Yasumitsu Hirano

Tissue oxygen saturation during colorectal surgery measured by near-infrared spectroscopy: pilot study to predict anastomotic complications.

We investigated the relation between tissue oxygen saturation measured by near-infrared spectroscopy (NIRS) and anastomotic complications associated with colorectal surgery. A series of 20 patients with colorectal cancer underwent radical surgery with enteric anastomosis. Measurements of tissue oxygen saturation (StO2) were performed at both the proximal and distal portions of the anastomotic site; in cases of anterior resection, we measured StO2 only in the proximal portion. Two anastomotic complications (one leakage, one stenosis) occurred in the 20 cases. The StO2 in patients with anastomotic complications was 58.0%, and that in patients without complications was 71.0%. Altogether, 18 patients had StO2 values > 66%, and none of them had anastomotic complications. In contrast, 2 patients had StO2 values < 60%, and both had anastomotic complications. The StO2 of the anastomotic site can be safely and reliably measured by NIRS during colorectal surgery. Low StO2 on both sides of the anastomosis may indicate an increased risk of anastomotic complications. Further study is needed to determine the cutoff value for StO2 required to prevent serious complications.

Laparoendoscopic single site partial resection of the stomach for gastrointestinal stromal tumor.

Laparoendoscopic single site surgery offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. Preliminary experience with single-incision laparoscopic partial resection of the stomach for gastrointestinal stromal tumor (GIST) is reported. A single curved intraumbilical 25-mm incision was made with pulling out the umbilicus, and a 12-mm and two 5-mm ports were inserted. The submucosal gastric tumor located in the anterior wall of the stomach was resected with 2 endoscopic staplers under the retraction of 2-mm mini-loop retractor. The procedure was completed successfully without any perioperative complications, and there was no need to extend the skin incision. The operative time was 64 minutes. The final pathologic diagnosis was benign GIST. Postoperative follow-up did not reveal any umbilical wound complication. Laparoendoscopic single site partial resection of the stomach for GIST is feasible and a promising alternative method for scarless abdominal surgery.

EFFICACY OF MULTI-SLICE COMPUTED TOMOGRAPHY CHOLANGIOGRAPHY BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

Background:  Bile duct injury is one of the serious surgical complications of laparoscopic cholecystectomy (LC). Clear biliary tract imaging to detect the anomaly of the bile ducts before operation is thought to be useful to prevent this complication. The objective of this study was to investigate the preoperative feasibility of using multi‐slice computed tomography scanning after drip infusion cholangiography–computed tomography (DIC‐CT) for LC.

Near-infrared spectroscopy for assessment of tissue oxygen saturation of transplanted jejunal autografts in cervical esophageal reconstruction

PurposeChecking bowel viability is difficult but important during surgery for ischemic bowel disease or jejunal autotransplantation. We investigated the effectiveness of two-wavelength near-infrared spectroscopy (NIRS) to quantify tissue oxygen saturation (StO2), which can affect bowel viability during reconstruction of the cervical esophagus using a free jejunal graft.MethodsFree jejunal autotransplantation was performed after resection of the hypopharynx, larynx, and cervical esophagus in 12 pigs. The arterial blood flow and StO2 of the graft were measured before harvesting the graft and after reperfusion. We analyzed the measurement site of the graft and the anastomotic method as possible factors influencing StO2. We also examined the relationship between the blood flow and StO2 of the autograft.ResultsThe StO2 at the distal site of the graft was significantly lower than that at the midpoint of the graft (P < 0.05). There was a correlation between the blood flow of the graft artery, measured by the transonic volume flowmeter, and the StO2 of the graft, measured by NIRS.ConclusionsTissue oxygen saturation of the free jejunal graft can be safely and reliably measured with two-wavelength NIRS. Therefore, NIRS is a promising new method for evaluating the viability of the gastrointestinal tract.

The use of a Greenfield filter to treat a pregnant woman for internal jugular venous thrombosis: report of a case.

