Hepatic cryosurgery via minilaparotomy in a porcine model

Background: Cryosurgery of liver lesions is becoming increasingly accepted for the ablation of liver tumors. Attempts at laparoscopic cryosurgery have been very limited and often need to be converted to open laparotomy due to the complexity of the procedure. Methods: Seven domestic pigs were anesthetized, and 17 small (0.7 cm mean diameter) tumor mimicking agar ``lesions' were percutaneously placed in the liver. Two small subcostal incisions (∼2.0 cm) were placed, and an endocavitary ultrasound transducer (with a 2.4-mm cryoprobe mounted on it) was placed on the liver surface. Lesions were localized and directly punctured with one or two cryoprobes under ultrasound guidance, and a single 15-min freeze was undertaken. The animals were then killed, and their livers were removed and serially sectioned. Results: Total time for probe placement was approximately 10 min after incisions had been made. Animals tolerated the procedure well and all survived until they were killed. No intraabdominal complications were detected at exploration. Mean cryolesion dimensions were 3.0 cm (single probe) and 3.3 cm (dual probe) (p > 0.05). Positive margins were detected in one lesion treated with a single probe, and in none of the lesions treated with dual probes. Mean margins were 0.9 cm: 1.2 cm for the single probe and dual probe techniques, respectively. Liver surrounding control agar lesions demonstrated a thin rim of necrosis, approximately 0.5 mm wide. Conclusions: We conclude that minilaparotomy is an effective, safe, and simple method for performing hepatic cryosurgery in this animal model. This minimally invasive technique may benefit a subset of patients with lesions in accessible locations. Lesions in posterior locations may not be as amenable to this technique due to deterioration of ultrasound image quality in the far field. Received: 10 December 1997/Accepted: 27 March 1998     

Complications of laparoscopic antireflux surgery in childhood

Background: The aim of this study was to assess the complications associated with the laparoscopic treatment of gastroesophageal reflux disease (GERD) in children. Methods: From March 1992 to March 1998, we used the laparoscopic approach to treat 289 children affected by gastroesophageal reflux disease. The patients' ages ranged between 4 months and 17 years (median, 4.3 years), and their body weight ranged between 5 and 52 kg. In 148 children (51.3%), we adopted a Nissen-Rossetti procedure and in 141 (48.7%) a Toupet technique. Results: The duration of surgery ranged between 40 and 180 min (median, 70). There were no deaths and no anesthesiological complications in our series. We recorded 15 (5.1%) intraoperative complications: six pleural perforations, four lesions of the posterior vagus nerve, two esophageal perforations, two gastric perforations, and one pericardiac perforation. Conversion to open surgery was necessary in only four cases (1.3%). We recorded 10 (3.4%) postoperative complications: one peritonitis due to an esophageal perforation not detected during the intervention that required a reoperation, five cases of herniation of the epiploon through a trocar orifice, three cases of dysphagia that disappeared spontaneously after a few months, and one case of delayed gastric emptying that subsequently required a pyloroplasty. We had six recurrences of GERD (2.1%). In two cases, a new fundoplication was performed using the laparoscopic approach; in the other four, the GERD was controlled with medical therapy. Conclusion: Our results show that laparoscopic fundoplication is an adequate treatment for children with GERD that has a low rate of complications. When severe complications do occur, they can be treated effectively via the laparoscopic approach. Received: 16 November 1999/Accepted: 16 December 1999/Online publication: 5 June 2000     

