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PubMed2006

Technique and assessment of sentinel lymph node biopsy usefulness in laparoscopy-assisted distal gastrectomy.

BACKGROUND: Recently, some studies have suggested that sentinel node biopsy also can be applied to gastric cancer. The authors apply sentinel lymph node biopsy in laparoscopy assisted distal gastrectomy to perform it as safe limited surgery. Limited surgery is a procedure in which the extent of lesion resection and lymph node dissection is reduced. The authors demonstrate that intraoperative diagnosis of lymph node metastasis is useful in this respect. METHODS: The study was conducted with 38 patients (29 men and 9 women) who had a preoperative diagnosis of T1 tumor invasion. The patients had a mean age of 66.2 years. Patent blue (1%) was injected submucosally into four or five different sites around the primary tumor at 1 ml per site. Blue-stained lymphatics and lymph nodes could be seen by turning over the greater omentum and the lesser omentum extraperitoneally. If blue nodes were found, biopsy was performed. RESULTS: The mean number of blue nodes dissected was 2.5 +/- 1.9. Intraoperative identification and biopsy of blue nodes could be performed for 35 (92.1%) of the 38 patients. Of the 35 patients in whom blue nodes were identified, 4 (9.7%) had metastases in blue nodes confirmed by intraoperative frozen-section diagnosis. Intraoperative frozen-section diagnosis was negative for blue node metastasis in 31 patients. Postoperative permanent section diagnosis also showed no evidence of lymph node metastasis in these 31 patients (100% accuracy, 0% false-negative rates). CONCLUSION: The reported method allows observation of blue-stained lymphatics up to 2 h after patent blue injection. Sentinel node biopsy was performed in laparoscopy assisted distal gastrectomy, making it technically equivalent to open gastrectomy. Sentinel node biopsy can serve as a method to determine the appropriate use of laparoscopy assisted distal gastrectomy for management of T1 gastric cancer.

Aged↗

PubMed2007

Laparoscopy for impalpable testis: classification-based management.

BACKGROUND: The undescended testis represents one of the most common disorders of childhood. The authors evaluated the safety and efficacy of laparoscopy for the abdominal testis and present a classification of the laparoscopic diagnostic findings to facilitate decision making. METHODS: Between 2000 and 2005, 95 patients (22 bilateral and 73 unilateral testes, for a total of 117 impalpable testes) with a mean age of 5 years underwent laparoscopy. The testis was managed according to a special classification of the diagnostic findings. Testicular position, size, and viability according to technetium-99m ((99m)Tc) were assessed during the follow-up evaluation. RESULTS: The laparoscopic findings were classified into six types: type 0 (no testis or vanished testis proximal to the internal ring; 9 patients [7.5%]); type 1 (atrophic intracanalicular testis; 6 patients [5.4%], for whom no further intervention was administered); type 2 (testis at the internal ring with looping vas; 15 patients [14.5%], for whom laparoscopic orchiopexy was performed); type 3 (testis at the internal ring without looping of the vas; 29 patients [24.7%], for whom laparoscopic orchiopexy also was performed; type 4 (high abdominal testes; 49 patients [41.9%], with Staged Fowler-Stephens orchiopexy performed for 47 testes and laparoscopic orchidectomy for 2 testes; and type 5 (persistence of Müllerian duct structures [PMDS] or other abnormalities; 7 testes [6%]). After a mean follow-up period of 3 years, the laparoscopic orchiopexy testes were of good size and viable, but four testes (8.7%) were at the neck of the scrotum. The laparoscopically staged Fowler-Stephens orchiopexy group showed atrophy in two testes (4.3%), and all were in the bottom of the scrotum. CONCLUSIONS: Classification of the laparoscopic findings facilitates decision making. Laparoscopic orchiopexy is a natural extension of diagnostic laparoscopy for the intraabdominal testis at the internal ring or that seen peeping from it. Laparoscopically staged Fowler-Stephens orchiopexy is the procedure of choice for the high intraabdominal testis not amenable to the one-stage procedure.

Adult↗

PubMed2000

Incidental discovery of pelvic cholelithiasis on diagnostic laparoscopy.

