Justin S. Wu

Laparoscopic-assisted ileocolic resections in patients with Crohn's disease: are abscesses, phlegmons, or recurrent disease contraindications?

BACKGROUND Because of the inflammatory nature of Crohns disease, ileocolic resections are often difficult to perform, especially if an abscess, phlegmon, or recurrent disease at a previous ileocolic anastomosis is present. Our goal was to determine whether the above factors are contraindications to a successful laparoscopic-assisted ileocolic resection. METHODS Between 1992 and 1996, 46 laparoscopic-assisted ileocolic resections were attempted. Fourteen patients had an abscess or phlegmon treated with bowel rest before operation (group I), 10 patients had recurrent Crohns disease at the previous ileocolic anastomosis (group II), and 22 patients had no previous operation and no phlegmon or abscess associated with their disease (group III). These groups were compared with each other and with 70 consecutive open ileocolic resections for Crohns disease during the same time period (group IV). RESULTS Operative blood loss and time were greater in group IV than in groups I, II, and III (245 versus 151, 131, and 195 ml, respectively, and 202 versus 152, 144, and 139 minutes, respectively). Conversion to open procedure occurred in 5 patients (group I, 1 [7%]; group II, 2 [20%]; group III, 2 [9%]). Morbidity was highest in group IV (21% versus 0%, 10%, and 10%, respectively). Only one patient died (group IV, 1%). Length of hospital stay was longest in group IV (7.9 versus 4.8, 3.9, and 4.5 days, respectively). CONCLUSIONS The laparoscopic-assisted approach to Crohns disease is feasible and safe with good outcomes. Co-morbid preoperative findings such as abscess, phlegmon, or recurrent disease at the previous ileocolic anastomosis are not contraindications to a successful laparoscopic-assisted ileocolic resection in select patients.

Experimental development of an endoscopic approach to neck exploration and parathyroidectomy

BACKGROUND Recent advances in minimally invasive surgical technology have the potential to lead to new applications outside body cavities. The purpose of the present study was to develop techniques for obtaining endoscopic exposure and access to the pretracheal space in the neck with the goal of performing neck exploration and parathyroidectomy and to evaluate the safety and efficacy of such an approach experimentally. METHODS The technique for endoscopic neck exploration was developed in eight adult mongrel dogs and was further evaluated in a survival dog model and in human cadavers. The pretracheal space was accessed by a 2.5 cm midline incision in the lower neck. This space was expanded with a balloon dissector, and exposure was maintained with an external lift device. A 5 or 10/12 mm midline port and two to four lateral 5 mm cervical ports were placed, and dissection was carried out with pediatric endoscopic instruments and an ultrasonic coagulator. Excised parathyroid tissue was verified histologically. RESULTS Two-gland parathyroidectomy was successfully completed in five of six dogs; inadequate exposure led to a failed procedure in one animal. Mean operative time was 130 +/- 6 minutes, and there were no operative complications. Serum calcium levels did not change significantly after operation (p = not significant). At autopsy, approximately 20 ml of clear sterile fluid was present in the pretracheal space of every dog. In five human cadavers mean dissection time for attempted four-gland parathyroidectomy was 69 +/- 38 minutes (range, 45 to 135 minutes). Four of four parathyroids were identified and removed in two patients, three of three parathyroids in one patient, three of four parathyroids in one patient, and two of four parathyroids in one patient. CONCLUSIONS Parathyroidectomy may be performed safely and reliably in an animal model with minimally invasive techniques that can be applied to parathyroid dissection in human cadavers. These results suggest that an endoscopic approach to neck exploration and parathyroidectomy is potentially feasible and may warrant further study in clinical trials.

Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair.

