Michel Gagner

Early experience with laparoscopic resections of islet cell tumors

BACKGROUNDnDiagnostic laparoscopy and laparoscopic ultrasonography have been applied recently for diagnosis and localization of islet-cell tumors. A further step was taken by performing resection of these tumors with laparoscopic techniques.nnnMETHODS AND RESULTSnWe studied a retrospective series of 12 patients operated on with laparoscopic techniques since January 1992. The seven female and five male patients had a mean age of 43 years. The mean tumor size was 3 cm. Thirty-six percent of the tumor site could not be identified before operation. Eight patients underwent planned laparoscopic distal pancreatectomy (five insulinomas, two gastrinomas, and one unknown origin), and four underwent planned laparoscopic enucleation (one insulinoma and three unknown origin). Of the eight distal procedures, three had conversions (one inability to localize the tumor and two metastatic gastrinomas). Average operating time was 4.5 hours, with an average hospital stay of 5 days. Of the four explorations for possible enucleation, one was performed and one was converted to a Whipple procedure for nesidioblastoma of the head of the pancreas. The other two had negative explorations. The successful enucleation of an insulinoma of the anterior body of the pancreas was performed in 3 hours, and the hospital stay was 4 days. No recurrence was seen in the enucleated or distal pancreatectomy group in follow-up (15 to 38 months).nnnCONCLUSIONSnLaparoscopic enucleation or resection of benign islet tumors results in a shorter hospital recovery and is a good alternative to open surgery.

Is laparoscopic adrenalectomy indicated for pheochromocytomas

BACKGROUNDnSince the introduction of laparoscopic adrenalectomy there has been major concern about proper indications for its use, including in pheochromocytoma. In this study we reviewed pheochromocytomas resected by means of laparoscopy to establish that procedures usefulness.nnnMETHODSnBetween January 1992 and June 1995, 90 laparoscopic adrenalectomies were performed in 82 patients. Three to five trocars were used intraperitoneally in each patient to remove the gland, and extraction was performed with a sterile plastic bag.nnnRESULTSnTwenty-three pheochromocytomas were operated on. Six patients had a bilateral adrenalectomy. Pheochromocytomas were significantly larger than other tumors, required more operating time, and necessitated longer hospital stays in patients. Of all the intraoperative complications 87% occurred in the pheochromocytoma group; 67% of all postoperative complications occurred in this group. In four patients metastasis from pheochromocytoma to the liver was unexpectedly found, and in one case metastasis from a medullary thyroid carcinoma was found. There has been no local recurrence after laparoscopic adrenalectomy.nnnCONCLUSIONSnLaparoscopic adrenalectomy for pheochromocytomas is difficult because tumors are larger and more complications are seen related to their hormonal secretions, in spite of adequate pharmacologic blockade. However, metastatic extensions can be diagnosed and laparoscopic ablation can be performed in most instances without recurrence. It is not, therefore, a contraindication for this approach.

The lateral approach to laparoscopic splenectomy

BACKGROUNDnLaparoscopic splenectomy has been shown to result in shorter hospital stays and a quicker return to work than conventional splenectomy. Having tried the anterior 5 trocar approach, we developed a 4 trocar lateral approach and now present our experience with 22 cases.nnnMETHODSnAll patients were placed in the right lateral decubitus position. A 10-mm trocar was inserted in the left subcostal region, 2 in the flank, and a 5-mm trocar dorsally. A 30 degrees laparoscope was used. Splenectomy was performed for varying pathologies.nnnRESULTSnOperating room (OR) time averaged 169 minutes, spleen weight 513 grams, and postoperative (post-op) stays 5.4 days (median 3 days). One patient was converted to laparotomy. There were no deaths, post-op abscesses, pancreatic injuries, or bleeding complications.nnnCONCLUSIONSnThe lateral approach affords superior exposure, allowing easier dissection of splenic hilar structures. Over varying patient habitus and spleen size it has been demonstrated to be the approach of choice for laparoscopic splenectomy.

Splenic artery aneurysms: Methods of laparoscopic repair

PURPOSEnSurgical therapy for splenic artery aneurysms (SAAs) has traditionally consisted of a laparotomy with resection of the aneurysm and possibly a splenectomy. Our early experience with the laparoscopic approach to treat SAAs is reported.nnnMETHODSnA retrospective review of medical records was conducted on all patients who underwent laparoscopic resection of SAAs at the Cleveland Clinic Foundation from May 1996 to August 1997.nnnRESULTSnFour patients with SAAs, three women and one man, with an average age of 55 years (range, 37 to 63 years), underwent successful laparoscopic SAA repair. The average size of the aneurysm was 3.2 cm (range, 2.5 to 5.0 cm). Three patients underwent an aneurysm resection, whereas one patient underwent simple ligation. Intraoperative ultrasound scanning with Doppler was used in three cases as a means of localizing the aneurysm and identifying all feeding vessels; the complete cessation of flow within the aneurysm in the case in which the feeding vessels were simply ligated was also documented. The average intraoperative time was 150 minutes (range, 100 to 190 minutes). The mean estimated blood loss was 105 mL (range, 20 to 300 mL). There were no intraoperative complications. The average hospital stay was 2.2 days (range, 1 to 4 days).nnnCONCLUSIONnThe laparoscopic approach to splenic artery aneurysm by aneurysmectomy or splenic artery ligation can be safe and effective. The laparoscopic approach affords a short hospital stay and an effective result.

