Laparoscopic Incisional Hernia Repair: Pros and Cons Compared to Open Hernia Repair
Evangelos P. Misiakos, MD
Incisional hernias develop in 2-20% of laparotomy incisions. Primary open repair with mesh is associated with a recurrence rate of 12-19%. However, the use of mesh seems to increase the incidence of wound infection, probably due to the need of larger incision and wide dissection. Laparoscopic repair eliminates the above factors and has been shown to be associated with lower morbidity and recurrence rates, and shorter hospital stay. The technique of laparoscopic approach with mesh is analyzed. The most difficult phase of the procedure is lysis of adhesions, which must achieve complete liberation of the abdominal wall. The most common postoperative complication is the development of seroma. Seromas usually resolve spontaneously within 4-10 weeks. Recurrence rate in the laparoscopic approach does not surpasses 7%, when transfascial sutures are used to fix the mesh. In general, laparoscopic incisional hernia repair contributes to better clinical results than the open approach, offering less discomfort, shorter recovery, and better patient’s acceptance.
Videothoracoscopic Sympathectomy for Palmar Hyperhydrosis
Aslan Sakarya, MD
Hyperhydrosis is a pathological condition of overperspiration due to excessive secretion of eccrine sweat glands in amounts greater than required for physiological needs. It may be primary or secondary. Primary hyperhydrosis can be described as a condition of excessive perspiration of eccrine glands innervated by cholinergic fibers from the symphatetic nervous system. The main functional and and social problem associated with hyperhydrosis is excessive palmar perspiration. It may sometimes cause severe embarrassment, presenting not only physcological and social problems but also educational and occupational handicaps. Various surgical and medical treatments have been used to treat palmar hyperhydrosis. Although medical therapies are noninvasive these approaches suffer from a transient success rate and the neccesity of reapplication. With our limited experience we do favor videothoracoscopic symphatectomy for the treatment of palmar hyperhydrosis for the following reasons: Its success rate is 86-94%, although 0-40% Horner’s syndrome or 47-98 % compensatory hyperhydrosis can be encountered; thoracoscopic approach gives the best cosmetic result and earliest return to work and is associated with minimal postoperative pain; the learning curve for this procedure is very short and can be done by general surgeons.
Particular Ultrasound Aspects in Patients With Total Gastrectomies for Gastric Cancer
Calin Tiu, MD
Objective: The objective of this study consist in underlining of several particular aspects of ultrasound examination in patients with gastric cancer, like identification of the main morphological and physiological characteristics of the esophagojejunal anastomosis, jejunal loop emptying evaluation and detailing of the US parameters in following-up of blind duodenal loop.
Patients and Method: 4600 consecutives patients were included in a computed soft protocol dedicated to detection of gastric cancer. On the same time, 66 patients with total gastrectomies performed between1998–2006 were checked by transcutaneous ultrasound focused on esojejunal anastomosis and blind duodenal loop. Standard fat meal it is of help for a better US vision and the histogram function was used to evaluate the emptying of jejunal loop.
Results: The US of esojejunal anastomosis offers certain perspective about wall thickness, surface, suppleness, perianastomotic space, anastomotic diameter, the length of abdominal esophagus, early detection of parietal abnormalities, visualization of supra diaphragmatic migrated anastomosis.
The blind duodenal loop is not accessible for Rx or endoscopy.
It is the main reason to appreciate the real value of transcutaneous ultrasound in pointing out details about duodenal wall thickness, duodenal stump evolution, common hepatic duct, peristaltic, diameter, contain, duodenal wall structure (remaining postoperative duodenitis). The jejunal emptying measurement was realized by applying the histogram function on repeated recordings on proximal jejunal loop, every 15 min, 2 hours long.
Conclusions: Transcutaneous ultrasound act to be the first line method in patients with total gastrectomies. It has a special value in visualization of esophagojejunal anastomosis. Real time follow-up method for the blind duodenal loop. Adequate technique for jejunal emptying measurement.
Ali Uzunkoy, MD
Because of unique location of Turkey as a bridge between Asia and Europe, it is possible to find out the traces of many eastern and western civilizations in the historical background of the Turkish Culture.
Following the 15,000 years of its known history, the current territory of Turkey has been inhabited by many nations which created important and dominant civilizations. The footprints of such civilizations can be detected on the master pieces which have survived until today with their impressive magnificence.
