Immunological consequences of laparoscopic surgery, speculations on the cause and clinical implications

Background: Immune suppression is an established consequence of surgical stress and trauma. Postoperative changes in the systemic immune system are proportional to the degree of surgical trauma and subsequent immune suppression may be implicated in the development of infectious complications and tumor metastasis formation. Laparoscopic surgery reduces the magnitude of the operative trauma and is thought to preserve postoperative immunological defenses. Methods: Relevant literature concerning postoperative immune functions and laparoscopic surgery was reviewed and clinical implications are discussed. Results: The influence of laparoscopic surgery on the postoperative systemic immune response is significantly less after laparoscopic cholecystectomy than with the conventional approach. Few immunological data are available concerning more advanced laparoscopic procedures. Various animal model studies of postoperative septic complications and tumor growth show that the postoperative preservation of the systemic immune response after laparoscopic surgery can have enormous clinical advantages. Conclusion: Laparoscopic surgery preserves the postoperative immunological defenses. In the future, this may imply a lower number of infections, less local recurrence and even fewer distant metastases. Prospective randomized studies are necessary to see whether these suspected advantages can be demonstrated in clinical practice. Received: 29 December 1998 Accepted: 25 March 1999     

Minimally invasive surgery of the pancreas in progress

Background Laparoscopic pancreatic surgery should be considered as an advanced laparoscopic procedure and should be performed only in institutions with experience in pancreatic surgery by a team with advanced laparoscopic skills.Aim This review discusses the current status of the laparoscopic approach for inflammatory pancreatic diseases and for benign-appearing pancreatic tumors.Results Laparoscopic surgery has been shown to be beneficial in patients with inflammatory tumors located in the body–tail of the pancreas for chronic pancreatitis. Furthermore, patients with pancreatic pseudocysts may be managed with laparoscopic internal drainage (to the stomach, duodenum, or jejunum). Also, laparoscopic or retroperitoneoscopic necrosectomy has been used with success in patients with necrotizing pancreatitis. At present, laparoscopic surgery has proven to be beneficial in patients with cystic pancreatic neoplasms and neuroendocrine pancreatic tumors.Conclusions The laparoscopic pancreatic approach was recently shown to be feasible and safe. Laparoscopy may contribute to reduced operation time and perioperative blood loss, and reduces surgical stress because of developments in devices, improvements in procedures, and advanced techniques.     

Open vs. laparoscopic procedures in bariatric surgery

Conclusions Laparoscopic GBP is a complex advanced laparoscopic operation that accomplishes the same objectives as open GBP but avoids a large upper midline abdominal incision. The differences between laparoscopic and open bariatric surgery are the method of access and exposure. By reducing the size of the surgical incision and the operative trauma associated with the operative exposure, the surgical insult should be less after laparoscopic compared to open bariatric surgery. We reported a reduction in the surgical insult after laparoscopic GBP and believe that this is the physiologic basis for the observed clinical advantages of laparoscopic GBP. The important clinical advantages of laparoscopic GBP are not the reduced length of hospitalization but the reduction in postoperative pain, lower rate of wound-related complications, and faster recovery. Given the currently available evidence-based data, laparoscopic bariatric surgery should be considered the new standard for the treatment of morbid obesity as long as the surgeon has passed the learning curve of the laparoscopic approach.     

A Prospective Evaluation of Laparoscopic Versus Open Left Lateral Hepatic Sectionectomy

Background Left lateral sectionectomy is one of the most commonly performed laparoscopic liver resections, but limited clinical data are actually available to support the advantage of laparoscopic versus open-liver surgery. The present study compared the short-term outcomes of laparoscopic versus open surgery in a case-matched analysis. Materials and Methods Surgical outcome of 20 patients who underwent left lateral sectionectomy by laparoscopic approach (LHR group) from September 2005 to January 2007 were compared in a case-control analysis with those of 20 patients who underwent open left lateral sectionectomy (OHR group). Both groups were similar for: tumor size, preoperative laboratory data, presence of cirrhosis, and histology of the lesion. Surgical procedures were performed in both groups combining the ultrasonic dissector and the ultrasonic coagulating cutter without portal clamping. Results Compared with OHR, the LHR group had a decreased blood loss (165 mL versus 214 mL, P = 0.001), and earlier postoperative recovery (4.5 versus 5.8 days, P = 0.003). There were no significant differences in terms of surgical margin and operative time. Morbidity was comparable between the two groups, but two cases of postoperative ascites were recorded in two cirrhotic patients in the OHR. Major complications were not observed in either groups. Conclusions Laparoscopic resection results in reduced operative blood loss and earlier recovery with oncologic clearance and operative time comparable with open surgery. Laparoscopic liver surgery may be considered the approach of choice for tumors located in the left hepatic lobe.     