Laparoscopic cholecystectomy, although a safe technique for removal of the gallbladder, is associated with surgery-related complications. We report a complication caused by this procedure in a young woman, in whom a diagnostic laparoscopy led to the incidental finding of retained gallstones in the pelvis. A 30-year-old woman underwent diagnostic laparoscopy for exclusion of an ectopic pregnancy. She had undergone laparoscopic cholecystectomy 3 years before presentation. Diagnostic laparoscopy ruled out ectopic pregnancy, but yellow nodules were noted in her pelvis. Removal of these nodules was not attempted because of their close proximity to the ureter. A biopsy of these lesions confirmed amorphous material suggestive of gall stones. The finding was documented in the case notes and explained to the patient after the procedure.

Adult↗

PubMed2000

Alterations in the immune system and tumor growth in laparoscopy.

BACKGROUND: The explosion in the use of therapeutic laparoscopy during the past decade has focused much research interest on finding a basic scientific support for the clinically apparent attenuation of the stress response to surgery. In particular, the potential impact that attenuation of the immune response to surgery may have on laparoscopy for the cure of malignancy has attracted much attention. METHODS: A review of the published literature on the stress response to laparoscopic surgery and the impact of laparoscopy on tumor growth was performed. RESULTS: Evidence favors an attenuation of the immune response to surgery with laparoscopic cholecystectomy. Whether this is true also of more major procedures such as laparoscopically assisted colectomy for malignancy is currently unclear. In animal models, tumor growth after laparoscopic surgery is less than after laparotomy and depends on the insufflation agent used. CONCLUSIONS: Laparoscopic cholecystectomy appears to be associated with attenuation of the immune response to surgery. The implications of these findings for the future use of laparoscopic surgical techniques for malignant disease remain unclear.

Acute-Phase Reaction↗

PubMed2000

Delayed recognition of inadvertent gut injury during laparoscopy.

Bowel injuries, which may occur as a result of the insertion of an insufflation needle or trocar, are a rare complication of laparoscopy. They are generally recognized either immediately or a few days after the operation. We present a case of laparoscopic perforation of the small intestine in a patient who had undergone previous pelvic surgery for an ovarian carcinoma. On ultrasound (US), the patient had multiple hepatic lesions resembling hepatic metastases. To confirm the diagnosis, laparoscopy with guided liver biopsy was performed on the grounds that this procedure is regarded as more appropriate than CT- or US-guided hepatic biopsy. Veress needle and trocar insertion were performed at a proper distance from the abdominal scar. However, the abdominal cavity was not visible after the trocar's insertion due to the unexpected presence of adhesions. This precluded the continuation of the procedure. In the following days, the patient experienced only mild abdominal discomfort. However, 2 weeks after laparoscopy, the patient presented signs of peritoneal reaction and underwent laparotomy. Adhesion-fixing jejunal loops to the anterior abdominal wall were discovered at the site of the trocar puncture. Moreover, two hiatuses of these loops were observed and sutured. The follow-up was uneventful. As this case illustrates, laparoscopic bowel injuries remain an unpredictable event. Recognition of this complication may occur several days after the procedure, as the tamponating effect of adhesions on the jejunal hiatus delays the involvement of the peritoneum.

Female↗

PubMed2001

Laparoscopy and unsuspected intra-abdominal malignancy with rapid peritoneal spread.

Use of the laparoscopic approach for intra-abdominal malignancy remains controversial because there have been multiple reports of tumor metastases at port sites after laparoscopy. Although several randomized trials have documented no difference in recurrence rates between laparoscopic and open surgery, there are still many questions about the behavior of tumor cells in laparoscopic conditions. The speed of tumor spread and time to recurrence appear to be variable. Abdominal insufflation and other effects of laparoscopy are only now being delineated. It is not clear whether tumor characteristics, preoperative tumor stage, or the laparoscopic milieu itself affect tumor spread during and after laparoscopic surgery. We present an unusual case of very rapid tumor dissemination in a young patient who underwent diagnostic laparoscopy.

Abdominal Muscles↗

PubMed2001

Laparoscopy of a traumatic rupture of a dysontogenetic splenic cyst. A case report.

