Shuichi Ohashi

Endoscopic thyroid surgery through the axillo-bilateral-breast approach.

&NA; We developed a new endoscopic thyroid surgery by the axillo‐bilateralbreast approach (ABBA) method, which is different from the previously described breast approach (BA) in that the port sites are modified to obtain a better view and to prevent the interference of surgical instruments. This modification also improves cosmetic results by eliminating the parasternal incision, which results in hypertrophic scar in a significant number of cases treated with BA. Twelve patients with benign thyroid tumors successfully underwent endoscopic thyroid surgery by ABBA, and their clinical outcomes were compared with those of four patients treated with BA. The mean operation time was significantly shorter in the ABBA group than in the BA group (188 minutes vs. 270 minutes; P < 0.01). Furthermore, the mean blood loss in the ABBA group (53 mL) was half of that in the BA group (108 mL). Neither conversion to open surgery nor significant intraoperative complications were experienced. The operative scars by ABBA became inconspicuous in a few weeks. These results seem to indicate that ABBA is a better method than BA and can be a feasible option, particularly for young patients who opt for the better cosmetic outcome.

Laparoscopic intragastric surgery for gastric leiomyoma

Abstract. Laparoscopic intragastric surgery (LIGS) was performed on a 63-year-old man with a gastric leiomyoma adjacent to the cardia. Because the tumor was about 5 cm in maximum diameter and showed ulceration, the possibility that the tumor was a leiomyosarcoma could not be ruled out preoperatively. Conventionally, major surgery has been performed on patients with a tumor located near the cardia, although it was not always malignant. Enucleation by LIGS enabled us to avoid excessive invasiveness and provided a favorable result. LIGS may be an appropriate new, minimally-invasive operation for gastric myogenic tumors and should be considered for such cases.

Ipsilateral recurrence frequency after video-assisted thoracoscopic surgery for primary spontaneous pneumothorax

OBJECTIVE We retrospectively evaluated the results of video-assisted thoracoscopic surgery for primary spontaneous pneumothorax and recurrence. METHODS A series of 424 patients with primary spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery-289 with an ipsilateral recurrent episode, 88 with persistent air leakage for 7 days or longer, 34 with a contralateral episode, 9 with hemopneumothorax, and 4 with tension pneumothorax. The commonest management was stapling of an identified bleb, undertaken in 375 patients (88.4%). Pleural abrasion was conducted in 250 (59.0%), but the abraded area was one-third or less of the thoracic cavity in 187 (74.8%). RESULTS No operative deaths occurred. Revisional thoracotomy was required in 1 patient with postoperative bleeding and another with incomplete postoperative lung reexpansion; 26 had prolonged air leakage, but none required revisional thoracotomy. During a mean follow-up of 31.4 months, ipsilateral pneumothorax recurred in 40 patients (9.4%), with 26 (65.0%) having recurrence within 1 year postoperatively. A video-assisted thoracoscopic surgery was conducted again in 8, and thoracotomy in 14. CONCLUSIONS The ipsilateral recurrence of primary spontaneous pneumothorax after video-assisted thoracoscopic surgery was high at 9.4%. If video-assisted thoracoscopic surgery is to be considered as a treatment for spontaneous pneumothorax, we must therefore reduce postoperative ipsilateral recurrence by training practitioners not to overlook blebs during the procedure and/or consider widening the area of pleurodesis.

Laparoscopic-assisted surgery for crohn’s disease: Reduced surgical stress following ileocolectomy

Recent progress in laparoscopic techniques has enabled operations for various intestinal disorders to be performed under laparoscopic assistance. This study was conducted to assess the benefits of performing laparoscopicassisted surgery (LAS) in patients with Crohn’s disease. LAS was performed in 24 selected patients with Crohn’s disease, most of whom underwent ileocolic resection for ileitis and/or colitis with stenosis. To determine the benefits of LAS, the postoperative inflammatory parameters of these patients were examined and compared with those of 17 patients who underwent conventional open surgery. Despite giving all patients total parenteral nutrition (TPN) for more than 2 weeks preoperatively, two patients with large inflammatory masses involving enteroenteric fistulas required conversion to laparotomy. No laparoscopic procedure was converted for adhesions after previous resection or intraoperative complications. The maximum C-reactive protein values and body temperatures were significantly lower, and the time taken to normalize body temperature and leukocyte counts was significantly shorter in the LAS group than in the laparotomy group. LAS should be performed for patients with Crohn’s disease in the inactive phase after appropriate nutritional support. Patients with terminal ileitis without a fistula are considered to have the highest indication for this procedure.

Influence of CO2 pneumoperitoneum during laparoscopic surgery on cancer cell growth

BackgroundCO2 pneumoperitoneum provides a new surgical environment to treat malignant disease. The purpose of this study was to investigate the influence of CO2 pneumoperitoneum during laparoscopic surgery on cancer cell growth.MethodsWiDr human colon cancer cells were incubated for 3 h under the following two conditions: 100% CO2 at 10 mmHg, and 95% air/5% CO2 (control). Cell proliferation was assessed by the WST-1 assay and BrdU assay. Tumor growth was assessed by subcutaneous injection into 20 nude mice. Cellular damage was measured by lactate dehydrogenase (LDH) assay.ResultsThe number of WiDr cells under pneumoperitoneal conditions decreased in the first 24 h. However, no significant difference was observed in the proliferation rate and tumor growth of the viable cells. LDH release of the CO2 pneumoperitoneal group was higher than that of the controls.ConclusionsOur data indicate that CO2 pneumoperitoneum does not promote cancer cell proliferation but instead has a toxic effect on cancer cells.