Laparoscopic insufflation of the abdomen reduces portal venous flow

Background: The adverse effects of sustained elevated intraperitoneal pressure (IPP) on cardiovascular, pulmonary and renal systems have been well documented by several reported experimental and clinical studies. Alteration in the splanchnic circulation has also been reported in animal experiments, but details of the exact hemodynamic changes in the flow to solid intraabdominal organs brought on by a raised intraperitoneal pressure in the human are not available. The aim of the present study was to estimate effect of increased IPP on the portal venous flow, using duplex Doppler ultrasonography in patients undergoing laparoscopic cholecystectomy. Methods: The studies were performed using the SSD 2000 Multiview Ultrasound Scanner and the UST 5536 7.0-MHz laparoscopic transducer probe. Details of the measurements were standardized in according to preset protocol. Statistical evaluation of the data was conducted by the two-way analysis of variance (ANOVA). Results: The flow measurement data have demonstrated a significant (p < 0.001) decrease in the portal flow with increase in the intraperitoneal pressure. The mean portal flow fell from 990 ± 100 ml/min to 568 ± 81 ml/min (−37%) at an IPP of 7.0 mmHg and to 440 ± 56 mmHg (−53%) when the IPP reached 14 mmHg. Conclusions: The increased intraperitoneal pressure necessary to perform laparoscopic operations reduces substantially the portal venous flow. The extent of the volume flow reduction is related to the level of intraperitoneal pressure. This reduction of flow may depress the hepatic reticular endothelial function (possibly enhancing tumor cell spread). In contrast, the reduced portal flow may enhance cryo-ablative effect during laparoscopic cryosurgery for metastatic liver disease by diminishing the heat sink effect. These findings suggest the need for a selective policy, low pressure or gas-less techniques to positive-pressure interventions, during laparoscopic surgery in accordance with the disease and the therapeutic intent. Received: 19 March 1996/Accepted: 4 July 1997     

A murine model of laparoscopic-assisted intervention

Background: In order to better investigate the effects of laparoscopic surgery, it is necessary to establish reliable, reproducible, and economical animal models of laparoscopic intervention. Here we describe a mouse model of laparoscopic-assisted colon resection. Methods: After successful induction of anesthesia the mouse is placed in Trendelenburg position and the peritoneal cavity is insufflated with carbon dioxide gas through an angiocatheter placed in the right upper quadrant. A 4-mm rigid scope with camera attachment is then inserted through a midline port created just caudal to the xiphoid. A second port is then created in the right lower quadrant to allow introduction of laparoscopic forceps into the peritoneal cavity. The cecum, which extends 1.5 cm beyond the ileocecal valve, is grasped with forceps and exteriorized through the operative port. Extracorporeally, the cecum is ligated and resected before the cecal stump is returned to the peritoneal cavity. The abdominal wall defects are then stapled closed. Results: This simple model can be mastered by individuals with very limited surgical experience. This laparoscopic model has been used successfully in our laboratory in a number of experiments with an intraoperative complication rate of 3.2% (3/94), which was similar to the open surgery group rate of 2.1% (2/95, p= 0.99 by chi square). We observed no postoperative leaks in either group. The only postoperative death occurred in the open resection group due to dehiscence of the laparotomy wound. Conclusions: We propose that this model may be useful for comparing the effects of open to laparoscopic surgery. Received: 19 June 1996/Accepted: 2 November 1996     

Use of CT Hounsfield unit density to identify ablated tumor after laparoscopic radiofrequency ablation of hepatic tumorsrid=""id=""Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Atlanta, Georgia, USA, 29 March–1 April 2000

Background: When attempting to interpret CT scans after radiofrequency thermal ablation (RFA) of liver tumors, it is sometimes difficult to distinguish ablated from viable tumor tissue. Identification of the two types of tissue is specially problematic for lesions that are hypodense before ablation. The aim of this study was to determine whether quantitative Hounsfield unit (HU) density measurements can be used to document the lack of tumor perfusion and thereby identify ablated tissue. Methods: Liver spiral CT scans of 13 patients with 51 lesions undergoing laparoscopic RFA for metastatic liver tumors within a 2-year time period were reviewed. HU density of the lesions as well as normal liver were measured pre- and postoperatively in each CT phase (noncontrast, arterial, portovenous). Statistical analyses were performed using Student's paired t-test and ANOVA. Results: Normal liver parenchyma, which was used as a control, showed a similar increase with contrast injection in both pre- and postprocedure CT scans (56.4 ± 2.4 vs 57.1 ± 2.4 HU, respectively; p= 0.3). In contrast, ablated liver lesions showed a preablation increase of 45.7 ± 3.4 HU but only a minimal postablation increase of 6.6 ± 0.7 HU (p < 0.0001). This was true for highly vascular tumors (neuroendocrine) as well as hypovascular ones (adenocarcinoma). Conclusions: This is the first study to define quantitative radiological criteria using HU density for the evaluation of ablated tissues. A lack of increase in HU density with contrast injection indicates necrotic tissue, whereas perfused tissue shows an increase in HU density. This technique can be used in the evaluation of patients undergoing RFA. Received: 1 March 2000/Accepted: 4 April 2000/Online publication: 9 August 2000     