Abstract.Internal jugular venous thrombosis is an unusual entity with the potential to develop into pulmonary embolism (PE). A 28-year-old woman at 15 weeks gestational age of pregnancy was referred to our hospital for pain and swelling on the left side of her neck. Magnetic resonance imaging and computed tomography of her neck revealed an occlusion of the left internal jugular vein. Left internal jugular venous thrombosis was thus diagnosed. She was successfully treated by placement of a Greenfield filter in the superior vena cava and delivered a full-term healthy infant. This procedure could be an effective and safe method to prevent PE in patients of internal jugular venous thrombosis in whom anticoagulation therapy has either failed or is contraindicated.

Single-incision laparoscopic hernioplasty for obturator hernia.

To the Editor: Obturator hernia is a rare type of hernia that tends to occur mainly in lean, elderly multiparous women, and laparotomy is carried out, because most operations are done under emergency situations because of the accompanying strangulation. Recently, a laparoscopic approach for nonstrangulated obturator hernia has been reported. It has some advantages over laparotomy, such as less postoperative pain and morbidity, which would be a benefit, especially for the elderly. Many surgeons have attempted to reduce the number and size of ports in laparoscopic surgery to decrease parietal trauma and improve cosmetic results. Recently an innovation has been developed in the form of single incision laparoscopic surgery (SILS), that completes laparoscopic procedures by trocars located at 1 umbilical incision. Although there are some procedures carried out with SILS, to our knowledge, there are no reports about laparoscopic transabdominal hernioplasty for obturator hernia. We experienced an extremely rare case of obturator hernia, which occurred in a young male patient with Marfan syndrome that was successfully treated by SILS. A 23-year-old male was admitted to our hospital with lower abdominal pain and vomiting. He had intermittent abdominal pain and nausea about every 3 months for the past 10 years. The patient was diagnosed with Marfan syndrome at the age of 3. He was slender, 170 cm in height, 55 kg in weight with a BMI of 18.0 kg/m. The abdominal CT scan revealed a thickened loop of the small bowel protruding through the left obturator foramen, but he had no signs of bowel strangulation. As abdominal pain and nausea improved after admission, elective single-incision laparoscopic hernioplasty under the diagnosis of the left obturator hernia was decided on and carried out. The patient was put under general anesthesia, and a single curved intraumbilical 25-mm incision was made with pulling out the umbilicus. After exposing the fascia, a 12-mm trocar was placed through the anterior sheet of the abdominal rectus muscle with an open approach, and the abdominal cavity was explored with a 10-mm flexible laparoscope. Pneumoperitoneum was induced and maintained at 10mm Hg with carbon dioxide. Two 5-mm ports were inserted through the anterior sheet of the abdominal rectus muscle, each placed 1 cm laterally from the laparoscope port. The patient was put in a Trendelenburg position. During exploration, the greater omentum was held in the left obturator canal (Fig. 1A). It was gently reduced with forceps without trauma (Fig. 1B). Inside the obturator foramen, we put an outer part of the Bard PerFix Plug (BARD, NJ) made of polypropylene (Fig. 1C), and the peritoneal was closed with Endo Universal (Covidien) at the entry of the foramen (Fig. 1D). Fascial closure was accomplished with absorbable sutures, and the umbilicus was restored to its physiologic position with absorbable cutaneous sutures. The operative time was 55 minutes. The postoperative course was uneventful and the patient was discharged 3 days after the operation in good condition. Many surgical approaches for obturator hernia are reported: abdominal approach, retropubic approach, obturator or crural approach, inguinal approach, and laparoscopic approach. In these approaches, some benefits are derived from the use of minimally invasive laparoscopic surgery in the high-risk patients: it is useful for both diagnosis and treatment; it enables clear bilateral visualization of the inguinal space and femoral and obturator spaces, a lower rate of postoperative ileus, and fewer pulmonary complications and less postsurgical pain result in shorter hospital stays; consequently, the aesthetic results tend to be better. Our institution began carrying out SILS in June 2009 as a less invasive procedure than conventional methods, because it requires only 1 intraumbilical 25-mm incision, and, subsequently, we developed a technique for hernioplasty for obturator hernia. This is, to our knowledge, the first case of a single-incision laparoscopic hernioplasty for obturator hernia described in the indexed literature. We suggest that a SILS approach may be used as treatment, when a nonstrangulated obturator hernia is diagnosed preoperatively. FIGURE 1. Tension-free mesh repair of an obturator hernia with the mesh plug technique. A, Laparoscopic exploration revealed an incarcerated obturator hernia containing a tongue-like projection of the greater omentum. B, The greater omentum was reduced and the defect around left obturator foramen (created by the ischium and pubis bones of the pelvis) can be visualized. C, Placement of the outer part of Bard PerFix Plug (BARD, NJ) inside the obturator foramen. D, Closure of the peritonium at the entry. LETTER TO THE EDITOR