AbstractBackground: Unlike sliding hiatal hernias, paraesophageal hiatal hernias (PEH) present a risk of catastrophic complications and should be repaired. To assess laparoscopic repair of PEH, we prospectively evaluated the outcome of 38 consecutive patients with type II (20 patients) or III (18 patients) PEH treated laparoscopically. Methods: With the use of 5 or 6 ports, laparoscopic PEH reduction and repair was attempted. One patient (3%) was converted to an open procedure. In the first 12 patients, the hiatus was closed using varying techniques including the placement of prothestic mesh in 6 patients, and the hernia sac was not routinely excised. In the next 25 patients, the hernia sac always was excised and the hiatus routinely sutured posteriorly to the esophagus. Twenty-nine patients also underwent either a Nissen (n= 27) or Toupet (n= 2) fundoplication, which is now performed routinely. Sutured anterior gastropexy was performed selectively in 10 of the first 20 patients, then routinely, using T-fasteners in the last 17 patients. Barium swallow studies were performed on all patients at 3 to 5 months postoperatively. Results: Mean ± standard error of the mean (SEM) age was 67 ± 2 year (range, 39–92 years; 11 men, 27 women), and the American Society of Anesthesia (ASA) score was 2.5 ± 0.1. The operating time was 195 ± 10 min: 244 ± 15 min in the first 12 patients and 170 ± 11 min in the last 25 patients (p < 0.001). There were three (8%) intraoperation complications, which were treated without sequelae, and four (11%) grade II postoperation morbidities. Median discharge was 3 days, and return to full activity was 14 days. Two patients (5%) died of cardiovascular disease after discharge. Barium swallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathoracic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but only 1 patient (4%) required medication for these symptoms. Conclusions: Laparoscopic PEH repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. Rapid recovery is achieved with acceptable morbidity and early outcome. Barium x-rays revealed hiatal abnormalities in a significant fraction of patients, many of whom were asymptomatic. Longer follow-up will be required to determine the ideal strategy for management of these patients.

The influence of surgical technique on clinical outcome of laparoscopic Nissen fundoplication

AbstractBackground: During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided, the crura reapproximated, or the wrap sutured to the crus. Methods: Since first performing LNF, we have consistently utilized a <2.5-cm wrap performed over a >50 Fr dilator. Other technical details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF, two were converted to open operation (2%). In the remaining 103 patients with ≥3-month follow-up (mean 17 months), the initial 46 (group 1; 45%, mean age ± SEM = 47 ± 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients (65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the subsequent 57 LNFs (group 2; 55%, 47 ± 2 years), all patients underwent SGV division, posterior crural closure, and suture of the wrap to the crus. Results: Clinical outcome at ≥3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and 13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of these technical variables were significantly related to the improved outcome in group II. Conclusion: Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure of the crura, and fixation of the wrap to the crus during LNF.

Effects of pneumoperitoneum on tumor implantation with decreasing tumor inoculum.

INTRODUCTION: The aim of this study was to determine the effect of pneumoperitoneum on the rate of trocar-site implantation with decreasing inoculum of cancer cells. METHODS: A total of 0.5 ml of GW-39 human colon cancer cell suspensions at 1 percent (∼3.2×105 cells) and at 0.5 percent (∼1.6×105 cells; v/v) were injected into the abdomen of hamsters through a midline incision. Animals in each group were randomized to receive either pneumoperitoneum (1 percent=33; 0.5 percent=43) or not (1 percent=32; 0.5 percent=39). Gross and microscopic tumor implants were documented seven weeks later at four trocar sites. RESULTS: In the 1 percent group, pneumoperitoneum significantly increased trocar-site tumor implants from 50 to 71 percent (P<0.001). Pneumoperitoneum also resulted in the following: 1) more frequent involvement of all four concurrent sites (38vs. 10 percent;P<0.02); 2) more frequent palpable tumors (13vs. 5 percent;P<0.01); 3) larger tumor mass (2.1±0.6 gvs. 0.2±0.1 g;P<0.02). In the 0.5 percent group, pneumoperitoneum did not significantly increase trocar-site tumor implants, and it did not result in a larger tumor mass. The percent increase in trocar-site implants owing to pneumoperitoneum was influenced by the amount of tumor inoculum (21 percent in the 1 percent group; 10 percent in the 0.5 percent group). The mass of palpable tumor implants after pneumoperitoneum decreased with decreased inoculum: 1 percent =2.1±0.6 g; 0.5 percent=0.3±0.1 g (P<0.0001). CONCLUSIONS: Pneumoperitoneum significantly increased both tumor implantation rate and mass when ∼3.2×105 colon cancer cells were injected into the peritoneal cavity. These effects of pneumoperitoneum diminished with one-half as many tumor cells injected in the peritoneal cavity.

Excision of trocar sites reduces tumor implantation in an animal model

PURPOSE: The purpose of this study was to determine the effect of excising abdominal trocar wound sites after pneumoperitoneum on the rate of trocar site tumor implantation in a hamster model. This would help determine whether tumor cells seed trocar sites during or after pneumoperitoneum. METHODS: A total of 0.5 ml of GW-39 human colon cancer cell suspension at 2.5 percent v/v (8×105 cells) was injected into the abdomens of 77 hamsters through a midline incision. Animals were subjected to ten minutes of pneumoperitoneum, after placement of four abdominal trocars, and then randomly assigned to undergo either simple suture closure or 4-mm radius trocar wound site excision at the end of the procedure. Gross and microscopic tumor implants were documented seven weeks later. RESULTS: There were three and four deaths in simple suture closure and wound site excision groups, respectively. Of the remaining 35 hamsters in each group, tumor cells implanted at 89 and 78 percent of trocar sites, respectively (P<0.03). There was no significant difference between the two groups in tumor implantation at midline laparotomy sites. Wound site excision also resulted in fewer palpable tumors (44vs. 61 percent;P<0.01) and a lower tumor implantation rate (49vs. 74 percent;P<0.05) at all four concurrent sites compared with simple suture closure. CONCLUSIONS: Excision of laparoscopic abdominal trocar wound sites can significantly, but not completely, reduce tumor implantation rate compared with simple wound closure.