The role of laparoscopy in the stepped approach to the diagnosis and treatment of blunt abdominal trauma has not yet been fully elucidated. Despite the use of a variety of imaging modalities, it can still be difficult to make a proper evaluation in cases where there are questionable abdominal injuries. In particular, when there is a discrepancy between a bland clinical picture and the results of diagnostic imaging procedures, laparoscopy should be given preference over laparotomy, provided the patient's circulatory situation is stable. Herein we describe a case in which laparoscopy allowed the detection and treatment of a traumatic rupture of a dysontogenetic splenic cyst that had mimicked a rupture of the spleen on both the ultrasound (US) and computed tomography (CT) images.

Abdominal Injuries↗

PubMed2001

Gasless laparoscopy-assisted colorectal surgery.

BACKGROUND: Laparoscopy has gained wide acceptance as a treatment modality in a variety of colonic and rectal disorders. Currently, most laparoscopic procedures are performed using a carbon dioxide (CO2) pneumoperitoneum, which can lead to cardiopulmonary loading and subsequent complications. The object of this study was to assess the feasibility of gasless laparoscopy-assisted colorectal surgery (GLACS) as an alternative method. METHODS: Patients with benign colonic lesions were enrolled in the study. The operative field was exposed with a subcutaneous wire lifting system. A small incision, ~5 cm in length, was made early in the operation. The surgeon operated through the trocar ports and this incision using both laparoscopic and conventional instruments. The cardiopulmonary responses of the patients were monitored continuously during the operation. RESULTS: Fifteen consecutive patients underwent GLACS. In two patients (13.3%), conversion to open surgery was necessary. The exposure and ease of the procedure were acceptable. However, when the patients were stratified into hemicolectomy and sigmoidectomy groups, GLACS scored more favorably in the sigmoidectomy group. There were no operative deaths. One minor complication developed postoperatively. All of the patients recovered uneventfully, with return of bowel function in 2.8 +/- 0.1 days. The mean postoperative hospital stay was 6.4 +/- 0.4 days. The cardiac and pulmonary status of the patients remained stable during the operation. CONCLUSION: Gasless laparoscopy-assisted colorectal surgery is technically feasible; thus, it provides an alternative means for the performance of minimal-access surgery.

Aged↗

PubMed1996

The abdominal drain. A convenient port for second-look laparoscopy.

Abdominal reexploration may occasionally be necessary in cases of doubtful bowel viability and intra-abdominal sepsis. When this is indicated, second-look laparoscopy may be a useful alternative to conventional surgery, because it avoids subjecting an often critically ill patient to the trauma and risks of relaparotomy. Performing the laparoscopy through a cannula fitted to a flexible tube drain, inserted at the first laparotomy or laparoscopy, is proposed. The drain is withdrawn slightly, a laparoscopic cannula is inserted into the drain, pneumoperitoneum is established, and the laparoscope is then passed down the cannula and the drain for exploration. The authors considered this technique in 11 cases and report four cases in which it was used. Therapeutic laparoscopic procedures-e.g., drainage of collections, adhesiolysis, and stroma formation-were carried out in two cases, and laparotomy was required in two. This method is safe, atraumatic, and technically simple, and it can serve diagnostic as well as therapeutic purposes. The simplicity and ease of this method may encourage wider application to benefit more patients.

Abdomen↗

PubMed1998

Emergency laparoscopy for abdominal stab wounds.

BACKGROUND: Management strategies for abdominal stab wounds (ASW) in initially asymptomatic patients range from mandatory explorative laparotomy (EL) to conservative approaches with observation alone. Emergency diagnostic laparoscopy (DL) may play a potential role between these two extremes-hence lowering the rate of unnecessary laparotomies and keeping the rate of missed injuries to a minimum. PATIENTS AND METHODS: At our institution mandatory EL was carried out in every patient with ASW until 1992. In a retrospective study the charts of 43 patients with ASW were reviewed in terms of initial diagnostic procedures, intraabdominal injuries, and course and length of hospital stay. Between 5/1993 and 4/1995 DL was performed in a prospective study in 15 patients with suspected peritoneal penetration (PP) after ASW according to a standardized diagnostic and therapeutic algorithm. RESULTS: In 17 patients (40%) EL showed no PP; 15 (35%) had significant intraabdominal injuries, while 11 patients with PP didn't have lacerations of intraabdominal organs, resulting in an overall rate of nontherapeutic laparotomy of 65%. Mortality was 6% (n = 3), average hospital stay 8 days. Primary DL could exclude PP in 10 out of 15 patients (66%). The remaining five patients (33%) showed PP: In two patients with ASW to the right upper quadrant, intraabdominal injuries could be excluded by DL, and in one patient a low-grade liver injury was treated laparoscopically, thus avoiding laparotomy in a total of 87% (n = 13). In two patients with PP laparoscopy was converted to laparotomy: no pathological finding in one case, splenectomy for spleen laceration in the second patient, resulting in a rate of nontherapeutic laparotomies of 7%. All patients in this series had an uneventful course; average hospital stay was 2.4 days. CONCLUSIONS: DL offers an important diagnostic tool in excluding peritoneal penetration in ASW, hence lowering the rate of unnecessary laparotomies. Given experience and skills, laparoscopy may be used therapeutically in selected cases of ASW.

