Takanobu Hoshino

Laparoscopic cholecystectomy: an approach without pneumoperitoneum.

SummaryDiagnostic pneumoperitoneum, which has been considered the first step of any laparoscopic procedure, is no longer an absolute necessity. We devised an alternative to pneumoperitoneum or abdominal insufflation by upward and outward traction on the anterior abdominal wall with a “hanger lifting method” using subcutaneous wiring. Fairly good room was produced intraabdominally, which was enough in which to perform the cholecystectomy procedure. We have successfully performed 40 cases of laparoscopic cholecystectomy with this procedure. No complication was experienced with this method and, moreover, excess instrumentation and complications related to pneumoperitoneum were avoided.

Abdominal wall lifting with subcutaneous wiring: An experience of 50 cases of laparoscopic cholecystectomy without pneumoperitoneum

Abdominal wall lifting is a method to produce operative space between the anterior abdominal wall and the intra-abdominal organs during laparoscopic surgery. We devised a hanger lifting procedure for the anterior abdominal wall to avoid complications as well as reduce the costs related to the pneumoperitoneum. In our series, we performed 50 cases of laparoscopic cholecystectomy with this abdominal wall-lifting procedure. Though at the beginning we performed laparoscopic cholecystectomy by the pneumoperitoneum, we discarded the insufflator for this operation since starting the new procedure. There was no incidence of conversion to pneumoperitoneum and a fairly good operative view was achieved enabling a smooth laparoscopic cholecystectomy.

Minilaparotomy approach for colonic cancer: initial experience of 54 cases

BackgroundThe early outcomes of minilaparotomy for resection of colonic cancer were evaluated.MethodsIn this study, 54 patients (34 Dukes’ A, 15 Dukes’ B, and 5 Dukes’ C) successfully underwent curative resection of colonic cancer via minilaparotomy (skin incision, =7 cm). The major exclusion criteria for this approach required a body mass index greater than 25 kg/m2, a tumor size exceeding 7 cm, a preoperative ileus, and tumor invading the adjacent organs. Patients (n = 54) who had undergone conventional open surgery before the introduction of this technique served as the control group by matching several clinicopathologic factors including body mass index.ResultsThe passage of flatus (p < 0.01) and the beginning of oral intake (p = 0.02) were earlier, analgesic requirements were lower (p < 0.01), and postoperative serum C-reactive protein levels were lower in the minilaparotomy group (p < 0.01). The blood loss and frequency of postoperative complications did not differ between the groups.ConclusionA minilaparotomy approach is a feasible, minimally invasive, and attractive alternative to conventional laparotomy for selected patients with colonic cancer.

Increased insufflation pressure enhances the development of liver metastasis in a mouse laparoscopy model

Background: The effect of different insufflation pressures and durations of CO2 pneumoperitoneum on the growth of liver metastasis was investigated in a mouse model. The possible mechanisms involved in the pressure-related enhancement of liver metastasis were also examined. Methods: Mice inoculated intraportally with colon 26 cells underwent CO2 pneumoperitoneum at different pressures (5,10, or 15 mmHg) for 30 or 60 min, or received no treatment other than tumor cell inoculation (control). The subsequent growth of liver mestastases was examined. Mice injected intraportally with 111In-oxine-labeled colon 26 cells underwent pneumoperitoneum at three different pressures or served as controls. The radioacitivity of the liver was determined to evaluate tumor accumulation in the liver. Mice received pneumoperitoneum at three different pressures or received trocar placement alone. Changes in plasma interleukin-6 levels were determined. Results: The growth of liver metastases on day 14 was influenced by increased insufflation pressures (p < 0.05) rather than the prolonged duration of pneumoperitoneum without significant interaction. The 15-mmHg pneumoperitoneum group showed a higher (p < 0.05) accumulation of radioactivity in the liver compared with the 5-mmHg pneumoperitoneum group and controls. Pneumoperitoneum groups with 5 and 10 mmHg showed higher (p < 0.05) peak levels of IL-6 compared with controls. Conclusions: An elevated insufflation pressure plays an important role in the enhancement of liver metastases, and this pressure-related adverse effect may be partly relevant to facilitating accumulation of tumor cells in the liver.

