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     

Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases

Background: Kuzmak's gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study was to analyze the complications of this approach. Methods: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique. A minimally invasive procedure using five trocars was performed. Results: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications: There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis. One fatality on the 45th day in a patient with a Prader-Willi syndrome. Conclusion: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure. Received: 28 May 1996/Accepted: 25 July 1996     

Laparoscopic repair of a paraduodenal hernia

Paraduodenal hernias have traditionally been treated by conventional laparotomy. We report the first case of a left paraduodenal hernia treated laparoscopically. A 44-year-old man was admitted with abdominal pain and nausea. Computed tomography and an upper gastrointestinal series with small-bowel followthrough showed accumulation of the small bowel on the left side of the abdomen. A laparoscopic repair was performed. The small bowel was observed beneath a thin hernia capsule. Approximately 1.5 m of jejunum was easily reduced into the abdominal cavity. The hernia orifice (5-cm diameter) was closed intracorporeally with five interrupted sutures. Good exposure of the operative field is critical to this procedure; poor exposure may limit the applicability of the laparoscopic approach. This minimally invasive operation is currently indicated in nonobstructive paraduodenal hernias, especially on the left. Received: 7 October 1996/Accepted: 11 April 1997     

Laparoscopic Roux-en-Y Gastric Bypass:Transoral Or Transgastric Anvil Placement?

Background: Laparoscopic techniques have been used to perform the Roux-en-Y gastric bypass (RYGBP). The gastrojejunostomy may be constructed using an end-to-end anastomosis (EEA) stapler. Most reports describe passing the EEA anvil transorally using an esophagogastroscope and a pullwire technique. Method: We describe problems experienced using this technique and present an alternative method. Results: Esophageal injury may occur during laparoscopic RYGBP (LRYGBP) using the transoral anvil placement technique. When the anvil is retrieved into the gastric pouch, the anvil may become lodged at the cricopharngeus muscle. Dislodgment can be problematic and time-consuming. We present a case of mild esophageal injury which occurred during transoral anvil placement. The patient had transient postoperative dysphagia and recovered without sequelae. We present an alternative method in which the anvil is passed through a gastrotomy. Conclusion: Transgastric anvil placement alleviates the need for endoscopy, thereby saving time and resources.This technique eliminates the potential for esophageal injury. The transgastric anvil placement technique has proven reliable. The transgastric method may make the LRYGBP operation safer and easier to perform.     

Indications for endo-organ gastric excision

Intragastric surgery for benign and malignant conditions is a new form of minimally invasive surgery, to which the term endo-organ gastric surgery has been applied. This procedure may provide improved results for patients, but reported studies are small, and follow-up evaluation is limited. The indications for endo-organ surgery are evolving as technology and operative expertise begin to meet the need for continued advancements in miniaturized surgery. This new approach is applied primarily to the removal of gastric neoplasms poorly positioned or too large for standard transoral endoscopic excision. Gastric polyps, benign gastric wall tumors such as leiomyomas and carcinoids, and low-grade as well as high-grade malignancies can be removed. The history of endo-organ surgery, the background technology, and surgical experience are reviewed. In addition, current indications for endo-organ surgery and the rationale for algorithms are included. Intraluminal gastric surgery is not widely performed or studied, therefore a further understanding of its role is provided. Received: 7 April 1999/Accepted: 18 August 1999     

