MULTIDISCIPLINARY
Understanding Endoscopic Anatomy of Inguinal Region
Parveen Bhatia, MD
Infiltrating Endometriosis: Bowel, Bladder and Ureter
Yves Leroy, MD
The objective of this presentation is to asses the importance of an accurate diagnosis and adequate Surgical approach to the infiltrating endometriotic lesions like nodules and fibrotic tissue within the bowel, bladder wall and ureter, causing pain and dysfunction.
Much too often we are confronted with cases of chronic pelvic pain which have been unsuccessfully treated by different specialists, mainly general surgeons.
The majority of these patients have a past history of severe dysmenorrea and infertility, or have been operated many times for Endometriosis. We should not forget that 87% of cases of severe dysmenorrea associated to Infertility will have Endometriosis. If the symptoms are dyspareunia, pain on defecation and diarrhea with menstrual periods, we have to look for bowel envolvement, rectovaginal nodules and fibrosis and probably structures of bowel loop and distal portion of urethers which may result in hidrone
frosis or cronic kidney infections. The Laparoscopic approach should look for the lesions mentioned above and excise the nodules, free the strictures if possible and perform resection of the fibrotic portion of bowel or urether and also an end to end anastomosis, with the assistance of a colorectal surgeon. As a complementary procedure we usually perform Ablation of uterosacral ligaments or presacral medial neurectomy to alleviate the chronic pain.
Education and Training for Endoscopic Surgery Basic Fundamentals and Advanced Techniques
Kazuo Tanoue MD, PhD, Satoshi Ieiri MD, Kozo Konishi MD, Kenoki Ohuchida MD, Takanori Nakatuji, MD, Hideo Uehara, MD, Naotaka Hashimoto, MD, Takashi Maeda, MD, Makoto Hashizume, MD
Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital, Fukuoka, Japan
Background: Recently, development of an endoscopic surgery is remarkable, but surgical complications has become a social problem in Japan. Since a professional training for the purpose of medical safe standard improvement is very important, we established the training center for endoscopic surgery.
Contents: By August, 2007, 380 surgeons attended in 32 times of the seminars. Training contents include; 1: A lecture, 2: The box training, 3: Virtual reality training, 4: Animal training. Before/after training, we perform our original technical assessment for trainee. The technical assessment task using the box trainer is to perform the round continuous sutures for 8 points. In each trainee, a lap time and a trace of both forceps were recorded, and the distance that was out of needle entry from the point, a tear of rubber, and a slack of a thread were recorded as errors.
Results: By skill assessment before/after training, the lap time of the initial suture ligature was significantly shortened, and average of the continuous suture number increased significantly. In a trace of forceps, movement distance decreased, and speed increased. However, the average of errors of a tear and a gap increased after the training.
Conclusion: The assessment system of fundamental skills are necessary for establishment of education in endoscopic surgery. Therefore, our training seminar is important as education of basics stage.
GENERAL SURGERY
Justice for Gallstone Sufferers: Looking at Over 1000 Patient Experiences
Tushar Samdani, MD, SHO.MBBS, MS, DNB, Santosh Balakrishnan, MBBS, MS, DNB, Tarun Singhal, MBBS, MS, DNB, Starlene Grandy-Smith, Specialist Nurse Practitioner, J Nicholls, RGN, ASP, Shamsi El-Hasani, MBChB, FRCS(Eng,Edin,Gen)
Department of General Surgery, The Princess Royal University Hospital
Introduction: Laparoscopic surgical techniques in synergy with modern imaging, endoscopic and interventional techniques have revolutionised the treatment of gallstone disease making it possible to provide prompt and definitive care to patients.
Materials & Methods: Patients with gall stone disease were treated based on a predetermined evidence-based protocol depending on their mode of presentation. Data was collected and analysed prospectively.
