Prehensile atraumatic grasper with intuitive ergonomics

Background: Minimal access surgery (MAS) procedures that require tissue to be grasped are impeded by the design of current instruments. The use of graspers and forceps can result in tissue damage and is highly inappropriate when handling larger organs such as the bowel, liver, and spleen. In addition, current instruments have unnatural handling characteristics. A new type of tissue grasper is presented as a solution to these problems. Methods: The new grasper design was evolved through a process of setting basic requirements and proceeding through cycles of design, construction, evaluation, and redesign. Results: The main features of the new device are prehensile grasping by finger-like jaws, which retain tissue by `capture,' and a novel handle design with intuitive ergonomics. The jaws are interchangeable to suit differing surgical tasks and the handle and trigger mechanism are designed so that the surgeon's forefinger movement mirrors the instrument jaw action. The grasper has been used in 32 MAS procedures with no indications of trauma. Conclusions: A grasper that functions by capture has been demonstrated to be an effective solution for atraumatic tissue handling during many MAS procedures. Received: 3 February 1997/Accepted: 28 February 1997     

Port-site metastases

Background: Port-site metastases after laparoscopic procedures in patients with digestive malignancies have evoked concern. The pathogenesis of port-site metastases remains unclear. Two experiments in rats were performed to determine the impact of both tissue trauma and leakage of CO₂ along trocars (chimney effect) in the development of port-site metastases. Methods: Experiment I: Ten WAG rats had four 5-mm incisions in all abdominal quadrants. The incisions on the right side were crushed to induce tissue trauma. After inserting 5-mm trocars in all incisions, a pneumoperitoneum was created, and CC-531 tumor cells were injected intraperitoneally. CO₂ was insufflated for 20 min. Experiment II: Ten WAG rats had 5-mm incisions in the left and right abdominal upper quadrant. A 5-mm trocar was inserted in the incision in the left upper quadrant, and a 2-mm trocar was inserted in the incision in the right upper quadrant. After insufflating the abdomen, CC-531 tumor cells were injected intraperitoneally. Total leakage of CO₂ along the trocar in the right quadrant was 10 liters. After 4 weeks, in both experiments, the tumor deposits at the trocar sites were assessed. Statistical analysis was performed by the Wilcoxon matched-pairs test. Results: Experiment I: The median weight of tumor deposits at the trocar sites without induced tissue trauma was 22 mg. At the traumatic port sites, median weight of tumor deposits was 316 mg (p= 0.007). Experiment II: The median weight of tumor deposits at the leaking trocar sites was 478 mg and at the control sites 153 mg (p= 0.009). Conclusion: Tissue trauma at trocar sites and leakage of CO₂ along a trocar appear to promote implantation and growth of tumor cells at port sites. Received: 15 May 1997/Accepted: 3 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     

Microlaparoscopic cholecystectomy

Background: We set out to compare a prospective evaluation of microlaparoscopic cholesystectomy (MLC) using 5-mm ports for the scope and operating ports and two 2-mm ports for retracting to the historic results of standard laparoscopic cholecystectomy (SLC). Methods: Fifty-six consecutive patients were operated electively for symptomatic gallstones between June 1997 and July 1998. Demographics, history of prior abdominal surgery, operative time, resident level, need to convert, length of stay, and postoperative analgesia were recorded for each case. In all, 43 women and 13 men aged 21 to 89 (average, 51 years) underwent MLC. Average weight was 78 kg (range, 48–119) and average height was 163 cm. Results: Operative time for MLC was 72 ± 25 min (range, 35–140), somewhat less than the referenced standard of 79 ± 27 min (p= 0.1). The skin-to-trocar time (6 ± 2 vs 13 ± 77 min) and intraoperative cholangiogram time (9 ± 8 vs 11 ± 6 min) were significantly shorter (p < 0.01 and p < 0.05, respectively) for MLC. Other partial times were not significantly different. PGY2 residents averaged 74 ± 21 min (range, 44–118) compared to 75 ± 27 min (range, 35–140) for PGY3 and 53 ± 5 (range, 43–59) for PGY5. Patient weight influenced time. Patients <65 kg averaged 56 ± 12 min; 66–80 kg, 72 ± 24 min; 81–95 kg, 78 ± 26 min; and >95 kg, 85 ± 22 min. Previous abdominal surgery did not affect operative time. Nine patients (16%) required conversion from 2- to 5-mm ports because of adhesions, wall thickening, or need for better retraction. Time in these patients was 95 ± 26 min vs 68 ± 21 min in other patients (p < 0.01). No patient was converted to an open procedure. Three patients (5%) had a positive cholangiogram and common bile duct exploration that required placement of an extra 5-mm trocar. Five patients (9%) required insertion of an additional 2-mm port. All patients received patient-controlled analgesia (PCA). Morphine use was 0.21 ± 0.19 mg/kg (range, 0–0.8). Hospital stay was 1.31 days (range, 0.5–4). Subjective satisfaction was excellent because of smaller incisions. No additional morbidity was seen with MLC. Conclusion: MLC is a feasible and safe approach that provides similar times to SLC with better cosmesis, a less painful recovery, and possibly an earlier return to normal activity. Received: 16 February 1999/Accepted: 8 October 1999     

