Technical considerations for laparoscopic right renal surgery in presence of Riedel's lobe of the liver

Riedel's lobe of the liver is an anatomic variant, described as a caudal extension of the right lobe of the liver, that presents a challenge in laparoscopic right renal surgery. A 52-year-old woman with a Riedel's lobe of the liver and a large right renal mass underwent laparoscopic right radical nephrectomy. Transperitoneal access with the Veress needle through a right lateral port was initially unsuccessful. After a supraumbilical approach, pneumoperitoneum was eventually achieved. The right lateral liver attachments were freed, and the lobe was retracted medially to expose the right kidney and its hilum. The surgery was then performed successfully. Riedel's lobe presents two special technical concerns: intraperitoneal access and hilar exposure. For access, an initial supraumbilical approach, or possibly an open approach, decreases the risk of liver injury. For renal and hilar exposure, the right lateral liver attachments can be taken down so that the hepatic lobe can be retracted medially instead of in the conventional cephalad direction. Retroperitoneal access, if feasible, may also circumvent these problems. Surgery can then be performed safely and effectively.     

The economic considerations in laparoscopic surgery

There has been increasing concern in the medical, business, and insurance communities and government agencies about the rising cost of health care. Since 1980 the cost of medical care has increased from $280 billion dollars per year to $670 billion dollars in 1990, and was estimated at $900 billion in 1993. Several factors have contributed to this increase, including the high cost of hospitalization and new expensive technology, such as laparoscopic cholecystectomy. This present cost analysis was undertaken to determine the cost variables in laparoscopic cholecystectomy to see if changes in physician, nursing, and administration work activities could decrease the cost of hospitalization. Fifty-four patients who had an uncomplicated elective cholecystectomy during a five-month period in 1993 were assessed in terms of cost components of hospitalization, including nursing unit labor costs, surgery personnel labor costs, supply/instrument cost, and ancillary costs. Nine general surgeons participated in this study, four of whom accounted for 71% of the annual volume of cases. This analysis was performed with the help of Baxter Corporate Consulting, a Division of Baxter Healthcare Corporation. From this study, it was found that the average cost for uncomplicated laparoscopic cholecystectomy patients was $1589±$223. The operating room and supply/instrument component costs were the two largest expenses, accounting for 42% of the total cost. Reimbursement from various insurance agencies were also evaluated, and it was determined that a contract made with a local HMO caused the hospital to lose an average of $443.00 per patient. Instrument cost was evaluated, showing that the surgeons who used disposable instruments had an average instrument cost of $806±$63 per case, whereas those using reusable products had an average cost of $303 per case. (A reprocessing cost of $200 was also added when reusable instruments were used. This included the cost of cleaning, repairs, and labor costs for this equipment.) The cost of disposable and reusable products was evaluated in terms of the initial purchase price, replacement charges, equipment maintenance charges, and labor costs for cleaning, repackaging and inspection, sterilization, and quality control. A second factor identified was that patients directed to an inpatient nursing unit incurred an average direct nursing labor cost of $124, whereas the cost was only $54 when the patient went to an out-patient unit. A third observation demonstrated that the operating room time averaged 203 min±31 min, and the length of the operative procedure accounted for only 96 min±20 min of the total operating room time. From this data it appears that, in hospitals with more than 300 laparoscopic cholecystectomy cases per year, the costs of using reusable and disposable instruments is similar. Time/motion studies in the operating room have also been instituted, along with changes in postoperative physician orders, to decrease the cost of the hospitalization.     

Technical considerations and pitfalls in laparoscopic live donornephrectomy

Background: Recent developments in laparoscopic solid organ surgery suggest a possible reduction in postoperative discomfort and disability for kidney donors. Technical aspects and the influence of surgical experience in laparoscopic donor nephrectomy were evaluated. Methods: The clinical outcome of 57 laparoscopic donor nephrectomies (LapNx) was compared with that for a historic control group of 27 open donor nephrectomies (OpenNx). Results: Three conversions to open nephrectomy (5.2%) were necessary. Postoperative complications were minor and comparable in both groups. Patients who underwent laparoscopic surgery demonstrated significantly less postoperative pain and a shorter hospital stay, but operative time and warm ischemia time were significantly longer. Graft survival after LapNx was 100% during a median follow-up period of 13 months. Operative time for LapNx decreased considerably with experience gained and seemed to be less for right nephrectomy. Stenotic ureter–bladder anastomoses occured after LapNx in four patients during the first half year (7.0%), but this problem seemed to be resolved after modification of the technique. Conclusion: LapNx is associated with less postoperative discomfort and improved convalescence.     