Observation: Our team treated 1142 patients with gall stone disease between September 1999 and December 2006.196 patients presented through accident & emergency with acute symptoms. Despite varied presentations laparoscopic treatment was possible in all but 7 patients. 562 patients underwent Laparoscopic cholecystectomy (LC) as overnight stay (23 hour) cases in a stand-alone centre, 208 as day cases and 372 had inpatient treatment. 53 patients with acute cholecystitis had their surgery within the 96 hours of acute presentation. 52 patients had Laparoscopic Subtotal Cholecystectomy. The overall morbidity was 1.8% with three patients having residual common bile duct stones; three cases had biliary leak from cystic or accessory duct stumps and one idiopathic right segmental liver atrophy. 11 patients had wound infections, 3 patients had port site hernia. There was no 30 days mortality.
Conclusion: We believe that prompt investigations with imaging and endoscopic intervention if needed along with LC at the earliest safe opportunity by a specialized dedicated team represents an effective method of treating gallstone disease. Our experience with over a thousand patients has offered us the courage of conviction to say that justice is finally coming the way of gallstone sufferers.
Laparoscopic Cholecystectomy—Ambulatory Treatment
Veroljub Pejcic, MD
Center for Minimally Invasive Surgery, Clinical Center Nis, Serbia and Montenegro; Health Center Nis, Serbia
Introduction: Laparoscopic cholecystectomy (LC) is becoming an ambulatory procedure in developed countries. Its advantages are: less postoperative pain, shortened hospital stay, quick recovery and return to normal activities, lower hospital costs. The aim of this study is to assess feasibility of ambulatory laparoscopic cholecystectomy in Clinic of Surgery, Nis.
Material and methods: From 01.01.2004 till 31.12.2006., 100 patients with cholecystolithiasis underwent ambulatory (LC). We used following criteria: ASA I and II, age <65, absence of upper abdominal operations, low risk for common bile duct stones, gallbladder wall <5mm (US), educated patients from urban environments (<30 km away). Operations started not later then 12 AM, on admission day. Patient satisfactory was assessed by independent telephone questionnaire 4 weeks postoperatively.
Results: There were 68 (68%) women and 32 (32%) men. (LC) was successfully accomplished in all patients. Average operating time was 40 minutes (25-60). All patients were discharged the same day. Average hospital stay was 11h (10-12). Twenty patients (80%) required postoperative analgesia. There were no postoperative complications. Twenty-four patients (96%) described their experience as “pleasant”. All patients stated that they would recommend this operation.
Conclusion: In well-selected patients, ambulatory laparoscopic cholecystectomy is safe and feasible in developing country.
HYSTERECTOMY
Laparoscopy Hysterectomy and Its Complications
Sheila Mehra, FRCOG, Gautam Mehra, MRCOG, Manju Hotchandani, MD, Indu Bala Khatri, MD
Setting: Two private city hospitals in New Delhi, India.Department of Obstetrics & Gynaecology, MCKR Hospital and Indraprastha Apollo Hospital, New Delhi.
Objectives: To evaluate the incidence and type of complications of laparoscopic hysterectomy.
Design: Retrospective review of case records (1990-1998) and Prospective study (1999-2004).
Outcomes: Type of Complications; Complication rates; Trend of complications in relation to surgical experience and type of pathology.
Inclusion Criteria: All women undergoing laparoscopic hysterectomy (LH) by a single surgeon over a period of 14 years.
Results: 2328 cases chosen for LH. Surgical techniques included a combined laparoscopic and vaginal approach in 72% cases and a total laparoscopic hysterectomy in 28% cases. Large tumours (ovarian & uterine) were present in 18% of cases. 26% had previous abdominal surgery. Majority complications were in women with Endometriosis, PID & previous surgery There were 26 bladder injuries (1.1%), 11 ureteric injuries (0.47%), 6 bowel trauma (0.38%), 8 peri-operative haemorrhage requiring laparotomy (0.34%) and 1 vascular injury. Febrile morbidity and urinary infection occurred in 11% and 14% cases respectively. Delayed complications included vault granulation (26%) and secondary haemorrhage (0.52%). There were no port-site hernias or vault prolapse in the long-term follow-up.