The main part of Turkey called Anatolia still bears the traces of many civilizations.
Gobeklitepe (in Sanliurfa) has been considered the garden of Adem and Eva. Catalhoyuk (in Konya) is the oldest organized settlement in Anatolia.
According to Der Spiegel, the ruins of Garden of Eden (Adam and Eve were expelled from this Eden for eating the forbidden apple) is in Gobeklitepe in Sanliurfa province of Turkey. The findings in Gobeklitepe have caused the previous information about prehistoric times and path to civilization to be requisitioned. 11,000 years old history has been discovered in Southeastern Anatolia. It is believed that the first man to hunt settled in Gobeklitepe.
Scientists have said that the “Balikligol Statue”, discovered during an excavation in Balikligol, is the oldest statue ever discovered. The statue was found in a Neolithic Temple. The statue believed to be 13,500 years old has amazed many archeologists all over the world.
Anatolia has been the land of Turks for about 7000 years. In the last 1000 years Turks founded Seljuk and the Ottoman Empires ruling over the three continents of Asia, Europe and Africa and have builded thousands of monuments, most of which are still actively used.
The effects of Turkish culture are not only seen in Anatolia but lively felt over more than 40 countries which were under the Ottoman rule once.
Common Biliary Duct Lithiasis. Is It Useful to Check and Treat Before Laparoscopic Cholecystectomy
Vincenzo Neri, MD
Introduction: We propose the endoscopic treatment of the choledocholithiasis before the laparoscopic cholecystectomy.
Patients and Methods: In the period 1997-2006 were treated 375 biliary lithiasis: mean age 58 years (range 26-83 years), 132 males, 243 females; among them there are 46 choledocholithiasis (12.2 %) without pancreatitis: in 13 cases there was the clinical evidence of the choledocholithiasis, in 33 cases there was only the suspicion of the choledocholithiasis. All the 46 patients were submitted to an ERCP/endoscopic sphyncterotomy for the treatment.
Results: In 5 cases the MRCP/ERCP do not confirmed the presence of stones; in 6 patients the size and the situation of the stones did not allow the endoscopic removal. So, the sequential therapeutic program with endoscopic extraction of the stones and later the laparoscopic cholecystectomy had a 87 % success rate and 3.3 % complication rate.
The univariate analysis of predictive factors of choledocholithiasis on 33 patients, identified alkaline phosphatase, gamma-GT, direct bilirubin and common biliary duct (CBD) dilatation on abdominal ultrasonography as predictors of choledocholithiasis (p<0.0001). A multivariate analysis subsequently identified alkaline phosphatase, gamma-GT and direct bilirubin as independent predictive factors of choledocholithiasis (p<0.0001); dilatation of the CBD (p=0.0783) did not have statistical significativity.
Conclusions: Often the choledocholithiasis is associated with a mild or absent dilatation of the CBD, doing hazardous the surgical maneuvers on it. The reference to the predictive factors shows feasibility. Then the choledocholithiasis associated with the lithiasis of the gallbladder can be treated by endoscopy with safeness and success before the laparoscopic cholecystectomy.
Laparoscopic Cholecystectomy Routine Intraoperative Cholangiography
Arash Nickkholgh, MD
During the 1990s, a higher rate of iatrogenic biliary tract injuries during laparoscopic cholecystectomy (LC) was reported, and this was attributed to the learning curve for LC. Among the most important reasons for ductal injury during LC, false identification of CBD or hepatic duct as the cystic duct can be prevented by liberal use of intraoperative cholangiography (IOC) and to cautiously interpret the lack of opacification of the proximal CBD as a sign of its closure. Several studies have shown that routine IOC (RIOC) can detect significantly more biliary injuries as well as unexpected biliary anatomy, many of potential surgical relevance. Although it has not been shown to prevent all injuries, RIOC has enabled surgeons to limit and correct biliary injuries earlier, leading to significantly reduced costs and fewer overall operative procedures to correct injuries.
Drains in Laparoscopic Cholecystectomy, Why and Why Not?
