L. M. Brunt

Wound complications of laparoscopic vs open colectomy

BACKGROUND: This study was conducted to determine if laparoscopic colon surgery has changed the incidence of wound complications after colon resection. METHODS: Eighty-three patients were randomized to undergo either laparoscopic (LCR) or open colon resection (OCR) for cancer at our institution as part of a multicenter trial. Data were tabulated from review of the prospective database and physician records. RESULTS: Thirty-seven patients were randomized to LCR and 46 to OCR. Seven patients in the LCR group were converted to OCR. LCR was performed using a limited midline incision for anastomosis and specimen extraction. Incision length was significantly greater (p <0.001) in the OCR group (19.4 ± 5.6 cm) compared to the LCR extraction site (6.3 ± 1.4 cm). Wound infections occurred in 13.5% of patients after LCR (2.7% trocar, 10.8% extraction sites) and in 10.9% of patients after OCR. Over a mean follow-up period of 30.1 ± 17.8 months, incisional hernias developed in 24.3% of patients after LCR and 17.4% after OCR. In the LCR group, extraction sites accounted for 85.7% of all wound complications. CONCLUSIONS: The extraction site for LCR is associated with a high incidence of complications, comparable to open colectomy. Strategies to alter operative technique should be considered to reduce the incidence of these complications.

Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly

Background: A study was conducted to determine whether extremely elderly patients, age 80 years or older, were at higher risk for adverse outcomes from laparoscopic cholecystectomy than patients younger than 80 years. Methods: Laparoscopic cholecystectomy was attempted in 421 patients age 65 years or older from 1989 through 1999. The patients were divided into two groups: group 1 (age 65-79 years; n = 351) and group 2 (age, 80-95 years; n = 70). A prospective database was analyzed for mean ± standard deviation and using Students t-test and chi-square analysis. Results: Advanced age (group 2) was associated with a higher mean American Society of Anesthesiology (ASA) class (2.7 vs 2.3; p < 0.001) and a greater incidence of common bile duct stones (43% vs 26%; p < 0.01), as compared with those of younger age (group 1). Mean operative times in group 2 were 106 ± 45 min as compared with 96 ± 38 min in group 1, a difference that is not significant. The extremely elderly (group 2) had a four-fold higher rate of conversion to open cholecystectomy (16% vs 4%) and a longer mean postoperative hospital stay (2.1 vs 1.4 days). Grades 1 and 2 complications also were more common in group 2: grade 1: group 1, 8.8% vs group 2, 17% and grade 2: group 1, 4.3% vs group 2, 7.1% (p < 0.05). One patient in group 1 had a myocardial infarction 13 days postoperatively, and two deaths occurred in the extremely elderly group within 30 days postoperatively. Conclusions: Laparoscopic cholecystectomy in the extremely elderly is associated with more complications and a higher rate of conversion to open cholecystectomy than in elderly individuals younger than 80 years. The greater chance of encountering a severely inflamed or scarred gallbladder and common bile duct stones as well as increasing comorbidities likely account for these differences in outcome.