Conclusion: Rate of complications are higher in the presence of risk factors like endometriosis, PID & previous surgery. Overall, LH appears to be a safe procedure with a low complication rate if undertaken with proper patient selection & expertise.
Emergence of Subtotal Hysterectomy
Paul I. Lee, MD
NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY
Endoluminal Management of Pseudopancreatic Cyst
Parveen Bhatia, MD
Single Point Access (SPA) Surgery—Initial Application to Gastric and Gallbladder Surgery
Erica Podolsky MD, Steven Rottman, MD, Paul G Curcillo II, MD
Drexel University College of Medicine, Department of Surgery, Philadelphia PA
Introduction: The origins of minimally invasive surgery date back to the early 1900's. Procedures adapted as visualization, insufflation, and instrumentation improved. Laparoscopic cholecystectomy was a milestone in the development of minimally invasive surgery and has been the standard of care since the 1990's. Recently, robotic surgery and NOTES procedures have emerged. These procedures introduced articulation and the desire for improved cosmesis, respectively. We believe these two new directions are necessary but should be delivered in a more efficient and cost effective procedure. More so, the advancement needs to be a technique that is easily taught and practiced and subsequently more readily available to both surgeons and large volumes of patients. We have developed a single port access (SPA) surgerical technique as the next step in minimally invasive surgery. SPA surgery combines the basic principles of laparoscopic surgery already being utilized by surgeons with readily available articulating instrumentation. This new approach can rapidly be made available to patients and improves cosmesis with the minimization of incisions. In our initial series, we have been able to hide the single incision in the umbilicus.
Methods: Four single port access (SPA) laparoscopic cholecystectomies were performed at our institution. Each procedure began with an incision in the umbilicus extending inferiorly approximately 2 to 3 mm through the midline crease (total incision < 18 mm). A 5mm trocar was inserted, and a scope was passed. After intra- abdominal inspection, skin flaps were raised on either side to allow two accessory trocars to be placed laterally, in a triangulated fashion, to the 5mm midline trocar within the same incision. An articulating grasper was introduced to retract the gallbladder over the liver. The cystic duct and artery were dissected with articulating instrumentation. The gallbladder dissection and resection was then carried out with the same technique as standard laparoscopic cholecystectomy. The gallbladder was removed through the umbilical port. The fascial incisions were then closed with a 0.0 Vicryl suture and the skin closed with a running subcuticular 4.0 Vicryl stitch.
Results: All patients tolerated the procedure without difficulty. The average duration of the procedures was less than 75 minutes. All of our patients were discharged within twenty-four hours. All patients reported minimal discomfort and were able to resume their activities of daily living within three days. All umbilical incisions were hidden nicely within the umbilicus on postoperative follow-up.
Discussion: The goal of Single Port Access (SPA) surgery is to minimize the incision required to perform the procedure while maintaining the surgeons comfort. This results in less scar formation, less post operative discomfort, and quicker return to daily activities. This procedure also reduces the cost and length of training by using familiar equipment and set up.
NOTES and robotic surgery have paved the way in the development of the SPA technique. NOTES eliminates the need for an incision, but adequate instrumentation is not yet available to safely perform these procedures. Its use in humans has been limited over the past few years. It also is a highly skilled technique, which may not be readily available to surgeons or gastroenterologists and subsequently less available to patients in the immediate future. Robotic surgery introduced the concept of operating with articulating instruments which greatly improves the surgeons maneuverability in a closed abdomen. However, the limitations of Robotics in terms of expense, availability and fixed port positioning need to be considered. We have applied the advantages of both of these concepts to the SPA procedure.
We have demonstrated that the technique of using a single port access with articulating instrumentation allows us to perform the standard laparoscopic cholecystectomy dissection without being confined to the port placements required by rigid instrumentation.
