MULTIDISCIPLINARY
Laparoscopic Management of Pelvic Emergencies
Vishwanath M. Pai MS DNB, Surendran DNB, Saravanan S. MS DNB, Dheeraj Reddy MBBS
Aim: To study the efficacy of laparoscopy in pelvic emergencies.
Materials and Methods: A total of 77 patients with a preoperative diagnosis of an emergency condition in the pelvis requiring surgery were taken up for laparoscopy and evaluated. Clinical examination, ultrasound and CT scans were done in the relevant cases.
Observation: Out of the 77 patients the breakup of cases was as follows:
Torsion of ovarian cyst: 15
Tubo-ovarian abscess: 8
Unruptured ectopic pregnancy: 3
Ruptured ectopic pregnancy: 10
Ileal perforation with pelvic abscess: 2
Sigmoid diverticulitis with pericolic abscess: 3
Ruptured apendicitis with pelvic abcsess: 36
All underwent laparoscopy and only 4 required an additional laparotomy. Even in these 4 cases, laparoscopy established the diagnosis. All the other patients were treated laparoscopically with no major morbidity or mortality.
Conclusion: Laparoscopy is an excellent modality in the diagnosis and treatment of pelvic emergencies.
No Future Without Suture—Art of Endosuturing
Parveen Bhatia, MD
GENERAL SURGERY
Laparoscopic Hemicolectomy for Ileocaecal Tuberculosis
Vishwanath M. Pai MS DNB, Surendran DNB, Saravanan S. MS DNB, Dheeraj Reddy MBBS
Aim: To study the efficacy of laparoscopy in ileocaecal tuberculosis and note the specific problems encountered during laparoscopy in this conditon.
Materials and Methods: Three cases of ileocaecal tuberculosis who were in subacute intestinal obstruction and requiring surgery were chosen for the study. The patients underwent colonoscopy and biopsy before surgery.
Observation: All 3 patients underwent laparoscopic right hemicolectomy. The salient features noted were:
(1) extensive adhesions
(2) thickened mesentery obscuring the blood vessels
(3) in the thickened mesentery, plenty of mesentric nodes were seen further obscuring the blood vessels and
(4) hence in all cases anastomosis was done extracorporeally and then the gut was replaced back into the abdomen through a small incision.
Conclusion: Laparoscopic hemicolectomy is a good procedure for mobilisation but the anastomosis is better done extracorporeally.
Culdolaparoscopy Not Only for Pelvic Organs, Also Appendectomy and Cholecystectomy. Novel Method for Tissue Extraction in Advanced Laparoscopy
Mercedes Birlain, MD, FACOG
The field of minimally invasive surgery has evolved tremendous in recent years. Smaller abdominal ports not only offer cosmetic advantages but also have important clinical implications. New technologies promise to lead us to an era of even less invasive procedures. The use of the natural orifice as the vaginal port in a posterior colpotomy is a procedure that some laparoscopists use to extract myomas, ovarian cysts, gallbladders and appendixes. It is an additional visual, operative or extracting port in laparoscopy. It is also a wide port that reduces abdominal ports bigger than 10mm or inclusive to avoid a minilapatotomy. The 10 mm or greater abdominal ports have been associated with complications in hernias. Indications and contraindications are going to be reviewed as well and also critical assessment of the procedure is going to be stated.
Conclusion: Culdolaparoscopy has provided good results in treating gynecological pathologies and has the potential to benefit females with other surgical pathologies.
Single Center Experience of Laparoscopic Distal Pancreatectomy: Intention to Preserve
Spleen and Splenic Vessels
Ho-Seong Han MD, PhD
Department of Surgery, Seoul National University
College of Medicine, Seoul, Korea
Background: Although an increasing number of reports on laparoscopic distal pancreatectomy (LDP) have recently been documented, it has not achieved worldwide acceptance yet. The aim of this study is to analyze our experiences of LDP and evaluate its usefulness.
