Jordi Garriga

Energy Sources for Laparoscopic Colectomy: A Prospective Randomized Comparison of Conventional Electrosurgery, Bipolar Computer-Controlled Electrosurgery and Ultrasonic Dissection. Operative Outcome and Costs Analysis

The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small to medium-sized vessels. Bipolar computercontrolled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model.

Minimally Invasive Treatment for Obstructive Tumors of the Left Colon: Endoluminal Self-Expanding Metal Stent and Laparoscopic Colectomy

Background: Obstruction of the left colon may be the first manifestation of colorectal cancer. Resection of the colonic segment involved and the construction of an end colostomy (Hartman’s procedure) is the most frequent treatment. Alternatives to the placement of a stoma are subtotal colectomy or intraoperative lavage of the colon and primary anastomosis, but their application depends on intraoperative findings and the availability of a skilled surgeon. The use of an expandable stent (SEMS) can enhance the feasibility of laparoscopic colectomy, avoiding the need for a colostomy and offering the advantages of a combination of two minimally invasive procedures. Study Design: Between 1997 and 2004, an SEMS was placed in 11 cases of left colonic obstruction due to cancer, the obstruction being successfully resolved in each case. Seven patients were approached by laparoscopy to attempt the definitive colectomy. We evaluated the location and pathological characteristics of the tumor, effectiveness and complications of SEMS insertion, time interval between the insertion of SEMS and laparoscopic surgery, and postoperative data. Results: The tumors were situated in the recto-sigma (1 case), sigma (3 cases) and descending colon (3 cases). Immediate relief of the obstruction was achieved in all cases after SEMS insertion of the stent, and oral diet was started at 24 h. The 7 patients were operated on an average of 8 days (range 6–14) after insertion of the stent. Conversion to open surgery was necessary in one case for reasons not related to the stent. Conclusions: Preliminary results of the combination of SEMS and elective laparoscopic surgery demonstrate that the procedure is feasible and that it presents all the clinical advantages of a minimally invasive approach. The procedure is a valid alternative to traditional major urgent surgery.

Laparoscopic surgery in situs inversus: a literature review and a report of laparoscopic sigmoidectomy for diverticulitis in situs inversus

BackgroundSitus inversus (SI) is a rare autosomal recessive congenital defect in which the position of abdominal and/or thoracic organs is a “mirror image” of the normal one, in the sagittal plain. In 25% of these cases, SI is part of the Kartagener syndrome, together with bronchiectasis and chronic sinusitis.MethodsWe present a case of a patient with Kartagener syndrome and complete SI that was laparoscopically operated on for diverticulitis. We also review the published English information available on this rare condition.ResultsA review of the literature revealed another single case of laparoscopic sigmoidectomy and 27 cases of other laparoscopic interventions in the presence of SI. Those laparoscopic procedures included basic procedures such as explorations and cholecystectomies, as well as advanced procedures such as gastrectomy and gastric bypass.ConclusionThe laparoscopic approach is feasible in cases of SI, although technically more complicated because of the different position of the organs and the different laparoscopic view of the anatomy.

Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura

BackgroundLaparoscopic splenectomy (LS) offers better short-term results than open surgery for the treatment of immune thrombocytopenic purpura (ITP), but long-term follow-up is required to ensure its efficacy. The remission rate after splenectomy ranges from 49 to 86% and the factors that predict a successful response to surgical management have not been clearly defined. The goal of this study was to determine the preoperative factors that predict a successful outcome following LS.MethodsFrom February 1993 to December 2003, LS was consecutively performed in a series of 119 nonselected patients diagnosed with ITP (34 men and 85 women; mean age, 41 years), and clinical results were prospectively recorded. Postoperative follow-up was based on clinical records, follow-up data provided by the referring hematologist, and a phone interview with the patient and/or relative. Univariate and multivariate analyses were performed for clinical preoperative variables to identify predictive factors of success following LS.ResultsOver a mean period of 33 months, 103 patients (84%) were available for follow-up with a remission rate of 89% (92 patients, 77 with complete remission with platelet count >150,000). Eleven patients did not respond to surgery (platelet count <50,000). Mortality during follow-up was 2.5% (two cases not related to hematological pathology and one case without response to splenectomy). Preoperative clinical variables evaluated to identify predictive factors of response to surgery were sex, age, treatment (corticoids alone or associated with Ig or chemotherapy), other immune pathology, duration of disease, and preoperative platelet count. In a subgroup of 52 patients, we also evaluated the type of autoantibodies and corticoid doses required to maintain a platelet count >50,000. Multivariate analysis showed that none of the variables evaluated could be considered as predictive factors of response to LS due to the high standard error.ConclusionLong-term clinical results show that LS is a safe and effective therapy for ITP. However, a higher number of nonresponders is needed to determine which variables predict response to LS for ITP.

The Massive Hiatal Hernia: Dealing With the Defect

The success of laparoscopic fundoplication has extended the use of the laparoscopic approach to treating more difficult situations such as paraesophageal hernias (PEHs) or type IlIl (mixed) hiatal hernia. The results have shown that laparoscopic repair is feasible and safe. However, several series have shown recurrence rates of up to 42% as a result of difficulty in the closure of the hiatal gap. Some authors recommend the use of prosthetic mesh to reinforce the hiatal closure. This review analyses the different techniques proposed to prevent recurrence after laparoscopic repair of PEHs. The information currently available shows that the use of a mesh for hiatal repair is safe and prevents recurrence. However, data on the long-term results are lacking, and infrequent but severe complications may arise. The mesh should be used selectively, and the decision to proceed should be based on clinical experience.

