Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve

Background: Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery. Methods: The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach, and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric bypass was performed. Results: The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of the stomach and surrounding upper abdominal organs. Conclusions: The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to decrease operation time. Received: 18 September 1996/Accepted: 26 December 1996     

Hand-assisted laparoscopic splenectomy for hydatid cyst

Splenic hydatidosis is a rare condition. We performed a hand-assisted laparoscopic splenectomy for a large hydatid cyst localized in the center of the spleen. We discuss the advantages of the ``helping hand.' Received: 27 September 1996/Accepted: 19 November 1996     

Semiautomatic suturing device (Maniceps®) for laparoscopic surgery

The only automatic device now available to laparoscopic surgeons is Endo-Stitch?, which is costly for single use and has the disadvantage of leaving a large needle hole in the tissue. A semiautomatic suturing device (Maniceps?) for laparoscopic use was developed from a forceps-type of needle holder for open pelvic surgery. The first generation of the instrument was designed for use with the abdominal wall-lift method of laparoscopic surgery, whereas the second generation can be applied for gas insufflation as well. Exchange of the needle is done by an automatic grasping action of a resilient slit in one jaw and by manual pull-down of the needle via the thread onto the other jaw. The new instrument was employed in 10 cases of laparoscopic surgery for various procedures including suture of the perforated gallbladder wall and running suture of the peritoneum after mesh placement in transabdominal repair of inguinal hernia. Maniceps? provides an economic advantage and has the merit of a smaller needle hole. Received: 4 February 1998/Accepted: 18 March 1998     

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     

Laparoscopic splenectomy

Background: With the evolution of laparoscopic surgery comes the need for specific instruments that apply traction to parenchymal tissue, like the spleen, without exposing the organ to the associated high risk of bleeding. To meet this need, we designed and developed a suction-cup grasper that allows easy grasping and manipulation of the spleen. Some of the difficulties usually encountered during laparoscopic splenectomy may be overcome by using this device. Materials: The instrument consists of a cone-shaped, silicone rubber suction cup designed with an antislip internal surface. The cup is connected to a support arm with a flexible distal end that can be rotated. Traction is exerted with a commonly available suction system. The device is inserted through a 12-mm-diameter guide sheath. Results: The two interventions performed with the atraumatic device were completed with laparoscopic technique. No complications arose during or after the operations. The average operating time was 110 min. The patients were discharged after 4 and 5 days postoperative, respectively. Conclusions: As a device specifically designed for grasping parenchymal organs, the atraumatic suction grasper affords the operator a faster and safer technique in laparoscopic splenectomy. Received: 18 October 1996/Accepted: 16 May 1997     

Long-term results after laparoscopic cholecystotomy in a child with symptomatic gallstone disease

Cholecystotomy has been suggested for symptomatic gallstone disease in selected children. This suggestion is supported by a potential reduction in the frequency of the so-called postcholecystotomy syndrome. To our knowledge, laparoscopic cholecystotomy has not been reported yet. However, gallstone recurrence has been reported up to 4 years after conventional cholecystotomy and therefore we waited to publish our results for that period of time. A 12-year-old girl with idiopathic symptomatic gallstone disease and a normal kinetic of the gallbladder underwent laparoscopic cholecystotomy. The laparoscopic technique was similar to laparoscopic cholecystectomy but the gallbladder was left in place and multiple gallstones were removed. Intraoperative cholecystoscopy revealed three additional small stones. They were removed by subsequent lavage of the gallbladder. Choledocholithiasis was excluded by intraoperative cholangiography and the gallbladder was closed using an Endo GIA. There were no intraoperative or postoperative events. The patient is free of complaints without recurrent gallstones on ultrasound examination today, 4 years after the operation. Laparoscopic cholecystotomy represents a feasible alternative to laparoscopic cholecystectomy. Received: 10 May 1996/Accepted: 29 May 1996     

A flower-shaped cannula for three-incision laparoscopic cholecystectomy

A simple flower-shaped cannula, in which up to three laparoscopic instruments can be inserted and manipulated freely, is described. Using this cannula, a three-incision gasless laparoscopic cholecystectomy can be performed easily. Received: 5 July 1996/Accepted: 12 September 1996     

A comparison of surgeons' posture during laparoscopic and open surgical procedures

