Kawano T

Endosonography during endoscopic mucosal resection to enhance its safety : A new technique

AbstractBackground: We have performed endoscopic mucosal resection of the esophagus (172 cases), stomach (102 cases), and colon (28 cases) using a transparent plastic cap. Because the lesion-bearing mucosa is suctioned up inside the cap under endoscopic suction, the mucosa should be dissected sufficiently from the proper muscle layer to prevent perforation. Methods: To avert the risk of perforation, we introduced endosonographic assessment of submucosal dissection (47 cases). In all cases, just keeping the ultrasonic probe on the surface of the mucosa allowed us to evaluate whether the mucosal lesion was lifted up sufficiently from the proper muscle layer after local saline injection. Results: It was possible to confirm that the muscle layer was kept outside the strangulating snare by the same procedure (32 of 37 cases, 86.5%). Conclusions: We experienced five muscular resections in cases without the ultrasonic probe and no muscular resection with the ultrasonic probe. Thus we recommend endosonographic assessment during endoscopic mucosal resection to enhance its safety.

Functional evaluation after vagus nerve–sparing laparoscopically assisted distal gastrectomy

BackgroundVagus nerve–sparing laparoscopically assisted distal gastrectomy (Vs-LADG) for early gastric cancer has been introduced to reduce postgastrectomy syndrome, but its clinical and functional outcomes remain unclear.MethodsOf the 105 patients reviewed in this study, 75 underwent Vs-LADG and 30 underwent laparoscopically assisted distal gastrectomy (LADG) for gastric cancer between January 1999 and May 2006. The clinical and functional outcomes of these two groups were compared.ResultsThe clinical and pathologic background between the two groups did not differ. The incidence of gallstone was significantly lower in the Vs-LADG group than in the LADG group (p < 0.05), but no differences existed in duration of surgery, intraoperative blood loss, number of retrieved lymph nodes, time to first flatus after surgery, or length of hospital stay between the two groups.ConclusionsAs shown by the findings, Vs-LADG is a safe and minimally invasive surgery that may decrease the incidence of gallstone formation after gastrectomy.

Development and clinical application of semi-loop-shaped retractor for gasless laparoscopic surgery

Background: Gasless laparoscopy has the advantage of avoiding the risk inherent in pneumoperitoneum, but has not gained widespread popularity because of limited exposure of the operative field. Improved retraction devices are therefore needed. Methods: A loop-shaped metallic retractor was designed for planar lifting of the anterior abdominal wall. Four types of retractor (5/6-, 3/4-, and 1/2-circle with rod at 90°, and 1/2-circle with rod at 97°) were studied in 15 pigs. The device was then used for 47 patients. Results: The 1/2-circle was the most smoothly inserted retractor and was significantly safer than the 5/6-circle (p < 0.05, Fisher’s exact probability test). The 1/2-circle with rod at 97° was utilized for clinical cases. This retractor can be readied within 1 min and was used successfully for all operations. Conclusions: This new retractor for gasless laparoscopic surgery provides good exposure and has the potential to enhance the performance of advanced laparoscopic surgery.

Open-jaw technique in laparoscopic knot tying

In laparoscopic surgery, intracorporeal suturing is one of the most important and difficult techniques. Each laparoscopic surgeon trains alone to improve their techniques of suturing. However, for most average surgeons the technique of tying a knot is still a difficult procedure in laparoscopic suturing. In laparoscopic esophageal surgery such as a Nissen fundoplication, Heller–Dor operation, it is necessary to perform intracorporeal suturing. This technique, which is called the open-jaw method, is very useful for average laparoscopic surgeons and it may already be used by some surgeons. However, it is still not widely known. This simple and useful technique of intracorporeal knot tying is demonstrated in this report.

CURRENT STATUS AND EVALUATION OF LAPAROSCOPIC SURGERY FOR GASTRIC CANCER

Laparoscopic gastrectomy for gastric cancer was developed in Japan and has been established as a treatment for early gastric cancer thanks not only to improvements in technology and medical equipment but also to great efforts made by surgeons. With increasing numbers of surgeons performing the procedure and extending its indication to some advanced gastric cancers, it has achieved an important position in the treatment of gastric cancer together with endoscopic mucosal resection and open surgery. In clinical practice, it has been accepted as a safe, minimally invasive and radical treatment for early gastric cancer through several clinical studies and case–control studies. A large‐scale randomized controlled trial to evaluate laparoscopic gastrectomy as an acceptable procedure for early gastric cancer is being prepared. In order to extend the indication to some advanced gastric cancers, first, we need to collect more cases of laparoscopic gastrectomy for advanced cancer and start a phase II study in the experienced hospitals.

A snare retractor for thoracolaparoscopic surgery

In thoracoscopic or laparoscopic surgery, a useful tool is sometimes needed to pull a target. Usually, a forceps passed through a new or inactive port is used for this purpose. However, this is a waste of money in some situations, such as when a simple aid for traction is needed, and it also requires a new wound. We employ a useful snare (loop) retractor set for the purpose of simple traction (Fig. 1). The set consists of an endoscopic snare and a needle with a sheath for intravenous hyperalimentation (IVH), both of which are commercially available. The snare retractor is inserted by one-step puncture at any site on the skin and produces only a tiny wound. Furthermore, insertion can be made at the precise moment it is needed (Fig. 2). These instruments are readily available, cheap, and can be reused.