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     

Video-laparoscopic staging of gastric cancer

Background: The high proportion of gastric carcinomas present in an unresectable stage, together with the emergence of multimodal treatments, increases the usefulness of objective staging methods that avoid unnecessary laparotomies. Methods: A prospective evaluation of the accuracy of laparoscopy in the staging of 71 patients with gastric adenocarcinoma is presented. Serosal infiltration, retroperitoneal fixation, metastasis to lymph nodes, peritoneal and liver metastasis, and ascites were determined in the staging workup. Sensitivity, specificity, and predictive values were calculated and compared with those obtained with ultrasonography (US) and computed tomography (CT). Results: The diagnostic accuracy of laparoscopy in the determination of resectability was 98.6%. Consequently, over 40% of patients were spared unnecessary laparotomies. Laparoscopy yielded diagnostic indices superior to US and CT for all the tumoral attributes studied. Our technique permits accurate assessment and pathologic verification of liver and the peritoneal and retroperitoneal extent of tumor invasion in the majority of patients. Conclusions: Laparoscopy in gastric adenocarcinoma is a reliable technique that provides accurate assessment of resectability and stage, thus avoiding unnecessary laparotomies in patients in whom surgical palliation is not indicated. A stepwise diagnostic workup combining imaging and minimally invasive techniques is proposed. Received: 5 May 1996/Accepted: 10 March 1997     

Hypopharyngeal Perforation during Laparoscopic Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass was recently introduced as an alternative surgical treatment for morbid obesity.The technique involves placement of a 21-mm anvil transorally down to the gastric pouch for creation of the gastroenterostomy anastomosis using an EEA stapler placed transabdominally. Esophageal injury is a theoretical concern with transoral manipulation of the anvil. The authors present a case of hypopharyngeal perforation after an attempted transoral insertion of an EEA anvil. The perforation was treated with neck exploration and drainage. We discuss the mechanism of injury and alternative method for placement of the gastric anvil.     

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     

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     

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     

One-year follow-up after laparoscopic Heller-Dor operation for esophageal achalasia

Background: The Heller-Dor operation has recently been proposed for the treatment of esophageal achalasia even via a laparoscopic approach. Methods: To measure the medium-term effectiveness of this new minimally invasive technique, an evaluation of pre- and postoperative symptoms, esophagogram, endoscopic findings, esophageal manometry, and pH monitoring was prospectively designed in 43 patients with primary esophageal achalasia. The mean clinical follow-up for all the patients is 12 months (range 3–43), while the mean radiological follow-up is 11 months (range 1–23). Endoscopic data 1 year after surgery are currently available for 27 patients (63%), whereas a 12-month (range 1–26) functional follow-up (including manometric and pH-monitoring studies of the esophagus) is currently available for 35 patients (81.4%). Results: No dysphagia was reported in 38 cases (88.4%); two (4.6%) complained of occasional swallowing discomfort which regressed spontaneously; two (4.6%) had persistent dysphagia which regressed with pneumatic dilatation. One patient (2.8%) reported mild occasional dysphagia after a 1-year asymptomatic period. Preoperatively, esophagograms showed an average maximum diameter of 40.6 ± 9.1 mm which decreased to 24.1 ± 6.0 mm after operation. Mean lower esophageal sphincter (LES) resting and residual pressures decreased significantly from 28.6 ± 10.7 mmHg to 8.8 ± 4.1 mmHg and from 17.0 ± 9.7 mmHg to 4.7 ± 4.0 mmHg, respectively (p < 0.0001). These effects on esophageal diameter and LES function seem to persist over time. The complete absence of any peristaltic contractions recorded preoperatively in all cases remained unchanged after surgery in all but four patients. However, this rare recovery of peristalsis proved to be transient, and patients revealed a manometric impairment of their esophageal body function, but without complaining of dysphagia. Twenty-four-hour pH monitoring showed abnormal gastroesophageal reflux episodes in two (5.7%) of the 35 patients who were monitored: one was asymptomatic; the other had heartburn and endoscopically demonstrated grade II esophagitis. Conclusions: Laparoscopic Heller-Dor operation achieves excellent medium-term results which, together with the already-demonstrated advantages of a minimal surgical trauma and rapid convalescence, validate the use of such a minimally invasive approach to treat patients with primary achalasia of the esophagus. Received: 19 March 1996/Accepted: 15 May 1996     

A new technique for laparoscopic resection of a submucosal tumor on the posterior wall of the gastric fundus