Abdominal Injuries↗

PubMed1998

Sterile and economic instrumentation in laparoscopic surgery. Experiences with 6,000 surgical laparoscopies, 1990-1996.

BACKGROUND: Because so many common surgical problems can now be addressed by the laparoscopic approach, the issue of sterile processing has to be reconsidered. METHODS: Selected laparoscopic instrumentation was analyzed regarding wear and tear and decontamination after sterile processing following 6,000 surgical laparoscopies carried out between 1990 and 1996 at the Academic Hospital Moabit, Berlin. RESULTS: Fewer than 7.9 (parts of) instruments failed per 100 laparoscopies. Most of the repairs involved scissors. The main problems were blunting, burnt or disconnected electromechanical components, defective insulation, and damaged or lost parts of dismantable instruments. Residues of human blood proteins were detected on a few instruments. The effect of intraluminal rinsing was documented by measuring the iron content (as an indicator for blood contamination). A comparison of costs showed that it was >10 times cheaper to use instrumentation with reusable components. CONCLUSIONS: The sterile processing of economic reusable instrumentation for laparoscopies needs staff well trained in sterile supply. Instrument design should allow easy dismantling and rinsing of internal parts. Insulating compounds present a problem for decontamination. Disinfection with aldehydes before cleaning the lumina of instruments must be avoided because protein coagulation will occur. A tube-in-tube concept for tubular instruments offering compatibility should be favored.

Data Collection↗

PubMed1998

Bedside diagnostic laparoscopy and peritoneal lavage in the intensive care unit.

BACKGROUND: Early diagnosis and treatment of intra-abdominal pathology in critically ill intensive care unit (ICU) patients remains a clinical challenge. The objective of this study is to assess the feasibility of portable, bedside diagnostic laparoscopy (DL) in the ICU for patients suspected of intra-abdominal pathology, and to contrast its accuracy with diagnostic peritoneal lavage (DPL). METHODS: All adult ICU patients for whom a general surgery consultation was requested were eligible. Patients with a recent laparotomy or obvious peritonitis were excluded. All procedures were performed in the ICU. RESULTS: Over a consecutive 16-month period, 12 patients underwent DPL/DL. Ages ranged from 28 to 88 (mean, 72) years. Causative findings were disclosed by DL in five patients, (42%) including intestinal ischemia in two. Perforated diverticulitis, thickened terminal ileum, and nonpurulent peritonitis were found in one patient each. All patients with findings by DL had a positive DPL (WBC > 200 cells/mm3), and one negative laparoscopy was positive by lavage. The average length of time to perform DPL was 14 min, and to complete DL 19 min. One patient underwent laparotomy based on DPL/DL and survived along with three others with negative DPL/DL. Eight patients died (67%), four from their surgically untreated intra-abdominal pathology. One patient sustained a procedure-related complication of bradycardia and high ventilatory airway pressures. Peak airway pressures increased an average of 8 mmHg and were significantly higher (p < 0. 001) than pre-DL pressures without any significant change in end-tidal CO2 or pCO2. There were no statistically significant hemodynamic changes based on mean arterial pressure (MAP), central venous pressure (CVP), or pulmonary artery diastolic pressure (PADP). CONCLUSIONS: Bedside laparoscopy can be performed rapidly and safely in the ICU. In predicting the need for laparotomy, DL was more accurate than DPL.