Laparoscopic treatment of gastric stromal tumors

Background: The laparoscopic resection of gastric stromal tumors (GST) is being performed with increased frequency. Methods: Between November 1993 and October 1998, nine consecutive patients with benign and low-grade gastric stromal tumors underwent laparoscopic resection using intraoperative endoscopy. For lesions located on the anterior wall (three cases), a direct approach was utilized. Lesions located on the posterior wall were resected via a transgastric approach (four cases) or through a small opening on the omentum or on the gastrocolic ligament (two cases). Excision of the lesions was performed manually by means of electrocautery and scissors in eight cases; the gastric incisions were closed by manual running suture. An endoscopic stapler device was used in one case only. Results: All patients were successfully treated laparoscopically; there were no conversions to open surgery. Operative time ranged from 75 to 120 min. There was one bleeding from the suture line of the gastric wall postoperatively that was treated conservatively. The average postoperative hospital stay was 4 days (range, 2–6). Conclusions: In light of the results reported in the literature and on the basis of the present work, it seems that laparoscopic resection of GST should be considered as the treatment of choice. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. In our opinion the direct approach should be reserved for lesions located on the posterior wall of the body, which can be easily reached through the greater omentum, while the transgastric approach should be preferred for lesions located on the fundus and antrum. Manual excision allows a tailored operation; hand-sewn sutures are always feasible, and they are cheaper than stapled ones. Received: 30 April 1999/Accepted: 7 October 1999/Online publication: 10 April 2000     

Laparoscopic interval appendectomy for periappendicular abscess

Background: Laparoscopic appendectomy was first described in the early 1980s and is currently widely used for the treatment of acute appendicitis. The application of laparoscopic techniques to interval appendectomy and the value of this procedure as compared to open elective interval appendectomy remains uncertain. Therefore, we set out to assess the usefulness of interval laparoscopic appendectomy following periappendicular abscess. Methods: This study analyzes the data for 10 patients who underwent interval laparoscopic appendectomy 8–10 weeks following documented periappendicular abscess in the period between January 1996 and June 1998. Results: Laparoscopic appendectomy was completed successfully in all 10 patients. Nine patients were discharged 1 day after the operation; one patient was discharged on the evening of the operative day. There were no complications and no wound infections. Conclusion: We conclude that the laparoscopic approach is the preferable treatment for interval appendectomy. It is associated with minimal or no morbidity and a very short hospital stay. Received: 13 May 1999/Accepted: 9 December 1999/Online publication: 12 July 2000     

Techniques for intrasplenic hepatocyte transplantation in the large animal model

Background: The preferred therapy for acute and chronic liver insufficiency and severe heritable disorders of liver metabolism is whole-organ transplantation. However, due to the shortage of organ doproposed, including transplantation of normal allogeneic hepatocytes. Recently, it has been reported that many hepatocytes transplanted into the spleen migrated to the liver. We therefore carried out a series of large-animal experiments to reexamine the intrasplenic route and to develop a method for large-scale hepatocellular transplantation in pigs. Methods: Allogeneic porcine hepatocytes were transplanted using the following routes: (1) retrograde injection of cells via the splenic vein, (2) intraarterial injection of cells, (3) direct intrasplenic injection of cells after laparotomy, (4) percutaneous intrasplenic injection of cells under laparoscopic control, (5) laparoscopic intrasplenic injection of cells. The number of cells injected varied from 2 × 10⁹ to 10 × 10⁹ cells. Results: Of all the methods tested, only direct intrasplenic injection of 2 bln of cells was found to be compatible with survival. However, even with this ``small' number of cells (2% original liver mass), there was a significant risk of spleen infarction, perisplenic adhesion formation, and portal vein thrombosis. The laparoscopic approach was found to be reliable, simple, and safe. Conclusion: Even though the spleen is considered by many authors the optimal site for hepatocellular transplantation, transplantation of cells in a number needed to support the failing liver may be associated with significant complications, morbidity, and mortality. Received: 2 March 1996/Accepted 17 May 1996     

The effect of high-definition imaging on surgical task efficiency in minimally invasive surgery

