Single port laparoscopic liver surgery:A minireview

Nowadays,the trend is to perform surgeries with"scarless"incisions.In light of this,the single-port laparoscopic surgery(SPLS)technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages,as the only entry point is usually hidden in the umbilicus.The interest in"scarless"liver resections did not grow as rapidly as the interest in other scarless surgeries.Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrowincision with limited exposure.There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections(SPL-LR)for hepatocellular carcinoma or metastatic colorectal cancer.In addition,getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging.In this article,we reviewed the published literature to describe history,indications,contraindications,ideal patients for new beginners,technical difficulty,advantages,disadvantages,oncological concern and the future of SPL-LR.     

Single port laparoscopic right hemicolectomy for ileocolic intussusception

A 36-year-old male was admitted with right lower abdominal pain and diarrhea for more than 3 mo. Colonoscopy and a barium enema study revealed a submucosal tumor over the cecum, but computed tomography showed an ileal lipoma. There was no definitive diagnosis preoperatively, but ileocolic intussusception was noted during surgery. Single port laparoscopic radical right hemicolectomy was performed because intra-operative reduction failed. The histological diagnosis of the resected tumor was lipoma. Single port laparoscopic surgery has recently been proven to be safe and feasible. There are advantages compared with conventional laparoscopic surgery, such as smaller incision wounds, fewer port site complications, and easier conversion. However, there are some drawbacks which need to be overcome, such as difficulties in triangulation and instrument clashing. If there are no contraindications to laparoscopy, single port laparoscopic surgery can be performed safely and should be considered for diagnosis and treatment of intussusception in adults. Here, we report the first case of ileocolic intussusception successfully treated by single port laparoscopic surgery.     

Pancreatic insulinomas:laparoscopic management

Insulinomas are rare pancreatic neuroendocrine tumors that are most commonly benign,solitary,and intrapancreatic. Uncontrolled insulin overproduction from the tumor produces neurological and adrenergic symptoms of hypoglycemia. Biochemical diagnosis is confirmed by the presence of Whipple's triad,along with corroborating measurements of blood glucose,insulin,proinsulin,C-peptide,β-hydroxybutyrate,and negative tests for hypoglycemic agents during a supervised fasting period. This is accompanied by accurate preoperative localization using both invasive and non-invasive imaging modalities. Following this,careful preoperative planning is required,with the ensuing procedure being preferably carried out laparoscopically. An integral part of the laparoscopic approach is the application of laparoscopic intraoperative ultrasound,which is indispensable for accurate intraoperative localization of the lesion in the pancreatic region. The extent of laparoscopic resection is dependent on preoperative and intraoperative findings,but most commonly involves tumor enucleation or distal pancreatectomy. When performed in an experienced surgical unit,laparoscopic resection is associated with minimal mortality and excellent long-term cure rates. Furthermore,this approach confers equivalent safety and efficacy rates to open resection,while improving cosmesis and reducing hospital stay. As such,laparoscopic resection should be considered in all cases of benign insulinoma where adequate surgical expertise is available.     

结直肠手术中微创技术和理念的进展

近年来随着微创技术的发展,结直肠外科手术取得了重大进步。内镜技术最初作为一项诊查手段,现已越来越多地用于胃肠道疾病的治疗。其中内镜下粘膜切除术和内镜下粘膜剥离术可用于治疗早期结直肠癌,避免了开腹或腹腔镜手术,且体表不遗留手术疤痕。随着器械的完善和技术的进步,腹腔镜技术也已广泛用于结直肠癌的根治性切除,且大量的临床实践证明其具有良好的可行性和安全性。三维腹腔镜的应用改善了术中的视野,提升了腹腔镜操作的精细程度。机器人手术系统的出现则将外科手术引入一个新时代,远程手术得以成功实施,且更加精细灵活的操作可在腹腔镜下狭小的空间里完成。此外,功能学的微创理念日益受到重视。外科医生不仅仅追求更小的切口和创伤,更开始追求更小的应激反应和更快的术后恢复。本文回顾了近年来微创技术和理念的进展,并对微创外科在结直肠手术中的应用做出了展望。     

Tips and tricks of laparoscopic distal pancreatectomy for ductal adenocarcinoma

Laparoscopic distal pancreatectomy for pancreatic cancer can be a challenging procedure that requires adherence to surgical principles respecting tissue planes and critical vascular structures to obtain the optimal surgical margins and peripancreatic node harvest, while minimizing damage to surrounding structures. This report provides a basic approach with some tips and tricks based on my experience with this procedure.     