The evolution and maturation of laparoscopic cholecystectomy in an academic practice

BACKGROUND The technique of laparoscopic cholecystectomy (LC) has evolved since its adoption in the late 1980s. We sought to document these changes and assess whether patient outcomes were influenced during this maturational process. STUDY DESIGN A prospective data base was used to record the outcomes of all LCs performed in an academic surgeons practice. Trends over time among 1,165 consecutive patients were assessed by comparing the first 100 LCs (group I), the middle 100 LCs (group II), and the most recent 100 LCs (group III). RESULTS During a 93-month period with 1,165 patients undergoing LC, 25 procedures (2.1%) were converted to open cholecystectomy. Perioperative complications occurred in 31 patients (3%): grade I in 9 (0.8%), grade II in 16 (1.4%), grade III in 5 (0.4%), and grade IV (death) in 1 (0.1%). Length of hospital stay and convalescence were 1.1 +/- 0.1 and 9.5 +/- 0.5 days, respectively. Nineteen patients (2%) were readmitted early after operation and 10 (1%) developed long-term complications (port-site hernia or retained stone). In group III, cholangiography was largely replaced by intraoperative ultrasonography for ductal evaluation. Operating room time decreased, while the rates of conversion, morbidity, and readmission remained the same. Patients had higher ASA classifications in the latter two groups, whereas operative charges were greater in Group III than in Groups I and II. These trends occurred even though most procedures are currently performed by residents, and fewer LCs are being done. CONCLUSIONS Laparoscopic cholecystectomy has matured into a more efficient operation, yet remains safe with low morbidity when performed by residents at an academic institution.

Early experience with laparoscopic abdominoperineal resection.

AbstractBackground: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients.

The utility of intracorporeal ultrasonography for screening of the bile duct during laparoscopic cholecystectomy

Different strategies and imaging modalities have been used to detect common bile duct (CBD) stones during laparoscopic cholecystectomy. We prospectively compared fluoroscopic intraoperative cholangiography (FIOC) and laparoscopic intracorporeal ultrasonography (LICU) in patients undergoing laparoscopic cholecystectomy for this purpose. In a consecutive series of 607 laparoscopic cholecystectomies, FIOC was used in the first 407 patients, whereas LICU was preferentially applied to the subsequent 200 patients. When LICU documented CBD stones, the duct was flushed with saline solution after intravenous administration of glucagon, and stone persistence or absence was confirmed by FIOC and/or repeat LICU. In the FIOC group, 10 patients were converted to open cholecystectomy and 16 patients did not undergo FIOC. Among the remaining 381 patients, FIOC was successful in 370 (97%). In the LICU group, two patients were converted and LICU was not performed in 26 patients. In the remaining 172 patients, the cystic duct (CBD) junction and the CBD were visualized in all cases (P <0.05 vs. FIOC). The mean (± SEM) times required to complete FIOC and LICU were 15.1 ± 0.4 minutes and 5.3 ± 0.2 minutes, respectively (P <0.0001). Choledocholithiasis was detected in 25 patients (7%) undergoing FIOC and in 22 patients (13%) undergoing LICU (P <0.05). In the LICU group, the mean sizes of the stones cleared by ampullary dilatation and flushing (17 of 22, 77 %) and those requiring more invasive methods (5 of 22, 23%) were 1.6 ± 0.2 mm and 2.7 ± 0.3 mm, respectively (P <0.01). Sludge was seen in the CBD by LICU in 10 patients (6%), which disappeared with flushing in all cases. LICU is accurate, safe, and permits more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. LICU may be overly sensitive in detecting small stones and sludge, which are of questionable significance. Stones 2 mm or less can usually be cleared by flushing, whereas larger ones often require invasive techniques for removal.

LAPAROSCOPIC SURGERY: PRINCIPLES AND PROCEDURES

Laparoscopic surgery :principles and procedures , Laparoscopic surgery :principles and procedures , کتابخانه مرکزی دانشگاه علوم پزشکی ایران