Margherita Cadeddu

Defining a learning curve for laparoscopic colorectal resections.

PURPOSE: The purpose of this review was to define the learning curve for laparoscopic colorectal resections. METHODS: A prospectively accumulated, computerized database of all laparoscopic colorectal resections performed by three surgeons between April 1991 and March 1999 was reviewed. RESULTS: A total of 461 consecutive resections were evenly distributed among three surgeons (141, 155, and 165). Median operating time was 180 minutes for Cases 1 to 30 in each surgeons experience and declined to a steady state (150–167.5 minutes) for Cases 31 and higher. Subsequently, Cases 1 to 30 were considered “early experience,” whereas Cases 31 and higher were combined as “late experience” for statistical analysis. There were no significant differences between patients undergoing resections in the early experience and those undergoing resections in the late experience with respect to age, weight, or proportion of patients with malignancy, diverticulitis, or inflammatory bowel disease. There were greater proportions of males (42vs. 54 percent,P=0.046) and rectal resections performed (14vs. 32 percent,P=0.002) in the late experience. Trends toward declining rates of intraoperative complications (9vs. 7 percent,P=0.70) and conversion to open surgery (13.5vs. 9.7 percent,P=0.39) were observed with experience. Median operating time (180vs. 160 minutes,P<0.001) and overall length of postoperative hospital stay (6.5vs. 5 days,P<0.001) declined significantly with experience. There was no difference in the rate of postoperative complications between early and late experience (30vs. 32 percent,P=0.827). CONCLUSIONS: The learning curve for performing colorectal resections was approximately 30 procedures in this study, based on a decline in operating time, intraoperative complications, and conversion rate. Learning was also extended to clinical care because it was appreciated that patients could be discharged to their homes more quickly.

Does a laparoscopic approach to total abdominal colectomy and proctocolectomy offer advantages

BackgroundControversy exists regarding the feasibility, safety, and outcomes of laparoscopic total abdominal colectomy (LTAC) and laparoscopic total proctocolectomy (LTPC). The object of this study was to assess the outcomes of LTAC and LTPC and compare them with those of institutional open procedure used as controls.MethodsPerioperative data and surgical outcomes of patients who underwent TAC or TPC were analyzed and compared retrospectively at a single institution between 1991 and 1999.ResultsA total of 73 TACs performed during a 9-year period were evenly distributed between laparoscopic (n=37) and open (n=36) approaches. There were no significant differences between patient groups with respect to genders, age, weight, proportion of patients with inflammatory bowel disease, and the number of patients undergoing ileorectal anastomosis. The median operative time was longer with the laparoscopic method (270 vs 178 min; p=0.001), but the median length of hospital stay was significantly shorter (6 vs 9 days; p=0.001). The short-term postoperative complication rate up to 30 days from surgery was not statistically different (25% vs 44%; p=0.137), although there was a clear trend toward a reduced number of overall complications in the laparoscopic group (9 vs 24). Wound complications were significantly fewer (0% vs 19%; p=0.015) and postoperative pneumonia was nonexistent in laparoscopic patients. Long-term complications also were less common in the laparoscopic group (20% vs 64%; p=0.002), largely because of reduced incidence of impotence, incisional hernia, and ileostomy complications. Total proctocolectomy was performed laparoscopically in 15 patients and with an open procedure in 13 patients over the same period. There were no statistically significant differences between the two groups with respect to gender, age, weight, and diagnosis. Median operating time was longer for the laparoscopic patients (400 vs 235 min; p=0.001), whereas the length of hospital stay, morbidity, and mortality were not significantly different.ConclusionsThe results indicate that LTAC can be performed safely with a statistically significant reduction in wound and long-term postoperative complications, as compared with its open counterpart. Operating time is increased, but there is a marked reduction in length of hospital stay. Preliminary results demonstrate that LTPC also is technically feasible and safe, with equal morbidity, mortality, and hospital stay, as compared with open procedures. Studies with larger numbers of patients and a randomized controlled trial giving special attention to patient quality-of-life issues are needed to elucidate the real advantages of this minimally invasive technique.

Determinants of outcomes in laparoscopic colorectal surgery: a multiple regression analysis of 416 resections.

AbstractBackground: To date, most large series of laparoscopic colorectal procedures have been descriptive reports that do not account for the potentially complex interaction of outcome predictors. The purpose of this study was to identify the preoperative factors that predict operative time, conversion to open surgery, and intraoperative and postoperative complications in laparoscopic colorectal surgery. Methods: Multiple regression techniques were used to analyze 416 laparoscopic resections from a prospective database of laparoscopic colorectal procedures performed between April 1991 and April 1998. The preoperative factors considered were patient-specific (age, gender, weight) or disease-specific (diagnosis of cancer, Crohns disease, diverticulitis, fistula). Surgical experience of ≤50 cases was also considered. Finally, all resections were represented by a combination of the following five procedure components: resections of the (a) hepatic flexure, (b) splenic flexure, (c) sigmoid, and (d) rectum, or (e) a perineal dissection. Results: Patient weight, Crohns disease, and each of the five individual procedure components incrementally lengthened operative time. Conversion to open surgery was influenced by the patients weight, malignancy, and early experience of the surgeon. The risk of a postoperative complication was increased by the patients age, resection of the perineum, and the presence of a fistula. No factors significantly influenced the risk of an intraoperative complication. Conclusions: Several preoperative factors that significantly affect outcomes in laparoscopic colorectal resections have been identified. Consideration of these factors may help in case selection and estimation of operating time; they should also be valuable when patients are informed of their risk of conversion and complications.

