Single-incision laparoscopic right colectomy in an unselected patient population

Background

Single-incision laparoscopic surgery has become increasingly utilized for colorectal surgery, with the most frequently reported single-incision laparoscopic operation being right hemicolectomy. While current data suggest that single-incision laparoscopic right colectomy is feasible, safe, and roughly equivalent to standard laparoscopic right colectomy, the technique has to date only been described in highly selected patients. Single-incision laparoscopic right colectomy has not yet been assessed in a standard patient population.

Methods

A retrospective review was conducted to evaluate all single-incision right hemicolectomies performed by a single surgeon between May 2010 and April 2011. Demographic data, operative parameters, and postoperative outcomes were assessed.

Results

Single-incision laparoscopic colectomy was performed in a series of 30 consecutive patients with indications for right colectomy. One patient required conversion to an open procedure for extensive adhesions, while no patients required additional port placement. Mean operative time was 107?min. All patients had negative margins and had an average of 20 lymph nodes harvested. Mean length of stay was 6?days. There were no intraoperative complications and no mortality in the study. The perioperative complication rate was 37%, with 71% of complications being grade 1.

Conclusions

Single-incision laparoscopic colectomy is feasible, safe, efficient, and oncologically sound for most patients who are seen in a typical colorectal practice. These data are useful as single-incision laparoscopic colectomy becomes more broadly implemented.     

Restorative restproctectomy as single-port surgery through the ostomy site in a three-stage procedure

Purpose

Single-port laparoscopic surgery as an alternative to traditional laparoscopic technique is anticipated to be beneficial in the early postoperative course. We describe restorative restproctectomy as single-port surgery through the ostomy site in a three-stage procedure for refractory ulcerative colitis 12?weeks after laparoscopic subtotal colectomy.

Surgical technique

After release of the terminal ileostomy, creating the ileal J pouch extra-abdominally, a single-port device was placed. Through this, the rectal stump was mobilized and extracorporeally closed. The ileal pouch anal anastomosis was created using circular double-stapling technique. The single-port device was removed, and the loop ileostomy was placed at the same site.

Results

We employed this technique in a 54?year-old patient who had suffered from ulcerative colitis. No postoperative complications were observed.

Conclusions

Restorative restproctectomy as single-port surgery through the ostomy site is safe and feasible. No additional incision is necessary. The trauma of conventional laparoscopic access can be further reduced.     

Laparoscopic Hyperthermic Intraperitoneal Chemotherapy: Indications, Aims, and Results: A Systematic Review of the Literature

Purpose

To evaluate laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) with neoadjuvant, adjuvant, or palliative purpose in order to discuss potential clinical implications.

Methods

A systematic search of PubMed??s Medline through August 2011 using the keywords laparoscopic, hyperthermic, and chemotherapy.

Results

Eight studies encompassing a total of 183 patients were considered. The indications for laparoscopic HIPEC was neoadjuvant in 5 patients, adjuvant in 102 patients, and palliative in 76 patients. There were 13 minor complications not requiring repeat operation, and no deaths related to procedure were recorded. When performed to treat refractory malignant ascites, the procedure was effective in 95?% of cases.

Conclusions

Laparoscopic HIPEC appears to be a safe and effective procedure when performed to treat malignant ascites refractory to less aggressive treatments. The effectiveness of laparoscopy to perform HIPEC with neoadjuvant or adjuvant purpose needs to be confirmed by further studies.     

Current advances in single-port laparoscopic surgery

Purpose

Single-port laparoscopic surgery has the intention to further minimize the access trauma similar to natural orifice transluminal endoscopic surgery. While special trocars and instruments are needed, the spectrum of clinical indications corresponds to the conventional laparoscopic surgery. This review gives an overview of the current applications and advances in single-port laparoscopic surgery.

Methods

The PubMed database was searched for “single incision laparoscopic surgery” or “single port” and different operations (e.g., cholecystectomy, colectomy, and appendectomy). The references and our own experiences were considered for historic development and current advances.

Results

The spreading of single-port laparoscopic surgery is not as fast as expected. References show that operations using a single-port technique are feasible, safe, and efficient. More technical difficulties for the surgeon and higher costs must be considered. A better cosmetic result, less postoperative pain, and a faster recovery could be potential benefits for the patients.