Aslan Sakarya, MD
Using drains was once a controversial subject after conventional cholecystectomies. While laparoscopic cholecystectomies became the standard surgical procedure for cholelithiasis, the use of drains became a matter of debate. We retrospectively investigated the LAP cholecystectomy cases in our department. During January 2002 and August 2006 a total of 386 patients underwent LAP cholecystectomy. Eighty-three patients had no drains and 303 patients had a 12F nelaton drain in the Winslow’s foramen inserted through one of the lateral port sites. In the no-drain group and drain group the mean hospital stay time were 1.79 and 1.84 days respectively. The mean drain stay time was 1.20 days. There were 1 post-op intraabdominal hemorrhage and 2 port site infections in the no-drain group and in the drain group 1 biliary fistula due to aberrant biliary canaliculi, 1 post-op intraabdominal hemorrhage, 3 port site infections as well as 1 esophageal perforation and 1 AV block which were not related to the use of drains. It seems that using drains is in the preference of the surgeon although it is logical not to use them while there are no difference between groups in terms of hospital stay and detecting the complications of biliary tract surgery and associated complication rates were similar.
ROBOTICS AND TECHNOLOGY
Arash Nickkholgh, MD
The feasibility of performing different surgical procedures with robotic systems has been demonstrated in different surgical fields. The trend toward robotically assisted minimally invasive surgery needs appropriate training and assessment for mastery of the new technology. Such training should simulate the real clinical setting as much as possible so that it can address the real problems faced by surgeons in a robot-assisted operation. Objective tools for quality control also are necessary for adequate evaluation of the surgical performance with robotic systems. Systematic training for a new surgical robotic system using a clinic-like animal model results in measurable improvement in robotic surgical skills, with surgeons and subsequently patients benefiting from such preclinical training. In an attempt to meet this need, some institutions developed training modules, integrating them into academic surgical programs for this new demanding surgical technique. However, several problems in robotic surgery must be resolved to allow the system to be spread more widely: the price of robots, medical insurance coverage, tactile and force feedback, downsizing, navigation systems, and better adaptation to abdominal operations.
Facing Homeward, Facing the Future
Calin Tiu, MD
Romania is now returning to Europe. Close to the splendid treasure of spirituality of the mankind.
There is a potential for a rich native culture to engage in dialogue with other traditional cultures. Facing to our intrinsic amount of values we have to consider a long and continuous historical process marked by important influences beginning with the ancient times. The main part of Romanian language is Latin, coming from the Roman Empire with the soldiers who never returned back. Surrounded by the Turks, Russians, Hungarians, permanently connected with the Greeks, Austrians, French or Germans we selected, borrowed and fitted usages and manners. The language and Christianity there are the base of 2000 years of Romanian continuity. There are the premises of Romanian national identity. We could mention famous Romanian names: architects, music conductors, surgeons, sculptors, politicians, sportsman and engineers, with recognized contributions in the global benefit of the world. There are many others, not so famous, but highly involved in general progress.
After half century behind the curtain Romania is active again. Facing the future. Developing the infrastructure.
Establishing connections. Creating opportunities. Romania is returning to the world. The world is facing to Romania. Come to Romania in 2007 at the Congress of the International Association of Surgeons and Gastroenterologists. Come to Romania in 2008 at Euroson Congress. And, why not, come in 2009 at the 21st International Conference of Society of Medical Innovation and Technology. I’m waiting for you.
Laparoscopy and Benign Proliferative Disease of the Ovary and Uterus
Liselotte Mettler, Prof Dr Med
Objective: To assess the necessity of minimal destruction of ovarian tissue at ovarian cystectomy or myometrium at myomectomy.
Design: 1) Evaluation of ovarian endocrine response prior and after ovarian cystectomies. 2) Evaluation of uterine well-being after myomectomy.
Setting: University hospital in northern Germany with regular presentation of benign and malignant ovarian tumors.
Patients: 1) Fifty-seven patients with histologically benign, unilateral or bilateral ovarian cystic tumors of at least 3cm in diameter were subjected to a pre-and postoperative endocrine work-up. Laparoscopic ovarian cyst enucleation was performed (18 bilateral and 39 unilateral). 2) 115 patients with laparoscopic myomectomies were evaluated.
Interventions: 1) The ovarian cysts were enucleated and the cystic base was coagulated with bipolar current. The wounds were left open. An adaptation of the ovarian edges with sutures was performed in four cases. 2) The fibroids were enucleated and the myometrium adjusted with deep intramuscular sutures.