Background: In 1995, when we first used a high-definition television (HDTV) video system during a laparoscopic cholecystectomy in Tuebingen, we were surprised by the excellence of the spatial impression achieved by an image with improved resolution. Although any improvement in vision systems entails a trade-off among cost, quality, and complexity, high-definition imaging may well become an essential part of 3-D video systems. The aim of this experimental study was to assess the impact of high definition on surgical task efficiency in minimally invasive surgery and to determine whether it is preferable to use a 3-D system or a 2-D system with perfect resolution and color—for instance, HDTV or the three-chip charge-coupled device (3CCD). Methods: We compared a 3-D video system with the vision through a stereoscopic rectoscope for transanal endoscopic microsurgery (TEM). Because its stereoscopic direct vision is not restricted to either shutter technology or video resolution, TEM optics represents the state of the art. For objective comparison, inanimate phantom models with suturing tasks were set up. The setups allowed the approach of parallel instruments as in TEM operations or via a laparoscopic approach, with oblique instruments coming laterally. Both types of procedure were carried out by highly experienced laparoscopic surgeons as well as those inexperienced in endoscopic surgery. These volunteers worked under 3-D video vision and/or TEM vision. Altogether, the model tasks were performed by 54 different persons. Results: The evaluation did not show a significant (p > 0.05) difference in performance time in all models, but there was a clear trend showing the benefit of a higher resolution. Conclusion: We found a tendency for both endoscopically inexperienced and experienced surgeons to benefit from the use of a system with improved resolution (direct vision) rather than a 3-D shutter video system. Received: 9 November 1998/Accepted: 19 April 1999     

Effectiveness of a hands-on training course for laparoscopic spine surgery in a porcine model

Background: Although it is widely proposed that surgeons, before introducing a novel laparoscopic technique in man, should practice in an appropriate animal model for acquisition of the necessary technical skills, the effectiveness of those hands-on training courses are rarely documented. Methods: In 1995 we have organized eight hands-on training courses for laparoscopic anterior interbody spine fusion in an in vivo porcine model. A total of 72 colleagues from 50 different centers of 12 countries participated, including orthopedic, trauma, visceral, neuro-, and vascular surgeons. Quality and effectiveness of the course were evaluated by a questionnaire after a 1.5- to 2.5-year period. Results: During this time, 42.2% of the participating centers had applied the new technique successfully in man. Centers which participated in the course with a team that included a skilled laparoscopic surgeon and an orthopedic or trauma surgeon introduced the technique more frequently to clinical practice (57.9%) than those represented by only one participant (30.8%). Moreover, there was a tendency toward a more frequent introduction of the technique to clinical practice in centers associated with university hospitals (57.1% vs. 29.2%), indicating the requirement of a particular infrastructure for this complex interdisciplinary procedure. Almost all participants (98.3%) agreed that for novel surgical techniques requiring advanced technical skills, there should first be training in a large animal model before the technique is applied in man. Conclusions: Complex laparoscopic procedures (i.e., laparoscopic spine surgery) can be successfully learned by in vivo hands-on training courses. We propose that for refinements and modifications of the technique (e.g., the lumboscopic approach), there should also first be training in a large animal model before these are applied in man. Received: 30 July 1997/Accepted: 26 March 1998     

Laparoscopic Collis gastroplasty and Nissen fundoplication

Background: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In our experience, ∼20–25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap. Methods: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying the technique clinically in 1996. We performed 220 laparoscopic antireflux procedures between January 1996 and July 1997. Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy. Results: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed by patient-initiated symptom scores. Conclusions: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of a minimally invasive approach. Received: 8 September 1997/Accepted: 17 December 1997     