Background: There is increasing recognition of surgeons' physical fatigue in the new ergonomic environment of laparoscopic surgery. The purpose of this study was to determine what the differences are in the movement of the surgeon's axial skeleton between laparoscopic and open operations. Methods: Surgeons' body positions were recorded on videotape during four laparoscopic (LAP) and six open (OP) operations. The percent of time the head and back were in a normal, bent, or twisted position as well as the number of changes in head and back position were tabulated using a computer program. A separate laboratory study was performed on four surgeons ``walking' a 0.5-inch polyethylene tubing forward and backward using laparoscopic and open techniques. The movements of the surgeons' head, trunk, and pelvis were measured using a three-camera kinematic system (Kin). The center of pressure was recorded using a floor-mounted forceplate (Fp). Results: In the operating room surgeons' head and back positions were more often straight in laparoscopic procedures and more often bent in open operations. The number of changes in back position per minute were significantly decreased when the laparoscopic-only part of surgery was analyzed. In the laboratory the subjects' head position was significantly (p= 0.02) more upright and the anteroposterior (AP) and rotational range of motion of the head was significantly reduced during laparoscopy. Subjects' CP was more anterior and there was a significant reduction in the AP range of motion of the CP during laparoscopy. Conclusions: Our study suggests that surgeons exhibit decreased mobility of the head and back and less anteroposterior weight shifting during laparoscopic manipulations despite a more upright posture. This more restricted posture during laparoscopic surgery may induce fatigue by limiting the natural changes in body posture that occur during open surgery. Received: 3 March 1996/Accepted: 2 July 1996     

Laparoscopic fundoplication in infants and children

Background: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication. Methods: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures. Results: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%). Conclusion: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication. Received: 22 March 1996/Accepted: 12 June 1996     

Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children

Infants and children requiring fundoplication for gastroesophageal reflux frequently have significant associated medical problems necessitating placement of a gastrostomy at the time of fundoplication. This article reviews the techniques, complications, and results of 141 laparoscopic Stamm gastrostomies performed in conjunction with laparoscopic fundoplication in infants and children. The three techniques employed were the T-fastener technique (63/141) which is best utilized in patients with thick abdominal walls; the trocar-site technique (53/141) which is technically easy to perform but prone to infection and fistula formation; and the U-stitch technique (26/141). General complications of laparoscopic gastrostomy include development of gastrocutaneous fistulae (2/141), perigastrostomy cellulitis (8/141), and the formation of granulation tissue at the gastrostomy site (45/141). The only perioperative death was due to a technical error during gastrostomy tube placement. Our preferred method for laparoscopic gastrostomy in most children is the U-stitch technique. Received: 19 March 1996/Accepted: 8 May 1996     

Laparoscopic removal of a swallowed toothbrush

Toothbrush swallowing is an uncommon occurrence. Unlike most cases of foreign-body ingestion, there have been no cases of spontaneous passage reported. Consequently, prompt removal is recommended before complications develop. We report a case of toothbrush ingestion which failed attempted endoscopic removal. This patient was managed successfully with laparoscopic assisted removal via gastrotomy. We recommend this approach for the removal of any ingested foreign bodies when surgical intervention is indicated. Received: 20 December 1995/Accepted: 1 March 1996     

Herniation of the stomach and necrotizing chest wall infection following laparoscopic Nissen fundoplication

This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis. Case history: A 46-year-old woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal herniation. Received: 12 April 1996/Accepted: 26 November 1996     

Cost and benefit of the trained laparoscopic team

Background: In spite of the emergence of laparoscopic cholecystectomy as the gold standard for treatment of symptomatic gallstones, questions still remain regarding its overall cost effectiveness, especially at low-volume centers where operating room (OR) time and operative complications are higher. We hypothesize that the presence of a well-organized, dedicated laparoscopic OR team will improve surgical outcomes for this procedure. This study compares the operative results of an advanced and a basic laparoscopic surgeon using either a designated laparoscopic operating team or a nondesignated team. Methods: The hospital records for 71 elective laparoscopic cholecystectomies with cholangiograms were retrospectively reviewed and anesthesia times and conversion rates were analyzed. Procedures were performed either at a hospital with a dedicated laparoscopy team or a hospital with nondedicated OR personnel. All procedures were done by an advanced laparoscopic surgeon or a basic laparoscopic surgeon. Results: Case characteristics were evenly matched between sites and surgeons. The mean total anesthesia time at the dedicated site was 120.8 min, compared to 152.3 min at the nondedicated site with a mean difference of 31.5 min (p= 0.001). A 12% conversion rate was documented at the nondedicated site. There were no conversions at the site with a dedicated laparoscopy team. No major complications were encountered in this series. Conclusion: This study demonstrates that having a designated laparoscopic trained team provides a time savings to both advanced and basic laparoscopic surgeons. Although no major complications were encountered, there was a significant conversion rate for the less experienced surgeon operating without the support of a trained team. The end result from having a dedicated team in endoscopic surgery is decreased operative time, an improvement in patient care, and decreased costs to the patient and institution. Received: 5 July 1996/Accepted: 9 January 1997     

Extracorporeal knotting simplified with a new instrument

We report a quick, reliable, inexpensive method that uses a new, reusable instrument which can be used in laparoscopic and thoracoscopic surgery to execute any kind of extracorporeal suture. Received: 11 June 1995/Accepted: 26 January 1996     