微创保胆取石术联合牛磺熊去氧胆酸预防胆囊结石复发效果观察

目的：观察牛磺熊去氧胆酸（TUDCA）降低微创保胆取石术后胆囊结石复发的临床效果。方法42例胆囊结石患者被随机分为单纯保胆手术组21例和联合治疗组21例,联合治疗组在微创保胆取石术后口服 TUDCA,每个月连续服用5天后,停止口服25天,为期1年。比较两组患者胆囊结石复发率、胆囊壁厚度及胆囊收缩功能的变化。结果在术后2年,单纯手术组患者胆囊结石症状复发率为33.3%（7/21）,显著高于联合治疗组患者的4.8%（1/21）。单纯手术组5例（23.8%）胆囊结石复发,而加服药物组无复发（x2=5.6757,P〈0.05）;单纯手术组患者术前和术后胆囊壁厚度分别为（3.95±0.56） mm 和（3.74±0.68）mm,胆囊收缩功能分别为（38.24±4.33）%和（37.89±6.42）%,而加服药物组患者胆囊壁厚度分别为（2.88±0.67） mm 和（2.43±0.71） mm,胆囊收缩功能分别为（48.78±6.45）%和（59.46±3.64）%,其改善程度均显著优于单纯手术组（P〈0.05）。结论微创保胆取石术后联用 TUDCA 口服能有效降低胆囊结石的复发,改善胆囊收缩功能。     

Safety considerations in laparoscopic surgery: A narrative review

Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.     

Comparison of Laparoscopic <Emphasis Type="Italic">vs.</Emphasis> Open Access Surgery in Patients with Rectal Cancer: A Prospective Analysis

Purpose Laparoscopic surgery of colon cancer has been accepted to be oncologically adequate compared with open resection. However, the situation in rectal cancer remains unclear, because anatomy and complex surgical procedures might specifically influence the long-term outcome. This study was designed to analyze perioperative and long-term outcome of patients with rectal cancer after laparoscopic vs. open access surgery. Methods A total of 389 patients (1998–2005) were prospectively analyzed; 114 patients had laparoscopic beginning, and 25 patients had conversion and were separately analyzed. Eighty-nine patients remained in the laparoscopic group and 275 had open access surgery. Results Both groups were comparable regarding age, gender, tumor localization, stage, and complications. Differences were found in harvested lymph nodes (laparoscopic 13.5/open access 16.9; P = 0.001) and hospitalization (15.1/18.7 days; P = 0.037). Local recurrence rate and metachronous metastasis were comparable. In patients with deep anterior resection with total mesenteric excision, favorable long-term survival in the laparoscopic group was found (P = 0.035, log-rank). Conclusions Minimally invasive surgery is equivalent in the treatment of rectal cancer and shows advantages of shorter hospitalization and faster recovery. Especially in patients with low rectal cancer, minimally invasive surgery with exact preparation of the total mesenteric excision seems to be favorable compared with open access surgery.     

Progress in laparoscopic anatomy research: A review of the Chinese literature

The development of laparoscopic surgery has generated the new field of study, laparoscopic anatomy. This article reviews the reported literature on laparoscopic anatomy and explores how it has evolved along with advances in abdominal surgery. In addition, the principal concerns in current laparoscopic anatomy research are discussed, including: (1) types of special adjacent anatomical structures; and (2) special surgical planes and anatomical landmarks. Understanding of systematic laparoscopic anatomy can pr...     