Laparoscopic gastro- and hepaticojejunostomy for palliation of pancreatic cancer

Background: Most patients presenting with pancreatic cancer are irresectable at the time the diagnosis is made. Therefore, they are in need of palliative treatment that can guarantee minimal morbidity, mortality, and hospital stay. To address this need, we designed a study to test the feasibility of laparoscopic gastroenterostomy and hepaticojejunostomy and to compare their results with those achieved with open techniques. Methods: We performed a case control study of a new concept in laparoscopic palliation based on the findings of preoperative imaging and diagnostic laparoscopy. Laparoscopic side-to-side gastroenterostomy and end-to-side hepaticojejunostomy (Roux-en-Y) were done in irresectable cases. Of 14 patients who underwent laparoscopic palliation, three had a laparoscopic double bypass, seven had a gastroenterostomy, and four underwent staging laparoscopy only. The results were compared with a population of 14 matched patients who had conventional palliative procedures. Results: Postoperative morbidity was 7% vs 43% for laparoscopic and open palliation, respectively (p < 0.05). There were no mortalities in the laparoscopic group, as compared to 29% in the group who had open bypass surgery (p < 0.05). Postoperative hospital stay averaged 9 days in the laparoscopic group and 21 days in the open group (p < 0.06). Operating time tended to be shorter in the laparoscopic group (p < 0.25). Morphine derivatives were necessary for a significantly shorter period after laparoscopic surgery (p < 0.03). Conclusions: Our preliminary experience strongly suggests that laparoscopic palliation can reduce the three major drawbacks of open bypass surgery—i.e., high morbidity, high mortality, and long hospital stay. Received: 24 February 1999/Accepted: 13 May 1999     

Laparoscopic treatment of large paraesophageal hernias

Background: We set out to evaluate the results of the laparoscopic treatment of large paraesophageal hernias in 22 patients. Methods: Between 1993 and 1998, we operated on 22 consecutive patients. Preoperative assessment consisted of endoscopy, barium esophagogram, 24-h pH testing, manometry, and gastric emptying times. Results: In the first three patients, the sac was not excised and gastropexy was not performed. Because of recurrences, we decided to change the technique in an attempt to avoid further complications. During middle- to long-term follow-up, only three recurrences were seen in the subsequent 19 patients. There were no deaths in this series. Conclusions: Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic treatment, both resection of the sac and some form of gastropexy are imperative. Received: 22 March 2000/Accepted: 30 April 2000/Online publication: 20 September 2000     

Laparoscopic treatment of hydatid cysts of the liver and spleen

Background: The short-term results from laparoscopic treatment of hydatid cysts of the liver and spleen were reported previously. The procedure was shown to be feasible and safe, offering the advantages of laparoscopic surgery. This is the first report on the long-term follow-up of this operation in a large group of patients. Methods: In this study, 108 hydatid cysts of the liver and spleen in 83 consecutive patients (43 males [52%] and 40 females [48%]) were approached laparoscopically. The mean age of the patients was 40 years (range, 13–85 years). There were 104 liver cysts and 4 spleen cysts. The liver cysts were located in the right lobe in 42 patients (53%), in the left lobe in 21 patients (26%) and in both lobes in 16 patients (21%). Of the 104 cysts, 44 (42%) were uniloculated and 60 (58%) were multiloculated. Results: All cysts were approached laparoscopically. The mean operative time was 80 min (range, 40–180 min). The conversion rate was 3%. The mean hospital stay was 3 days (range, 2–7 days). There were no mortalities, and complications occurred in nine patients (11%). All were managed conservatively except one patient in whom a laparotomy was needed. All patients were followed up for a mean period of 30 months (range, 4–54 months) with serological testing and ultrasonography if needed. In three patients (3.6%) recurrence of the disease developed. Conclusion: The laparoscopic approach to uncomplicated hydatid cysts of the liver and spleen is a safe and effective option with favorable long-term results. Received: 27 August 1998/Accepted: 13 July 1999     

