V. Paolucci

Tumor Seeding following Laparoscopy: International Survey

Abstract. The aim of the study was to determine if tumor seeding during laparoscopic surgery for cancer is a rare event or a typical complication of this procedure. Laparoscopic staging and treatment of intraabdominal tumors is increasing in gastroenterology, gynecology, and general surgery. A total of 1052 questionnaires were mailed to surgical department chairmen, members of the German Society of Surgery, Swiss Association for Laparoscopic and Thoracoscopic Surgery, and Austrian Society of Minimal Invasive Surgery asking them to list their departments experience with tumor seeding after laparoscopy for nonapparent or known malignancy. There were 607 (57.7%) surgeons who reported a total of 117,840 laparoscopic cholecystectomies, 409 incidental gallbladder carcinomas, and 412 laparoscopies on patients with colorectal carcinoma. Altogether 109 patients who developed tumor recurrence in connection with laparoscopic surgery have been reported. Port-site recurrence was identified in 70 of 409 patients (17.1%) with a median of 180 days following laparoscopic cholecystectomy for nonapparent gallbladder carcinoma. In 8 cases (11.5%) a protective plastic bag had been used for gallbladder retrieval. Six patients without port-site metastases were found to have a diffuse peritoneal carcinomatosis a median of 120 days after cholecystectomy. Of 412 laparoscopies for colorectal cancer, 19 cases (4.6%) of tumor seeding have been reported, 16 of which (3.9%) had documented port-site and scar recurrences a median of 196 days after laparoscopy. The tumor specimen was intact, and a plastic bag was used for extraction in seven cases. In 14 patients trocar-site metastases have been reported a median of 70 days after laparoscopy for different nonapparent or known malignancies. The probability of developing abdominal wall metastasis is higher after laparoscopy for cancer than after open surgery. An intact surgical specimen and the use of a plastic retrieval bag do not exclude the risk of port-site recurrences. These facts and the early appearance of peritoneal carcinosis in a few cases of intraabdominal malignancies seem to confirm a specific laparoscopic risk for intraperitoneal tumor cell seeding and implantation.

Port Site Recurrences after Laparoscopic Surgery

Port site metastasis has been a surprising event after laparoscopic procedures in cancer patients. No clear data exist about this phenomenon. The aim of this study is to summarize current epidemiologic knowledge about the risk of this complication. A review of all case reports about port site recurrences was undertaken. To date, 164 cases of port site metastases after videoscopic procedures have been reported in 90 papers. We found 108 cases of implantation after laparoscopy for digestive tumors, 23 after thoracoscopy, 29 after gynecological and 4 after urological laparoscopy. Analysis of the current literature confirms that laparoscopy is associated with abdominal cell mobilization to the trocars and instruments. Also low-staged and highly differentiated tumors have been reported to cause post-laparoscopy tumor seeding. The temporary data of the CAE registry ‘port site metastases’ (Workgroup for Surgical Endoscopy of the German Society of Surgery) are also reported. The analysis of 80 histologically confirmed cases of port site recurrence shows a particular frequency after laparoscopic cholecystectomy for unsuspected gallbladder cancer (n = 59). Postoperative specimen examination revealed a T1 carcinoma in 9 cases (15%), T2 carcinoma in 33 (21%), T3 in 3 (5%) and T4 in 1 case (1.7%). The mean time to clinical tumor relapse was 6 months. Similar patterns were found in a lower number of port site metastases after laparoscopy for colon cancer (n = 2) and for other cancers (n = 9).Clinical evidence that laparoscopy with CO2 pneumoperitoneum can enhance tumor dissemination is given. Port site metastases seem to be secondary to multiple factors including the gas used, local trauma, tumor manipulation, biologic properties of the tumor, and individual surgical skills.

The phagocytosis activity during conventional and laparoscopic operations in the rat : A preliminary study

AbstractBackground: Numerous experimental and clinical investigations indicate that the mononuclear phagocyte system (MPS) has a relevant function in terms of physiological defense against tumor metastasis and bacterial infection. Consequently, a point of major interest is the influence of surgical techniques on the MPS function. Method: The model investigation examines the phagocytosis activity of the rats MPS during conventional fundoplication (group 1, n= 10), laparoscopic fundoplication using a pneumoperitoneum (group 2, n= 10), and gasless laparoscopic fundoplication (group 3, n= 10). The MPS function is evaluated by an intravascular carbon clearance test (G. Biozzi). Results: The fastest carbon elimination half-life was found in group 3. By way of contrast, there was a significant increase of carbon half-life in group 2 (p < 0.005). Even group 1 caused less MPS depression (p < 0.1) than group 2. Conclusion: Gasless laparoscopic procedures have a favorable effect on phagocytosis activity. The CO2 pneumoperitoneum seems to be the main reason for a decreased antigen elimination in laparoscopic treatments.

