Oliver O. Koch

Robot-assisted laparoscopic surgery of the colon and rectum

IntroductionLaparoscopic techniques have induced a tremendous revolution in the field of general surgery. Recent multicenter trials have demonstrated similar patient-oriented and oncologic outcomes for laparoscopic colon and rectal resections compared with their open counterparts. Meanwhile, robotic technology has gradually entered the field of general surgery, allowing increased dexterity, improved operative view, and optimal ergonomics. The objective of this study was to review the current status of clinical robotic applications in colorectal surgery.MethodsA systematic review of the literature using the PubMed search engine was undertaken to identify relevant articles. The keywords used in all possible combinations were: surgical robotics, robotic surgery, computer-assisted surgery, colectomy, sigmoid resection, sigmoidectomy, and rectal resection.ResultsThirty-nine case series or comparative nonrandomized studies were identified. A specific interest for robot-assisted rectal surgery during the past few years was recorded in the literature. The retrieved articles included 13 ileocecal resections, 220 right colectomies, 190 left colectomies/sigmoid resections, 440 anterior resections, 149 abdominoperineal/intersphincteric resections, and 11 total/subtotal colectomies. The clinical application of the da Vinci robotic system in right and left/sigmoid colectomies yielded satisfactory results in terms of open conversion (1.1 and 3.8%, respectively) and operative morbidity (13.4 and 15.1%, respectively). Robot-assisted anterior resection was accompanied by a considerably low conversion rate (0.4%), morbidity (9.7%), and adequate number of harvested lymph nodes (14.3, mean).ConclusionsRobotic applications in colorectal surgery are feasible with low conversion rates and favorable morbidity. Further studies are required to evaluate its oncologic and patient-oriented outcomes.

Lower recurrence rates after mesh-reinforced versus simple hiatal hernia repair: a meta-analysis of randomized trials.

Mesh hiatoplasty has been postulated to reduce recurrence rates, it is however prone to esophageal stricture, and early-term and mid-term dysphagia. The present meta-analysis was designed to compare the outcome between mesh-reinforced and primary hiatal hernia repair. The databases of Medline, EMBASE, and the Cochrane Library were searched; only randomized controlled trials entered the meta-analytical model. Anatomic recurrence documented by barium oesophagography was defined as the primary outcome endpoint. Three randomized controlled trials reporting the outcomes of 267 patients were identified. The follow-up period ranged between 6 and 12 months. The weighted mean recurrence rates after primary and mesh-reinforced hiatoplasty were 24.3% and 5.8%, respectively. Pooled analysis demonstrated increased risk of recurrence in primary hiatal closure (odds ratio, 4.2; 95% confidence interval, 1.8-9.5; P=0.001). Mesh-reinforced hiatal hernia repair is associated with an approximately 4-fold decreased risk of recurrence in comparison with simple repair. The long-term results of mesh-augmented hiatal closure remain to be investigated.

Meta-analysis of randomized trials on single-incision laparoscopic versus conventional laparoscopic appendectomy

BACKGROUND Single-incision laparoscopic appendectomy has emerged as a less invasive alternative to conventional laparoscopic surgery. High-quality relevant evidence is limited. METHODS A systematic review of electronic information sources was undertaken, with the objective of identifying randomized trials that compared single-incision with conventional laparoscopic appendectomy. Outcome measures included 30-day morbidity, abdominal abscess, wound infection, open conversion, reoperation, operative time, length of hospital stay, and postoperative pain. Fixed-effects and random-effects models were used to calculate combined overall effect sizes of pooled data. Data are presented as odds ratios or weighted mean differences with 95% confidence intervals (CIs). RESULTS Five randomized trials were identified, with a total of 746 patients. Thirty-day morbidity (9.6% vs 8.6%; odds ratio, 1.14; 95% CI, .69 to 1.89) and wound infection rates were similar between single-incision and conventional laparoscopy (4.0% vs 4.8%; odds ratio, .83; 95% CI, .41 to 1.68), whereas the duration of surgery was longer in the single-incision group (46.3 vs 40.7 minutes; weighted mean difference, 6.01; 95% CI, 2.26 to 9.76). Available data were not adequately robust to reach conclusions regarding the remaining outcome measures. CONCLUSIONS Similar postoperative morbidity and wound infection rates for single-incision and conventional laparoscopic appendectomy are supported by the current literature, but single-incision surgery requires longer operative time.