Laparoscopic treatment of lymphocele after kidney transplantation

Background: Laparoscopic treatment of pelvic lymphocele secondary to kidney transplant has gained popularity in the last few years, although lesions of the urinary tract (ureter, renal pelvis, and bladder) have been reported frequently. To evaluate the result of this treatment and the associated risk of urinary tract lesions, we reviewed our experience and reports in the medical literature on open and laparoscopic surgery. Methods: From 1991 to 1999, we laparoscopically treated 12 patients (7 men and 5 women; median age, 43 years; range, 17–59 years) with symptomatic pelvic lymphocele causing a deterioration of renal function because of compression on the ureter in 10 of the 12 patients and lymphocele compression of the iliac vein in the other 2 patients. In nine patients, the lymphocele wall was opened and sutured to the peritoneum to keep the window open. In two patients, an omentoplasty was performed, and in the remaining patient, both techniques were used. All patients were followed up clinically with ultrasound and biochemistry for a median period of 33 months (range, 1–96 months). Using Medline, we reviewed the medical literature from 1980 to 1998 and collected 252 cases in which operations had been performed to drain an internal lymphocele secondary to kidney transplantation. Results: Laparoscopic treatment was successful in 11 of the 12 patients. One patient was converted to open surgery because of a lesion in the transplanted ureter. One patient needed repeat laparoscopy 24 hours after the operation because of bleeding from the peritoneal window. The median duration of the operation was 120 min (range, 70–200 min), and the median postoperative hospital stay was 5 days (range, 2–12 days). None of the patients needed to discontinue oral cyclosporine assumption. The serum creatinine level dropped significantly after surgery (p < 0.05). No symptomatic recurrences were observed. Of the 252 patients found in the medical literature, in 129 the procedure was performed with open surgery and in 123 laparoscopically (our 12 patients included). The prevalence of iatrogenic lesions to the urinary tract increased threefold with the use of laparoscopic surgery (from 1.6% in open surgery to 7% in laparoscopy). The recurrence rate of symptomatic lymphocele, however, decreased from 15% to 4%. Conclusions: Laparoscopic drainage of posttransplantation lymphocele is a relatively simple method for treating this complication, although it bears the burden of an increased incidence of urinary tract lesions, as confirmed by a review of the literature. The major advantage of the laparoscopic approach is the absence of postoperative ileus with the opportunity to continue the enteral immunosuppressive regimen and a lower recurrence rate. These data suggest that laparoscopic lymphocele treatment might be considered the therapy of choice, provided the iatrogenic lesions of the urinary tract diminish as more experience with this technique is gained. Received: 1 March 1999/Accepted: 1 July 1999     

Long-term results after laparoscopic unroofing of solitary symptomatic congenital liver cysts

Background: Reports about laparoscopic management of symptomatic nonparasitic liver cysts are increasing, proving the procedure feasible and safe. However, late results of endoscopic unroofing currently are not available. The primary aim of the study was to offer long-term results with a follow-up of more than 5 years. Two diagnostic pitfalls are presented. Methods: Preoperatively, diagnosis was established by sonography, computed tomography (CT) scan, echinococcus serology, and tumor-marker measurement. The outcome of 12 laparoscopic fenestrations in 11 patients with symptomatic solitary liver cysts is presented. Nine patients were reexamined after a median observation time of 3.1 years (range, 0.6–6.4 years) by clinical investigation and ultrasonography, CT scan, or magnetic resonance imaging (MRI), respectively. Results: All operations could be finished laparoscopically, and no death occurred. Simultaneous cholecystectomy was performed in six cases. All patients experienced immediate relief of symptoms. Postoperatively, no complications were observed except one patient with unilateral brachial vein thrombosis. Histologically, we discovered one hydatide cyst and one cystadenoma underlying the cystic disorder leading to further therapy. At follow-up, one of the remaining seven patients (14.3%) suffered symptomatic recurrence and successfully underwent reoperation endoscopically. Conclusions: The results of this study confirm the outcome reported previously after short- and intermediate-term follow-up showing that laparoscopic management of symptomatic solitary nonparasitic liver cysts is permanently successful in a large majority of cases when diagnosis is correct. Received: 16 July 1998/Accepted: 17 December 1998     

Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases

Background: Kuzmak's gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study was to analyze the complications of this approach. Methods: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique. A minimally invasive procedure using five trocars was performed. Results: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications: There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis. One fatality on the 45th day in a patient with a Prader-Willi syndrome. Conclusion: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure. Received: 28 May 1996/Accepted: 25 July 1996     

Videoscopic surgery under local and regional anesthesia with helium abdominal insufflation

Background: High-risk patients may not be good candidates for laparoscopic surgery due to the metabolic consequences of transperitoneal absorption of insufflated CO₂ gas and the necessity of general anesthesia because CO₂ insufflation produces pain. Helium gas is metabolically inert and does not produce pain. Thus it permits an alternative approach to performing laparoscopic surgery in high-risk patients. Methods: Laparoscopic cholecystectomy, appendectomy, hernia repair, and peritoneal dialysis catheter procedures were performed under local or regional anesthesia in high-risk patients utilizing helium gas as the insufflation agent. Results: Twenty-one patients underwent laparoscopic procedures under local or regional anesthesia. None of the procedures initiated under local-regional anesthesia required abandonment of the laparoscopic approach or conversion to general anesthesia. There were no operative or perioperative mortalities. Two incidences of pneumothorax occurred with extraperitoneal hernia repair; one required a tube thoracostomy. Conclusions: Helium gas should be considered the agent of choice for intraperitoneal insufflation in high-risk patients not only because helium avoids the metabolic consequences of CO₂ insufflation but also because it permits selected procedures to be performed under local-regional anesthesia. Helium may be contraindicated for laparoscopic procedures involving extraperitoneal insufflation due to the increased risk for pneumothoraces. Received: 15 April 1998/Accepted: 25 August 1998     