Laparoscopic treatment of post renal transplant lymphoceles

Background: Traditionally, a post transplant lymphocele (PTL) is drained by widely opening the wall connecting the lymphocele cavity to the intraperitoneal space via laparotomy. We hypothesize that laparoscopic techniques can be effectively used for the treatment of PTL.Methods: Patients requiring intervention for PTL between 1993 and 2002 were identified via a retrospective review. Results of drainage via laparotomy and laparoscopy were compared.Results: During the study period 685 renal transplants (391 cadaveric, 294 living) were performed. The incidence of lymphocele was 5% [34/685 (36 cases)]. The indications for surgical drainage were local symptoms (69%), graft dysfunction (14%), or both (17%). The mean time to surgical therapy was 4.9 months. Laparoscopic drainage was performed in 25 patients (74%) and open drainage in 9 patients (26%). Open procedures were performed in cases for: previous abdominal surgery (5), undesirable lymphocele characteristics or location (2), or with concomitant open procedures (3). There were no conversions or operative complications in either group. There was no difference in operative time for the laparoscopic group vs the open group (108 ± 6 vs 123 ± 18 min, p = 0.8). Hospital stay was significantly shorter for the laparoscopic group (1.7 ± 0.8 vs 3.8 ± 1.0, p = 0.0007), with 88% of laparoscopic patients being either overnight admissions or same day surgery. Two patients (5%) developed symptomatic recurrences requiring reoperation [1 laparoscopic (4%), 1 open (10%)].Conclusions: Laparoscopic fenestration of a peritransplant lymphocele is a safe and effective treatment. The large majority of patients treated with laparoscopic fenestration were discharged within one day of surgery. Unless contraindications exist, laparoscopy should be considered first-line therapy for the surgical treatment of posttransplant lymphocele.     

Urologic laparoscopy

Recent applications of laparoscopy to urologic surgery have demonstrated the efficacy, safety, and shorter convalescence times with these techniques. Laparoscopy still is the most accurate diagnostic tool for impalpable testes and allows surgeons to select the proper treatment. Because of the need for general anesthesia, laparoscopic varicocelectomy is not considered less invasive than subinguinal low ligation under local anesthesia. However, a future trend toward day surgery might favor laparoscopy, which requires a smaller skin incision and thus enables young men to return to work earlier. Laparoscopic adrenalectomy has been established as a standard operative technique because it offers many advantages in comparison with conventional open surgery. Laparoscopic nephrectomy is also a minimally invasive operation, although the most appropriate method for kidney retrieval has not been determined, and currently in Japan insurance reimbursements are limited to benign disease. Laparoscopic nephrectomy for renal cell carcinoma and upper urinary tract transitional cell carcinoma is very promising, although there is debate on laparoscopic cancer surgery. Furthermore, the recent great success with laparoscopic radical prostatectomy in France is stimulating Japanese investigators. In the 21st century, laparoscopy will be standard for many surgical procedures in urology.     

Training, credentialing, and evaluation in laparoscopic surgery.

Laparoscopic cholecystectomy has become the procedure of choice for the treatment of gallbladder disease. Many general surgeons have incorporated laparoscopic cholecystectomy into their clinical practices, usually after completing a postgraduate didactic and laboratory animal training course. This additional formal training is both appropriate and necessary because laparoscopic surgery involves techniques different from those of traditional celiotomy, and most surgeons who completed their residencies prior to 1992 have had no laparoscopic training. Because additional formal training for practicing surgeons is necessary at this time, it is appropriate for hospitals to mandate separate granting of operative privileges for laparoscopic surgical procedures. In the near future, when graduates of general surgery residency programs have had training in laparoscopic surgery, separate privileges will no longer be necessary, and laparoscopic procedures should be included in the standard privilege category of biliary tract surgery. Once privileges in laparoscopic surgery are granted, laparoscopic operations, like all surgical procedures, should be monitored by peer review to ensure that they continue to be performed safely and appropriately. Only those laparoscopic procedures that are similar to open operations and have been shown by pilot studies to be safe (e.g., cholecystectomy) should be included currently in a surgeon's laparoscopic privileges. Laparoscopic procedures that are very different from proven open procedures and are investigational (e.g., inguinal herniorrhaphy) should be permitted by the hospital only as part of an experimental protocol monitored by an institutional review board. Only after their safety and efficacy have been established should they become part of standard privilege categories.     