Gasless laparoscopic surgery for ulcerative colitis and familial adenomatous polyposis

PURPOSE We evaluated the data on initial experience of gasless laparoscopic surgery for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). PATIENTS AND METHODS Seven patients (male/female = 3:4, median age 23, UC/FAP=5:2) underwent gasless laparoscopic total (procto) colectomy. Our basic surgical procedure involved (1) a 6- to 8-cm incision made at the beginning of the operation, (2) the wound pulled upward and/or laterally by retractors, and (3) conventional surgical instruments used through the wound; occasionally laparoscopic assistance and abdominal lifting were employed. The results were compared to those of 7 patients who had undergone conventional open surgery. RESULTS Oral intake started earlier (p = 0.03) and C-reactive protein level on POD 4 was lower (p = 0.03) in the gasless group than in the control group. Duration of surgery, blood loss, requirement of analgesia, and morbidity rate were not significantly different between the groups. CONCLUSION Our preliminary results suggest that gasless laparoscopic surgery for UC and FAP is feasible and can be an alternative method for minimally invasive surgery.

Modified liver-hanging maneuver designed to minimize blood loss during hepatic parenchymal transection in hemihepatectomy.

PurposeWe evaluated the efficiency of a modified liver-hanging technique for minimizing intraoperative blood loss during right and left hemihepatectomy.MethodsThe lower end of the hanging tape was repositioned between the parenchyma of the left paramedian sector and the hilar plate. The upper end of the tape was positioned between the right hepatic vein and middle hepatic vein for right hepatectomy (Belghiti), and between the middle hepatic vein and left hepatic vein for left hepatectomy. The tape was positioned prior to the parenchymal transection. We compared the results of this operative technique, performed in 15 recent patients, with those of conventional hemihepatectomy performed in 14 earlier patients.ResultsThere were no intergroup differences in baseline characteristics or postoperative outcomes. Intraoperative blood loss (P = 0.02), especially blood loss during the parenchymal transection (P = 0.005), was significantly less in patients undergoing the modified technique. Multivariate analysis revealed that this modified liver-hanging technique offered a significant advantage in blood-loss reduction during parenchymal transection over the conventional techniques (P = 0.005).ConclusionUsing the liver-hanging technique during hemihepatectomy could be crucial for liver surgeons.

Liver metastases are less established after gasless laparoscopy than after carbon dioxide pneumoperitoneum and laparotomy in a mouse model

Background: Although the liver is the most frequent site of cancer recurrence after conventional open surgery for colorectal cancer, the effect of laparoscopic procedures with or without gas insufflation on the development of liver metastases is largely unknown. Methods: Male BALB/C mice inoculated intraportally with colon 26 cells were randomized to undergo carbon dioxide pneumoperitoneum (n = 14), abdominal wall lifting (n = 14), or full laparotomy (n = 12), or to serve as control subjects without any procedures other than tumor inoculation (n = 13). Results: The growth of liver metastases 14 days after surgery was enhanced after full laparotomy (p < 0.01) and pneumoperitoneum (p = 0.02), as compared with that in the control subjects, whereas there was no difference in the growth of liver metastases between abdominal wall lifting and the control condition (p = 0.99). Conclusions: These results suggest that the defense against liver metastasis is better preserved after the gasless procedure than after laparotomy and carbon dioxide pneumoperitoneum in the reported animal model.

Anorectal Agenesis with a Rectourethral Fistula Diagnosed in an Adult: Report of a Case

We report an unusual case of anorectal agenesis with a rectourethral fistula diagnosed in a 48-year-old man. The patient presented after noticing hematuria, although he had been aware of urinary leakage from his colostomy with occasional fecal urine for about 4 years. He had had a double-barrel colostomy created soon after birth for an imperforate anus, with revision at the age of 4 years to correct a prolapse of the stoma, but his malformation had never been repaired. We performed a physical examination, which did not reveal a perineal fistula, but urethrocystography demonstrated high anorectal agenesis with a rectourethral fistula. Thus, we resected the rectourethral fistula and created an end-colostomy. The patient had an uneventful postoperative course, and was discharged in good health on postoperative day 19. To our knowledge, this is the oldest patient to be diagnosed with anorectal agenesis and undergo resection of a rectourethral fistula.

Doppler echography for hemodynamic studies of the azygos vein

SummaryUsing a convex array transducer, the advantages and shortcomings of transesophageal real-time two-dimensional Doppler echography (TE2DD) were assessed in a study of the vessels around the esophagus and the stomach in 67 adult patients with (n=56) or without (n=11) liver cirrhosis. In most cases, all but the upper- and lowermost margins of the azygos vein could be visualized. The more caudally the portion located, the smaller its diameter and flow velocity became. The average number of intercostal veins visualized by TE2DD was 4 per person. The observable esophagogastric varices seemed to be limited to deeply located ones around the esophagogastric junction. In five patients who had undergone distal splenorenal shunt, splenic venous flow, or shunt flow could be seen from the stomach over a length of about 5 cm. The azygos venous flow in cirrhotic patients was significantly greater than that of patients without cirrhosis. TE2DD appears to be very useful for evaluating flow in the cephalad collateral veins and other vessels around the esophagus and the stomach.