Conclusions

Current advances in single-port laparoscopic surgery are difficult to define. The most common procedures are single-port laparoscopic cholecystectomies, colectomies, and appendectomies. Significant clinical benefits have not yet been proven even in prospective, randomized studies.     

Simple technique for gasless transumbilical single-incisional laparoscopic-assisted appendectomy

Purpose

Single-incision laparoscopic surgery has recently received more attention. We developed a novel simple technique of gasless transumbilical single-incisional laparoscopic-assisted appendectomy (TUSILAA) and retrospectively analyzed our initial experience.

Methods

TUSILAA has been attempted in 50 consecutive patients with acute appendicitis. The vertical incision through the umbilicus was used for laparoscopic access and the abdominal wall was lifted by a Kent retractor set system.

Results

Our technique was successful in 45 out of 50 (90 %) patients. The median operating time was 59 min (range 35–140). The median length of postoperative hospital stay was 4 days (range 2–12). None of the cases were converted to open appendectomy. There were no perioperative surgical complications.

Conclusions

Our novel technique, gasless TUSILAA, is safe and feasible with acceptable operative time and excellent cosmetic result. Furthermore, this procedure has the advantage of cost-effectiveness since any disposable instruments including trocars, staplers, or expensive devices are not required. Therefore, this could be used as the first-choice surgical procedure for selected patients with uncomplicated acute appendicitis.     

Effectiveness of electrothermal bipolar vessel-sealing devices versus other electrothermal and ultrasonic devices for abdominal surgical hemostasis: a systematic review

Background

Adequate hemostatic techniques are essential for optimal intra- and postoperative results. A number of different hemostatic techniques and devices have been developed over the past few years, but which device should be preferred during laparoscopic and open abdominal procedures?

Methods

We conducted a systematic search for randomized controlled trials (RCTs) that compared the effectiveness and costs of vessel-sealing devices with those of other electrothermal or ultrasonic devices in abdominal surgical procedures.

Results

Seven RCTs that included 554 patients met the inclusion criteria. Various procedures that used a vessel-sealing device (LigaSure?) (n?=?264) were compared to ultrasonic devices (n?=?139) and mono- (n?=?20) or bipolar devices (n?=?130). LigaSure was favored in two studies with respect to less blood loss, shorter operating time, and lower costs. However, no differences were observed in the other studies. Considering the relatively low number of complications, all hemostatic devices used may be considered relatively safe. None of the studies reported on quality of life or cost effectiveness.

Conclusions

Vessel-sealing devices may be considered safe and their use may reduce costs due to reduced blood loss and shorter operating time in some abdominal surgical procedures compared to mono- or bipolar electrothermal devices. Wider-ranging RCTs of sufficient quality that assess (cost) effectiveness are required to make firm conclusions.     

Laparoscopic versus open colorectal resection in the elderly population

Background

Elderly patients are often regarded as high-risk patients for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The aim of this systematic review and pooled analysis was to review the current data published regarding the differences in operative outcomes of laparoscopic and open surgery in the elderly population.

Methods

A systematic literature search of Medline, Embase, Web of Science, and Cochrane databases was performed. Studies that compared outcome following laparoscopic and open colorectal resections in the elderly (≥70) population were included. Primary outcomes were operative death, anastomotic leak, pneumonia, length of hospital stay, and return to bowel function. Secondary outcomes were operative time, intraoperative blood loss, postoperative cardiac morbidity, ileus, and postoperative wound infection.

Results

The results of this systematic review and pooled analysis demonstrate the safety and potential benefits of laparoscopic colorectal resection in the elderly population. The latter include reduction in length of hospital stay, intraoperative blood loss, incidence of postoperative pneumonia, time to return of normal bowel function, incidence of postoperative cardiac complications, and wound infections.

Conclusion

The results of this pooled analysis demonstrate the potential short-term advantages of laparoscopic colorectal resection in the elderly population. Further studies are required to examine the long-term survival following laparoscopic and open colorectal resections in the elderly population.     

Laparoscopic approach for the management of gastrointestinal stromal tumours (GIST) of the stomach

Aim-Background

The present review of the literature evaluates whether laparoscopic resection of gastric GISTs can become the new “gold standard” treatment, analyzing perioperative characteristics and long-term oncological outcome. Surgery remains the standard treatment for non-metastatic gastrointestinal stromal tumours (GISTs). Laparoscopic surgery is considered a suitable option, since the biological behaviour of these tumours allows for curative resection without the necessity for large margins or extensive lymphadenectomies.