Predicting conversion to open surgery in laparoscopic colorectal resections A simple clinical model

AbstractObjective: The objective of this study was to develop a simple model for clinical use in predicting the individual risk of conversion to open surgery in patients undergoing laparoscopic colorectal resections. Methods: A multiple logistic regression analysis of 367 laparoscopic colorectal resections completed between 1991 and 1998 was performed. The following 13 factors were considered: patient-specific factors (age, gender, weight levels less than 60 kg 60–90 kg, 90 kg or more), disease-specific factors (Crohns disease, diverticulitis, malignancy, fistula), and procedure-specific factors (resection of the hepatic flexure, splenic flexure, sigmoid, rectum, perineum, experience with less than 50 cases). A scoring system was developed on the basis of the three factors found to be predictive of the risk for conversion to open surgery: diagnosis of malignancy (odds ratio 3.23; p= 0.0037; one point), surgeon experience with 50 cases or less (odds ratio 2.26; p= 0.0363; one point), and weight level (odds ratio 3.42; p= 0.005; 60 to 90 kg, one point, 90 kg or more, two points). Results: The predicted conversion rates for the cumulative scores of 0 to 4 points were 1.1%, 3.3%, 9.8%, 25.4%, and 49.7%, respectively. No significant difference was found between predicted and actual conversion rates, indicating a good fit of the model (chi square = 1.774; p > 0.5). Conclusions: This novel scoring system is simple, accurate, and readily applicable in an office setting. It represents the large experience of one surgical group and remains to be validated by other centers.

Local recurrence and survival after laparoscopic mesorectal resection for rectal adenocarcinoma

BackgroundLaparoscopic resection for rectal cancer is controversial. Actuarial survival and local recurrence rates have not been determined.MethodsA prospective database containing 80 consecutive unselected laparoscopic resections of rectal cancers performed between November 1991 and 1999 was reviewed. Local recurrence was defined as any detectable local disease at follow-up assessment occurring either alone or in conjunction with generalized recurrence. The tumor node metastases (TNM) classification for colorectal cancers and the Kaplan-Meier method were used to determine staging and survival curves. The mesorectal excision technique was used during surgery.ResultsThe median follow-up period was 31 months for patients with stages, I, II, and III cancer, and 15.5 months for patients with stage IV cancer. The overall 5-year survival rate was 65.1% for all cancer stages and 72.1% for stages I, II, and III cancer. No trocar-site recurrence was observed. The overall local recurrence rate was 3.75% (3/80) for all cancer stages, and 4.3% (3/70) for stages I, II, and III cancer.ConclusionsThe survival and local recurrence rate for patients with rectal cancer treated by laparoscopic mesorectal excision do not differ negatively from those in the literature for open mesorectal excision. Further validation is needed.

Needlescopic surgery. A logical evolution from conventional laparoscopic surgery.

Background: The purpose of this study was to analyze the safety and feasibility of needlescopic surgery and to compare the short-term outcomes relative to conventional laparoscopic surgery. Methods: Needlescopic surgery patients were compared to matched cohorts of conventional laparoscopic surgery patients from the same prospective database for a variety of selected procedures. Results: A total of 101 needlescopic procedures were analyzed (30 cholecystectomy, 28 Nissen fundoplication, 12 bilateral sympathectomy, 10 splenectomy, 10 Heller myotomy, three adrenalectomy, two colon resection, two splenic cyst excision, four other). There was no significant difference between the needlescopic and conventional laparoscopic groups in conversion rates, morbidity, or mortality. A higher proportion of patients were in hospital <24 h for needlescopic splenectomies (40% vs 0%, p = 0.087), fundoplications (68% vs 42%, p = 0.107), and myotomies (90% vs 30%, p = 0.022) than for conventional laparoscopic surgery. Operative times were significantly shorter for needlescopic sympathectomy than for laparoscopic sympathectomy and Heller myotomy (p = 0.004 and 0.013, respectively), and they were equivalent for other procedures. Conclusion: Needlescopic surgery can be performed in a variety of procedures with no apparent increase in conversions, operative time, morbidity, or mortality. There is a trend toward reduced hospital stays for certain procedures. Randomized prospective trials comparing needlescopic to conventional laparoscopic surgery are still needed to confirm and/or extend our findings.

Laparoscopic excision of retroperitoneal tumors: technique and review of the laparoscopic experience.