Benefits of hand-assisted laparoscopic restorative proctocolectomy: a comparative study

PURPOSE: Hand-assisted laparoscopic colectomy is thought to facilitate colonic mobilization while maintaining the benefits of laparoscopic surgery. Although previous studies of hand-assisted colectomy have focused on segmental colonic resection, the use of hand-assisted laparoscopic restorative proctocolectomy has not been investigated. This study evaluated the effectiveness of hand-assisted laparoscopic approach compared with a conventional laparoscopic method in patients undergoing restorative proctocolectomy.METHODS: From a prospective database, a consecutive series of patients were identified undergoing conventional and hand-assisted laparoscopic restorative proctocolectomy and results were compared. Twenty-three patients, comprising 10 hand-assisted and 13 conventional laparoscopic patients, were identified. Patient characteristics, perioperative parameters, and outcomes were assessed.RESULTS: Both groups were well matched with no differences in age, gender, body mass index, operative indication, diagnosis, comorbidity, or steroid usage. There were no differences among incision size between the hand-assisted (8 (range, 8–20) cm) and conventional laparoscopic cases (8 (range, 5–10) cm). The median operative time was significantly shorter in the hand-assisted group (247 (range, 210–390) minutes) compared with the conventional laparoscopic group (300 (range, 240–400) minutes; P < 0.01). The length of stay was similar between groups (hand-assisted: 4 (range, 3–13) days vs. conventional: 6 (range, 4–17) days). Complications occurred in four hand-assisted patients (40 percent; 2 ileus, mechanical obstruction, and dehydration) and in four patients undergoing conventional laparoscopic method (31 percent; 2 anastomotic leak, ileus, and mechanical obstruction).CONCLUSIONS: Compared with conventional laparoscopic restorative proctocolectomy, the hand-assisted method resulted in a significant reduction in operative time without detriment to bowel function, length of stay, or patient outcome. The hand-assisted approach to restorative proctocolectomy is likely to replace conventional laparoscopic methods as the preferred laparoscopic approach for this technically challenging procedure.Reprints are not available.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Emergency laparoscopic partial splenectomy for ruptured spleen: A case report

Splenic rupture is a common consequence of blunt abdominal trauma. Emergency splenectomy is indicated when conservative management is not effective. With better understanding of the immunologic function of the spleen, surgeons have begun to perform the splenic-preserving surgery. However, it is technical challenge to perform emergency laparoscopic partial splenectomy for patient with spleen rupture. A 15-year-old male patient suffered from grade III spleen injury basing on the American association for the surgery of trauma splenic injury scale. Conservative treatment failed to success basing on the dramatically decreased hemoglobin level. During the laparoscopic exploration, we found that two individual ruptures were associated with the upper pole of spleen. An emergency laparoscopic partial splenectomy was successfully carried out. The operative time was approximate 150 min and the estimated blood loss was 200 mL. The post-operative course was uneventful and the patient was discharged on the 7^th post-operative day.     

Single port laparoscopy in gastroenterology and hepatology: A fine step forward

Single incision laparoscopy (SIL) has become an emerging technology aiming at a further reduction of abdominal wall trauma in minimally invasive surgery. Available data is encouraging for the safe application of standardized SIL in a wide range of procedures in gastroenterology and hepatology. Compared to technically simple SIL procedures, the merit of SIL in advanced surgeries, such as liver or colorectal interventions, compared to conventional laparsocopy is self-evident without any doubt. SIL has already passed the learning curve and is routinely utilized in expert centers. This minimized approach has allowed to enter a new era of surgical management that can not be acceded without a fruitful combination of prudent training, consistent day-to-day work and enthusiastic motivation for technical innovations. Both, basic and novel technical specifics as well as particular procedures are described herein. The focus is on the most important surgical interventions in gastroenterology and aims at reviewing the current literature and shares our experience in a high volume center.     

Hand-assisted laparoscopic colorectal resections：the preferred option

作者对1995年至2009年间该院的微创结直肠手术进行了总结和综述,2002年后,作者开始实施手辅助下腔镜结直肠手术。在这14年间,一共实施了155例开腹手术,225例全腔镜手术和504例手辅助腔镜结肠手术。全腔镜组和手辅助组总的手术并发症发生率是2.9%,其中全腔镜组为5.3%,手辅助组为1.8%。吻合口瘘发生率在开腹组、全腔镜组和手辅助组分别为1.9%(3/155)、1.3%(3/225)和1.3%(7/504)。开腹组、全腔镜组和手辅助组的平均住院天数分别为6.4 d、3.1 d和2.9 d。腔镜组住院时间的缩短抵消了手术费用的增加,腔镜组的总费用明显少于开腹组(平均节省5053美元)。得益于手术时间的缩短和较少的器械费用,手辅助组的成本效益(7334美元)甚至优于全腔镜组(4215美元)。结果显示微创手术在并发症发生率、住院时间和总费用方面优于开腹手术,而且与开腹手术相比,手辅助下腔镜手术不仅具有腹腔镜手术的先天优势,而且手术时间更短,费用更少。     