Methods: Thirty-two patients underwent LDP from June 2004 to July 2007 in Seoul national University Bundang Hospital. The preservation of splenic vessels and spleen was tried unless the tumor was very close to splenic vessels or malignancy was suspected in preoperative radiologic studies. We retrospectively analyzed of the clinical outcome of these 32 patients.
Results: There were 11 men and 21 women, with a mean age of 47.8 years. Indications were 10 cystic neoplasm, 7 intraductal papillary mucinous tumor, 5 solid pseudopapillary tumor, 2 pseudocyst, 5 endocrine tumor, 1 traumatic laceration, and 2 pancreas tail cancer. No conversion or transfusion occurred. Spleen was sacrificed in 4 patients with suspected malignancy. Spleen and splenic vessels were successfully preserved in 23 out of 28 patients (82.1%). The mean operation time was 231 minutes, mean size of the lesion was 4.8cm and mean hospital stay was 11.1 days. Postopereative complications occurred in 10 cases (31.3%), including 5 subclinical fluid collection, 1 symptomatic pleural effusion, 1 ileus (n=1), 2 intra-abdominal abscess, and 1 pancreatic fistula, which were improved by conservative management.
Conclusion: Our experiences show that LDP with preservation of spleen & splenic vessels is a technically feasible and safe procedure in the patients having benign or borderline malignant disease.
COLORECTAL & HERNIA
Laparoscopic Repair of Margagni Hernias in Adults
Atilla Cokmez, MD
Introduction: Morgagni hernias are rare diaphragmatic hernias. They account 3 -5% of all diaphragmatic hernias and majority of the cases are asymptomatic. They are caused by trauma, obesity or pregnancy. The laparoscopic repair has become an excellent alternative to open repair for Morgagni hernias. We report five cases of Morgagni hernia repaired with laparoscopic approach.
Patients: A retrospective review composed of five patients who had a Morgagni hernia repaired laparoscopically. Data from these patients were collected for the period between Feb2001 and May 2005.
Results: The mean age of patients was 61. The anatomic pathology was detected preoperatively using X-rays and CT scans in four of our patients. Hernia was detected incidentally in one patient during the elective cholecysectomy. Three hernias were right sided and two were left. The contents of the hernias were omentum and transvers colon in majority of the patients. The hernia was repaired laparoscopically in all patients: using mesh in four patients and using primary closure with nonabsorbable sutures in one patient.
There were no postoperative complications and all patients well tolerated laparoscopic repair. No recurrences has been detected during the follow-up.
Conclusions: Laparoscopic repair is a candidate to be a standard treatment for the Morgagni type hernias. It is an effective and safe technique and can be performed by a general surgeons with a certain learning curve. It has several advantages relative to the open operation.
Early Rectal Malignancies Laparoscopic Resection with Harmonic in Series of 21 Cases
A. Zameer Pasha, MD, Shakila Zameer, MD, Z. Shakir Tabrez, MD
Shanawaz Hospital Trichy, India
The presentations of colorectal malignancies are mostly late for multifactorial reasons. But in early presentation along with bleed and haemorrhoids, the detection is easy but acceptance of surgery is frowned upon. Colostomy is a taboo. Laparoscopy offers an alternative.
Early cases (21) with mucosal invasion, no lymphadenopathy and secondries, laparoscopic dissection with harmonic is done with considerable ease. Pararectal delineation and skeletinization of mesocolic vessels is very delicately done. Aeterial ligation, wide excision of rectal growth and hand sewn margins offer excellent long term results and aesthetic acceptance. This study is presented to highlight low morbidity and aesthetic acceptance with ease of surgical performance.
Laparoscopic Repair of Ventral Hernias, What We Have Learned from our Initial Experience
Aslan Sakarya, MD
Celal Bayar University Faculty of Medicine
Department of General Surgery Manisa - Turkey
We have retrospectively investigated the cases of laparoscopic ventral hernia repairs during May 2000 and August 2007 in our clinic. Total 35 operations were done for 34 patients. Male patients were numbered 24 (68.6% ) whlie females were 11 ( 31.4% ) Diagnosis fore those patients were insicional 16, umblical hernia: 15, Lomber hernia : 2 and epigastric hernia: 2. Conversion to open procedure were 2 (5.7% ). There were total 6 complications (17.1 % ) namely 1 seroma formation, 2 small intestinal injury, 1 postoperatif respiratory failure, 1 intestinal obstruction, 1 recurrence. There were 2 ( 5.7% ) mortality. As a result repair of ventral hernias laparoscopically may be a gold standard for these cases.