Standardized Technique of Laparoscopic Surgery in the Rat

The evolution of advanced laparoscopic techniques requires animal models for instrument development, evaluation of the physiopathological correlation and physician training. Selection of surgical models is primarily based on cost, availability, anatomic and physiologic considerations, and housing and anesthetic methods. The use of large animals is becoming increasingly difficult due to restrictive legislation, public concern, and economic factors. A standardized technique of laparoscopic surgery in the rat has been developed to perform procedures in all abdominal regions including fundoplication, splenectomy, nephrectomy, liver resection, herniorraphy, colotomy, colectomy, and retroperitoneal exploration. The equipment consists of a specially designed small animal operating table, a standard arthroscope and micro-instruments. The rat model gives the opportunity to investigate the physiopathological relations and immune functions of laparoscopic procedures, to develop micro-instruments under realistic conditions of a live organism, and it is an excellent training model especially for pediatric and microsurgery. Besides low costs and easy availability, the rat model requires less logistic and financial efforts.

Experiences with Percutaneous Endoscopic Gastrostomy

Abstract. Today the procedure of choice for long-term enteral tube feeding in patients with prolonged swallowing difficulties or inabilities is percutaneous endoscopic gastrostomy (PEG). The primary indications are head and neck cancers, neurologic dysphagia, cancer cachexia, and obstruction of the esophagus and pharynx with enough space for an endoscopic procedure. This technique requires no general anesthesia and is possible in patients with contraindications to surgical gastrostomy. Between September 1994 and April 1995 a total of 115 patients underwent PEG placement attempts. We employed the pull-technique with 15-Freka PEG tubes. The average procedure time, including esophagogastroduodenoscopy, was 17 minutes. In nine cases PEG insertion was impossible owing to severe obstruction of the esophagus. In 46 (40%) patients local abdominal pains started on the first or second postoperative day; 7 of these patients required surgical consultation, and no further intervention was needed. In only one patient was there a serious complication that required surgical intervention: a presumed perforation that turned out to have no correlate upon review. All patients received single-shot antibiotic prophylaxis; and only in those patients with abdominal symptoms do we recommend a prolonged antibiosis. The abdominal symptoms reported were due to a slight leak of gastric fluid causing a topical peritonitis, which required no further treatment. In our experience PEG is a useful alternative to surgical gastrostomy. The simplicity of this procedure leads to low complication rates, short hospitalization, and is possible on an outpatient basis. It is cost-efficient and has a much better psychological tolerance than nasogastric tubes.

Gasless laparoscopy in abdominal surgery

Pneumoperitoneum, as a necessary precondition of laparoscopic procedures, represents a restriction of the surgeons freedom of movement and can lead to rare but typical complications. We describe our first experiences with laparoscopic surgery without using pneumoperitoneum. Under direct vision and digital control a fan-formed wall retractor, which is attached to an electric lift arm, is introduced into the abdominal cavity. After raising the abdominal wall, the scope is introduced through the same access and the laparoscopic procedure can be started without the technical and physiopathological problems which may occur using a pneumoperitoneum. In this gasless laparoscopic procedure, simple valveless trocars and instruments can be used. Furthermore, an unlimited suction can be obtained without a loss of exposure. During anesthesia, neither increased ventilation nor increased ventilation pressure is necessary, and the surgeon has increased freedom of action. Not only special laparoscopic instruments, but the conventional instruments, used in open surgery, can also be employed in gasless laparoscopy. In this way we performed gasless laparoscopic surgery on 54 patients: cholecystectomy (n=37), abdominal exploration for NSAP (n=5) or tumor staging (n=4), fenestration of liver cysts (n=5), and appendectomy (n=3). We did observe three wound infections as related complications. Six times, we had to change the surgical procedure. Compared to the traditional procedure with a CO2 pneumoperitoneum, the results of the first gasless procedures demonstrate potential advantages.