Endoscopic endocrine surgery in the neck

Background: The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties. Methods: After experimental success in an animal model, we recently performed our first case of endoscopic subtotal parathyroidectomy in a 37-year-old man. The patient, who had a history of severe pancreatitis and pancreatic calculi, was diagnosed as having hyperparathyroidism. The option of endoscopic parathyroidectomy was proposed and accepted. After placing the first trocar directly under the platysma, a space was created by bluntly dissecting with the tip of a 5-mm endoscopic camera. Four parathyroid glands were identified, and after a frozen-section diagnosis of parathyroid hyperplasia, three-and-one-half of the glands were resected. Results: The patient developed slight hypercarbia and subcutaneous emphysema during the procedure, but no other problems were noted. His postoperative course was otherwise unremarkable. Conclusions: This is the first case reported of an endoscopic parathyroidectomy. This experience makes us optimistic about the future of endoscopic neck surgery. Received: 3 April 1997/Accepted: 6 August 1997     

Intraperitoneal thermal variations during laparoscopic surgery

Background: The aim of this study was to measure thermal variations during laparoscopy in the vicinity of heat sources such as monopolar (MC) and bipolar coagulation (BC) and to evaluate their possible negative consequences for the patient. Methods: This study included 43 patients who underwent laparoscopic cholecystectomy. The temperature measurements were taken with a sterile thermal probe (Mallinkrot Medical) introduced through a 5-mm trocar coupled with a recording monitor reading variations between 20 and 80°C. The variation in temperature was measured as a function of the power applied to the electrodes (20 or 30 W) and in relation to the distance (1, 2, 3, 4, and 5 cm) from the electrodes. Results: The temperature varied by 3° for BC and 29° for MC when the distance increased from 1 to 5 cm. With respect to the power delivered, 20 or 30 W, the variations were 1° for BC and 17° for MC. Conclusions: The minimal temperature variations associated with the use of BC makes it the option of choice for operating near structures such as the common bile duct or the gastrointestinal tract. Received: 7 January 1998/Accepted: 27 April 1998     

Active electrode monitoring

Background: In recent years, the use of minimally invasive surgery (MIS) has expanded to a wide variety of surgical specialties. The increased popularity of the procedure, however, has been accompanied by its share of complications, including trocar lacerations and inadvertent thermal injuries to nontargeted tissues during monopolar electrosurgery. Methods: A survey on electrosurgical thermal injuries and three case studies are presented. The new technology of active electrode monitoring (AEM) is described. Results: AEM eliminates stray currents generated by insulation failure and capacitive coupling. Conclusions: To reduce the incidence of injury by monopolar electrosurgery at laparoscopy, there is a need for advanced technology, such as AEM. In addition, laparoscopic surgeons should be encouraged to study the basic concepts of the biophysics of electrosurgery. Received: 26 June 1997/Accepted: 10 December 1997     