Laparoscopic reconstruction of vagina using sigmoid autograft

Abstract. With the advent of advanced laparoscopic techniques in surgery, new applications have been found, which have expanded the role of laparoscopy in the gynecological field. The aim of this paper is to introduce our laparoscopic technique of taking a sigmoid colon autograft for colpopoiesis in a patient with congenital agenesis of the vagina. This technique is less invasive and is easy to perform, and it may be the best choice of operation in respect to the naturalness and the permanency of the vagina that results. The success of this laparoscopic technique of taking a sigmoid autograft for colpopoiesis suggests diverse possible applications in the future.

Construction of a regional telementoring network for endoscopic surgery in Japan

This paper introduces a regional telementoring network for endoscopic surgery in Japan. The telecommunication center was established at Osaka University and it has been operational since 1997 using six ISDN B-channels. The network, composed of five remote hospitals, aimed at tele-educating young surgeons in constituent hospitals, was applied not only to tele-education in routine endoscopic surgery, but also to telementoring in advanced operations. As the significance of telementoring in surgery has been gradually recognized, several networks following our model are now under consideration in other areas of Japan. Although there remain several problems with the wide and general propagation of telesurgery, such as the expenditure and privacy protection, it will be beneficial to prevent professional isolation to share the limited resources of surgical experts, and it is expected to contribute to patients receiving advanced surgical therapies.

Is laparoscopic colorectal surgery less invasive than classical open surgery? Quantitation of physical activity using an accelerometer to assess postoperative convalescence

Background: With the technical advances of recent years, the number of operative manipulations in the abdominal cavity by laparoscopic surgery is now considered to be the same as that using classical open surgery. The question has been raised whether laparoscopic colorectal surgery with lymphadenectomy improves the recovery compared to open surgery. Methods: We compared patients’ physical activity for 7 days postoperatively as measured with an accelerometer between laparoscopic-assisted colorectal resection (LAC, n = 32) and classical open colorectal surgery (OC, n = 30). Results: Physical activity expressed as cumulative acceleration was significantly higher in the LAC than in the OC group on each postoperative day. The recovery time, defined as the day on which the cumulative acceleration recovered to 90% of the preoperative level, was significantly shorter (p < 0.05) in the LAC (3.4 ± 1.2 days) than in the OC group (6.8 ± 1.7 days). Conclusion: Our results showed that the duration of convalescence with LAC was significantly shorter than that with the OC procedure. Laparoscopic colorectal surgery appears to allow an earlier recovery after the operation than the classical open procedure, and it is less invasive as assessed by convalescence.

Revision laparoscopy for incarcerated hernia at a 5-mm trocar site following pediatric laparoscopic surgery.

We report the case of a 6-month-old female infant who developed post-operative bowel obstruction due to an incarcerated hernia through a 5-mm laparoscopic wound. The patient underwent laparoscopic Nissen fundoplication for gastroesophageal reflux. On day 6, she showed symptoms of ileus, and the diagnosis of a trocar wound hernia was made on day 13. The herniated intestine was reduced and the defective peritoneum and fascia were closed under relaparoscopic guidance, thus avoiding full-scale laparotomy. A trocar wound hernia causing early postoperative bowel obstruction is a rare complication, especially at 5-mm trocar puncture sites. Intraoperative dislodgment and reinsertion of working trocars may create fascial defects larger than the actual size of the trocar. All laparoscopic puncture wounds, even those <10 mm in size, should be closed at the fascial level in infants. Revision laparoscopy is considered preferable to manage trocar site complications in children.

Thoracoscopic surgery combined with a supraclavicular approach for removing superior mediastinal tumor

Abstract. This report introduces our new technique of thoracoscopic surgery combined with a supraclavicular approach for removing superior mediastinal tumor. A 68-year-old woman noticed a tumor palpable in the left supraclavicular fossa. The patient had no pain around the neck and shoulder. A radio-opaque shadow 6 cm in diameter was detected in her left apical lung field on chest roentgenogram. Chest CT and MRI showed that the tumor was located in the superior mediastinum, extending up to the thoracic inlet, and there was no invasion of the surroundings. At first, a thoracoscopic examination was performed to assess the possibility of the excision. After dissecting the tumor from the mediastinal tissue and the first costovertebrae as far as possible by thoracoscopic surgery, a supraclavicular approach was used to enter the thoracic cavity. Complete resection of the tumor was successfully performed by thoracoscopic surgery combined with a supraclavicular approach. The tumor was removed in a plastic bag through the supraclavicular defect. Postoperative histopathology revealed that the tumor was a benign neurogenic one. A satisfactory follow-up of 5 postoperative days was observed without any complications, and the patient was discharged. The procedure was safe, easy, and minimally invasive to perform. Moreover, the supraclavicular approach could be used to add trocar port if needed.