Kristi L. Harold

Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries

Background: Advanced laparoscopic procedures have necessitated the development of new technology for vascular control. Suture ligation can be time-consuming and cumbersome during laparoscopic dissection. Titanium clips have been used for hemostasis, and recently plastic clips and energy sources such as ultrasonic coagulating shears and bipolar thermal energy devices have become popular. The purpose of this study was to compare the bursting pressure of arteries sealed with ultrasonic coagulating shears (UCS), electrothermal bipolar vessel sealer (EBVS), titanium laparoscopic clips (LCs), and plastic laparoscopic clips (PCs). In addition, the spread of thermal injury from the UCS and the EBVS was compared. Methods: Arteries in three size groups (2–3, 4–5 and 6–7 mm) were harvested from freshly euthanized pigs. Each of the four devices was used to seal 16 specimens from each size group for burst testing. A 5-Fr catheter was placed into the open end of the specimen and secured with a purse-string suture. The catheter was connected to a pressure monitor and saline was infused until there was leakage from the sealed end. This defined the bursting pressure in mmHg. The ultrasonic shears and bipolar thermal device were used to seal an additional 8 vessels in each size group, which were sent for histologic examination. These were examined with hematoxylin and eosin stains, and the extent of thermal injury, defined by coagulation necrosis, was measured in millimeters. Analysis of variance was performed and, where appropriate, a Tukey’s test was also performed. Results: The EBVS’s mean burst pressure was statistically higher than that of the UCS at 4 or 5 mm (601 vs 205 mmHg) and 6 or 7 mm (442 vs 175 mmHg). EBVS had higher burst pressures for the 4 or 5-mm group (601 mmHg) and 6 or 7-mm group (442 mmHg) compared with its pressure at 2 or 3 mm (128 mmHg) (p = 0.0001). The burst pressures of the UCS and EBVS at 2 or 3 mm were not significantly different. Both clips were statistically stronger than the thermal devices except at 4 or 5 mm, in which case the EBVS was as strong as the LC (601 vs 593 mmHg). The PC and LC were similar except at 4 or 5 mm, where the PC was superior (854 vs 593 mmHg). The PC burst pressure for 4 or 5 mm (854 mmHg) was statistically higher than that for vessels 2 or 3 mm (737 mmHg) but not different from the 6 or 7 mm pressure (767 mmHg). Thermal spread was not statistically different when comparing EBVS and UCS at any size (EBVS mean = 2.57 mm vs UCS mean = 2.18 mm). Conclusions: Both the PC and LC secured all vessel sizes to well above physiologic levels. The EBVS can be used confidently in vessels up to 7 mm. There is no difference in the thermal spread of the LigaSure vessel sealer and the UCS.

Laparoscopic repair of traumatic diaphragmatic injuries.

Background: The purpose of this study was to evaluate the feasibility and limitations of laparoscopic repair of traumatic diaphragmatic injuries. Methods: Laparoscopic repair of an acute traumatic diaphragmatic laceration or chronic traumatic diaphragmatic hernia was attempted in 17 patients between January 1997 and January 2001. The patients in the study included 13 men and 4 women with a mean age of 33.2 years (range, 15–63 years). Nine patients had a blunt injury, and eight patients had a penetrating injury. Laparoscopic repair was attempted for eight patients during their hospitalization for the traumatic injury (mean, 2.3 days; range, 0–6 days) and for ten patients with a chronic diaphragmatic hernia (mean, 89 months; range, 5–420 months). The chronic diaphragmatic hernias-presented with abdominal pain (9/9), or vomiting (3/9). Results: Thirteen traumatic diaphragmatic injuries were repaired laparoscopically, and four (2 acute and 2 chronic) required conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using expanded polytetrafluoroethylene (ePTFE), and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5–12 cm). The mean operative time was 134.7 min (range, 55–200 min). The mean estimated blood loss was 108.5 ml (range, 30–500 ml), and the postoperative length of stay was 4.4 days (range, 1–12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n = 2) or communicating with the esophageal hiatus (n = 2). One patient also required spleneotomy for an unrecognized splenic laceration that had occurred at the time of the original trauma. The four patients undergoing laparotomy had a mean postoperative discharge date of 8.7 days (range, 6–14 days). Conclusions: Laparoscopy is an alternative approach to repairing acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias. Large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.n

Comparison of Thermal Spread after Ureteral Ligation with the Laparo-Sonic™ Ultrasonic Shears and the Ligasure™ System

BACKGROUND AND PURPOSEnThe extent of lateral spread of tissue injury is important in the success of a primary anastomosis. We compared the injury produced by the Laparo-sonic Coagulation Shears and the Ligasure system.nnnMATERIALS AND METHODSnUreters were harvested from domestic farm pigs and ligated with the Laparo-sonic (N = 13) or Ligasure (N = 9) system. The tissues were then fixed, stained, and examined by two pathologists without knowledge of the type of treatment.nnnRESULTSnThe mean length of thermal damage from the Ligasure was 2.11 mm (range 1.0-4.0 mm) whereas it was 1.92 (range 0.5-4.25 mm) from the Laparo-sonic system. The difference is not statistically significant.nnnCONCLUSIONnDebridement of as much as 5 mm of each cut end produced by the Laparo-sonic or Ligasure system may be beneficial in reducing stricture and leak.