Minimally invasive surgery for posterior gastric stromal tumors

Background: Because involvement is extremely rare, surgery for gastric stromal tumors consists of local excision with clear resection margins. The aim of this study was to report the results of a consecutive series of nine patients with posterior gastric stromal tumors that were excised using a minimally invasive method. Methods: Patients received a general anesthetic before placement of three laparoscopic ports— a 10-mm (umbilical) port for the telescope and two working ports, a 12-mm port (left upper quadrant) and a 10-mm port (right upper quadrant). Grasping forceps were placed through an anteriorly placed gastrotomy to deliver the tumor through the gastrotomy into the abdominal cavity, thus allowing an endoscopic linear cutter to excise the tumor with a cuff of normal gastric tissue. Results: Nine consecutive patients with a median age of 73 years (range, 47–83) were treated. In seven patients, laparoscopic removal of the tumor was achieved. Two patients required conversion to an open operation because the tumor could not be delivered into the abdominal cavity. The median length of postoperative stay for the seven patients in whom the procedure was completed laparoscopically was 3 days (range, 2–6). Conclusions: Posterior gastric stromal tumors can be removed safely using this minimally invasive method. Delivery of the tumor through the gastrotomy is essential for success. Received: 30 April 1999/Accepted: 12 July 1999     

Prospective, multicenter study of laparoscopic ventral hernioplasty

Background: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias ≥4 cm²) is being used in a prospective, multicenter, long-term study. Methods: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7–10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. Results: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5–731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. Conclusions: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery. Received: 3 April 1997/Accepted: 10 August 1997     

An ergonomic comparison of in-line vs pistol-grip handle configuration in a laparoscopic grasper

Background: Laparoscopic instruments incorporate both in-line and pistol-grip handle configurations, yet it is unclear which design is most advantageous for surgeons, particularly when operating at angles perpendicular to the surgeon's position. We present a detailed electromyographic (EMG) comparison of these handle configurations under different force and angle conditions. Methods: Nine general surgeons used a Microsurge grasper with the handle in an in-line (MS-IL) and pistol (MS-PS) configuration, as well as a standard hemostat (HE), to grasp and close two spring-loaded metal plates. The task was performed randomly by each subject with the three instrument configurations at two forces levels (0.7 N, 4.2 N) and at three angles to the surgeons' body (0, 45, and 90°). Surface EMG was measured from the flexor carpi ulnaris (FCU), flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), extensor carpi ulnaris (ECU), extensor digitorum comunis (EDC), and thenar compartment (TH). The peak root mean squared (RMS) EMG voltage was calculated for each instrument, force, and angle condition. Statistical comparison was carried out by ANOVA. Results: Both laparoscopic handle configurations required significantly higher contractions of all muscle groups compared to the hemostat at the high force level. TH was not affected by laparoscopic handle configuration. MS-IL required higher FCU, ECU, and EDC contractions at 45° compared to MS-PS. However, MS-IL decreased the flexor compartment muscle contractions (FDP, FDS, FCU) at 90° compared to MS-PS. Conclusions: Laparoscopic grasping requires higher forearm and thumb muscle contractions compared to the use of a hemostat. The in-line handle configuration is no better than the pistol configuration except when grasping at 90° to the surgeon, where rotation of the handle and wrist back toward the surgeon significantly decreases forearm flexor compartment muscle contractions. Received: 3 April 1997/Accepted: 10 August 1997     

Minilaparoscopically assisted placement of ventriculoperitoneal shunts

Background: Ventriculoperitoneal (VP) shunting remains the preferred treatment for hydrocephalus. Laparoscopic techniques to aid in the placement of the peritoneal portion of the catheter have been reported previously. We describe a minilaparoscopic VP shunt (MLVPS) insertion technique that facilitates directed placement of the peritoneal portion of the catheter in most patients, including those with obese abdomens previously subjected to surgery. In this study we review our experience with MLVPS placement. Methods: All cases of MLVPS insertions at the University of Kentucky Medical Center and Lexington VA Hospital performed between February 1998 and March 1999 were reviewed retrospectively. A total of 27 patients (13 males and 14 females) ranging in age from 4 to 81 years (mean, 41 years) underwent VP shunting. The MLVPS insertion was performed via a 2-mm laparoscope and a separate 2-mm incision for catheter insertion using a venous introducer kit. In patients who had prior abdominal surgery, a 5-mm direct-view trocar was used. Results: The MLVPS procedure was successful in 27 patients (100%). The mean number of prior shunts was 2 (range, 0–28). Of the 27 patients, 16 (59%) had undergone previous abdominal surgery. The mean operative time was 76 min (range, 19–155 min). There were no intra- or postoperative complications, and no mortalities. The follow-up period extended from 1 to 12 months. Conclusions: Findings show MLVPS placement to be safe and feasible. It allows accurate, directed placement of the VP shunt with a 2-mm laparoscope and a second 2-mm incision for shunt insertion. The procedure is associated with reduced trauma to the abdominal wall and minimal postoperative ileus. Long-term follow-up assessment of shunt function is planned. Received: 30 April 1999/Accepted: 27 October 1999/Online publication: 17 May 2000     