Hand-assisted videolaparoscopic surgery of the abdominal aorta: preliminary experience with the first 9 cases

Laparoscopic surgery decreases postoperative pain, shortens hospital stay, and returns patients to full functional status more quickly than open surgery in a variety of surgical procedures. This study was undertaken to evaluate laparoscopic techniques as applied to aortic surgery. Nine patients underwent elective hand-assisted laparoscopic surgery, 8 for obliterative disease and 1 for an aneurysm of the abdominal aorta. Five patients had a left aorto-femoral bypass, 3 patients an aorto-bifemoral bypass, and 1 patient an aorto-aortic bypass after aneurysmectomy. There were no laparotomic conversions and all procedures were completed with transperitoneal hand-assisted laparoscopic surgery. Mean aortic clamping time was 39 minutes and mean operative time 194 minutes. Mean blood loss was 500 ml and the mean postoperative hospital stay was 4.2 days without major complications. At control examinations all grafts were patent. Hand-assisted laparoscopic aortic surgery is feasible, safe, and effective. In selected cases it may be a valid surgical procedure in addition to conventional and endovascular surgery. The advantages observed in our patients were minimal tissue trauma, less postoperative pain and faster postoperative recovery.     

腹腔镜技术诊治脾外伤的临床体会

目的:探讨腹腔镜技术诊治脾外伤的手术技巧与临床效果.方法:回顾分析2010年4月至2012年4月为32例脾外伤患者行腹腔镜手术的临床资料.结果:29例顺利完成腹腔镜手术,3例因损伤脾门血管导致术中出血过多及时中转开腹.手术时间平均(75±26) min,平均住院(7.3±1.8)d,无手术并发症及死亡病例.结论:只要掌握手术指征,治疗团队具有丰富的开放脾外伤手术经验及娴熟的腹腔镜手术技巧,注重手术操作细节,即可迅速、安全地完成腹腔镜手术.     

Laparoscopic Roux-en-Y pancreatic cyst-jejunostomy

Background: The surgical management of pancreatic pseudocysts can be established through a variety of techniques. Internal drainage has consistently proven to be the treatment of choice for both acute and chronic pancreatic pseudocysts. With the growing popularity of minimally invasive surgery and improvements in surgical technique, laparoscopic internal drainage procedures for pancreatic pseudocysts are being attempted. While most authors have focused on laparoscopic cyst-gastrostomies, few have written about laparoscopic cyst-jejunostomies. Methods: In this article, we report our experience with eight laparoscopic Roux-en-Y cyst-jejunostomies. Of the eight patients, six had alcoholic pancreatitis, and two had gallstone pancreatitis. There were five men and three women with a mean age of 48 (range 35–71 years). Results: The mean operative time was 150 min, with a range of 100–215 min. We report a mean EBL of 78 cc, a minor complication rate of 20%, and no major complications or mortalities. Conclusions: These data compare favorably with both open and laparoscopic internal drainage procedures. Laparoscopic cyst-jejunostomy offers a feasible alternative in the minimally invasive management of pancreatic pseudocyst.     

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world,an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery.Thus,a certain sized skin incision is required to remove the resected colon.Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction.We present a case characterized by a laterally spreading type of tumor of the cecum.We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy.Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction.The patient was discharged without complications on postoperative day 4.Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique.Although our method is restricted to flat or small lesions,we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.     

Single incision laparoscopic right colectomy

Objective  

This study was designed to describe the surgical technique for single-incision laparoscopic right colectomy and present preliminary short-term results. Laparoscopic surgery has been fully validated as alternative, minimally invasive treatment for different benign and malignant conditions. In the attempt to reduce even more the surgical trauma, natural orifices transluminal endoscopic surgery (NOTES™) and single-incision laparoscopic surgery (SILS) have been proposed. Although the lack of proper instrumentations makes NOTES™ not fully suitable for advanced procedures, SILS might play a significant role, although, to date, only limited series and few case reports of single-incision right colectomy are present in the literature.     