Subjective and objective data on esophageal manometry and impedance pH monitoring 1 year after endoscopic full-thickness plication for the treatment of GERD by using multiple plication implants

BACKGROUND Subjective and especially objective data after endoluminal full-thickness gastroplication are scarce. OBJECTIVE To evaluate symptoms and reflux activity 12 months after gastroplication by using multichannel intraluminal impedance monitoring. DESIGN Open-label, prospective, single-center study. SETTING Tertiary referral hospital in Zell am See, Austria. PATIENTS Subjects without hiatal hernias with documented GERD and persistent or recurrent symptoms despite treatment with a proton pump inhibitor. INTERVENTIONS A total of 36 patients underwent endoscopic full-thickness gastroplication with 1 or more Plicator implants. MAIN OUTCOME MEASUREMENTS Mean Gastrointestinal Quality of Life Index and reflux-specific symptom scores significantly improved on follow-up (P < .01). Atypical reflux, gas/bloating, and bowel dysfunction-specific symptom scores as well as belching and dysphagia scores improved. Twenty-two patients returned for esophageal manometry and multichannel intraluminal impedance testing 1 year after surgery. DeMeester scores decreased from 20 to 10 (P < .029). The median numbers of total, acid, proximal, upright, and recumbent reflux episodes were all significantly reduced (P < .05). Manometric data were virtually unchanged. The percentage of patients taking proton pump inhibitors on daily basis after the procedure was 11.5%. There was only 1 postprocedure incident (bleeding) that required intervention. Three of 36 patients (8.3%) were considered treatment failures because of persistent symptoms and were assigned to undergo laparoscopic fundoplication. LIMITATIONS No randomized comparison with a sham procedure or laparoscopic fundoplication; follow-up interval. CONCLUSIONS Endoscopic plication is safe and improves objective and subjective parameters at 1-year follow-up, without side effects seen after laparoscopic fundoplication. Further studies on the clinical merit of this procedure in specific patient populations are warranted.

Effectiveness of laparoscopic total and partial fundoplication on extraesophageal manifestations of gastroesophageal reflux disease: a randomized study.

The aim of the present study was to evaluate the clinical effect of partial and total fundoplication on extraesophageal symptoms in a selected cohort of patients with gastroesophageal reflux disease (GERD). Hundred patients with documented GERD were randomized to either undergo floppy Nissen (n=50) or Toupet fundoplication (n=50). Symptom scores of cough, asthma, hoarseness, and distortion of taste were prospectively evaluated using a standardized symptom questionnaire before surgery and at 3- and 12-month follow-up. Statistical significance was set at a P-value of 0.05. All evaluated symptoms exhibited substantial improvement after Nissen fundoplication at 3- and 12-month follow-up. Similar therapeutic results were documented for Toupet fundoplication, although statistical significance could not be reached for asthma at long-term follow-up. In conclusion, the application of laparoscopic fundoplication is justified for patients with documented GERD and atypical symptoms refractory to medical treatment. Toupet fundoplication may have a lesser effect on asthma.

Meta-analysis of laparoscopic vs open cholecystectomy in elderly patients

AIM To investigate the comparative effect of laparoscopic and open cholecystectomy in elderly patients. METHODS Laparoscopic cholecystectomy has induced a revolution in the treatment of gallbladder disease. Nevertheless, surgeons have been reluctant to implement the concepts of minimally invasive surgery in older patients. A systematic review of Medline was embarked on, up to June 2013. Studies which provided outcome data on patients aged 65 years or older, subjected to laparoscopic or open cholecystectomy were considered. Mortality, morbidity, cardiac and pulmonary complications were the outcome measures of treatment effect. The methodological quality of selected studies was appraised using valid assessment tools. Τhe random-effects model was applied to synthesize outcome data. RESULTS Out of a total of 337 records, thirteen articles (2 randomized and 11 observational studies) reporting on the outcome of 101559 patients (48195 in the laparoscopic and 53364 in the open treatment group, respectively) were identified. Odds ratios (OR) were constantly in favor of laparoscopic surgery, in terms of mortality (1.0% vs 4.4%, OR = 0.24, 95%CI: 0.17-0.35, P < 0.00001), morbidity (11.5% vs 21.3%, OR = 0.44, 95%CI: 0.33-0.59, P < 0.00001), cardiac (0.6% vs 1.2%, OR = 0.55, 95%CI: 0.38-0.80, P = 0.002) and respiratory complications (2.8% vs 5.0%, OR = 0.55, 95%CI: 0.51-0.60, P < 0.00001). Critical analysis of solid study data, demonstrated a trend towards improved outcomes for the laparoscopic concept, when adjusted for age and co-morbid diseases. CONCLUSION Further high-quality evidence is necessary to draw definite conclusions, although best-available evidence supports the selective use of laparoscopy in this patient population.

Meta-analysis of laparoscopic versus open repair of perforated peptic ulcer.

A meta-analysis of four randomized trials comparing laparoscopic versus open repair of perforated ulcer did not demonstrate significant superiority of the laparoscopic or open approach.