Transgastrostomal endoscopic surgery for early gastric carcinoma and submucosal tumor

Background: Laparoscopic intraluminal surgery of the stomach is now widely used for a lesion on the posterior wall. However, this procedure has some technical limitation related to the intricate introduction of the surgical instruments into the gastric lumen. In this article, we report our newly developed technique of transgastrostomal endoscopic surgery that overcomes this limitation and is also suitable for full-thickness gastric wall resection of a lesion in the wall. Methods: After making a 4-cm-long temporary gastrostomy, a Buess-type endoscope is inserted into the gastric lumen through the gastrostomy. The operation is performed inside the gastric lumen under video camera guidance using electrocautery, scissors, and forceps. After resection, the wound in the mucosa or the wound after full-thickness resection is endoluminally sutured. Mucosal resection was performed in six cases of early gastric carcinoma, two cases of atypical epithelium, and one case of ectopic pancreas. Full-thickness wall resection was performed in four cases of a leiomyoma. Results: In all 13 cases, the lesion could be precisely located by the video camera. All lesions were then resected endoluminally. The mean duration of the operation was 148 min. The postoperative course in all cases was uneventful. Conclusions: Transgastrostomal endoscopic surgery is minimally invasive and an efficient tissue-preserving technique for the removal of early gastric carcinoma or submucosal tumor. Received: 7 September 1996/Accepted: 27 January 1997     

The use of bipolar cautery, laparosonic coagulating shears, and vascular clips for hemostasis of small and medium-sized vessels

Advanced laparoscopic surgery requires a reliable method of hemostasis. In order to determine the efficacy of common hemostatic devices, we tested bipolar electrosurgery (BPES), laparosonic coagulating shears (LCS), and vascular clips (VC) on arteries of various sizes to compare the strength of hemostasis against elevated intraarterial pressure. The procedures were performed on a porcine model through a laparotomy. Segments of visceral arteries were isolated and cannulated with an angiocatheter that was linked to a pressure monitor. After hemostasis with the tested instrument and division of the vessel, the intraarterial pressure was elevated by infusion of saline solution through the angiocatheter. The pressure was recorded when bleeding occurred through the cut end of the vessel or when the pressure reached 300 mm Hg. All three devices were effective in maintaining hemostasis on small (diameter, 0.25–0.5 mm) and medium-sized arteries (diameter, 2–3.5 mm) with a success rate ranging between 75% and 100% (p= n.s.). Practice and technical finesse were required with the use of the LCS and BPES before excellent results could be obtained. The LCS has an advantage over BPES because it allows the surgeon to perform hemostasis and division simultaneously, thus keeping the operating field clean and avoiding instrument adhesion to the tissue. Received: 3 April 1997/Accepted: 4 July 1997     

Laparoscopic anterior gastroplasty

Background: The treatment of the morbidly obese patient is difficult because compliance with dietary regimens is poor. As a result, most weight reduction programs fail very quickly. Surgical treatment, on the other hand, provides a reliable method for sustained weight reduction. The most frequently performed procedure has been the vertical banded gastroplasty. Adaptation of the standard open procedure to laparoscopic techniques has been technically difficult and imprecise. We have developed, in the laboratory, an anterior wall banded gastroplasty that can be performed precisely and reproducibly using laparoscopic techniques. Methods: Five Yorkshire pigs were used in attempt to laparoscopically perform the standard vertical banded gastroplasty. The procedure was difficult and was associated with a risk of staple line leak and with bleeding along the lesser curvature of the stomach. Furthermore, a reproducible pouch of proper dimension could not be created reliably. Fifteen animals were then used to develop a new technique using a small gastric pouch based on the anterior gastric wall. Results: A reproducible pouch, 4 cm in length, was created over an 18-Fr nasogastric tube. A standard polyproylene band of 5.2 cm in length was utilized at the gastric pouch outlet. Conclusions: This operation can be reproduced accurately and has not demonstrated any leaks on postmortem examination. Received: 14 July 1997/Accepted: 4 February 1998     

Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentationrid=""id=""Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27 March 1999

Background: Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation. Methods: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation was performed in eight adult hydrocephalus patients from August 1996 to September 1998. All eight patients had undergone 1 to 18 prior shunt revisions. The procedures were performed with two 2-mm trocars. The instrumentation consisted of a 2-mm laparoscope, a 2-mm grasper, and 2-mm scissors. All shunts were placed in an area free of adhesions and checked for flow under direct vision. Four of the patients required a lysis of adhesions to create a space adequate for catheter placement. Results: All of the procedures were successful, with no operative complications. The operative times ranged from 29 to 99 min, (mean, 63 min). The blood loss in all of the procedures was minimal. At this writing, none of the patients have required subsequent distal shunt revisions. No conversions to larger instruments or an open procedure were required. Conclusions: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation is safe and effective, offering several advantages over the open procedure. This procedure is ideal for the use of 2-mm instruments. Received: 19 March 1999/Accepted: 23 June 1999/Online publication: 10 April 2000     

Experimental studies of thermal therapy for severe nonvariceal bleeding in dogs

Background: There are several methods of achieving endoscopic hemostasis for nonvariceal hemorrhage, including use of a heater probe, bipolar electrocoagulation, use of a Gold probe, and injection therapy with epinephrine or ethyl alcohol. However, due to clinical variations, clinical studies comparing thermal with injection therapy have yielded conflicting results. Therefore, we used a canine model of acute bleeding from gastric serosal vessels to examine the efficacy of the heater probe and the Gold probe in achieving hemostasis and to compare the injurious effects of these methods with injection therapy. Methods: Seven mongrel dogs were used in the study. Four were assigned to acute experiments in which transected blood vessels were allowed to bleed profusely. Two dogs of this group were treated with either a large or small Gold probe, while the other two were treated with either a large or small heater probe. In the other three dogs, we tested the chronic effects of the heater probe, the Gold probe, and injection therapy with dilute epinephrine. Results: Complete hemostasis was achieved for all four dogs in the acute experiments. Dogs treated with either a large or small heater probe had coagulation necrosis that extended to the serosa and muscularis but not to the mucosa. The large Gold probe had similar results, but the small Gold probe caused tissue damage to the serosa, muscularis, submucosa, and mucosa at several of the application sites. Both probes caused scarring of the gastric wall. In the chronic experiments, we found that the Gold probe caused larger mucosal ulcers than the heater probe. All ulcers healed in 3 weeks. The epinephrine injection caused localized swelling and discoloration, but after 1 week the tissue returned to normal. Conclusions: Both the heater probe and the Gold probe are effective in achieving hemostasis in a canine model of nonvariceal hemorrhage, and both methods are superior to injection therapy. For active bleeding ulcers, we currently recommend a combination therapy, using first injection therapy and then a heater or Gold probe. However, clinicians should be aware of the potential for tissue damage. Received: 31 July 1998/Accepted: 22 March 1999     

Long-term effects of repeated injection sclerotherapy on esophageal motility and mucosa

Background: Endoscopic sclerotherapy (ST), widely used as treatment of bleeding esophageal varices, might cause motility disturbances of the esophagus as well as mucosal damage. We performed this study to evaluate the long-term effects of repeated sclerotherapy on esophageal motility and mucosa. Methods: Ten patients with liver cirrhosis and bleeding esophageal varices treated with repeated ST were evaluated after the last ST, median 52 months, by esophageal manometry and gastroscopy where forceps biopsies were taken. Results: We found a significant difference in the distal esophageal sphincter intraabdominal length. The distal esophageal sphincter pressure was somewhat lower in the ST group although the difference did not reach statistical significance. There was infiltration of neutrophil leukocytes in biopsies from four patients and normal findings in the rest. Conclusions: Long-term follow-up evaluation showed statistically longer distal esophageal intraabdominal length in the ST group. No mucosal alterations were found at the histopathological investigation. Received: 22 April 1996/Accepted: 20 August 1996     