GYNECOLOGY
Leuprorelin Acetate Therapy in Patients with Uterine Myoma Prior to Laparoscopic Hysterectomy and Myomectomy
Mitsuru Shiota M.D., Masahiko Umemoto M.D., Takako Tobiume M.D., Masao Shimaoka M.D., Hiroshi Hoshiai M.D.
Department of Obstetrics & Gynecology, Kinki University School of Medicine, Osaka-Sayama, Japan
The objective of this study was to examine whether patients become candidates for laparoscopically assisted vaginal hysterectomy (LAVH) when leuprorelin acetate(LP) was preoperatively administered to patients with large uterine myomas that seems to require total abdominal hysterectomy (preoperative LP group), and to compare the results with those in patients who underwent LAVH alone during the same period (LAVH group).
Although the preoperative LP group had significantly larger myomas than the LAVH group prior to treatment, a marked reduction in size was achieved through administration of leuprorelin, and the volume of the myoma after administration was not significantly different from the volume in the LAVH group. Thus, all patients in the preoperative LP group become suitable for LAVH or vaginal hysterectomy, suggesting the usefulness of preoperative administration of leuprorelin acetate.
Also, we studied to examine whether patients become candidates for laparoscopic myomectomy (LM) when LP was preoperatively administered to patients with large uterine myomas that seems to require abdominal myomectomy. The results suggest that laparoscopic myomectomy is indicated for myomas with diameters of 10 cm or less, independent of the number of myomas. For larger myomas, preoperative administration of GnRH agonist may reduce the myoma size to safety perform the laparoscopic procedure.
Is it Necessary to Perform Pre-IVF Hysteroscopic Evaluation
Aygul Demirol, MD
The major determinant of the success of the IVF treatment is embryo quality; on the other hand uterine receptivity and uterine integrity have also an important impact for the achievement and continuation of pregnancy. It has been well established that implantation of fertilized eggs is effected by intrauterine environment. Benign endometrial pathologies, such as endometrial polyps, adhesions, hyperplasia, endometritis and uterine mullerian abnormalities can have a negative effect on pregnancy rates (PR) (1-7) (Valle et al., 1980; Kirsop et al., 1991; Shamma et al., 1992; Balmaceda et al., 1995; La Sala et al., 1998; Lass et al., 1999; Varasteh et al., 1999).
Office hysteroscopy can be performed without general anesthesia in an ambulatory setting with low cost, minimal morbidity and inconvenience to the patients (13-16) (Nagele et al., 1996; Vercellini et al., 1997; Ruach et al., 1998; Valle et al., 1999), and some lesions diagnosed can be operated easily using different equipments introduced through the operative channel of the hysteroscopy. Intrauterine pathologies and structural uterine abnormalities which may responsible for the embryo implantation failure (such as adhesions, polyps, uterine septum or submucous myomas) can be detected and treated hysteroscopically resulting in improved pregnancy rates.