The role of intraoperative ultrasonography during laparoscopic adrenalectomy

BACKGROUNDnThe role of laparoscopic intraoperative ultrasonography (IOUS) in intraoperative decision making has grown rapidly in recent years. The purpose of this study was to evaluate its usefulness during laparoscopic adrenalectomy.nnnMETHODSnSince 1995, laparoscopic ultrasonography has been used to evaluate the adrenal gland and surrounding organs in selective laparoscopic adrenalectomies. IOUS was performed in 19 of 114 laparoscopic adrenalectomies.nnnRESULTSnIOUS effected a change in management in 68% of these patients. IOUS displayed the location of the gland after a failed attempt at open resection; the adrenal vein, expediting control in four operations; no extraadrenal involvement by two large lesions (benign); vascular invasion in one tumor (carcinoma), prompting open resection; periadrenal invasion by one metastatic cancer and lymph node involvement in another; a 7 mm hyperaldosteronoma; no adenoma in two cases; bilateral hyperplasia; and a 14 cm cyst originating from the adrenal gland. IOUS facilitated partial adrenalectomy in two patients and revealed centrally located adenomas in two others requiring total adrenalectomy.nnnCONCLUSIONSnLaparoscopic IOUS during adrenal operation is valuable in selected cases. It is helpful to locate the gland and vein, confirm the presence or absence of abnormality, discern the resectability of large masses, and facilitate a partial adrenalectomy when desirable.

Trends in bile duct injuries from laparoscopic cholecystectomy

Bile duct injuries are a serious complication of cholecystectomy Laparoscopic cholecystectomies (LC) were originally associated with an increased incidence of injuries Patients referred to a tertiary center were reviewed to assess the trends in the number, presentation, and management Seventy-three patients were referred over a 6-year period with a maximum of 17 patients referred in 1992, but the number has not declined substantially over time The persistent number of referrals is a consequence of ongoing injuries One third of injuries were diagnosed at LC, and the use of cholangiography has not mcreased The number of cystic duct leaks has not decreased and they represent 25% of all cases The level of injury has remained unchanged with Bismuth types I and II in 3 7% and types III and IV in 38% Excluding patients with cystic duct leaks, 58% were referred after a failed ductal repair Definitive treatment with biliary stenting was successful in 37%, and 34 patients (47%) required a bihary-entenc anastomosis Complications occurred in 18 patients (25%) including seven with postoperative stricture or cholangins No biliary reoperations have been performed at a mean follow-up of 36 months

Robotically assisted laparoscopic microsurgical uterine horn anastomosis

OBJECTIVEnTo evaluate the feasibility, safety, and sterility issues with regard to the use of a robotic device to perform uterine horn anastomosis in a live porcine model.nnnDESIGNnProspective animal study.nnnSETTINGnLandrace-Yorkshire pigs in a conventional laboratory setting.nnnINTERVENTION(S)nSix female pigs underwent laparoscopic bipolar electrocoagulation of the distal uterine horns. Two weeks later, the uterine horns were reanastomosed laparoscopically with use of a robotic system for microsuturing. Necropsy was performed 4 weeks later to assess postoperative adhesions and anastomosis patency.nnnMAIN OUTCOME MEASURE(S)nTubal patency; secondary measures were operative time, complications, and surgeon fatigue.nnnRESULT(S)nThe mean (+/-SD) total operative time per animal was 170+/-34 minutes including setting up and dismantling the robotic arms. The robot functioned well with only minor technical problems. All pigs survived both surgeries with no perioperative complications related to the use of the robot. Patency was confirmed after completing each anastomosis (12 anastomoses; 100% patency). Four weeks later, necropsy showed that eight anastomoses were still patent (67%). Only one pig had bilateral occlusion. Surgeons fatigue was mild for each animal study.nnnCONCLUSION(S)nRobotic technology can be used safely in creating laparoscopic microsurgical anastomoses. The robot functioned properly in a sterile operating room environment. Adequate patency rates were achieved during the acute phase and at 4-week follow-up. Robotic technology has the potential to make laparoscopic microsuturing easier.

Minimal-invasive Verfahren am Pankreas

Summary. Laparoscopic pancreatic surgery is technically difficult and demanding owing to its retroperitoneal location and its complex anatomic relationships. Performing these operations requires familiarity with the anatomy of the retroperitoneum and advanced laparoscopic skills. Intracorporeal suturing skills are also mandatory. Due to the small number of operations performed in centers, an evaluation period of at least 5 years is necessary to determine the role of laparoscopic procedures in pancreatic disease processes. However, laparoscopic procedures are beginning to represent an undeniable part of the surgical repertoire against pancreatic pathology.Zusammenfassung. Die laparoskopische Pankreaschirurgie ist technisch schwierig und anspruchsvoll aufgrund ihrer retroperitonealen Lokalisation und komplexen anatomischen Beziehungen. Die Durchführung dieser Eingriffe erfordert eine Vertrautheit mit der Anatomie des Retroperitoneums und fortgeschrittene laparoskopische Erfahrungen. Kenntnisse über intracorporale Nahttechniken sind ebenfalls obligatorisch. Aufgrund der kleinen Operationszahlen in den Zentren ist eine Evaluierungsphase von zumindest 5 Jahren notwendig, um die Rolle festzulegen, die laparoskopische Verfahren bei Pankreaserkrankungen spielen. Laparoskopische Verfahren sind jedoch gerade dabei, einen nicht zu leugnenden Teil des chirurgischen Repertoires bei krankhaften Pankreasprozessen zu repräsentieren.