Tratamiento laparoscópico de la intususcepción del intestino delgado en el adulto

Resumen Intususcepcion e invaginacion son los terminos que se utilizan para describir la introduccion en forma telescopica espontanea de una porcion del intestino en otra asa intestinal. Su incidencia es mas frecuente en ninos, y en adultos representa el 1-5% de las oclusiones intestinales. El diagnostico de intususcepcion en adultos es dificil, y la intervencion quirurgica es necesaria en todos los casos. Hasta en el 90% de los casos dentro de la invaginacion se encuentra una lesion organica. El abordaje laparoscopico ofrece una opcion diagnostica y terapeutica. Objetivo Se presentan 2 casos de intususcepcion en el adulto tratados de forma satisfactoria por via laparoscopica. Caso 1: varon de 51 anos que ingresa por presentar melenas, en el que la enteroscopia evidencia un tumor ulcerado en el yeyuno. Se interviene por laparoscopia, observando el intestino delgado invaginado en la zona del tumor. El diagnostico es de tumor del estroma gastrointestinal con bajo riesgo de malignidad. Caso 2: mujer de 72 anos, que ingresa por suboclusion intestinal. Mediante tomografia axial computarizada se evidencia una masa pelvica en relacion con un asa intestinal, compatible con invaginacion de la masa en un asa ileal. Se efectua la reseccion del tumor invaginado por laparoscopia, que corresponde a un tumor de estirpe mesenquimal y con bajo grado nuclear. Conclusion. El abordaje laparoscopico puede ser de utilidad con finalidad diagnostica o terapeutica en la intususcepcion del adulto.

Esplenectomía laparoscópica: resultados a largo plazo de una serie prospectiva de 257 pacientes en función del diagnóstico hematológico

Resumen Introduccion El abordaje laparoscopico ha demostrado ser un procedimiento seguro y eficaz en el tratamiento de las enfermedades hematologicas que requieren la realizacion de una esplenectomia, especialmente en las que el bazo mantiene un tamano dentro de la normalidad. Sin embargo, aunque los resultados inmediatos son prometedores, no existe suficiente informacion sobre la evolucion a largo plazo. Objetivo Evaluar los resultados a largo plazo en una serie prospectiva de 257 pacientes a los que se ha realizado una esplenectomia laparoscopica (EL), en funcion de la indicacion hematologica por la que se indico la cirugia. Material y metodos Desde febrero de 1993 hasta octubre de 2003, se han realizado 257 EL, en 100 varones y 157 mujeres, con una edad media de 45 ± 19 anos. La informacion clinica fue recopilada de forma prospectiva en una base de datos. Las indicaciones de esplenectomia incluyeron los siguientes diagnosticos: purpura trombocitopenica idiopatica (PTI) (n = 115), PTI asociada al virus de la inmunodeficiencia humana (VIH) (n = 9), sindrome de Evans (n = 6), anemia hemolitica autoimmune (AHAI) (n = 13), esferocitosis hereditaria (EH) (n = 19), patologia hematologica maligna (n = 66), purpura trombocitopenica trombotica (PTT) (n = 1) y otros (n = 26). Se han analizado los resultados inmediatos (tiempo operatorio, conversion, morbilidad y estancia), asi como en el seguimiento a largo plazo (resultados analiticos, cursos clinicos del hematologo de referencia, asi como entrevistas telefonicas tanto con el paciente como con el hematologo de referencia). Resultados El tiempo operatorio medio fue de 137 ± 56 min, con un indice de conversion del 6,7%, una mortalidad postoperatoria del 0,8% y una estancia media de 5 dias. Se consigio el seguimiento a largo plazo en 188 casos (75%) durante un periodo medio de 35 meses: PTI, seguimiento de 87 pacientes (76%) con remision en el 89% de los casos; PTI-VIH, 6 pacientes seguidos (86%) con remision completa en el 83%; sindrome de Evans, 4 pacientes seguidos (67%) con remision completa en el 100%; PTT, el unico paciente con este diagnostico fue controlado durante el seguimiento y presento una remision completa; AHAI, 9 pacientes seguidos (82%) con remision completa en el 67%, EH: 13 pacientes seguidos (76%) con remision completa en el 100%; patologia hematologica maligna, 47 pacientes seguidos (73%) con una mortalidad del 22%; otros: 18 pacientes seguidos (78%) sin presentar mortalidad. Durante el seguimiento no se han detectado casos de sepsis relacionada con la esplenectomia. Conclusiones La EL es aplicable en todas las indicaciones hematologicas de esplenectomia, con resultados satisfactorios a largo plazo.

Cirugía laparoscópica y situs inversus. Revisión de la literatura y presentación de un caso de sigmoidectomía por diverticulitis

Resumen El situs inversus es un defecto congenito de herencia autosomica recesiva, poco frecuente, que se caracteriza por la localizacion de los organos abdominales o toracicos en el lado opuesto, en sentido sagital. En el 25% de los casos se presenta formando parte del sindrome de Kartagener, caracterizado por la presencia de situs inversus , bronquiectasias y sinusitis de repeticion. Presentamos el caso de una paciente con sindrome de Kartagener y situs inversus completo que desarrollo una diverticulitis aguda recidivante y a la que se le realizo una sigmoidectomia laparoscopica. En la revision de la literatura se encuentra otro unico caso de sigmoidectomia por laparoscopia en pacientes con situs inversus , asi como 27 casos intervenidos por otras enfermedades, que incluyen tecnicas laparoscopicas tanto basicas (laparoscopia exploradora, colecistectomia) como avanzadas (gastrectomia y bypass gastrico). El abordaje laparoscopico es factible en casos de situs inversus , a pesar del incremento en la dificultad tecnica que significa la disposicion anatomica visceral especular.