Metaanalysis of trials comparing laparoscopic and open surgery for Crohn’s disease

Background: Several studies in the literature have suggested that laparoscopic surgery for Crohn’s disease is associated with faster postoperative recovery and a morbidity and recurrence rate similar to that for open surgery. Most of these studies have been limited by a small sample size and a short follow-up period. Methods: To clarify whether open or laparoscopic resection results in a better outcome, a metaanalysis of studies was performed comparing the two procedures for Crohn’s disease. Pooled effects were estimated using a random-effects model. Results: Laparoscopic surgery required more operative time than open surgery (26.8 min; 95% confidence interval [CI], 6.4–47.2 min), but resulted in a shorter duration of ileus and a decreased hospital stay (−2.62 days; 95% CI, −3.62 to −1.62). Laparoscopic surgery also was associated with a decreased rate for postoperative bowel obstruction and surgical recurrences. Conclusions: Laparoscopic surgery for Crohn’s disease is feasible, safe, and associated with shorter duration of ileus and a shorter hospital stay.     

Laparoscopic pancreatic surgery

In the past, in the pancreas, a minimally invasive technique was only used for diagnostic laparoscopy in evaluating periampullary malignancy. Recent advances in operative techniques and instrumentation have empowered surgeons to perform virtually all procedures in the pancreas, including the Whipple procedure. Some of these procedures represent the most sophisticated application of minimally invasive surgery, and their outcomes are reportedly better than those of conventional open approaches. In addition to the evaluation of resectability in periampullary malignancy, palliative procedures, including biliary bypasses and gastrojejunostomy, can be performed laparoscopically. Although it is reportedly feasible to perform a Whipple procedure laparescopically, no benefit of the laparoscopic approach over the conventional open approach has been documented. Laparoscopic distal pancreatectomy, with or without preserving the spleen, is technically easier than the Whipple procedure, and is more widely accepted. Indications for laparoscopic distal pancreatectomy include cystic neoplasms and islet-cell tumors located in the pancreatic body or tail. Complications of acute and chronic pancreatitis may be treated with the use of surgical laparoscopy. When infected necrotizing pancreatitis is identified, surgical intervention for drainage and debridement is required. According to the type and location of infected necrotizing pancreatitis, three laparoscopic operative approaches have been reported: infracolic debridement, retroperitoneal debridement, and laparoscopic transgastric pancreatic necrosectomy. When internal drainage is indicated for a pseudocyst, a minimally invasive technique is a promising option. Laparoscopic pseudocyst gastrostomy, cyst jejunostomy, or cyst duodenostomy can be performed, depending on the size and location of the pseudocyst. Especially when a pseudocyst is located in close contact with the posterior wall of the stomach, it is best drained by a pseudocyst gastrostomy, which can also be done with the use of an intragastric operative technique.     

Laparoscopic esophageal surgery

In its 9-year history, laparoscopic esophageal surgery has become second only to gallbladder surgery in the frequency of minimally invasive procedures performed in routine surgical practice. Laparoscopic fundoplication has assumed a central role in the surgical treatment of gastroesophageal reflux. Laparoscopic myotomy has emerged as the optimal form of therapy for achalasia, and staging laparoscopy has been identified as an important adjunct to the preoperative evaluation of esophageal and gastroesophageal junction carcinoma. Laparoscopic paraesophageal hernia repair and remedial laparoscopic antireflux surgery currently are gaining acceptance. Laparoscopic gastroplasty, esophagectomy, and diverticulectomy are undergoing clinical trials, and their roles remain to be defined.     

普外科腹腔镜手术中转开腹原因的探讨

目的探讨普外科腹腔镜手术中转开腹的原因及其防治.方法回顾分析1999年6月-2005年12月间7574例接受普外科腹腔镜手术病例中83例中转开腹的原因.结果本组中转开腹率为1.10%(83/7574),主要原因为严重的腹腔粘连和大出血,分别为55.4%(46/83)和26.5%(22/83).另有恶性病变,病灶体积过大,器官损伤及暴露困难等.中转开腹率,有腹部手术史者20%(21/105),明显高于无腹部手术史者0.83%(62/7469),差异显著(P＜0.05).结论腹腔镜胰腺、肝、脾手术、有腹部手术史、严重出血和是腹腔粘连是中转开腹重要原因,术前应严格掌握腹腔镜手术指征,腹腔镜手术困难有可能导致严重并发症时应果断中转开腹手术.     