Laparoscopic colposuspension

Background: The laparoscopic approach must be shown to be cost-effective as well as safe and technically effective before being widely adopted. A review of 54 consecutive patients who underwent open and laparoscopic colposuspension is presented and a cost-analysis is performed comparing the two approaches. Methods: This study was a retrospective controlled review of patient records and accounts of in-hospital costs incurred at a private hospital. Results: Theater costs were significantly greater in the laparoscopic group but this was balanced by a shorter length of stay and subsequent reduced accommodation cost. There was no difference in the overall in-hospital costs between the two groups. Conclusion: The laparoscopic surgical approach is safe and effective and by no means more expensive than the open approach. In the future, the laparoscopic approach can only become more cost efficient; techniques will improve and there will be earlier returns to work and, subsequently, greater productivity. Received: 19 August 1996/Accepted: 20 December 1996     

Telementoring

Background: Telemedicine offers significant advantages in bringing consulting support to distant colleagues. There is a shortage of surgeons trained in performing advanced laparoscopic operations. Aim: Our aim was to evaluate the role of telementoring in the training of advanced laparoscopic surgical procedures. Methods: Student surgeons received a uniform training format to enhance their laparoscopic skills and intracorporeal suturing techniques and specific procedural training in laparoscopic colonic resections and Nissen fundoplication. Subsequently, operating rooms were equipped with three cameras. Telestrator (teleguidance device), instant replay (to critique errors), and CD-ROM programs (to provide information of reference) were used as intraoperative educational assistance tools. In phase I, four colonic resections were performed with the mentor in the operating room (group A) and four colonic resections were performed with the mentor on the hospital grounds, but not in the operating room (group B). The voice and video signals were received at the mentor's location, using coaxial cable. In phase II, two Nissen fundoplications were performed with the mentors in the operating room (group C) and two Nissen fundoplications were performed with the mentors positioned five miles away from the operating room (group D), using currently existing land lines at the T-1 level. Results: There were no differences in the performances of the surgeons and outcome of the operations between groups A & B and C & D. It was possible to tackle the intraoperative problems effectively. Conclusions: The telementoring concept is potentially a safe and cost-effective option for advanced training in laparoscopic operations. Further investigation is necessary before routine transcontinental patient applications are attempted. Received: 17 May 1996/Accepted: 19 August 1996     

Postoperative complications of laparoscopic-assisted colectomy

Background: This study was performed to prospectively assess the complications of 118 consecutive patients who underwent laparoscopic assisted colorectal resections. Methods: The variables included were: indication for surgery, type of resection, duration of operation, duration of postoperative ileus, length of hospital stay, port-site recurrence, and complications in relation to the laparoscopic technique. Results: 118 Laparoscopic-assisted procedures were performed between July 1992 and October 1995. Surgical indications were: 106 patients for colonic malignancy, six for diverticulitis, two for Crohn's disease, two for benign polyps, one for endometriosis, and one for ischemic colitis. Fifteen patients required conversion to open techniques for completion of the operations (12.7%). The mean operating time was 168.8 min. The amount of operative blood loss was 98 ml. The mean time for passing flatus was 36 ± 16 h. Mean postoperative stay was 5.4 (range 3–13) days. Eight patients (6.8%) sustained complications: four unrelated to laparoscopy (three wound infection, one anastomotic leak); and four complications related to the laparoscopic approach: one small-bowel obstruction, one trocar injury, one rotation of the anastomosis, and one misdiagnosed synchronous adenocarcinoma. Conclusions: We suggest that with the development of improved technical devices and more experience, the indications for laparoscopic colectomy should continue to expand. The low incidence of infectious complications suggests an important role for the laparoscopic approach to colorectal surgery. Received: 25 March 1996/Accepted: 8 July 1996     

Preemptive analgesia in the laparoscopic patient

Background: One hundred consecutive laparoscopic patients were prospectively followed in the Post-anesthesia Recovery Unit (PAR) in a community hospital. Methods: Data was collected regarding (1) intraoperative administration of ketorolac, (2) instillation of local anesthesia into the wound, and (3) requirements for analgesic administration in the PAR. Those patients receiving both forms of preemptive analgesia required less narcotic administration in the PAR. The results were highly significant. Results: Based on these data and the observance of markedly reduced pain in patients during the early postoperative period, an institutional plan of care was developed which has resulted in the virtual elimination of the need to administer narcotics to patients undergoing routine laparoscopic surgical procedures. Conclusions: The resultant plan of care, which includes preemptive analgesia, rapid ambulation, early feeding, and routine timed administration of non-narcotic pain medications, is presented. Data is also presented which demonstrates a more rapid discharge of patients from the hospital. Received: 5 April 1996/Accepted 2 November 1996     

Hemostasis with the ultrasonically activated scalpel

In patients with implanted pacemaker/cardioverter defibrillator (ICD), the use of electrocautery can lead to serious pacemaker dysfunction. The ultrasonically activated scalpel, however, which has been introduced mainly for the use in laparoscopic surgery, could potentially avoid the outlined problem, since no electrical current flows while in use. This hypothesis was tested in a pacemaker patient undergoing laparoscopic cholecystectomy. During the procedure, no abnormal rhythms or ECG interferences were detected while working in close vicinity to the device. Thus, the ultrasonically activated scalpel provides adequate hemostasis and does not bear the risk of pacemaker dysfunction. Received: 12 January 1999/Accepted: 20 January 1999