Outcomes analysis of laparoscopic resection of pancreatic neoplasms

BackgroundExperience with laparoscopic resection of pancreatic neoplasms remains limited. The purpose of this study is to critically analyze the indications for and outcomes after laparoscopic resection of pancreatic neoplasms.MethodsThe medical records of all patients undergoing laparoscopic resection of pancreatic neoplasms from July 2000 to February 2006 were reviewed. Data are expressed as mean ± standard deviation.ResultsLaparoscopic pancreatic resection was performed in 22 patients (M:F, 8:14) with a mean age of 56.3 ± 15.1 years and mean body mass index (BMI) of 26.3 ± 4.5 kg/m2. Nine patients had undergone previous intra-abdominal surgery. Indications for pancreatic resection were cyst (1), glucagonoma (1), gastrinoma (2), insulinoma (3), metastatic tumor (2), IPMT (4), nonfunctioning neuroendocrine tumor (3), and mucinous/serous cystadenoma (6). Mean tumor size was 2.4 ± 1.6 cm. Laparoscopic distal pancreatectomy was attempted in 18 patients and completed in 17, and enucleation was performed in 4 patients. Laparoscopic ultrasound (n = 10) and a hand-assisted technique (n = 4) were utilized selectively. Mean operative time was 236 ± 60 min and mean blood loss was 244 ± 516 ml. There was one conversion to an open procedure because of bleeding from the splenic vein. The mean postoperative LOS was 4.5 ± 2.0 days. Seven patients experienced a total of ten postoperative complications, including a urinary tract infection (UTI) (1), lower-extremity deep venous thrombosis (DVT) and pulmonary embolus (1), infected peripancreatic fluid collection (1), pancreatic pseudocyst (1), and pancreatic fistula (6). Five pancreatic fistulas were managed by percutaneous drainage. The reoperation rate was 4.5% and the overall pancreatic-related complication rate was 36.4%. One patient developed pancreatitis and a pseudocyst 5 months postoperatively, which was managed successfully with a pancreatic duct stent. There was no 30-day mortality.ConclusionsLaparoscopic pancreatic resection is safe and feasible in selected patients with pancreatic neoplasms. With a pancreatic duct leak rate of 27%, this problem remains an area of development for the minimally invasive technique.

The positive impact of laparoscopic adrenalectomy on complications of adrenal surgery

Background: This study was conducted to determine whether laparoscopic adrenalectomy (LA) has had a positive impact on the incidence and nature of adrenalectomy-related complications, as compared with the prelaparoscopic era. Methods: All English language reports of patients undergoing either open adrenalectomy (OA) or LA from 1980 to 2000 were identified by Medline search. Reports were analyzed for the frequency and type of complications, with a minimum of 10 cases or studies required for inclusion. Complications were stratified by type and/or organ system involved, and groups were compared statistically using generalized linear model methods. Results: Complications were tabulated from 50 studies of LA involving 1,522 patients and 48 studies of OA comprising 2,273 patients. Among the reports, 22 compared LA and OA within a single institution. The total reported complication rate was 25.2% with LA versus 10.9% with OA (p ? 0.0001). The incidence of bleeding complications was higher with LA (4.7%) than OA (3.7%) (p ? 0.0001). As compared with LA, OA had a significantly higher incidence of associated organ injury (2.4% vs 0.7%), mainly to the spleen, and more wound (6.9% vs 1.4%), pulmonary (5.5% vs 0.9%), cardiac (1.6% vs 0.3%), and infectious (5.8% vs 1.6%) complications (p ? 0.0001). No significant differences in gastrointestinal, thromboembolic, or neurologic complications were seen. The mortality rate was 0.3% after LA and 0.9% after OA. The difference was not significant. Conclusions: Laparoscopic adrenalectomy has resulted in fewer adrenalectomy-related complications than seen historically with OA. Fewer wound and pulmonary complications and a reduced incidence of incidental splenectomy are primarily responsible for this improved outcome.

Laparoscopic distal pancreatectomy in the porcine model.

Our aim was to assess the feasibility and safety of laparoscopic distal pancreatectomy in an animate model. After developing the technique in acute animal experiments, laparoscopic distal pancreatectomy was performed in five young domestic pigs. Five trocars were used (2–10 mm, 2–12 mm, 1–11 mm) for video laparoscopic access to the peritoneal cavity. The operations were performed without complication in 62-95 min (mean±SEM, 77±7 min). Each animal tolerated oral feedings on the first postoperative day and subsequently gained 6–11 kg (10±2 kg) in the 4-7-week interval prior to sacrifice. Although there was a significant increase in serum amylase on the first postoperative day, this was associated with a comparable increase in hematocrit, possibly representing hemoconcentration. The weight of the laparoscopically resected pancreatic segment ranged from 16 to 36 g (19±2 g) while that of the pancreatic head at sacrifice was 13-29 g (21±3 g). At the time of sacrifice, there were few intraabdominal adhesions and no evidence of fluid collection or pancreatitis. The staple line across the body of the pancreas was grossly intact in all animals. We conclude that laparoscopic distal pancreatectomy in the porcine model is feasible and safe. It may therefore be possible to perform laparoscopic distal pancreatectomy in humans.