Laparoscopic Colorectal Resection for Malignancy: an Evaluation of Oncologic Outcome
Wai Lun Law, MD
The first laparoscopic colectomy was reported in 1991 for colon cancer. However, the development of laparoscopic surgery in colorectal diseases has not been met by the same pace as witnessed in other laparoscopic procedures. Such a difference in popularity is mainly due to the concerns on the oncologic safety of laparoscopy in the management of colorectal malignancy. Results from randomized controlled trials comparing laparoscopic and open colectomy for colorectal cancer demonstrated that laparoscopic resection was not inferior to open surgery in terms of the oncologic outcome. We recently reported our results of 255 laparoscopic resections for cancer of the colon and rectosigmoid. In addition to the favorable short-term outcome, those patients with laparoscopic resection also had better survival when compared to those who underwent open resection. Regarding rectal cancer, the safety and feasibility of laparoscopic total mesorectal excision have been shown in experienced centers. The adequacy of excision and the ability to achieve clear circumferential margin have also been demonstrated to be equivalent to open resection. Recent report from the CLASICC (Conventional versus Laparoscopic Assisted Surgery in patients with Colorectal Cancer) trial showed similar results in laparoscopic and open resection for rectal cancer. It represented the first report of long-term results from randomized trial on rectal cancer. The long-term of laparoscopic colorectal resection will be critically appraised in the presentation. The impact of postoperative complications and conversion on the long term outcome will also be discussed.
ROBOTICS
Safety of Laparosopic Cholecystectomy: Preoperative Imaging of Bile Duct Variations
Kunihiko Izuishi, MD, Keiichiro Kakinoki, MD, Keiichi Okano, MD, Hisao Wakabayashi, MD, Hisashi Usuki, MD, Yasuyuki Suzuki, MD
Department of Gastroenterological Surgery,
Faculty of Medicine, Kagawa University, Japan
Introduction: Unsuspected anatomical variations of biliary tree have the possibility of bile duct injuries in the laparoscopic cholecystectomy (LSC). In this study, we evaluated the type and frequency of the anatomical variation of biliary tree by multislice CT (MCT) cholangiography, and present the anatomical pitfalls in LSC.
Patients and Methods: Two hundred and twenty six subjects with biliary disease gave informed consent and underwent MCT cholangiography after infusion of meglumine iotroxate before LSC. Raw data were reconstructed by workstation, and the images of the multiplanar reconstruction and volume rendering were created.
Results: MCT cholangiography clearly revealed 28 cases (12%) of anatomical variations of the hepatic duct. We classified the variations of aberrant duct into major type (draining a particular segment of the liver), found in 13 cases (6%), and minor type (draining a particular subsegment of the liver), found in 15 cases (7%). We found particular types of dangerous anatomical variants of bile ducts before operation. 1: A right posterior subsegmental duct (S6) entering the CHD directly close to the cystic duct. 2: A right posterior segmental duct draining directly in the cystic duct. 3: A right posterior segmental duct situating adjacent to the elongated cystic duct. 4: A gallbladder neck positioning into the liver. All these cases, laparoscopic cholecystectomy were performed uneventfully of its preoperative information.
Conclusions: The pre-operative evaluation of biliary variation is important to achieve a successful uncomplicated operation. Moreover the knowledge and typical image of dangerous variation may reduce bile duct injury.
