L. Michael Brunt

Perioperative outcomes of laparoscopic versus open splenectomy: A meta-analysis with an emphasis on complications

BACKGROUND The purpose of this study was to analyze the published perioperative results of laparoscopic splenectomy (LS) compared to open splenectomy (OS), and to determine the impact of LS on the incidence and type of splenectomy-related complications. METHODS Perioperative results and complications were tabulated from all English-language reports of LS from 1991 through 2002, and complications were analyzed further by type. Data were taken from 26 series that compared OS to LS within an institution (paired analysis) and from an additional 25 series of only LS (unpaired analysis), and a meta-analysis was performed. RESULTS A total of 2940 patients from 51 published series were included (LS, 2119 patients; OS, 821 patients). Age, gender, and American Society of Anesthesiologists class were similar. In the analysis of paired OS and LS studies, the mean operative time for LS was significantly longer (LS, 180 minutes; OS, 114 minutes; P<.0001,) but the postoperative hospital stay was shorter (LS, 3.6 days; OS, 7.2 days; P<.001). Accessory spleens were identified in 11% of cases in both groups. The total complication rate for LS was 15.5%, compared with 26.6% for OS (P<.0001). LS was associated with significantly fewer pulmonary, wound, and infectious complications (P<.001 for all) but with more hemorrhagic complications, when conversions for bleeding were included. Mortality rates for LS and OS were similar (OS, 1.1%; LS, 0.6%; P=not significant). Comparable results were obtained when the unpaired LS series were added to the analysis. CONCLUSIONS Although operative times are longer for LS than OS, LS is associated with a significant reduction in splenectomy-related morbidity, primarily as a function of fewer pulmonary, wound, and infectious complications.

Comparative analysis of laparoscopic versus open splenectomy

BACKGROUND Laparoscopic splenectomy (LS) has been used to treat a variety of splenic disorders. However, there have been few direct comparisons of this approach with open splenectomy (OS). METHODS Results and outcomes were compared retrospectively in 46 consecutive patients treated by laparoscopic (n = 26) or open splenectomy (n = 20) from January 1990 through March 1996. The two groups were similar in age, sex, and American Society of Anesthesiology classification. Splenectomy was performed for a variety of indications, and the majority of patients in both groups had normal or near-normal size spleens. All data are expressed as mean +/- standard deviation. RESULTS Laparoscopic splenectomy was successfully completed in all 26 attempted cases. Operative times were significantly longer for LS (202 +/- 55 minutes) than for OS (134 +/- 43 minutes) (P < 0.001); however, operative times in the last 13 LS cases (176 +/- 48 minutes) averaged 51 minutes less than in the first 13 cases (227 +/- 51 minutes). Estimated operative blood loss was less for LS (222 +/- 280 mL) than for OS (376 +/- 500 mL) (P = not significant). A mean of 2.0 units of red blood cells was transfused in 4 (15%) of 26 patients during LS vs 1.0 unit transfused in 2 (10%) of 20 patients who had OS (P = NS). Patients who underwent LS required significantly less parenteral pain medications, had a more rapid return to regular diet, and were discharged sooner than patients who had OS. Complication rates were similar in the two groups. CONCLUSIONS These results suggest that LS is technically safe and has several advantages over OS. Laparoscopic splenectomy should become the procedure of choice for the removal of normal and near-normal size spleens.

Pooled Data Analysis of Laparoscopic vs. Open Ventral Hernia Repair: 14 Years of Patient Data Accrual