重症急性胰腺炎腹腔镜手术治疗的临床研究

目的 探索重症急性胰腺炎（SAP）微创外科治疗的可行性、时机与方式。方法 运用微创外科技术对13例SAP患者实施腹腔镜手术治疗,其中SAP早期用膜腔及网膜囊大量积液3例、胰腺实质及胰周组织不同程度局限性坏死伴感染4例、胰周囊肿（或）脓肿形成6例,手术方式因SAP不同阶段而异。结果 （１）SAP的急性反应期腹腔粘连轻、腹腔积液未局限,腹腔镜扩创引流术快捷、创伤小、术后恢复快。（2）SAP的亚急性期,尚未形成良好的包裹,组织水肿,腹腔内粘连,此期腹腔镜手术显露困难、出血多、时间长。（3）SAP后期,B超定位导向下的腹腔镜扩创引流术安全、快捷、可靠,13例患者无1例死亡。结论 SAP的腹腔镜外科手术治疗应遵循个体化原则,在熟练掌握腹腔镜操作技能的前提下开展SAP的腹腔镜手术治疗,是安全有效的。     

Impact of previous abdominal surgery on laparoscopic appendectomy for acute appendicitis

Background Laparoscopic appendectomy is one of the most commonly performed laparoscopic procedures. Impact of previous abdominal surgery on laparoscopic appendectomy has not been previously reported. Methods From January 2001 to December 2005, 2029 patients with clinically suspected acute appendicitis underwent laparoscopic surgery in our hospital. Of these, 234 patients (11.5%) were found to have other pathology by intraoperative or histologic findings and were excluded from the study. The 1795 patients who underwent laparoscopic appendectomy for acute appendicitis were divided into three groups: group 1, patients without a history of previous abdominal surgery (n = 1652, 92%); group 2, patients with a history of upper abdominal surgery (n = 20, 1.1%); group 3, patients with a history of lower abdominal surgery (n = 123, 6.8%). Data were collected retrospectively by chart review and analyzed for conversion rate, operative time, intraoperative and postoperative complications, and hospital stay. Results Of the 1795 patients, 13 (0.7%) were converted to open appendectomy because of technical difficulty. Overall mean operative time was 57.2 (range, 20–225) min. There was no mortality or intraoperative complications. Overall postoperative complication rate was 10.7% (n = 193): rate of surgical wound infection was 8.2 % (n = 147), surgical wound seroma 1.3% (n = 24), and intra-abdominal abscess 0.8% (n = 14). Overall postoperative hospital stay averaged 3.2 (range, 0–39) days. There were no significant differences between the three groups regarding the conversion rate (0.8% vs. 0% vs. 0%, p = 0.567), operative time (57.3 vs. 55.8 vs. 56.9 min, p = 0.962), postoperative complication rates (10.7 vs. 10 vs. 12.2%, p = 0.863), and hospital stay (3.2 vs. 3.6 vs. 3.1 days, p = 0.673). Conclusions Previous abdominal surgery, whether upper or lower abdominal, has no significant impact on laparoscopic appendectomy for acute appendicitis.     

血CRP、IL-6、IL-10在不同类型胆囊切除术中的变化研究

目的探讨日间腹腔镜胆囊切除术与常规胆囊切除术两种手术方法对患者血c反应蛋白（CRP）、白细胞介素6（IL-6）、白细胞介素10（IL-10）的影响,比较两种手术对患者身体的损伤程度及优越性。方法90例胆囊疾病患者随机分为两组,60例行腹腔镜胆囊切除术,30例行常规胆囊切除术。其中行腹腔镜胆囊切除术60例病例随机分为两组,30例行腹腔镜胆囊切除术30mjn内完成,30例行腹腔镜胆囊切除术在30min以上完成。比较2种术式手术时间、术前和术后及行腹腔镜胆囊切除术30min内完成和30min以上完成的血C反应蛋白（CRP）、白细胞介素6（IL-6）、白细胞介10（IL-10）的变化,术后抗生素使用率。结果腹腔镜组的手术效果明显优于对照组,血CRP、IL-6、IL-10明显低于对照组（P〈0．05）;腹腔镜手术30min内完成的手术效果明显优于腹腔镜手术30min以上,血CRP、IL-6、IL—10明显低于对照组（P〈0．05）。结论日问腹腔镜胆囊切除术是一种安全可靠的手术方法,与传统的开腹手术相比具有创伤小、出血少、术野清楚、切口美观、术后恢复快、抗生素使用率低、住院时间短等优点,将成为胆囊切除术的首选术式。     

腹腔镜诊治盆腔开放性手术史附件包块患者的临床分析

目的:探讨为有盆腔开放性手术史的附件包块患者行腹腔镜手术的安全性和可行性.方法:2005年1月至2009年12月腹腔镜手术诊治附件包块患者共765例,随机抽取有盆腔开腹手术史112例作为研究组,无盆腔手术史的125例为对照组,对比分析两组患者手术情况,结果:两组在手术成功率、术中出血量、术后胃肠功能恢复时间、住院时间等...