Origami using da Vinci Surgical System

Great progress has been made in the development of robotic surgical technology, but it is necessary to become skilled in using a robot. Among the advantages of a robot is practice in acquiring skill with stereoscopic three-dimensional (3D) imaging. We describe use of the da Vinci surgical system (Intuitive Surgical, Inc. Sunnyvale, CA) in developing necessary skills by practicing traditional Japanese Origami (paper folding), and we quantified the robotic-assisted dexterity.

Laparoscopic Surgery for the Ascending Colon Cancer Associated with Malrotation of the Midgut

Malrotation of the midgut is a congenital anomaly of the gastrointestinal tract that usually presents in neonates. Moreover, synchronous colon cancer has rarely been reported. In the present article, we report a preliminary experience with laparoscopic approach for intestinal malrotation with early colon cancer in a 68-year-old woman who presented with bloody stools. Colonoscopy revealed a lateral spreading tumor of the ascending colon. An air-barium contrast enema showed that the entire colon lay within the left hemiabdomen. A computed tomography revealed the superior mesenteric vein rotation sign. At surgery, a condition of malrotation of the midgut was observed: the third and the fourth part of the duodenum descended vertically without Treitz’s ligament, and the small bowel and colon were located in the right and left side of the abdominal cavity, respectively. We mobilized the terminal ileum and the right colon with laparoscopic approach. A 3-cm abdominal incision was made via the umbilicus. Right colectomy with lymph node dissection was achieved following extracorporealization. Pathological examination revealed well-differentiated tubular adenocarcinoma without nodal involvement. The patient had an uneventful postoperative course. Laparoscopic surgery for colon cancer associated with malrotation of the midgut is feasible and a promising method because of its less invasiveness and its adaptability to the malrotation without extending the skin incision.

Single-incision laparoscopic surgery for stage IV colon cancer.

Aim:The safety and efficacy of single-incision laparoscopic resections for patients with stage IV colorectal cancer have not been examined explicitly. This article describes our experience with single-incision laparoscopic procedures for patients with stage IV colorectal cancer. Methods:Seventy-seven patients who underwent single-incision laparoscopic colectomy between August 2010 and January 2012 were investigated retrospectively. Eleven patients were in clinical stage IV (ST4 group) and were compared with 66 patients in clinical stages 0 to III (control group). Results:There were no differences in the intraoperative and the postoperative complications, the 30-day mortality rate, the number of the lymph nodes harvested, and the duration of postoperative hospital stay between the 2 groups. Conclusions:Our initial experiences suggested that single-incision laparoscopic colectomy is feasible for stage IV colon cancer patients. This is a good start comparing the outcomes of single-incision colectomy in stage IV patients with open and traditional laparoscopic colectomy.

Suture damage after grasping with EndoWrist of the da Vinci Surgical System

Abstract Robotic surgery using the da Vinci Surgical System promises to extend the capabilities of minimally invasive surgery and many surgical specialties are applying this new technology. With the progress of robotic surgery, we have many opportunities to perform intracorporeal anastomosis and knotting. In these procedures, we use needle drivers, and we sometimes experience collapse of sutures after grasping them due to the lack of tactile feedback. In this study, we evaluated the relationship between the decrease of durability and robotic manipulation and whether a difference in endurance can be observed using different types of robotic instruments or needle drivers for conventional laparoscopic surgery. We held 4-0 mono-filament sutures with three types of EndoWrist: Large Needle Driver (LND), Cadiere Forceps (CF) and Debaky Forceps (DF) of the da Vinci surgical system once or three times and measured the decrease of durability of the suture. The mean tensions of the suture were significantly decreased after robotic manipulation with LND. The mean tension after holding three times with LND was significantly less than that with the CF. During intracorporeal anastomosis and knotting in robotic surgery, it is important to decrease the necessity to hold the suture directly with EndoWrist. If needed, the best EndoWrist to use is CF or DF, but not LND.