Johannes Bodner

GALLSTONE ILEUS: RARE AND STILL CONTROVERSIAL

Background:  Gallstone ileus is a rare disease and accounts for about 1−3% of mechanic ileus of the small bowel, but for 25% of all small bowel obstructions in patients older than 65 years. Concomitant cardiorespiratory diseases or diabetes are frequent in older patients and responsible for the high mortality rate. The aim of the present study was to evaluate and discuss different surgical approaches and to analyze the clinical outcome.

A Critical Comparison of Robotic Versus Conventional Laparoscopic Splenectomies

The benefit of robotic systems for general surgery is a matter of debate. We compare our initial series of robotic splenectomies with our first series of conventional laparoscopic ones. A retrospective analysis of the first six robotic versus the first six conventional laparoscopic splenectomies is presented. Patients were matched with regard to age, bodymass index, ASA score, and preoperative platelet levels. All procedures were performed by a single surgeon. Size and weight of the resected specimens were comparable in both groups. Median overall operating time was 154 (range, 115–292) min for the robotic and 127 (range, 95–174) min for the laparoscopic group. No complications occurred. There were no open conversions. The median postoperative hospital stay was 7 (robotic group) and 6 (laparoscopic group) days. Median average costs were

Diagnostic and therapeutic challenges of a large pleural inflammatory myofibroblastic tumor.

6927 for the robotic procedure versus

Perforated right colonic diverticulitis complicating pregnancy at 37 weeks' gestation.

4084 for the conventional laparoscopic procedure (p < 0.05). Minimally invasive splenectomies are feasible using either conventional laparoscopic techniques or the da Vinci™ robotic system. In this analysis, procedures performed with the da Vinci™ robotic system resulted in prolonged overall operative time and significantly higher procedural costs. The use of a robotic system for laparoscopic splenectomy offers, at this stage, no relevant benefit and thus is not justified.

First Experiences with Robotic‐Assisted Laparoscopic Cholecystectomies

We report a 48-year-old woman with a pleural pseudoneoplasm requiring different diagnostic and therapeutic strategies. After initial presentation with increasing dyspnoea, temperature, dry cough, and interscapular pain diagnostic processing showed a large mediastinal mass with marked pleural effusion and high metabolic activity in the 18F-FDG-PET/CT. Extensive CT-guided biopsy of the tumor reaching from the visceral pleura into the right upper lobe revealed no malignancy, but a marked inflammatory tissue reaction containing foam cells. Initial empiric antibiotic therapy was temporarily successful. However, in the further course the mass relapsed and was resistant to antibiotics and a corticosteroid trial. With the working hypothesis of an inflammatory myofibroblastic tumor the patient underwent surgical tumor resection, finally confirming the suspected diagnosis. Due to residual disease intravenous immunoglobulins were administered leading to sustained response. This case with a pleural localisation of a large inflammatory pseudotumor with responsiveness to immunomodulation after incomplete resection extends the reported spectrum of thoracopulmonary manifestations of this rare entity.

Early experience with robot-assisted surgery for mediastinal masses

Dear Editor: Diverticular disease of the colon represents a quite common clinical condition in developed countries, showing a tremendous preponderance in the left-sided colon. Its prevalence increases with age, reaching about 75% for those over the age of 80 years. In young adults diverticulosis is a rare condition. Thus, diverticular disease rarely affects gestation and is usually not taken into consideration when facing pregnant women with abdominal complaints. This letter has been written with the intent of sensitising this entity because complicated diverticulitis results in acute danger for both the mother’s and the unborn child’s lives. A 33-year-old pregnant woman was admitted for surgical consultation because of increasing right lower quadrant pain at 37 weeks’ gestation. Relevant previous medical history included the amputation of the right lower extremity for Ewing sarcoma during childhood. Throughout the 2 days preceding her admission, she had noticed the gradual onset of right lower and right mid abdominal pain accompanied with nausea and two episodes of vomiting. Neither chills, diarrhea, rectal bleeding nor other gastrointestinal symptoms were observed by the patient. Mild constipation since the onset of pregnancy was her only abdominal complaint over the last few months. On examination, the patient was afebrile and in good condition, the fundal height was correct for the gestational age. Her abdomen was soft and non-distended, but the right mid and lower abdomen were pressure-sensitive. There was no abdominal tenderness reflecting peritoneal irritation. Peristalsis sounds were normal and rectal examination was unrevealing. Laboratory examination showed an elevated white blood cell count and C-reactive protein of 15.3 g/l and 10.6 mg/dl respectively. Urine tested positive for leucocytes and erythrocytes, but was negative for nitrite. Abdominal ultrasound showed inflammatory infiltration of the paracaecal tissue and a faecalith of unclear location at the site of the appendix or the caecum. A singleton, vertexpresented fetus with growth parameters correct for gestational age and amniotic fluid volume was found. Following this first examination, the patient’s symptomatology was considered consistent with the start of appendicitis. Given the patient’s afebrile status, the discrete clinical findings and the patient’s negative clinical history concerning diverticulosis, diverticulitis was not considered to be causing the symptoms. In order to avoid surgery and allow for eventual spontaneous recovery and labour, in-patient conservative management with short-term clinical observation was prescribed. The patient received intravenous hydration, parenteral double antibiotics and anJ. Bodner (*) . G. Wetscher . W. Mark Department of General and Transplant Surgery, Innsbruck University Hospital, Anichstrasse 35, 6020 Innsbruck, Austria e-mail: johannes.bodner@uibk.ac.at Tel.: +43-512-50480763 Fax: +43-512-50422577

Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects

SummaryBackground: The recent introduction of surgical robotic systems marks a new milestone in surgical medicine comparable to the laparoscopic approach in the late 1980s. At Innsbruck University Hospital we have been using the da Vinci™ robotic system (Intuitive Surgical, Mountain View, CA, USA) since June 2001. Our first general surgical experiences with this device and laparoscopic cholecystectomies are reported here. Methods: The da Vinci™ robot is a supervised on-line system in which the surgeon at a remote console controls the endoscopic instruments and a binocular 3-D videoscope via three robotic arms. A scrubbed ‘conventional’ team consisting of at least one surgeon and a nurse assists the procedure to change the robotic surgical instruments as well as to allow immediate conversion to a conventional laparoscopic or open procedure, if necessary. During the first 6 months, 25 cholecystectomies were performed using the da Vinci™ surgical robot. Results: Two out of 25 cholecystectomies had to be converted to conventional laparoscopy due to system break-down. Two intraoperative complications were managed successfully, and one redo-operation was necessary because of postoperative bleeding at a port site. Operating time was 100 (60–171) min with a duration of 52 (35–99) min for the robot-assisted act itself. Postoperative results and hospitalization times did not differ from conventional laparoscopic procedures. Conclusions: Laparoscopic cholecystectomy can be performed with the surgical robotic da Vinci™ system as safely as with the conventional laparoscopic approach. The longer operating time is mainly due to the learning curve and the time-consuming installation of the robot itself. Laparoscopic cholecystectomy is the ideal procedure for learning and teaching robot-assisted operations in general surgery. Although the present limitations of the system are evident (cumbersome equipment, lack of special instruments, only two working arms) we feel ready to perform more complex procedures in the near future.ZusammenfassungGrundlagen: Operationsroboter stellen die innovativste, technische Weiterentwicklung der laparoskopischen Chirurgie seit dem Ende der 80er Jahre dar. Die Universitätsklinik Innsbruck verfügt seit Juni 2001 über den da Vinci™ Operationsroboter (Intuitive Surgical, Mountain View, CA). Wir berichten über unsere ersten Erfahrungen mit dem Roboter an Hand von 25 Cholezystektomien. Methodik: Beim da Vinci™ Operationsroboter steuert der Chirurg von einer Konsole aus, über drei Roboterarme eine 3-D-Kamera sowie spezielle laparoskopische Instrumente. Direkt beim Patienten befinden sich ein weiterer Chirurg und eine Instrumentenschwester, die das Auswechseln der Instrumente an den Roboterarmen übernehmen und jederzeit bereit sind, den Eingriff konventionell laparoskopisch oder offen weiterzuführen. In den ersten sechs Monaten wurden 25 Cholezystektomien mit dem da Vinci™ Operationsroboter durchgeführt. Ergebnisse: Zweimal mußte aufgrund eines technischen Gebrechens am Gerät auf das konventionelle laparoskopische Verfahren umgestiegen werden. Es traten zwei beherrschbare intraoperative Komplikationen auf. Eine Revision erfolgte aufgrund einer Blutung aus einer Trokareinstichstelle. Die mediane Operationszeit betrug 100 (60–171) min, wobei der eigentliche Roboterakt 52 (35–99) min dauerte. Die postoperativen Ergebnisse sowie die stationäre Aufenthaltsdauer unterscheiden sich nicht von denen konventionell laparoskopisch operierter Patienten. Schlußfolgerungen: Die laparoskopische Cholezystektomie kann mittels Operationsroboter ohne Qualitätsverlust durchgeführt werden. Die im Vergleich zur konventionellen laparoskopischen Cholezystektomie längere Operationszeit ist in erster Linie auf die Aufrüstzeit des Roboters zurückzuführen, der Eingriff selbst dauert mit einiger Erfahrung sogar kürzer. Die roboterassistierte Cholezystektomie stellt in der Allgemeinchirurgie die ideale Lehr- und Lernoperation für das Arbeiten mit dem Operationsroboter dar. Trotz der momentan noch systembedingt begrenzten technischen Möglichkeiten (limitierte Auswahl an Arbeitsinstrumenten, Fehlen eines dritten Roboterarms für Instrumente, unpraktische Instrumente) streben wir komplexere Eingriffe mit dem Operationsroboter für die nahe Zukunft an.