Laparoscopic surgery: The effects of insufflation gas on tumor-induced lethality in nude mice

OBJECTIVE The aim of the study was to examine the effect of helium (group 2), carbon dioxide (group 3), and heated carbon dioxide (group 4) pneumoperitoneum on survival in case of intraabdominal spread of tumor cells in nude mice. STUDY DESIGN The pneumoperitoneum was induced by a microhysteroflator with an intraperitoneal pressure of 8 mm Hg for 30 minutes. A washed tumor solution (0.4 ml) of a mesothelioma was injected intraperitoneally. RESULTS The survival rate of group 3 was significantly reduced compared with the controls (group 1) and group 4. The latter groups showed similar survival rates. In groups 2 and 3 no significant differences in survival rate were observed. CONCLUSION Clinical observations and the results of this animal study warn against the use of standard unheated carbon dioxide pneumoperitoneum in case of malignant tumors. Heated carbon dioxide seems to be advantageous.

Exposure of the operative field in laparoscopic surgery

Abstract. Endoscopic surgery, as a result of over 90 years of investigation, has now become the most innovative part of general surgery; every procedure in the thoracic and abdominopelvic cavity, intraperitoneal or extraperitoneal, has been reviewed for feasibility. The basic principles in the management of surgical patients, however, have not changed: adequate exposure and good lighting remain important and may become more important with endoscopic techniques. Historical review shows the dependence of advances in laparoscopy upon technical development in the field of intraabdominal exposure as the result of two objectives: namely abdominal wall displacement and bowel retraction.

Port site metastases in laparoscopic surgerys

Metastatic disease at trocar wounds after laparoscopic surgery is one of the most important factors that precludes wide employment of laparoscopic techniques to resect malignant disease. Various reports of port-site metastases after laparoscopic resection of colorectal cancer, diagnostic laparoscopy for digestive cancer, or laparoscopic removal of gallbladders with occult cancer have been published [19]. In the first years of laparoscopic colorectal surgery, incidences of port-site metastases as high as 21% were quoted [19]. These high rates were probably due to poor surgical technique during early experience because more recent studies of larger populations of patients have documented incidences of port-site metastases as low as 2% [1, 13, 14]. Recurrence of colorectal cancer in abdominal wounds after conventional, open surgery for colorectal malignancy, has always been suggested to be rare. An incidence of 0.69% is frequently quoted on the basis of a study by Hughes [8]. However, Gunderson and Sosin [5] reported a higher incidence of wound recurrence after open curative resection and colorectal cancer. At routine relaparotomy 3 months after initial colorectal surgery, 3.3% of patients had colorectal cancer in the abdominal wall. Two-thirds of these recurrences had not been discovered at physical examination, probably because they were located at the fascial level. Therefore, it remains unclear whether abdominal wall metastases occur more frequently after laparoscopic than open surgery until randomized clinical trials have been completed. The pathogenesis of port-site metastases has not been unraveled. Development of port-site metastases requires the presence of viable cancer cells at the trocar site. This situation is very likely to occur when a malignant tumor is removed through a narrow incision of the abdominal wall. Such direct implantation of tumor cells has been confirmed by Clair et al. [4], who encountered an abdominal wall metastasis at the extraction site scar after laparoscopic removal of a gallbladder with unsuspected carcinoma. In an experimental study with rats, Bouvy et al. [3] recorded increased tumor growth at the extraction site of a lump of CC 531 colon cancer, which had been placed in the peritoneal cavity for 20 min while C02 was insufflated. Krii.henbiihl et

Systems and instruments for laparoscopic surgery without pneumoperitoneum

Abstract. The insufflation of carbon dioxide into the peritoneal cavity is a routine technique of abdominal exposure in laparoscopic surgery. Because of adverse physiological effects and technical disadvantages of the pneumoperitoneum, alternative methods of abdominal wall lifting have been explored recently. Two groups of retraction systems exist: intraabdominal lifting and subcutaneous lifting of the abdominal wall. Some systems require additional pneumoperitoneum, because the extent of intraabdominal exposure is not sufficient. Other systems are working completely without gas insufflation. Two systems combine abdominal wall lifting with pressure on the internal organs. Every method allows the use of standard laparoscopic instruments, which originally were designed for a regular pneumoperitoneum. The use of a low-pressure pneumoperitoneum in combination with mechanical augmentation of the peritoneal cavity reduces physiological disadvantages of laparoscopy. But technical advantages, such as combination of laparoscopic and open techniques, can be realized only without gas insufflation. Conventional instruments have been designed to fit the ergonomical needs of isopneumic laparoscopy and to be employed with simple valveless cannulae.