Several reports have been published which describe the technique of using an Endo GIA to resect submucosal tumors on the anterior wall of the stomach. Lesions on the posterior wall, however, especially near the esophagocardiac junction (ECJ), are difficult to resect using these reported techniques. This is because the surgeon must divide the omentum and enter the omental bursa in order to use a similar extraluminal technique. Furthermore, special care must be taken to ensure that resections do not involve the ECJ and narrow the esophagus. In order to overcome these difficulties, we have proposed a new technique for the laparoscopic excision of a submucosal tumor located on the posterior wall of the gastric fundus. The principle of this procedure involves the intraluminal resection of the submucosal tumor, including the surrounding stomach wall, using the Endo GIA. This technique is safe, simple, and effective. We believe that we are the first to address the excision of a submucosal lesion by resecting the full thickness of the posterior gastric wall lesion intraluminally. Received: 11 November 1996/Accepted: 2 April 1997     

Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis

Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation. Methods: We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved preoperatively by stent placement via endoscopy (n= 6, 37.5%), percutaneous access (n= 5, 31%) or bilioenteric anastomosis (n= 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively. Results: Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention; there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%) patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain oral intake during the remaining survival time. Conclusions: We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional result while impairing the quality of life only to a minimal extent. Received: 7 May 1996/Accepted: 12 December 1996     

Laparoscopic pancreaticoduodenectomy in the porcine model

Background: Minimally invasive techniques offer theoretical advantages for treating resectable periampullary neoplasms. Laparoscopic pancreaticoduodenectomy (LPD) was first reported in 1992 and has been performed clinically despite lack of animal data to support the operation. The purpose of this study was to develop LPD in an acute porcine model and to assess safety and efficacy before considering clinical trials. Methods: LPD was initiated in six domestic pigs under general anesthesia. Once pneumoperitoneum was created, five 10-mm access ports were placed (one central and two in each flank). After cholecystectomy, the duodenum was mobilized and the proximal jejunum was divided distal to the ligament of Treitz. The neck of the pancreas was separated from the superior mesenteric vein, and the midstomach was divided by a stapler. Pancreaticojejunostomy (PJ), choledochojejunostomy (CDJ), and gastrojejunostomy (GJ) were performed using interrupted sutures. The animals were immediately sacrificed and the operative site was examined. Results: LPD was aborted in three animals due to complications: intestinal perforation with fecal contamination (one) and prolonged resection time ≥ 2.5 h (two). LPD was completed in three animals (operative time ranged from 5.0 to 7.5 h, blood loss < 200 cc); however, at sacrifice one PJ and two CDJs had small posterior leaks. The efferent loop of the GJ was narrowed by the staple line in one pig. All animals had extensive ecchymosis of the jejunal serosa due to excessive manipulation. Conclusion: Despite a significant number of anastomotic leaks in the immediate postoperative period, laparoscopic pancreaticoduodenectomy is feasible in a porcine model. Further studies and technical development are necessary before laparoscopic pancreatic resection can be performed on a more widespread basis. Received: 22 April 1996/Accepted: 10 July 1996     

Fully thoracoscopic pulmonary lobectomy and specimen extraction through rib segment resection

Background: A technique of fully thoracoscopic pulmonary lobectomy with rib-segment resection for specimen extraction is described, and preliminary results in 18 patients are presented. Methods: Surgery is performed through four 15-mm ports. For all lobes except one, the surgeon operates in front of the patient, where the rib spaces are widest and rib-space trauma is less. When lobar dissection is complete, specimen extraction is performed after resection of a rib segment proportional to tumor size. Muscle section is kept to a minimum. There is no rib retraction. Results: There were no deaths, three conversions to open surgery, and three major complications. Average postoperative stay was 5.4 days for patients without complications and 9.6 days for patients with complications. In total six patients presented with some degree of air leaks, and two had post-thoracotomy pain (>2 month's duration). The literature is reviewed to analyze current techniques and to define parameters of a truly minimally invasive pulmonary lobectomy. Conclusions: This technique is safe and promising; however, thoracoscopic lobectomy still needs refining. Before valid randomized studies comparing thoracoscopic lobectomy and muscle-sparing thoracotomy or posterolateral thoracotomy can be credible, technical issues related to the production of a truly minimally invasive procedure should be resolved. Received: 20 August 1996/Accepted: 19 September 1996     