Minimal access adrenal surgery

Laparoscopic adrenalectomy has become the preferred method for removal of most adrenal tumors. An important component in selecting patients for this operation is to understand the clinical presentation and diagnostic workup for the various functioning and nonfunctioning adrenal tumors. In this review, an overview of the key clinical and diagnostic aspects of the most common adrenal tumors is presented. The indications and contraindications for a laparoscopic approach are discussed and the technique for laparoscopic adrenalectomy is then presented with inclusion of video links to demonstrate the technique. A review of the results of laparoscopic adrenalectomy is then considered with regard to common outcome measures and complications. A current controversy in adrenal surgery is the role of laparoscopic adrenalectomy in the management of patients with large tumors and malignant or potentially malignant adrenal lesions and the literature on this topic is reviewed in detail. The article concludes with a discussion of the indications and technique for partial adrenalectomy.

Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.

Background: Although the laparoscopic totally extraperitoneal (TEP) approach to hernia repair has been associated with less pain and a faster postoperative recovery than traditional open repair, many practicing surgeons have been reluctant to adopt this technique because of the lengthy operative times and the learning curve for this procedure. Methods: Data from all patients undergoing TEP repair since 1997 and open mesh repair (OPEN) since 1999 were collected prospectively. Selection of surgical approach was based on local hernia factors, anesthetic risk, previous abdominal surgery, and patient preference. Statistical analyses were performed using unpaired t-tests and chi-squared tests. Data are mean ± SD. Results: TEP repairs were performed in 147 patients and open repairs in 198 patients. Patients in the OPEN group were significantly older (59 ± 19 years OPEN vs 51 ± 13 years TEP) and had a higher ASA (1.9 ± 0.7 OPEN vs 1.5 ± 0.6 TEP; p < 0.01). TEP repairs were more likely to be carried out for bilateral (33% TEP, 5% OPEN) or recurrent hernias (31% TEP, 11% OPEN) than were open repairs (p < 0.01). Concurrent procedures accompanied 31% of TEP and 12% of OPEN repairs (p < 0.01). Operative times (min) were significantly shorter in the TEP group for both unilateral (63 ± 22 TEP, 70 ± 20 OPEN; p = 0.02) and bilateral (78 ± 27 TEP, 102 ± 27 OPEN; p = 0.01) repairs. Mean operative times decreased over time in the TEP group for both unilateral and bilateral repairs (p < 0.01). Patients undergoing TEP were more likely (p < 0.01) to develop urinary retention (7.9% TEP, 1.1% OPEN), but were less likely (p < 0.01) to have skin numbness (2.8% TEP, 35.8% OPEN) or prolonged groin discomfort (1.4% TEP, 5.3% OPEN). Conclusions: Despite a higher proportion of patients undergoing bilateral repairs, recurrent hernia repair, and concurrent procedures, operative times are shorter for laparoscopic TEP repair than for open mesh repair. TEP repairs can be performed efficiently and without major complications, even when the learning curve is included.

Evaluation of acellular human dermis reinforcement of the crural closure in patients with difficult hiatal hernias