We performed a prospective randomized study in our IVF Unit (Demirol and Gurgan, RBM Online, 2004). Four hundred twenty-one patients who had undergone 2 or more failed IVF cycles in which two or more good quality embryos transferred participated prospectively in the study. They all had normal HSG. Patients were randomized into two groups using computer generated random numbers. Those in-group I (n=211) did not have office hysteroscopic evaluation of uterine cavity and cervix before commencing controlled ovarian stimulation for IVF treatment whereas patients in Group II (n=210) had office hysteroscopy. The patients who had normal hysteroscopic findings included in Group IIa ( n=154) and patient who had abnormal hysteroscopic findings were included in Group IIb (n=56). Intrauterine lesions diagnosed were operated during the office procedure . All office hysteroscopies were performed 2 to 6 months after the last failed IVF cycles by the same physician. All IVF treatments carried out on the menstrual cycles after office hysteroscopies. Patients were placed on a COH protocol that began daily subcuteneous injections of leuprolide acetate (lucrin, Abbott, France) 1 mg on the day 21 of that cycle and continued until day 3 of the next menstrual cycle. If the ovarian supression is achived( E2|< 40pg/ml) 225 IU/d of gonadotrophin (recombinantFSH, Gonal-F, Laboratories Serono, Switzerland) started on day 3 or 4 and the dose arrangement was performed on the basis of individual response. Ovulatory dose of 10.000 IU human chorionic gonadotropin (hCG, Profasi, Laboratories Serono, Switzerland) were given when at least two 18 mm or more diameter follicles were observed. Transvaginal USG (TVS) guided oocyte retrieval was performed and embryo transfer (ET) was performed on day 3 and maximum 4 embryos selected according to their quality were transferred. Luteal support was given by progesterone vaginal suppositories (Progestan, Koçak, Turkey). Clinical pregnancies were confirmed by TVS at 6 to 7 weeks of gestation.
Results: There was no difference in the mean age, duration of infertility, number of failed cycles and causes of infertility in either groups. Among the 210 patients (GroupII) who had office hysteroscopy 56 (26%) had intrauterine pathologies. y. Thirty-three patients (15.7%) had endometrial polyps ranging in size from 0.9 to 2 cm. Of which 11 patients had multiple polyps (5 patients had 3 polyps and 6 patients had 2 polyps). All polyps were excised with forceps and confirmed with histologic examination. Filmy or mild intrauterine adhesions involving the uterine cavity diagnosed and operated in 18 patients. Five patients had cervical adhesions, which easily lysed by scissors.
No difference existed in the mean number of oocyte retrieved, fertilization rate, number of embryos transferred among the patients in groups. Of the 421 patients, 3 were not included in the analysis secondary to failed ET poor ovarian response or availability of only poor graded embryos (2 in group I and one in group IIB). Clinical pregnancy rates in group I, group IIa and Group IIb were 21.6%, 32.5% and 30.4% respectively. There was a statistically significant difference in the clinical pregnancy rates between patients in Group I and Group IIa ( 21.6% and 32.5%, P=0.044, respectively) and GroupI and GroupIIb ( 21.6% and 30.4%,P=0.044, respectively). There was no significant difference in the clinical pregnancy rates patients in groups IIa and IIb. There were no significant differences in terms of first trimester abortions in all groups. Our prospective randomized study showed that the clinical PR could be improved significantly after treatment of mild intrauterine and cervical abnormalities by office hysteroscopy. It is possible that these mild abnormalities are altering the uterine environment and hence negatively affecting uterine receptivity and ultimately pregnancy outcome. In conclusion, patients with normal HSG but recurrent IVF-ET failure should be evaluated prior commencing IVF-ET cycle to improve the clinical PR.
A Case Series of Severe Asherman Syndrome Treated by Hysteroscopy Under Laparoscopy
Nora Sahly, MB, ChB, Fathia Hassanain, MD, Abdulrahim Rouzi, FRCSC
Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia
Objective: To evaluate the success of hysteroscopic treatment of women with severe Asherman syndrome.
Design: Case Series
Materials and Methods: Seven women diagnosed with severe Asherman syndrome stage 4 (total agglutination of the uterine wall) according to the European Society of Hysteroscpy were treated by hysteroscopy under laparoscopic guidance using monopolar energy. The mean age was 30. 2 years and the mean parity was 4. Six women had at least one cesarean section and four women also had at least one dilatation and curettage before. One woman had five dilatation and curettage before. They presented with amenorrhea and infertility. Investigations showed normal semen analysis, normal hormonal profile and completely obliterated uterine cavity by hysterosalpingography. They underwent hysteroscpic removal of uterine adhesions with monoplar energy under laparoscopy control. Prophylactic single dose antibiotic was given to all patients. Intrauterine contraceptive device was inserted in two women. Postoperative hormonal therapy was given to all women.