Methods

A systematic review of gastrointestinal stromal tumours of the stomach treated by laparoscopy was conducted.

Results

Up to 2008, laparoscopic surgery was attempted in 442 patients, of whom 254 were male and 188 female. Their average age was 61 years. The mean tumour size was 4.3 cm (1.0–7.5 cm); operative time ranged from 49–194.3 min, blood loss from 15–196ml, and hospital stay from 2.3 up to 12.2 days. All lesions had negative resection margins. The follow-up period for all patients ranged from 19 up to 61 months while the overall survival was 82%.

Conclusions

The review of the literature concurred that laparoscopic resection is safe and effective in treating gastric GISTs. Taking into consideration the associated benefits of this minimally invasive approach, laparoscopic surgery should be considered in the surgical treatment of small- and medium-sized gastrointestinal stromal tumours of the stomach.     

Revisional laparoscopic antireflux surgery after unsuccessful endoscopic fundoplication

Background

Transoral incisionless fundoplication (TIF), a novel endoscopic procedure for treating gastroesophageal reflux disease (GERD), currently is under evaluation. In case of treatment failure, subsequent revisional laparoscopic antireflux surgery (rLARS) may be required. This study aimed to evaluate the feasibility, safety, and outcomes of revisional antireflux surgery after previous endoscopic fundoplication.

Methods

Chronic GERD patients who underwent rLARS after a previous TIF procedure were included in the study. Pre- and postoperative assessment included GERD-related quality-of-life scores, proton pump inhibitor (PPI) usage, 24-h pH-metry, upper gastrointestinal endoscopy, and registration of adverse events.

Results

Revisional laparoscopic Nissen fundoplication was feasible for all 15 patients included in the study without conversions to open surgery. Acid exposure of the distal esophagus improved significantly after rLARS, and esophagitis, PPI usage, and hiatal hernia decreased. Quality of life did not improve significantly after rLARS, and 33 % of the patients experienced dysphagia.

Conclusion

Revisional laparoscopic Nissen fundoplication was feasible and safe after unsuccessful endoscopic fundoplication, resulting in objective reflux control at the cost of a relatively high rate of dysphagia.     

Laparoscopic surgery for palliative resection of the primary tumor in incurable stage IV colorectal cancer

Background

The purpose of the study was to evaluate the feasibility and efficacy of laparoscopic palliative resection in patients with incurable stage IV colorectal cancer.

Methods

We reviewed 100 patients with incurable stage IV colorectal cancer who underwent palliative resection of the primary tumor between 2002 and 2009 at National Cancer Center Hospital East (NCCHE). Outcomes and postoperative course were compared between patients who underwent open and laparoscopic surgery.

Results

Of the 100 patients, 22 were treated with a laparoscopic procedure and 78 underwent an open surgical procedure. There was no difference in the preoperative characteristics of the two groups. In the laparoscopic group, the mean operation time was significantly longer (177 vs. 148?min, p?=?0.007) and the amount of blood loss was significantly lower (166 vs. 361?ml, p?=?0.002). Postoperative complications occurred in 5 patients (22.7?%) after laparoscopic surgery and in 21 patients (26.9?%) after open surgery, with no significant difference between the two groups. Time to flatus, time to start of food intake, and hospital stay were all shorter after laparoscopic surgery (3.0 vs. 3.8?days, p?=?0.003; 3.6 vs. 5.0?days, p?<?0.001; and 12.0 vs. 15.0?days, p?=?0.005; respectively). Significantly more patients in the laparoscopic group had >15?% lymphocytes on postoperative day 7 (p?=?0.049). Overall survival rates were 73.7 and 75.5?% at 1?year after laparoscopic surgery and open surgery, respectively (p?=?0.344).

Conclusions

A laparoscopic procedure should be considered for palliative resection of the primary tumor for incurable stage IV colorectal cancer, because the results of this study indicate that the procedure is safe and effective.     

The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review

Objective

This review aimed to determine the role of single-incision laparoscopic surgery (SILS) in abdominal and pelvic operations.

Data sources

The Medline, EMBASE, and PsycINFO databases were systematically searched until October 2009 using ??single-incision laparoscopic surgery?? and related terms as keywords. References from retrieved articles were reviewed to broaden the search

Study selection

The study included case reports, case series, and empirical studies that reported SILS in abdominal and pelvic operations.