BackgroundBiologic prosthetics may circumvent mesh-related complications at the esophageal hiatus by becoming remodeled by native cells. We present our experience with acellular human dermal matrix in the repair of difficult hiatal hernias (HH).MethodsRecords of 17 patients who underwent laparoscopic HH repair using acellular human dermis to buttress the crural closure were analyzed. Hernias were paraesophageal (PEH) in 12 patients, large type 1 in 1 patient, and recurrent after prior HH repair in 4 patients. Barium swallow (BAS) was obtained 6–12 months after surgery. (Data are presented as mean ± standard deviation.)ResultsMean patient age was 65 ± 12 years and BMI was 31 ± 4. Mean gastroesophageal (GE) junction distance above the diaphragm in the PEHs was 4.9 ± 1.5 cm; 9 of 12 patients with PEH had more than 50% of the stomach in the chest. Mean operating time was 273 ± 48 min. Average hiatal defect size was 4.7 × 2.7 cm, with 4.2 ± 1.2 sutures used to close the crura. Nissen fundoplication was performed in all patients, esophageal lengthening in four patients, and anterior gastropexy in three patients. Mean hospital length of stay (LOS) was 2.3 ± 0.8 days. Mean followup was 14.4 ± 4.4 months. Postoperatively, only one (6%) patient had heartburn/regurgitation, one (6%) had mild dysphagia, and two (12%) take proton pump inhibitors. Followup BAS at 10.3 ± 4.9 months after surgery showed small recurrent hernias in two patients (12%), but only one was symptomatic. In addition, there was one symptomatic failure of a redo Nissen in an obese patient. Reoperative gastric bypass 15 months later showed an intact crural closure with a remodeled buttress site.ConclusionsAcellular human dermal matrix may be an effective method to buttress the crural closure in patients with large hiatal hernias. Longer followup in larger numbers of patients is needed to assess the validity of this approach.

Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective

AbstractBackground: The elderly have prevalence rates and clinical features of gastroesophageal reflux disease (GERD) similar to those in younger individuals, but the role of laparoscopic antireflux surgery (LARS) in the elderly has not been clearly established. The purpose of this study was to determine if the results of LARS in the elderly are comparable with those in younger patients. Methods: All patients undergoing LARS for GERD at the Washington University Medical Center were entered prospectively into a computerized database. Between May 1992 and June 1998, 339 patients underwent LARS and were divided into two groups based on age: nonelderly (ages, 18–64 years; n= 303) and elderly (age, ≥65 years; n = 36). Data were expressed as mean ± standard deviation (SD) and statistical analysis was performed. Results: Elderly patients had a higher American Society of Anesthesiology (ASA) score (2.3 ± 1.5) and a longer hospital stay (2.1 ± 0.2 days) than the younger group (ASA, 1.9 ± 0.5; hospital stay, 1.6 ± 0.9 days; p < 0.001). Operation times averaged 154 ± 68 min in the elderly compared with 134 ± 49 min in the nonelderly (p= NS). Grade I complications occurred significantly more frequently in the elderly (13.9%) than in the nonelderly (2.6%), but the incidence of grade II complications was similar between the groups (elderly 2.8% vs nonelderly 2.7%). There were no grade III complications in either group, but there was one death in the nonelderly group. At follow-up ranging to 81 months (median, 27 months), the two groups had similar low incidences of heartburn and dysphagia. Anatomic failures of LARS developed in 19 nonelderly patients (6.2%) compared with 2 elderly patients (5.5%; p= NS). Conclusions: As shown in this study, LARS is safe and effective in elderly patients with GERD. Age older than 65 years should not be a contraindication to laparoscopic antireflux surgery in properly selected patients.

Laparoscopic splenopexy for wandering (pelvic) spleen

Wandering spleen is a rare clinical diagnosis with a high incidence of splenic torsion and infarction. The preferred treatment for this condition currently is splenopexy to reposition and fixate the spleen in the left upper quadrant of the abdomen to preserve splenic function. We recently performed the first splenopexy for a wandering spleen using laparoscopic techniques. The patient was a 19-year-old woman who had an asymptomatic lower abdominal/pelvic mass found on physical examination. Diagnostic evaluation (ultrasound, computed tomography scan, and liver-spleen scan) showed an absent spleen in the upper abdomen, normal uterus and ovaries, and an 11 x 7-cm pelvic spleen. Laparoscopic splenopexy was performed using Vicryl mesh to suspend and fixate the spleen in the left upper quadrant of the abdomen. Total operative time was 175 min, there were no intra- or postoperative complications, and the patient was discharged on the 1st postoperative day. Follow-up at 2 and 7 months indicated that she was asymptomatic with a nonpalpable spleen. The results suggest that a laparoscopic approach to splenopexy should be considered for the treatment of patients with a wandering spleen.