic nervous system. The technique for laparoscopic autonomic nerve preserving total mesorectal excision is reported. A three- or four-port technique is used. Vascular ligation, sharp mesorectal dissection and identification and preservation of the autonomic pelvic nerves are described.

Thiopurines Are Associated with a Reduction in Surgical Re-resections in Patients with Crohn's Disease: A Long-term Follow-up Study in a Regional and Academic Cohort

Background:Combination therapy of thiopurines and anti–tumor necrosis factor alpha (TNF-&agr;) antibodies is the most effective medical treatment of Crohns disease (CD). Data on thiopurines and anti-TNF-&agr; antibodies in preventing surgical recurrence (need for re-resection) of CD are scarce. Therefore, we analyzed which factors were involved in surgical recurrence of CD in a large cohort of patients with CD operated in a regional and a university hospital. Methods:This is a retrospective cohort study of 567 patients who underwent surgery for CD. Clinical data and risk factors for surgical recurrence were analyzed, focusing on medical therapy and hospital type. Results:Overall, 237 (41.8%) patients developed a surgical recurrence, after a median of 70 (2–482) months. Before surgical recurrence, 235 patients (41.4%) and 116 patients (20.5%) used thiopurines and anti-TNF-&agr; antibodies, respectively. Multivariate analysis identified 3 independent risk factors associated with surgical recurrence of CD. A higher risk was seen in patients with colonic disease compared with patients with ileal disease (hazard ratio, 1.56; 95% confidence interval, 1.10–2.21; P = 0.012) and in patients using multiple types of medication (hazard ratio, 1.38; 95% confidence interval, 1.25–1.54; P < 0.001). However, a lower risk was seen in patients using thiopurines (hazard ratio, 0.51; 95% confidence interval, 0.34–0.77; P = 0.001). Conclusions:Thiopurines are effective in preventing surgical recurrence of CD. The role of anti-TNF-&agr; antibodies seems promising as well. Combination therapy of thiopurines and anti-TNF-&agr; antibodies for prevention of surgical recurrence of CD should be studied in a randomized trial.

Cerebral gas embolism due to upper gastrointestinal endoscopy

Cerebral gas embolism as a result of upper gastrointestinal endoscopy is a rare complication and bares a high morbidity. A patient is presented who underwent an upper endoscopy for evaluation of a gastric-mediastinal fistula after subtotal oesophagectomy and gastric tube reconstruction because of oesophageal cancer. During the procedure, cerebral gas emboli developed resulting in an acute left-sided hemiparesis. After hyperbaric oxygen therapy, the patient recovered almost completely. The aetiology and treatment is discussed based on the reviewed literature. Once cerebral gas emboli are recognized, patient outcome can be improved by hyperbaric oxygen therapy.

Improved healing of extraperitoneal intestinal anastomoses in the early phase when surrounded by omentum.

Background: The extra-anatomical position of a cervical oesophagogastrostomy is a reason for impaired anastomotic healing, but transposition of the omentum that is covered with mesothelial cells may be a way to improve that. Method: This hypothesis was tested in a rat model. An end-to-end jejuno-jejunostomy was placed subcutaneously in group I (n = 29), subcutaneously surrounded by omentum in group II (n = 29) and intra-abdominally surrounded by omentum in group III (n = 20). After 3, 7 or 14 days, the rats were sacrificed and bursting pressure (BP) of the anastomosis or jejunum was measured and the hydroxyproline (HP) level was determined. Results: In group I 5/29, in group II 2/29 and in group III 0/20 rats died following anastomotic leakage (nonsignificant) and were excluded from other measurements. BP was decreased after 3 days in group I (60 ± 9 mm Hg) compared with group II (101 ± 8 mm Hg) and group III (107 ± 11 mm Hg) (p = 0.002). After 7 days, BP in groups I (122 ± 10 mm Hg) and II (132 ± 10 mm Hg) were lower as compared with group III (230 ± 8 mm Hg) (p < 0.001). Differences in HP levels were not statistically significant between the groups after 3, 7 and 14 days. Conclusion: The healing of intestinal anastomoses in an extraperitoneal position is improved in the early phase only when surrounded by omentum.

Elective laparoscopic recto-sigmoid resection for diverticular disease is suitable as a training operation

PurposeSome authors state that elective laparoscopic recto-sigmoid resection is more difficult for diverticular disease as compared with malignancy. For this reason, starting laparoscopic surgeons might avoid diverticulitis, making the implementation phase unnecessary long. The aim of this study was to determine whether laparoscopic resection for diverticular disease should be included during the implementation phase.MethodsAll consecutive patients who underwent an elective laparoscopic recto-sigmoid resection in our hospital for diverticulitis or cancer from 2003 to 2007 were analysed.ResultsA total of 256 consecutive patients were included in this prospective cohort study. One hundred and fifty-one patients were operated on for diverticulitis and 105 for cancer. There was no significant difference in operation time (168 vs. 172 min), blood loss (189 vs. 208 ml), conversion rates (9.9% vs. 11.4%), hospital stay (8 vs. 8 days), total number of peroperative (2.3% vs. 1.6%) or postoperative complications (21.9% vs. 26.9%). The occurrence of anastomotic leakages was associated with higher American Society of Anesthesiologists (ASA) classification, which differed between the groups (86.8% vs. 64.8% ASA I–II, p < 0.001).ConclusionSince there are no differences in operation time, blood loss, conversion rate and total complications, there is no need to avoid laparoscopic recto-sigmoid resection for diverticular disease early in the learning curve.