Data extraction

Number of patients, type of instruments, operative time, blood loss, conversion rate, length of hospital stay, length of follow-up evaluation, and complications were extracted from the reviewed items

Data synthesis

The review included 102 studies classified as level 4 evidence. Most of these studies investigated SILS in cholecystectomy (n?=?34), appendectomy (n?=?24), and nephrectomy (n?=?17). For these procedures, operative time, hospital stay, and complications were comparable with those of conventional laparoscopy. Conversion to conventional laparoscopy was seldom performed in cholecystectomy (range, 0?C24%) and more frequent in appendectomy (range, 0?C41%) and nephrectomy (range, 0?C33%).

Conclusion

The potential benefits of SILS include superior cosmesis and possibly shorter operative time, lower costs, and a shortened time to full physical recovery. Careful case selection and a low threshold of conversion to conventional laparoscopic surgery are essential. Multicenter, randomized, prospective studies are needed to compare short- and long-term outcome measures against those of conventional laparoscopic surgery.     

Learning Curve of Transumbilical Single Incision Laparoscopic Cholecystectomy (SILS): A Preliminary Study of 80 Selected Patients with Benign Gallbladder Diseases

Background

Transumbilical single incision laparoscopic surgery (SILS) is a new laparoscopic procedure in which only one transumbilical incision is made, demonstrated as a scarless procedure. Here we report a single-center preliminary experience of transumbilical single incision laparoscopic cholecystectomy (SILC) in the treatment of benign gallbladder diseases, defining a single surgeon’s learning curve.

Methods

A total of 80 patients underwent SILC successfully by a single experienced laparoscopic surgeon. The operation was performed following the routine LC procedure. Then the perioperative demographics were recorded and the operative time was used to define the learning curve.

Results

The study group included 27 male and 53 female patients with gallstones (56 cases), cholesterol polyps (16 cases), an adenomatous polyp (3 cases), adenomyomatosis (1 case), or complex diseases (4 cases), and all consented to undergo SILC. No patient was converted to normal LC or open surgery. There were no perioperative port-related or surgical complications. The average operative time was 46.9 ± 14.6 min. The average postoperative hospital stay was 1.8 ± 1.3 days. The learning curve of the SILC procedures for this series of selected patients confirmed that SILC is a feasible, safe, and effective approach to the treatment of benign gallbladder diseases.

Conclusions

For experienced laparoscopic surgeons, SILC is an easy and safe procedure. Patients benefit from milder pain, a lower incidence of port-related complications, better cosmesis, and fast recovery. The SILC procedure may become another option for the treatment of benign gallbladder diseases for selected patients.     

Laparoscopic radical cholecystectomy and Roux-en-Y choledochojejunostomy for gallbladder cancer

Background

Although laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches to preoperatively suspected gallbladder cancer.

Methods

Like the standard laparoscopic cholecystectomy, the minimally invasive procedure is performed with four trocars. The surgeon operates with the patient in the French position. A totally laparoscopic radical cholecystectomy including wedge resections of segments IVB and V is undertaken with hepatoduodenal lymphadenectomy and common bile duct excision. The biliary system is reconstructed via a laparoscopic choledochojejunostomy.

Results

Six patients have undergone laparoscopic radical cholecystectomy. Three of these patients were found to have gallbladder cancer according to the final pathology. All the final surgical margins were negative, and the average lymph node retrieval was 3 (range, 1–6).

Conclusion

The minimally invasive approach to gallbladder cancer is feasible and safe. It should currently be performed in high-volume centers with expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether either the open or laparoscopic approach offers any advantage.     

Minimally invasive surgical treatment of sigmoid diverticulitis

Introduction

Diverticular disease is very common in Western societies. However, there is a trend towards reducing indications for the surgical management of diverticulitis. Minimally invasive surgery offers many potential advantages to patients in the treatment of diverticulitis and may optimise surgical indications.

Methods

A systematic literature review of minimally invasive techniques was carried out for the treatment of diverticulitis. The following techniques were reviewed: laparoscopic, single-port, natural orifice specimen extraction, natural orifice transluminal endoscopic surgery and laparoscopic lavage for the treatment of diverticulitis.