Laparoscopic treatment of gastric stromal tumors

Background: The laparoscopic resection of gastric stromal tumors (GST) is being performed with increased frequency. Methods: Between November 1993 and October 1998, nine consecutive patients with benign and low-grade gastric stromal tumors underwent laparoscopic resection using intraoperative endoscopy. For lesions located on the anterior wall (three cases), a direct approach was utilized. Lesions located on the posterior wall were resected via a transgastric approach (four cases) or through a small opening on the omentum or on the gastrocolic ligament (two cases). Excision of the lesions was performed manually by means of electrocautery and scissors in eight cases; the gastric incisions were closed by manual running suture. An endoscopic stapler device was used in one case only. Results: All patients were successfully treated laparoscopically; there were no conversions to open surgery. Operative time ranged from 75 to 120 min. There was one bleeding from the suture line of the gastric wall postoperatively that was treated conservatively. The average postoperative hospital stay was 4 days (range, 2–6). Conclusions: In light of the results reported in the literature and on the basis of the present work, it seems that laparoscopic resection of GST should be considered as the treatment of choice. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. In our opinion the direct approach should be reserved for lesions located on the posterior wall of the body, which can be easily reached through the greater omentum, while the transgastric approach should be preferred for lesions located on the fundus and antrum. Manual excision allows a tailored operation; hand-sewn sutures are always feasible, and they are cheaper than stapled ones. Received: 30 April 1999/Accepted: 7 October 1999/Online publication: 10 April 2000     

Subfascial hemorrhage after endoscopic perforator vein ligation

Ligation of perforator veins in the lower extremity for the treatment of venous ulceration can be performed using a minimally invasive technique with endoscopic instruments. Several studies have documented that the endoscopic technique has a lower wound-related complication rate compared to open perforator vein ligation. We report the complication of postoperative subfascial hemorrhage requiring reexploration after subfascial endoscopic perforator vein ligation and describe a minimally invasive method for its control using balloon tamponade. Received: 15 January 1997/Accepted: 7 May 1997     

Laparoscopic repair of a colonoscopic perforation

We report a case of laparoscopic repair of a diagnostic colonoscopic perforation. No other such reports were noted in the literature. The management of colonoscopic perforations has become controversial. Operative vs nonoperative treatment is continually debated. The morbidity of operative management is significant. Colostomy is often performed. Laparoscopy should allow early evaluation of operative patients and primary repair of those with minimal contamination and no residual pathology. The benefits of minimally invasive surgery, such as shortened hospitalization and rapid return to full activities, including work, were realized in our patient. Laparoscopy should be considered in the selective management of colonoscopic perforations. Received: 15 September 1995/Accepted: 16 January 1996     

The efficacy of laparoscopic surgery in the diagnosis and treatment of peritonitis

Background: Peritonitis continues to be an important cause of morbidity and mortality and often an etiologic diagnosis is unclear. To evaluate the efficacy and safety of laparoscopy the authors analyzed their 5-year experience with this modality of treatment. Methods: A review was made of 107 consecutive nonselected laparoscopic procedures performed between October 1990 and November 1995. The diagnosis was established by clinical, laboratory, and imaging findings and confirmed by laparoscopy and/or laparotomy. Results: An etiologic diagnosis was unclear in 35% of the cases and was established in all by laparoscopy; 94 patients (87.9%) were successfully treated by laparoscopy while 13 (12.1%) required conversion. Mortality was 4.6%; 14% had postoperative complications and 7.4% had reoperations. Conclusions: Laparoscopic surgery is safe and very efficient in the diagnosis and treatment of patients with peritonitis. In most instances a definitive treatment can be carried out without conversion and has the additional and well-known advantages of minimally invasive surgery. Received: 15 March 1996/Accepted: 29 August 1996