Abdomen, Acute↗

PubMed1999

Pain after laparoscopy.

BACKGROUND: In the context of the much-heralded advantages of laparoscopic surgery, it can be easy to overlook postlaparoscopy pain as a serious problem, yet as many as 80% of patients will require opioid analgesia. It generally is accepted that pain after laparoscopy is multifactorial, and the surgeon is in a unique position to influence many of the putative causes by relatively minor changes in technique. METHODS: This article reviews the relevant literature concerning the topic of pain after laparoscopy. RESULTS: The following factors, in varying degrees, have been implicated in postlaparoscopy pain: distension-induced neuropraxia of the phrenic nerves, acid intraperitoneal milieu during the operation, residual intra-abdominal gas after laparoscopy, humidity of the insufflated gas, volume of the insufflated gas, wound size, presence of drains, anesthetic drugs and their postoperation effects, and sociocultural and individual factors. CONCLUSIONS: On the basis of the factors implicated in postlaparoscopy pain, the following recommendations can be made in an attempt to reduce such pain: emphathically consider each patients' unique sociocultural and individual pain experience; inject port sites with local anesthesia at the start of the operation; keep intra-abdominal pressure during pneumoperitoneum below 15 mmHg, avoiding pressure peaks and prolonged insufflation; use humidified gas at body temperature if available; use nonsteroidal anti-inflammatory drugs at the time of induction; attempt to evacuate all intraperitoneal gas at the end of the operation; and use drains only when required, rather than as a routine.

Humans↗

PubMed1999

In vitro assessment of back pressure on ventriculoperitoneal shunt valves. Is laparoscopy safe?

BACKGROUND: Whereas there are case reports of laparoscopy in patients with ventriculoperitoneal shunts, there are no studies assessing the potential failure of shunt valves with the increased intra-abdominal pressure of laparoscopy. This study aims to assess this factor. METHODS: An in vitro model was used to assess the potential for retrograde failure of ventriculoperitoneal shunt valves in a commonly used shunt. Nine shunts were subjected to graded increases in back pressure and observed for retrograde valve leak. RESULTS: None of the shunts tested showed any signs of leak associated with the increased back pressure. However, disruption of shunt seals was noted in seven of the nine shunts, occurring at the minimal pressure of 80 mmHg. CONCLUSIONS: There appears to be minimal risk of retrograde failure of the valve system in the ventriculoperitoneal shunt tested. However, tests on different types of ventriculoperitoneal shunts would be needed to confirm these results if laparoscopy is to be considered safe in patients with ventriculoperitoneal shunts in situ.

Equipment Failure↗

PubMed1999

Is laparoscopy safe and effective for treatment of acute small-bowel obstruction?

BACKGROUND: Acute small bowel obstruction (SBO) has been a relative contraindication for laparoscopic treatment due to the potential for bowel distention and the risk of enteric injury. However, as laparoscopic experience has increased, surgeons have begun to apply minimal access techniques to the management of acute SBO. METHODS: A retrospective review was performed of all patients with acute SBO in whom laparoscopic treatment was attempted. Patients with chronic symptoms and elective admission were excluded. Patients treated by laparoscopy were compared to those converted to laparotomy for differences in morbidity, postoperative length of stay, and return of bowel function as evidenced by toleration of a liquid diet. RESULTS: Laparoscopy was performed in 40 patients for acute SBO. The etiologies of obstruction included adhesions (35 cases), Meckel's diverticulum (two cases), femoral hernia (one case), periappendiceal abscess (one case), and regional enteritis (one case). Laparoscopic treatment was possible in 24 patients (60%), but 13 patients required conversion to laparotomy for inadequate laparoscopic visualization (two cases), infarcted bowel (two cases), enterotomy (four cases), and inability to relieve the obstruction laparoscopically (five cases). There were ten complications-one in the laparoscopic group (pneumonia) and nine in the converted group (prolonged ileus, four cases; wound infection, two cases; pneumonia, two cases; and perioperative myocardial infarction, one case). Respectively, the laparoscopic and converted groups had mean operative times of 68 and 106 min a mean return of bowel function of 1.8 and 6.2 days, and a mean postoperative stay of 3.6 and 10.5 days. Long-term follow-up was available in 34 patients. One recurrence of SBO requiring operation occurred in each group during a mean follow-up of 88 weeks. CONCLUSIONS: Laparoscopy is a safe and effective procedure for the treatment of acute SBO in selected patients. This approach requires surgeons to have a low threshold for conversion to laparotomy. Laparoscopic treatment appears to result in an earlier return of bowel function and a shorter postoperative length of stay, and it will likely have lower costs.