Review of single incision laparoscopic surgery in colorectal surgery

As surgical techniques continue to move towards less invasive techniques,single incision laparoscopic surgery(SILS),a hybrid between traditional multiport laparoscopy and natural orifice transluminal endoscopic surgery,was introduced to further the enhanced outcomes of multiport laparoscopy. The safety and feasibility of SILS for both benign and malignant colorectal disease has been proven. SILS provides the potential for improved cosmesis,postoperative pain,recovery time,and quality of life at the drawback of higher technical skill required. In this article,we review the history,describe the available technology and techniques,and evaluate the benefits and limitations of SILS for colorectal surgery in the published literature.     

肝脏外科的微创化

微创治疗应用于肝脏外科的方式和方法层出不穷,本文从腹腔镜、药物和物理等方面,对肝脏疾病外科治疗的发展和现状作一综述。     

Transcatheter mitral valve intervention: an emerging treatment for mitral regurgitation

Mitral regurgitation (MR) is a valvular heart disease associated with significant morbidity and mortality. Transcatheter mitral valve intervention (TMVI) repairs or replaces the mitral valve through small arterial and venous entry sites and so avoids risks associated with open heart surgery. Transcatheter devices targeting components of the mitral apparatus are being developed to repair or replace it. Numerous challenges remain including developing more adaptable devices and correction of multiple components of the mitral annulus to attain durable results. The mitral valve apparatus is a complex structure and understanding of the mechanisms of MR is essential in the development of TMVI. There will likely be a complementary role between surgery and TMVI in the near future.     

Core value of laparoscopic colorectal surgery

Since laparoscopy was first used in cholecystectomy in 1987, it has developed quickly and has been used in most fields of traditional surgery. People have now accepted its advantages like small incision, quick recovery, light pain, beauty and short hospital stays. In early times, there are still controversies about the application of laparoscopy in malignant tumor treatments, especially about the problems of oncology efficacy, incision implantation and operation security. However, these concerns have been fully eliminated by evidences on the basis of evidence-basis medicine. In recent years, new minimally invasive technologies are appearing continually, but they still have challenges and may increase the difficulties of radical dissection and the risks of potential complications, so they are confined to benign or early malignant tumors. The core value of the laparoscopic technique is to ensure the high quality of tumor’s radical resection and less complications. On the basis of this, it is allowed to pursue more minimally invasive techniques. Since the development of laparoscopic colorectal surgery is rapid and unceasing, we have reasons to believe that laparoscopic surgery will become gold standard for colorectal surgery in the near future.     

Single-surgeon surgery in laparoscopic colonie resection

Purpose Short-term benefits have been demonstrated for laparoscopic-assisted colectomy. However, minimally invasive surgery is still in an evolutionary phase. In demonstrating that robotic devices also are useful in laparoscopic colonie surgery, it is fundamental to prove that a single surgeon can perform almost the entire operation on his own. METHODS: A single surgeon performed forty-one, laparoscopic-assisted, colorectal resections with the assistance of a robotic device (Automated Endoscopie System for Optimal Positioning, Computer Motion^TM) maneuvering the laparoscope. A surgical assistant was included only for the open part of the operation. Main outcome measures were conversion rate, total operating time, and percentage of assistance by a second surgeon. RESULTS: There were no intraoperative complications, one case of conversion to open surgery, and three postoperative complications. The total operating time ranged from 126 to 252 minutes. A single surgeon with the assistance of a robotic device was able to perform approximately 70 percent of an ileocecal resection, 70 percent of a right hemicolectomy, 80 percent of a sigmoid resection, and 85 percent of a anterior rectal resection without further help of a surgeon. CONCLUSIONS: A single surgeon with the assistance of a computerized robotic system can complete at least two-thirds of a laparoscopic-assisted, colorectal resection on his own. The use of a robotic device in laparoscopic-assisted, colonie surgery is safe, efficient, and feasible, and will proven even more so in future. This also will result in a patient-driven demand for high-standard, minimally invasive surgery.