BackgroundThe purpose of this study was to analyze the published perioperative results and outcomes of laparoscopic (LVHR) and open (OVHR) ventral hernia repair focusing on complications and hernia recurrences.MethodsData were compiled from all English-language reports of LVHR published from 1996 through January 2006. Series with fewer than 20 cases of LVHR, insufficient details of complications, or those part of a larger series were excluded. Data were derived from 31 reports of LVHR alone (unpaired studies) and 14 that directly compared LVHR to OVHR (paired sudies). Chi-squared analysis, Fisher’s exact test, and two-tailed t-test analysis were used.ResultsForty-five published series were included, representing 5340 patients (4582 LVHR, 758 OVHR). In the pooled analysis (combined paired and unpaired studies), LVHR was associated with significantly fewer wound complications (3.8% vs. 16.8%, p < 0.0001), total complications (22.7% vs. 41.7%, p < 0.0001), hernia recurrences (4.3% vs. 12.1%, p < 0.0001), and a shorter length of stay (2.4 vs. 4.3 days, p = 0.0004). These outcomes maintained statistical significance when only the paired studies were analyzed. In the pooled analysis, LVHR was associated with fewer gastrointestinal (2.6% vs. 5.9%, p < 0.0001), pulmonary (0.6% vs. 1.7%, p = 0.0013), and miscellaneous (0.7% vs. 1.9%, p = 0.0011) complications, but a higher incidence of prolonged procedure site pain (1.96% vs. 0.92%, p = 0.0469); none of these outcomes was significant in the paired study analysis. No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% with LVHR and 0.26% with OVHR (p = NS). Trends toward larger hernia defects and larger mesh sizes were observed for LVHR.ConclusionsThe published literature indicates fewer wound-related and overall complications and a lower rate of hernia recurrence for LVHR compared to OVHR. Further controlled trials are necessary to substantiate these findings and to assess the health care economic impact of this approach.

Laparoscopic paraesophageal hernia repair, a challenging operation: Medium-term outcome of 116 patients

Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were pro-spectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (± SD)ageof65 ± 13 years and an American Society of Anesthesiology score of 2.3 ± 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 ± 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months’ follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3 %). When only the patients with recurrent hiatal hernias are considered, 13 (62 %) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair.

Rationale and Use of the Critical View of Safety in Laparoscopic Cholecystectomy

t l c t d t t a c c m t c p o l c b q t f d t s f o 1 he introduction of laparoscopic cholecystectomy was associted with a sharp rise in the incidence of biliary injuries. espite the advancement of laparoscopic cholecystectomy echniques, biliary injury continues to be an important probem today, although its true incidence is unknown. The most ommon cause of serious biliary injury is misidentification. sually, the common bile duct is mistaken to be the cystic uct and, less commonly, an aberrant duct is misidentified as he cystic duct. The former was referred to as the “classical njury” by Davidoff and colleagues, who described the usual attern of evolution of the injury at laparoscopic cholecystecomy. In 1995, we authored an analytical review of this subect and introduced a method of identification of the cystic tructures referred to as the “critical view of safety” (CVS) Fig. 1). (This approach to ductal identification had been decribed in 1992, but the term critical view of safety was used irst in our 1995 article.) During the past 15 years, this ethod has been adopted increasingly by surgeons around the orld for performance of laparoscopic cholecystectomy. hen the method was initially described, it was done so with brief description and picture, without a thorough explanaion of the rationale for this approach. The primary purpose f this short communication is to present that rationale so that urgeons can better apply CVS by understanding why the ethod is protective against misidentification. A second purose is to review the current status of the use of CVS and to uggest approaches that might reduce the incidence of biliary njury through its use.

Portal vein thrombosis after splenectomy

BACKGROUND Portal vein thrombosis (PVT) has been described after splenectomy, but the factors associated with its development and the clinical outcomes are poorly characterized. METHODS Case logs of four surgeons from 1996 to 2001 were retrospectively reviewed to identify cases of postsplenectomy PVT. RESULTS Eight cases of PVT (8%) among 101 splenectomies were identified. Indications for splenectomy in patients with PVT were myeloproliferative disease (n = 4), hemolytic anemia (n = 3), and myelodysplastic disorder (n = 1). All patients had splenomegaly (mean 1698 g, range 360 to 3150 g). Among 10 patients with myeloproliferative disease (MP), 4 patients (40%) developed PVT, compared with 4 of 12 patients (25%) with hemolytic anemia. Three of 4 patients (75%) with MP disease and spleen weight greater than 3,000 g developed PVT. Five patients developed PVT despite receiving prophylactic subcutaneous heparin postoperatively. Presenting symptoms included anorexia in 7 (88%), abdominal pain in 6 (75%), and both elevated leukocyte and platelet counts in 8 patients (100%). All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One patient died of intraabdominal sepsis; the others are alive with no clinical sequelae at 38 months of follow-up. CONCLUSIONS PVT is a relatively common complication of splenectomy in patients with splenomegaly. A high index of suspicion, early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation are key to a successful outcome.

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.