A technique for laparoscopic excision of benign retroperitoneal tumors, including a teratoma and two cystic lesions, is described. Laparoscopic resection of a 12-cm retroperitoneal teratoma was accomplished with the patient in the left lateral decubitus position. Medial mobilization of the ascending colon and the duodenum was required for access to the lesion. Resections of two cystic lesions (measuring 20 cm and 12 cm) were performed with the patients in the lithotomy position. The colon required medial mobilization in both cases to gain access to the cysts. Once the cysts were dissected from surrounding structures, they were punctured, and the aspirated fluid was sent for cytologic analysis. There were no complications or conversions. Mean operating time was 122 minutes (range, 80–190). Patients were discharged 1 day after surgery, requiring only nonsteroidal anti-inflammatory medications for analgesia. Retroperitoneal tumors can be resected laparoscopically with careful preoperative investigation and meticulous laparoscopic technique. A major advantage of laparoscopic resections is that the patient recovers rapidly with minimal morbidity.

Transperitoneal laparoscopic nephrectomy for giant polycystic kidneys: a case control study.

OBJECTIVES To describe the technique and compare the surgical outcomes of patients with autosomal dominant polycystic kidney disease (ADPKD) undergoing laparoscopic or open nephrectomy for giant kidneys. METHODS The surgical outcome of our first 10 consecutive patients with ADPKD who underwent laparoscopic nephrectomy was analyzed from a large prospective computer database. The results were compared with the 10 most recent open nephrectomy procedures performed for ADPKD at the same institution. To facilitate safe laparoscopic hilar dissection, the kidneys were made manageable by volume reduction, accomplished through diligent cyst puncture and aspiration using a novel prototype suction device with a beveled tip. RESULTS No statistically significant differences were found between the laparoscopic and open surgical groups relative to patient sex, age, or median preoperative kidney size (24.0 versus 21.5 cm, respectively). The laparoscopic patients were significantly heavier than their open counterparts (94 versus 78 kg, P = 0.0095) and had a longer operative time (247 versus 205 minutes, P = 0.04). One conversion to open surgery occurred in the laparoscopic group because cysts were adherent to the spleen and colonic mesentery. No intraoperative complications or deaths occurred in either group and the postoperative complications were similar. The mean length of the postoperative hospitalization was markedly reduced with the laparoscopic compared with the open approach (2.6 versus 6.6 days, P = 0.00002). At a median of 12 months after surgery, none of the laparoscopic patients had recurrent pain, bleeding, or infection. CONCLUSIONS Laparoscopic nephrectomy is technically safe and feasible in patients with ADPKD. Progressive cyst aspiration is a critical step, facilitating the identification of vital structures and the creation of enough abdominal cavity space to operate. The advantages of this minimally invasive technique include a short hospital stay, minimal pain, low morbidity, and superior cosmesis.

Laparoscopic colorectal resection in octogenarians.

BackgroundThe number and proportion of patients aged ≥80 years are increasing. These patients often require surgical care and suffer subsequent high rates of morbidity and mortality. However, the surgical outcomes of laparoscopic colorectal resection in octogenarians are not well documented.MethodsOctogenarians were identified from a large prospective database comprising 507 consecutive laparoscopic colorectal resections performed between 1991 and 1999 in a university setting. Preoperative comorbidity and surgical outcomes were analyzed.ResultsSixty-two patients (30 men, 32 women) aged ≥80 years were identified. Their mean age and weight were 85 years and 63 kg, respectively. Seven patients (11%) were converted to an open procedure. Four (6%) intraoperative complications occurred in four patients (one colon perforation, one small bowel perforation, one burned gallbladder serosa, and one missed lesion), necessitating two conversions. Twenty-four postoperative complications occurred in 19 patients (31%) (six ileus [10%], five wound infections [8%], five cardiac problems [8%], two urinary retentions [3%], two hemorrhages [3%], one abscess [2%], one pneumonia [2%], and two other [3%]). Intraoperative complications did not increase postoperative morbidity. Three patients (5%) died within 30 days of surgery. When the procedure was completed laparoscopically, the overall median postoperative hospital stay was 10.0 days; occurrence of a postoperative complication increased the median length of stay to 15.0 days.ConclusionsThese results are superior to published historical controls involving open colorectal resection in octogenarians. Overall mortality, lung, and urinary tract complications were decreased, and there were no reoperations for small bowel obstruction. Laparoscopic colorectal resection is technically feasible and can be done safely in elderly patients. Results require randomization against those for open surgery to elucida te the real advantages of this technique.

Minimally invasive adrenalectomy for pheochromocytoma during pregnancy.

Pheochromocytoma during pregnancy is a very rare condition; fewer than 200 cases have been reported in the literature. We present the case of a 24-year-old pregnant woman found to have a pheochromocytoma during investigation of abdominal pain. This is the second reported case of laparoscopic adrenalectomy for pheochromocytoma detected during pregnancy. After appropriate radiologic investigation and medical management, a laparoscopic left adrenalectomy was performed at the beginning of the second trimester. There were no complications, and she was delivered of a healthy baby at term. We review the management of pheochromocytoma in pregnant patients and discuss the role of laparoscopy.