Influence of Bone Quality on Precision of Calcaneal Ultrasonometry

This study was designed to determine the changes in precision of the ultrasound parameters speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index (SI) as a function of bone quality. The instrument used in this investigation was the LUNAR Achilles. Of the 608 female patients who had paired measurements with repositioning, 200 had t scores ≥−1 and 408 had t scores ≤−2.5, thus rendering a normal and a grossly abnormal group for comparison of precision results. It was found that the median precision error (CV%) for BUA was 1.99% for normal bone and 1.44% for abnormal bone (P= 0.02). No significant difference was obtained between median precision errors in normal and abnormal bone for the parameters SOS and SI, which were 0.23% and 0.19%, and 2.15% and 2.02%, respectively. In the interquartile range, the mean precision errors for SOS and BUA were significantly different in normal and abnormal bone: SOS was 0.25% and 0.21%, respectively, and BUA was 2.31% and 1.85%, respectively. No significant change was registered for SI. Precision error appears to decrease slightly at lower values for calcaneal variables. Received: 21 August 1996 / Accepted: 5 March 1997     

Micropuncture laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) significantly reduces the discomfort and disability typically associated with open cholecystectomy, but there is still room for improvement. Methods: In order to further reduce the trauma of access, we have introduced a technique of micropuncture laparoscopic cholecystectomy (MPLC) that utilizes three 3-mm cannulae in addition to the standard 10-mm cannula at the umbilicus. MPLC was performed in 25 patients (median age, 52 years; m/f, three of 22) with symptomatic cholelithiasis. Results: The operation was completed in all patients. The median duration of surgery was 75 min (range, 45–180). Sixteen patients were discharged the same day and nine patients the next day. All the patients had an uncomplicated recovery. Only eight patients requested postoperative analgesia while in hospital. Micropuncture exploration of the bile duct was carried out in one patient. Conclusions: MPLC is a feasible and safe technique that appears to improve on the benefits of LC; it makes the operation even more feasible as a day-surgery procedure. Received: 28 January 1998/Accepted: 7 May 1998     

Endoscopic axillary exploration and sentinel lymphadenectomy

Background: Minimally invasive approaches have changed the practice of surgery in several specialties. The purpose of this study was to develop a reproducible endoscopic technique for the evaluation of the axilla in breast cancer patients. Methods: A total of 23 patients with biopsy-proven breast carcinoma were enrolled. Patients were positioned in the supine position with the ipsilateral arm abducted at 90°. A 1-cm skin incision was made at the superior aspect of the axilla. Dissection was carried bluntly to the lateral border of the pectoralis major. A balloon distention device was inserted into the tract and distended under endoscopic vision to create a working space. Insufflation was initiated up to a pressure of 8 mmHg. A 30° laparoscope was introduced for visualization of axillary contents. One or two additional 5-mm cannulas were placed as needed under direct visualization. Manipulation of axillary contents was performed, and in 19 patients a sentinel node identification technique was applied. Results: In all patients, using insufflation and minimal instrument dissection, the axillary vein, long thoracic, and thoracodorsal nerves were found in their usual anatomical locations. Utilizing blunt and sharp dissection, the axilla was thoroughly inspected, and individual lymph nodes were easily identified and extracted. In 11 of 19 patients, a sentinel node or blue dye was identified using isosulfan blue. There was a procedure concordance of 84%, and there were no complications. Conclusions: We describe a novel endoscopic technique for the evaluation of the axilla in breast cancer patients. This technique allows (a) creation of a minimally invasive working space within the axilla, (b) recognition of key axillary anatomic landmarks, and (c) instrument manipulation within the axilla to identify and extract lymph nodes, and apply the sentinel node technique. This is the first report of a minimally invasive approach to axillary exploration to employ sentinel lymph node mapping. Received: 22 April 1996/Accepted: 15 May 1998