Prospective randomized evaluation of surgical resident proficiency with laparoscopic suturing after course instruction.

nBackground: Laparoscopic suturing is required to develop competency in advanced laparoscopy. Methods: Manuals detailing laparoscopic suturing were give to 17 Surgery residents. One week later they performed a suture on a training model. Time (s), accuracy (mm), and knot strength (lb) were recorded. The residents were blindly randomized to intervention (n = 9) and control (n = 8) groups. The intervention residents attended a 60-min course with lecture, video, and individual proctoring. Two weeks later they performed a stitch with standard laparoscopic instruments and a stitch with a suturing assist device. Statistical analysis included a Wilcoxon rank-sum test. Results: The intervention residents decreased their suturing time from the first to the second stitich (732.4–257.6s), the control and residents decreased their time from 500.2 s to 421.8 s. The time required to perform the second stitch showed no significant difference between the two groups (p = 0.46), but the difference in reduced time between the first and second stitch was significant (p = 0.001). Using the suturing assist device for the third suture, the intervention and control groups both decreased their times significantly. The control residents performed almost as quickly as the intervention residents with the suturing; device (p = 0.11). Accuracy and knot strength were not different in any test. Conclusions: Residents can improve suturing skill with a short didactic course and individual proctoring. A suturing assist device decreases time required by inexperienced surgeons to device perform an intracorporeal tie.n

Plastic wound protectors do not affect wound infection rates following laparoscopic-assisted colectomy

Background: Wound protectors are plastic sheaths that can be used to line a wound during surgery. Wound protectors can facilitate retraction of an incision without the need for other mechanical retractors and have been proposed as deterrents to wound infection. The purpose of this study was to define the ability of wound protectors to reduce the rate of infection when used in laparoscopic-assisted colectomy. Methods: We completed a retrospective review of the medical records of patients undergoing nonemergent laparoscopic-assisted colectomy between February 1999 and November 2002. All completely laparoscopic cases were excluded. The wound protector, when used, was applied to the extraction incision during the externalized portion of the procedure (colon and mesentery transection, anastomosis). Outcomes for patients with and without the use of a wound protector were compared. Results: A total of 141 patients underwent laparoscopic-assisted colectomy (98 for benign/malignant tumors, 35 for diverticular disease, and eight for Crohn’s disease). There were no differences between the wound protector group (n = 84) and the no wound protector group (n = 57) with respect to mean age (55 vs 58 years), average body mass index (27 vs 29 kg/m2), gender, indication for surgery, comorbidities, antibiotics used, or mean operative time (185 vs 173 min). Nine patients in the wound protector group and eight in the no wound protector group developed a wound infection at the colon extraction site (p = 0.42). Patients undergoing resection for Crohn’s disease or diverticulitis had a higher infection rate (18.6%) than patients undergoing resection for polyps or cancer (9.2%; p < 0.05). No wound recurrence of cancer was observed in either group at a mean follow-up of 23 months (range, 3–48). Conclusions: The wound protector, although useful for mechanical retraction of small wounds, does not significantly diminish the rate of wound infection at the bowel resection/anastomotic site. Patients undergoing elective resection for inflammatory processes have higher infection rates than patients undergoing laparoscopic-assisted colectomy for polyps or cancer.