Diagnosis and management of biliary complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the operation of choice for symptomatic cholelithiasis. However, this operation may result in serious biliary complications. Our aims were to review our experience with biliary complications of laparoscopic cholecystectomy and to document the mechanisms of the injuries and the techniques of managing these complications. We treated 20 patients with biliary complications of laparoscopic cholecystectomy. Symptomatic collections of bile (bilomas) were present in five patients. One of these patients underwent operative ligation of an accessory bile duct in the gallbladder bed, whereas the others had percutaneous or endoscopic therapy. In the remaining 15 patients (of whom 13 were referred from other hospitals), injuries to the major bile ducts were managed by combined radiologic, endoscopic, and operative therapies. In 10 of these patients (67%), the mechanism of injury was the misidentification of the common bile duct as the cystic duct. In 3 of 15 patients, a noncircumferential injury to the lateral aspect of the common bile duct occurred. The Bismuth levels of the remaining bile duct injuries were type I in 3, type II in 4, type III in 3, and type IV in 2. Early outcome of therapy for these bile duct injuries has been favorable. One patient was lost to follow-up, and 2 died of nonbiliary causes, whereas 12 patients are alive and well with normal serum liver enzyme levels at 4 to 19 months postoperatively (mean: 14 months). The most common cause of major bile duct injury during laparoscopic cholecystectomy is mistaking the common bile duct for the cystic duct. Most bilomas can be managed successfully with noninvasive methods. Coordinated efforts by radiologists, endoscopists, and surgeons are necessary to optimize the management of patients with major bile duct injury, suggesting that patients with biliary complications of laparoscopic cholecystectomy should be referred to specialty centers for optimal care.

Preservation of the recurrent laryngeal nerves in thyroid and parathyroid reoperations

BACKGROUND The recurrent laryngeal nerve (RLN) is vulnerable to injury in thyroid and parathyroid reoperations because of the presence of scar tissue and displacement of the nerve from its normal position. METHODS Since 1993, we have performed 132 reoperations for recurrence of thyroid or parathyroid carcinoma (102 cases), persistent hyperparathyroidism (21 cases), and recurrent goiter (9 cases). One or both RLNs were identified in all cases (208 nerves). Exposure of the nerve was accomplished by a lateral approach (159 nerves), a low anterior approach (41 nerves), or the identification of the nerve between the larynx and the upper pole of the thyroid, in parathyroid reoperations (8 nerves). Dissection was then done while the nerve was kept in view at all times. RESULTS Preoperatively, unilateral vocal cord paralysis was noted in 6 patients. Resection of a functioning RLN encased with a tumor was intentionally carried out in 5 patients. The RLNs were identified and preserved in all other cases. Among these 121 patients, transient hoarseness lasting up to a month occurred in 12 patients. CONCLUSIONS Careful identification and exposure of the RLN through a previously undissected area can be done safely in thyroid and parathyroid reoperations and resulted in no permanent recurrent nerve injuries in our experience.

Single-Incision Laparoscopic Cholecystectomy: Initial Experience with Critical View of Safety Dissection and Routine Intraoperative Cholangiography

BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) is emerging as a potentially less invasive alternative to standard laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery cholecystectomy. As this technique is more widely used, it is important to maintain well-established practices of the critical view of safety (CVS) dissection and intraoperative cholangiography (IOC). We present our initial experience with SILC using CVS dissection and routine IOC. STUDY DESIGN Fifty-four patients with biliary colic were offered SILC, which was performed through the umbilicus. CVS with photo documentation was attained before clipping and transecting the cystic structures. IOC was done using various needle puncture techniques. Assessment of CVS was carried out by independent surgeon review of operative still photos or videos using a 3-point grading scale: visualization of only 2 ductal structures entering the gallbladder; a clear triangle of Calot; and separation of the base of the gallbladder from the cystic plate. RESULTS SILC was performed in 54 patients (15 male and 39 female). Six patients required 1 supplementary 3- or 5-mm port. Complete IOC was successful in 50 of 54 patients (92.6%). CVS was achieved at the time of operation in all 54 patients. Photo documentation review confirmed 3 of 3 CVS criteria in 32 (64%) patients, 2 of 3 in 12 patients (24%), 1 of 3 in 3 patients (6%), and 0 in 3 patients (6%). CONCLUSIONS As laparoscopic cholecystectomy becomes less invasive, proven safe dissection techniques should be maintained. Dissection to obtain the CVS should be the goal of every patient and IOC can be accomplished in a high percentage of patients. This approach places patient safety considerations foremost in the evolution of minimally invasive cholecystectomy.