Comparison of a standard CO2 pressure pneumoperitoneum insufflator versus AirSeal™: study protocol of a randomized controlled trial

BackgroundAirSeal™ is a novel class of valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and carbon dioxide (CO2) recirculation during laparoscopic surgery. Comparison data to standard CO2 pressure pneumoperitoneum insufflators is scarce. The aim of this study is to evaluate the potential advantages of AirSeal™ compared to a standard CO2 insufflator.Methods/DesignThis is a single center randomized controlled trial comparing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair with AirSeal™ (group A) versus a standard CO2 pressure insufflator (group S). Patients are randomized using a web-based central randomization and registration system. Primary outcome measures will be operative time and level of postoperative shoulder pain by using the visual analog score (VAS). Secondary outcomes include the evaluation of immunological values through blood tests, anesthesiological parameters, surgical side effects and length of hospital stay. Taking into account an expected dropout rate of 5%, the total number of patients is 182 (n = 91 per group). All tests will be two-sided with a confidence level of 95% (P <0.05).DiscussionThe duration of an operation is an important factor in reducing the patient’s exposure to CO2 pneumoperitoneum and its adverse consequences. This trial will help to evaluate if the announced advantages of AirSeal™, such as clear sight of the operative site and an exceptionally stable working environment, will facilitate the course of selected procedures and influence operation time and patients clinical outcome.Trial registrationClinicalTrials.gov NCT01740011, registered 23 November 2012.

Influence of the esophageal hiatus size on the lower esophageal sphincter, on reflux activity and on symptomatology

Hiatal hernia is an underlying factor contributing to gastroesophageal reflux disease (GERD). However, it remains elusive whether the size of the esophageal hiatus has a de facto influence on the lower esophageal sphincter (LES), on the intensity of patient reflux, on GERD symptoms and on the quality of life (QoL). One hundred patients with documented chronic GERD underwent laparoscopic fundoplication. QoL was evaluated before surgery using the Gastrointestinal Quality of Life Index (GIQLI). Additionally, GERD symptoms and nonspecific gastrointestinal symptoms were documented using a standardized questionnaire (score 0-224). The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Correlation analysis between the preoperative QoL, GERD symptoms, esophageal manometry, multichannel intraluminal impedance monitoring data and HSA size was performed, in order to investigate whether the HSA has an influence on the patientssymptoms, GIQLI, manometry and multichannel intraluminal impedance monitoring data. Statistical significance was set at a P-value of 0.05. The HSA sizes ranged from 1.51cm(2) to 16.09cm(2) (mean 4.14cm(2) ). The preoperative GIQLI ranged from 15 points to 133 points (mean 94.37 points). Symptom scores ranged from 2 points to 192 points (mean 49.84 points). No significant influence of the HSA on GIQLI or preoperative symptoms was recorded. HSA size had a significant negative effect on LES pressure. Additionally, there was a significant positive correlation between HSA size and number of refluxes in supine position. For the rest of the evaluated data, including DeMeester score, total number of refluxes, refluxes in upright position, acid reflux events, proximal reflux events, LES length and body motility, no significant correlation was found. Although patients subjectively are not significantly affected by the size of the hiatus, it has significant effects on the LES pressure and on gastroesopageal reflux in supine position.

Magnetic Resonance–Visible Meshes for Laparoscopic Ventral Hernia Repair

Background and Objectives: We aimed to evaluate the first human use of magnetic resonance–visible implants for intraperitoneal onlay repair of incisional hernias regarding magnetic resonance presentability. Methods: Ten patients were surgically treated with intraperitoneally positioned superparamagnetic flat meshes. A magnetic resonance investigation with a qualified protocol was performed on postoperative day 1 and at 3 months postoperatively to assess mesh appearance and demarcation. The total magnetic resonance–visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces. Results: We were able to show a precise mesh demarcation, as well as accurate assessment of the surrounding tissue, in all 10 cases. We documented a significant decrease in the magnetic resonance–visualized total mesh surface area after release of the pneumoperitoneum compared with the original mesh size (mean, 190 cm2 vs 225 cm2; mean reduction of mesh area, 35 cm2; P < .001). At 3 months postoperatively, a further reduction of the surface area due to significant mesh shrinkage could be observed (mean, 182 cm2 vs 190 cm2; mean reduction of mesh area, 8 cm2; P < .001). Conclusion: The new method of combining magnetic resonance imaging and meshes that provide enhanced signal capacity through direct integration of iron particles into the polyvinylidene fluoride base material allows for detailed mesh depiction and quantification of structural changes. In addition to a significant early postoperative decrease in effective mesh surface area, a further considerable reduction in size occurred within 3 months after implantation.