Acute Disease↗

PubMed2004

Laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.

Herein, we report the successful performance of a laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for a patient with pancreatic cystadenoma, as a minimally invasive procedure with the preservation of function. The laparoscopy-assisted distal pancreatectomy procedure involved detaching the spleen and the distal pancreas from the retroperitoneum by a hand-assisted procedure, removing them from the peritoneal cavity through a small incision, and detaching the distal pancreas by ligating and transecting the short gastric artery and vein and the branches of the splenic artery and vein, while the spleen and main splenic artery and vein were preserved under direct view. The pancreatic parenchyma was transected with a stapling device (TL-30), and continuous suturing was added to the resected margin. The patient's postoperative course was uneventful; the patient started to eat and walk on postoperative day 2 and was discharged on day 8. It is considered that the combination of hand-assisted and laparoscopy-assisted distal pancreatectomy, with conservation of the splenic artery and vein, is a minimally invasive and clinically useful technique for treating tumors of cystic disease of the pancreas with low-grade malignant potential, or benign solitary neuroendocrine tumors.

Adult↗

PubMed2000

Determining resectability for hepatocellular carcinoma: the role of laparoscopy and laparoscopic ultrasonography.

We reviewed our experience with preoperative determination of resectability in patients with hepatocel-lular carcinoma (HCC) over the last 10 years, and evaluated the role of laparoscopy with laparoscopic ultrasonography (USG) since we instituted this technique in June 1994. From January 1989 to December 1998, 500 of 1741 patients with HCC (28.7%) were considered suitable for hepatic resection after preoperative assessment. Significantly more contrast-enhanced computed tomography (CT) scans and fewer percutaneous USGs or hepatic arteriograms were performed in the 299 patients managed since June 1994 (group 2) than in the 201 patients managed before then (group 1). One hundred and ninety-eight patients in group 2 (66%) underwent laparoscopy with laparoscopic USG. Unresectable disease was found in 41 patients in group 1 (20.4%) (all at laparotomy), and in 68 patients in group 2 (22.7%) (16 at laparotomy without laparoscopic examination, 31 at laparoscopic examination alone, and 21 at laparotomy after an inconclusive laparoscopic examination) (P = 0.5). The most common features of unresectable disease were the presence of bilobar intrahepatic metastases and an inadequate liver remnant with cirrhosis. The adoption of the laparoscopic examination after June 1994 improved the overall resection rate at laparotomy in group 2 from 77.3% to 86. 2%, which was better than that in group 1 (79.6%, P = 0.057). For patients with unresectable disease, the operation time and hospital stay were significantly shorter in group 2. The postoperative morbidity and mortality rates were 9.8% and 4.9%, respectively, in group 1, and 5.9% and 2.9% in group 2. There was no operative morbidity in the 31 patients who had unresectable disease detected by the laparoscopic examination alone. Laparoscopy with laparoscopic USG avoids unnecessary laparotomy, and has a definite role in determining resectability in patients with HCC.

Adolescent↗

PubMed2005

Laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal cancer.

Laparoscopy-assisted low anterior resection (LAR) for low rectal cancer is a difficult procedure, presenting problems with rectal washout, selecting the appropriate distal transection line, and achieving safe anastomosis. To resolve these problems, we used a prolapsing technique to perform laparoscopy-assisted LAR. Total mesorectal excision (TME) is performed laparoscopically. The proximal colon is transected laparoscopically with the aid of an endoscopic stapler, and the distal rectum, including the lesion, are everted and pulled transanally to outside the body. Only washout of and wiping off the distal rectum and intestinal resection are performed extracorporeally. The distal rectum is pushed back through the anus into the pelvis, and intracorporeal anastomosis is completed laparoscopically with a double-stapling technique. Our limited experience suggests that the prolapsing technique helps to prevent problems with laparoscopy-assisted LAR in selected patients with low rectal cancer.

Colectomy↗