Results

In total, 2,050 minimally invasive cases were reviewed. Of all the different minimally invasive techniques published regarding the management of diverticular disease, laparoscopic surgery is the only technique that has undergone the rigours of randomised controlled trials. The documented benefits are less blood loss, less pain and analgesic requirements, a reduction in major complications, a reduction in the frequency of drain usage, a reduction in the duration of postoperative ileus and shorter hospital stay. However, operative time does appear to be longer. It has also been demonstrated that elective laparoscopic surgery results in improved quality of life and social functioning.

Conclusion

Minimally invasive surgery for the treatment of diverticular disease appears feasible and safe. The result of future randomised trials will more clearly define the role each minimally invasive technique will play in the future.     

Laparoendoscopic single site (LESS) vs. conventional laparoscopic fundoplication for GERD: is there a difference?

Background

This report details our experience with laparoendoscopic single site (LESS) fundoplication for GERD and provides a comparison to earlier contiguous patients undergoing conventional laparoscopic fundoplication.

Methods

With institutional review board approval, symptoms before and after LESS fundoplications and conventional laparoscopic fundoplications were scored by patients. Outcomes after 130 consecutive LESS fundoplications were compared to 130 contiguous consecutive outcomes after conventional laparoscopic fundoplications.

Results

Patients undergoing conventional laparoscopic vs. LESS fundoplication were very similar. There were no conversions to “open” operations and no notable complications with LESS fundoplication. Symptom reduction was broad and dramatic for patients undergoing LESS or conventional laparoscopic fundoplication; 96 % of patients who underwent LESS fundoplication scored their incision as ≥8 (1 = revolting to 10 = beautiful).

Conclusions

Relative to conventional laparoscopy, LESS surgery provides excellent resolution of symptoms without an apparent scar. In comparison to conventional laparoscopy, LESS fundoplication is as safe with similar symptom improvement and superior cosmesis.     

Minimalinvasive Chirurgie primärer und sekundärer Lebertumoren

Background

Initially, mainly superficial liver lesions were resected laparoscopically but now even major resections are performed using a minimally invasive procedure. Careful selection of suitable patients is of key importance.

Aims and methods

This article describes the current state of the art in patient selection and choice of the appropriate laparoscopic technique based on a review of the recent literature. Perioperative and oncological outcome parameters of laparoscopic liver resection are presented.

Results

Laparoscopic liver resection offers significant benefits compared to open liver resection in terms of reduced intraoperative blood loss, reduced overall and liver-specific complications and length of hospital stay without compromising oncological outcomes.

Conclusion

Lesions in the peripheral anterolateral segments (segments 2, 3, 4b, 5 and 6) are particularly suitable for laparoscopic liver resection. Access to the posterosuperior segments 1, 4a, 7 and 8 is more challenging but safe and feasible in experienced centers.     

Extending the limitations of liver surgery: outcomes of initial human experience in a high-volume center performing single-port laparoscopic liver resection for hepatocellular carcinoma

Background

Single-port laparoscopic surgery is slowly but steadily gaining popularity among surgeons performing minimally invasive abdominal surgeries. The aim of the present study is to assess our initial experience with single-port laparoscopic liver resection for hepatocellular carcinoma.

Methods

Between March 2009 and April 2011, 24 patients underwent single-port laparoscopic liver resection for hepatocellular carcinoma. Of these, 13 were laparoscopic segmentectomies, 4 were laparoscopic left lateral sectionectomies, 1 was a right hepatectomy, 1 was a left hepatectomy, and 4 were nonanatomical resections.

Results

Median operating time and blood loss were 205?min (95–545?min) and 500?ml (100–2,500?ml), respectively. Two procedures were converted to multiport laparoscopic hepatectomy due to instrument length limitations, and four were converted to open surgery. There were no serious intraoperative or postoperative complications in this series. Median postoperative stay was 8.5?days (5–16?days).

Conclusions

Although the procedure requires a lot of technical expertise added to the skill of liver surgery, single-port laparoscopic liver resection for hepatocellular carcinoma seems a feasible approach in a variety of well-selected cases. In spite of the demanding nature of the procedure and the requirement of better instrumentation for single-port laparoscopic surgery, the results seem to compare favorably with conventional laparoscopic surgery and open surgery.     

The Evolving Role of Laparoscopy in Colonic Diverticular Disease: A Systematic Review

Background

A PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials.

Results

Elective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis.

Conclusions

Elective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.