Outcomes for Laparoscopic Bilateral Adrenalectomy

BACKGROUND AND PURPOSEnLaparoscopic adrenalectomy has become the preferred surgical approach to manage adrenal disorders. Bilateral adrenalectomy is performed for diseases that are unresponsive to medical management and, frequently, for neoplastic disease. The aim of this study was to review our experience with laparoscopic bilateral adrenalectomy and to evaluate its safety, efficacy, and outcomes.nnnPATIENTS AND METHODSnBetween July 1996 and May 2001, five male and two female patients with a mean age of 46 years (range 15-69 years) presented for bilateral adrenalectomy (pheochromocytoma [N = 3], Cushings disease [N = 3], and metastatic cancer [N = 1]). All procedures were performed using a lateral transperitoneal approach. One gland was excised, the patient was repositioned to the opposite lateral decubitus position, and the remaining gland was removed.nnnRESULTSnLaparoscopic bilateral adrenalectomy was completed in all seven patients. The mean tumor/gland size on the right was 5.0 cm (range 3.1-7.0 cm) and on the left was 5.6 cm (range 3.6-7.0 cm). The mean operative time was 308 minutes (range 190-430 minutes), and the mean estimated blood loss was 138 mL (range 30-300 mL). One patient with a pheochromocytoma experienced intraoperative hypertension necessitating treatment. There were no postoperative complications. The mean postoperative hospital stay was 5.1 days (range 3-9 days). All patients have been treated postoperatively with daily hydrocortisone and fludrocortisone replacement. After a mean follow-up of 33 months (range 2-45 months), six patients are alive. The patient undergoing bilateral adrenalectomy for metastatic lung cancer died from recurrent disease 13 months after resection.nnnCONCLUSIONnLaparoscopic bilateral adrenalectomy is safe and effective. Patients are discharged postoperatively in a relatively short time with few complications. Appropriate steroid replacement and close follow-up allows these patients to return to self-reliance.

Ectopic pancreatic tissue presenting as submucosal gastric mass

BACKGROUNDnEctopic pancreas is pancreatic tissue found outside its usual anatomic location without connection to the normal pancreas. We describe the presentation and minimally invasive management of four patients with ectopic pancreatic tissue in the stomach.nnnMETHODSnData were collected from a retrospective chart review of four patients undergoing laparoscopic resection of gastric pancreatic rests.nnnRESULTSnFour patients underwent laparoscopic resection of gastric pancreatic tissue. All patients were discharged on postoperative day 3. No complications developed.nnnCONCLUSIONnLaparoscopic gastric wedge resection is a safe and effective treatment for symptomatic pancreatic rests located in the stomach.

Laparoscopic approach to open gastric bypass

BACKGROUNDnGastric bypass is a successful tool in the treatment of morbid obesity. In recent years, laparoscopic Roux-en-Y gastric bypass has gained popularity. However, open bypass is sometimes more suitable for patients who are superobese. Laparoscopic instrumentation can be used during an open gastric bypass to facilitate dissection, formation of the gastric pouch, and creation of the gastrojejunostomy.nnnMETHODSnWe describe the use of laparoscopic ultrasonic coagulating shears for dissection during open gastric bypass. Additionally, laparoscopic gastrointestinal anastomosis and end-to-end anastomosis staplers are used for creating bowel anastomoses.nnnCONCLUSIONSnLaparoscopic instrumentation can be useful in the setting of open procedures. Their long handles and jaw design make them ideal for working in the depths of a superobese abdomen.

Umbilical Stalk Technique for Establishing Pneumoperitoneum

The Veress needle technique for establishing pneumoperitoneum is widely used yet associated with slow insufflation and potentially life-threatening complications. The open or Hasson technique is relatively safer but considered cumbersome by many. We describe a mini-open technique that uses a 5-mm transumbilical incision and placement of a 5-mm blunt cannula without the trocar. We have employed this technique for 4 years in 600 patients without a midline laparotomy incision incorporating the umbilicus and have accessed the abdomen safely for laparoscopy without any complications. The time from skin incision to the start of the procedure is usually under 2 minutes. Our umbilical stalk technique provides rapid and safe access to the abdomen, eliminating the dangers of a blind sharp needle or trocar insertion and the need for a larger incision with placement of stay sutures. We recommend this simple technique for entry into the uncomplicated abdomen.

Laparoscopic "radical appendectomy" is an effective alternative to endoscopic removal of cecal polyps

BACKGROUNDnThe endoscopic removal of cecal polyps can be complicated by hemorrhage, perforation, or incomplete resection. Laparoscopic radical appendectomy represents a safe alternative for the definitive resection and accurate pathologic evaluation of selected cecal polyps.nnnMETHODSnPatients with cecal cap polyps not involving the ileocecal valve were candidates for laparoscopic radical appendectomy. Intraoperative colonoscopy and resection of the appendix and cecum to the level of the ileocecal valve were accomplished via three midline ports. For each patient, histologic evaluation by frozen section ruled out malignancy and ensured complete resection.nnnRESULTSnFive patients, four of whom had significant medical comorbidities, presented with large adenomatous polyps contained within the cecum. Each polyp was determined to be unresectable endoscopically; therefore, a laparoscopic radical appendectomy was performed. One patient with cirrhosis also underwent intraoperative liver ultrasonography and biopsies, which contributed to the longest operative time and hospital stay. The histologic diagnosis by frozen section was benign for each patient. The mean operative time was 95 minutes, and the mean length of hospital stay was 1.8 days. No postoperative complications were observed during a mean follow-up of 6 months.nnnCONCLUSIONnLaparoscopic radical appendectomy is an effective treatment for selected cecal adenomatous polyps. Our ability to resect the polyps completely and avoid a standard right hemicolectomy supports this approach.