Results: 1) The laparoscopic procedures were carried out within 30-100 minutes. No complications occurred. The cysts were extracted in an endobag. During the procedure rinsing was performed with at least 1 liter of Ringer’s lactate. Histological verification showed endometriotic, dermoid, and serous cystomas, and in four cases corpus luteum cysts. Estrogen, progesterone, LH and FSH measurements were taken prior to surgery and in the following 3-5 months, 10 and 20 days after the first day of menstruation. Pre- and postoperative measurements revealed statistically significant lower values of E2, with a slight increase in LH and FSH values. The clomifen stimulation test revealed in 15% of patients a decreased FSH output. The samples taken on day 20 of the cycle pre- and postoperatively revealed statistically significantly lower progesterone output. 2) In 115 myomectomies, the uterine cavity was opened 24 times. No complications occurred and there resulted a consecutive pregnancy rate of 51%. Conclusions: 1) Any surgery on the ovary results in an altered hormonal response of the ovary, especially with regard to estradiol and progesterone values. Thus, ovarian surgery must be performed with utmost care trying to preserve as much ovarian tissue as possible using as little coagulation as possible. Other energy sources may give better results in preservation of underlying ovarian tissue. 2) Laparoscopic myomectomy represents the best surgical treatment today.
Laparoscopy in Geriatric Patients
Aslan Sakarya, MD
It has been estimated that within few decades persons older than 65 will constitute 25% of the world's population, especially in western countries. More and more surgeons will be confronted with elderly patients who need surgical interventions. We investigated retrospectively the patients older than 65 years of age who had undergone laparoscopic procedures in our department during January 2002 and August 2006.There were 66 cases, 45 female and 21 male. The mean age was 68.8 for females and 67.2 for males. There were total 59 comorbid states for these patients including 25 hypertension, 17 chronic arterial disease, 8 COPD, 7 diabetes mellitus, 1 chronic renal failure and 1 congestive heart failure. The laparoscopic procedures for these patients were: 59 laparoscopic cholecystectomies, 4 laparoscopic ventral hernia repairs, 1 laparoscopic inguinal hernia repair, 1 laparoscopic sigmoid colostomy and 1 laparoscopic liver biopsy. No mortality has been seen and only 1 surgical site infection has been encountered in one of the cases as morbidity. With our limited experience it can be said that laparoscopy is safe in geriatric age group with appropriate patient management.
Two and Three Trocars Laparoscopic Appendectomy
Ali Uzunkoy, MD
Despite the first reported laparoscopic appendectomy (LA) was done in 1982, its indications and efficiency are still debated. However, LA has become an increasingly popular surgical alternative technique for acute appendicitis. Besides, laparoscopy has an advantage in suspected diagnosis for appendicitis and it reduces unnecessary appendectomy.
Operative tecniques: Three trocars are generally used for LA. We are using two trocars in LA for uncomplicated appendicites and three trocars for complicated appendicitis.
Pneumoperitoneum is created by inserting a Verres needle through a subumblical skin incision in order to obtain a pressure of 12-14 mmHg. After that, a 10 mm trocar is inserted in this area. At first abdominal cavity is examined with laparoscopic camera inserted through subumlical trocar port. If uncomplicated acute appendicitis is diagnosed, a second trocar of 10 or 12 mm is placed above the base of the appendix and top of the appendix is grasped with endoscopic grasper. Appendix is extracted from abdomen through the trocar canule and appendectomy is performed extra corporally. If complicated appendicitis or retroceacal appendicitis diagnosed, the third trocar of 5 mm is placed. After periappendiceal adhesiolysis, mesoappendix ligated or clipped or stapled. After stapling or ligating appendedix stump, the appendix is divided with scissors and removed through the 10 or 12 mm port.
We planned a prospective study to investigate the outcomes of laparoscopic LA compored to OA. Thirty-five patients who underwent laparoscopic and 37 patients who underwent open appendectomy. Twenty-eight patients underwent two trocars LA and 7 patients underwent three trocars LA.
LA is a safe operation for acute appendicitis and it has an advantage of being explorative, along with shorter hospitalization time, early recovery time and superior cosmetic results. For uncomplicated acute appendicitis, two trocar LA is an easy method and superior than three trocar LA in terms of operating time and cosmatic results.