Results: The procedure was done in all women without complications except one uterine perforation during cervical dilatation. All women resumed menstruation after the procedure. Three women had to repeat the procedure to maintain menses. Mean duration of follow-up is 4 years. Only one woman got pregnant but aborted at 20 weeks gestation. This was complicated by retained products of conception requiring evacuation.
Conclusions: Hysteroscopic treatment of severe Asherman syndrome is effective in restoring menses but not pregnancy rate is low after the procedure.
GENERAL SURGERY
Minimally Invasive Esophagectomy for Cancer
Simon Law. MS, MA (Cantab), MBBChir, FRCSEd, FCSHK, FHKAM, FACS
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
Innovative minimally invasive surgical (MIS) techniques have been explored for the purpose of esophagectomy since the early 1990's, including various combinations of thoracoscopy, laparoscopy or laparoscopic-assisted methods, mediastinoscopy and open thoracotomy and laparotomy. MIS esophagectomy has been shown to be feasible and safe, and at least equivalent postoperative morbidity and mortality rates to open surgical resection have been demonstrated. Similar survival is also reported compared to open surgery. Selected series have achieved less blood loss, reduction in some postoperative complications, decrease in intensive care and hospital stay, and better preservation of pulmonary function. It is expected that with further improvements in instrumentation and experience, these difficult procedures may become more accessible and widely practiced. The author's technique of MIS esophagectomy is presented. A combined thoracoscopic- laparoscopic technique is used. The thoracoscopic phase is performed in the left lateral position under one-lung anesthesia. Access is through a 5cm mini-thoracotomy wound together with 4 other ports. Esophageal mobilization with mediastinal nodal dissection is carried out. The patient is then placed supine. Six port sites are used for laparoscopic gastric mobilization and celiac lymphadenectomy. A left cervical incision enables completion of esophageal mobilization from above and division of the cervical esophagus. Two abdominal port sites at the right upper quadrant are joined together to make a 5cm laparotomy, and the esophagus and stomach are retrieved outside the abdomen. The stomach is then transected and the specimen removed. A pyloroplasty is performed. The gastric tube is delivered up to the neck for cervical esophago-gastrostomy.
Robot-Assisted Aortoiliac Vascular Procedures Using a Modified Direct Transperitoneal Approach; Experience of Over 80 Cases
Petr Stádler, MD, PhD
Department of Vascular Surgery, Na Homolce Hospital,
Prague, Czech Republic
Introduction: The aim of our study was to evaluate the clinical experience of robot-assisted aortoiliac reconstruction for occlusive disease and aneurysm performed using the da Vinci system. We analyze the impact of the da Vinci system on vascular surgery.
Materials/Method: Between November 2005 and September 2007, robot-assisted laparoscopic aorto-iliac reconstructions were performed on 83 patients in our institution. Dissection of the aorta and iliac arteries were performed laparoscopically, using our own modified direct transperitoneal approach, and the robotic system was used to construct the anastomosis, for the thromboendarterectomy and for posterior peritoneal suturing.
Results: Eighty out of the 83 procedures (96.4%) were successfully completed robotically, while three (3.6%) were converted to mini or full laparotomies. Non-lethal postoperative complications were observed in two patients. One patient had an incisional hernia in the port nine months after the first operation, which was treated under local anesthesia. The first converted patient had postoperative fever and methicillin-resistant Staphylococcus aureus was detected from the central venous catheter and confirmed by hemoculture. In this case antibiotics were applied over the long term.
Conclusion: Our clinical study confirms the safety and feasibility of robot-assisted laparoscopic vascular surgery. The main advantages of robot-assisted laparoscopic procedures are the availability of three-dimensional imaging and easier instrument manipulation than can be obtained with standard laparoscopy. The next advantage of the da Vinci robotic system over standard laparoscopy lies in the construction of the vascular anastomosis and the reduction of aortic clamping times.