DaVinci-Assisted Low Anterior Resection for Rectal Cancer
Seung-Hyuk Baik, MD
Department of Surgery, Yonsei University College of Medicine, Seoul, Korea; Severance Hospital, Seoul, Korea
Background: Laparoscopic colorectal resection has become popularzied. The recently developed da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) promises to facilitate endoscopic surgery and overcome its disadvantages. Therefore, the aim of this study is to compare the short-term results between robotic tumor specific mesorectal resection (R-TSME), using the da Vinci® Surgical System, and conventional laparoscopic tumor specific mesorectal resection (L-TSME) in rectal cancer patients.
Methods: Thirty-six patients were randomly assigned to receive R-TSME or L-TSME between April 2006 and Febuary 2007. Eighteen patients each underwent robotic low anterior resection using the da Vinci® Surgical System and conventional laparoscopic low anterior resection. Patient characteristics, perioperative clinical results, complications, and pathologic details were compared between groups. Results: Patient characteristics were not significantly different between groups. Mean operating time, hemoglobin (Hb) change, and conversion rate were not significantly different between groups. Complications were treated conservatively and did not require surgical intervention in the R-TSME group. The average length of stay was 6.9 ± 1.3 days in the R-TSME group and 8.7 ± 1.3 days in the L-TSME group (P<0.001). The specimen quality of the R-TSME group was acceptable.
Conclusion: TSME was performed safely and effectively, using the da Vinci® Surgical System. Use of the system resulted in acceptable perioperative outcomes.
MULTIDISCIPLINARY
Newer Horizons in Laparoscopic Surgery
Parveen Bhatia, MD
Pitfalls in Preoperative Evaluation and General Anesthesia in Laparoscopy Patients
E. Alp Yentur MD, Associated Professor
Celal Bayar University, Anesthesiology Department, Manisa, Turkey
Laparoscopic surgery needs special anesthetic approach compared to conventional surgery. This presentation focus on anesthetic pitfalls that has to be taken into consideration before and during laparoscopic surgery. Main differences between conventional anesthesia, risks and benefits of laparoscopy in the view of aneshesiology will be discussed. At the same time the basic differences and important aspects of these group of patients and surgical operation will be pointed out.
HYSTERECTOMY
Strategies to Make Total Laparoscopic Hysterectomy Simple, Safe as well as Effective
Prashant Mange-Shikar, MD
Laparoscopic Hysterectomy is Still a Provocation for the Classic Gynecologist
Liselotte Mettler, Prof Dr Med
Department of Obstetrics and Gynaecology,
University Hospitals Schleswig-Holstein, Campus Kiel, Germany
The three major modalities offered today are laparoscopic-assisted vaginal hysterectomy, laparoscopic total hysterectomy and laparoscopic supracervical hysterectomy, also called subtotal hysterectomy. In cases of malignancies, a radical total laparoscopic hysterectomy is performed. Robotic assistance to any of the three basic hysterectomy modalities adds precision, magnification and tremor-free work at the computer console and thus does improve the surgical outcome.
Laparoscopic assistance to vaginal hysterectomy had been practised in Kiel under Kurt Semm since the mid 1980s. After Harry Reich's publication on LAVH, this procedure was performed as the surgical technique to increase vaginal hysterectomies with laparoscopic assistance.
Laparoscopic supracervical hysterectomy is a minimally invasive surgical method that has to be regarded as an alternative to all other methods of total hysterectomy in benign conditions of the uterus, such as uterine fibroids, dysfunctional uterine bleeding and uterine adenomyosis. It is associated with a low perioperative morbidity and a rapid period of convalescence. This technique compares well to the CISH technique propagated by Kurt Semm in the early 1990s. It is of special interest that LASH can also be performed on nulliparous patients and on patients who have undergone previous abdominal surgery.
In 2008, it is a provocation for any gynaecologist to remain performing laparotomies for hysterectomies if the vaginal approach and the laparoscopic approach are given. At the Department of Obstetrics and Gynaecology, University of Kiel we perform hysterectomies in 55% of cases transvaginally, in 30% of cases laparoscopically, including the supracervical approach, and in only 10% of cases is a laparotomic hysterectomy performed (including cancer cases).
Need for Re-Classification or the Modification of Laparoscopic Hysterectomy
Paul I. Lee, MD