Conversion factors for laparoscopic splenectomy for immune thrombocytopenic purpura

Background: Since 1994, 27 patients at our institution have undergone laparoscopic splenectomy for immune thrombocytopenic purpura (ITP). Laparoscopic splenectomy was completed in 22 of these patients. We sought to identify factors that precluded successful laparoscopic splenectomy in the remaining 5 patients. Methods: Retrospective review of 27 patients with ITP undergoing laparoscopic splenectomy was performed at Duke University Medical Center from August, 1994 to September, 1997. Results: Laparoscopic splenectomy was performed in 16 women and 11 men with a mean age of 47.2 years. Five (18%) of these procedures were converted to open splenectomy. There was no significant difference in age, ASA score, gender, weight, height, or splenic size between the converted and laparoscopic groups. However, preoperative and postoperative platelet counts were significantly higher in the laparoscopic group than in the converted group (p < 0.001). Operative times also were significantly longer for the laparoscopic group than for the converted group (p < 0.001). Adherent adjacent structures, associated comorbidities, and technical errors prohibited laparoscopic completion in five patients. Technical errors with subsequent bleeding required conversion in two patients. A thickened greater omentum blanketing the splenic capsule and a densely adherent pancreatic tail extending well into the splenic hilum prevented laparoscopic completion in two patients. Increased peak airway pressures greater than 60 mmHg after pneumoperitoneum necessitated conversion in the remaining patient, who had a previous history of pulmonary insufficiency. Regardless of surgical approach, all patients achieved a therapeutic response after splenectomy. Splenectomies completed laparoscopically resulted in a significantly shorter length of hospital stay (p < 0.01). Conclusions: Densely adherent adjacent structures, technical errors, and cardiopulmonary instability may preclude successful completion of laparoscopic splenectomies. Thorough preoperative evaluation with an emphasis on the cardiopulmonary system may elicit a cohort of individuals with ITP who are unlikely to undergo laparoscopic splenectomy successfully. This cohort also may include individuals with preoperative platelet counts less than 35,000 mm⁻³. Received: 15 April 1998/Received: 15 January 1999     

Pneumoperitoneum risk prognosis and correction of venous circulation disturbances in laparoscopic surgery

Background: This study was initiated to find a method of determining the prognosis for possible changes in hemodynamic and respiratory parameters in patients with pneumoperitoneum (PP). Methods: We devised a model for a pseudopneumoperitoneum (PPP), which is created by encircling the wide pneumochamber on the entire abdomen and inflating it to a preset pressure. To verify the prognostic possibilities of the proposed model, we studied the pneumotachygraphy parameters, noninvasive and invasive monitoring parameters of PPP after induction of anaesthesia, and venous circulation disturbances, as well as the medical effect of the intermittent sequential compression device. Results: In healthy patients, the restrictive lung syndrome did not approach the risky limit. In patients ≥60 years old, this syndrome was very close to the limit. In a number of patients with serious cardiovascular and pulmonary pathology, the pressure of >10 mmHg was considered to be intolerable. Lung compliance, which was the parameter most sensitive to the increased intraabdominal pressure, was 47 ± 10 at baseline, and 29 ± 4 (p > 0.05) at both PPP and real PP (14 mmHg). Conclusions: The PPP model is quite similar to the real PP and can be used for preoperative prognosis in laparoscopic surgery. The elevated intraabdominal pressure results in a significant disturbance of venous blood flow in the lower extremities. The use of the device for peristaltic pneumomassage of the lower limbs is effective in correcting negative changes in venous hemodynamics in laparoscopic surgery. Received: 28 July 1997/Accepted: 12 January 1998