Technical considerations in laparoscopic resection of gastric neoplasms

Background: The purpose of this study was to determine the use of different laparoscopic approaches in the management of gastric neoplasms based on tumor type and location. Methods: We retrospectively reviewed the records of seven patients (3 men and 4 women) with 11 gastric lesions who were referred to our facility between March 2000 and October 2001 for laparoscopic excision of gastric neoplasms. Results: Two patients had gastrointestinal stromal lesions (3 lesions); two patients had hyperplastic polyps (3 lesions); one patient had carcinoid tumor (2 lesions); one patient had a carcinoma in situ and an adenoma; and one patient had an ectopic pancreas. Extraluminal laparoscopic wedge resection was used in four patients with lesions at the anterior gastric wall or along the lesser or greater curvature. Intragastric excision was used in two patients with small posterior wall lesions, and a transgastrotomy approach was used in one patient with a posterior wall lesion that could not be removed by the intragastric approach. All the lesions were completely excised with clear margins. The median hospital stay was 3 days. Complications developed in two patients. One patient presented with a perforated ulcer 2 weeks after surgery, and a second patient had postoperative pyloric edema that resolved with conservative treatment. Conclusions: The use of different laparoscopic approaches based on gastric neoplasm type and location facilitates tumor access and resection.     

Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations

Laparoscopy has become an effective modality for the treatment of many pediatric urologic conditions that need both extirpative and reconstructive techniques. Laparoscopic procedures for urologic diseases in children, such as pyeloplasty, orchiopexy, nephrectomy, and bladder augmentation, have proven to be safe and effective with outcomes comparable to those of open techniques. Given the steep learning curve and technical difficulty of laparoscopic surgery, robot-assisted laparoscopic surgery (RAS) is increasingly being adopted in pediatric patients worldwide. Anything that can be performed laparoscopically in adults can be extended into pediatric practice with minor technical refinements. We review the role of laparoscopic and RAS in pediatric urology and provide technical considerations necessary to perform minimally invasive surgery successfully.     

Hand-assisted laparoscopic liver surgery

HYPOTHESIS: The hand-assisted laparoscopic technique may be applied to the treatment of liver tumors. DESIGN: A case series with mean follow-up of 13 months. SETTING: University-affiliated tertiary care center. PATIENTS: A total of 15 patients with hepatic neoplasms underwent screening tests, including appropriate tumor marker analyses, abdominal sonography, and computed tomographic scan and, in most cases, magnetic resonance imaging to determine operability. Contraindications included extrahepatic disease, more than 5 liver lesions, coagulopathy, and ascites. INTERVENTION: Between March 1, 1998, and April 30, 2001, 15 patients underwent 16 hand-assisted diagnostic laparoscopic operations to rule out extrahepatic disease. Four patients had extrahepatic disease. In the 11 patients without evidence of extrahepatic disease, intraoperative ultrasound was used to establish the number and location of liver lesions. Operative strategies included resection, cryoablation, or both. MAIN OUTCOME MEASURES: Operative time, conversion to open procedure, length of stay, complications, and recurrence of disease. RESULTS: Of the 15 patients with liver tumors, 6 patients had more extensive disease than was detected by either preoperative imaging or laparoscopic exploration They included extrahepatic disease (3), additional liver lesion (2), or both (1). Hand-assisted management included resection only (3), cryoablation only (5), and a combination of the 2 (3). A total of 9 lesions were resected and 10 lesions were cryoablated. The mean operative time was 197 minutes with a mean length of stay of 4.5 days. There were no conversions to open procedures. One patient experienced minor postoperative bleeding but required no treatment. All treated patients are alive, and 5 have had recurrence of disease. CONCLUSIONS: Hand-assisted technique can be applied safely and effectively to laparoscopic liver surgery and may identify presence of otherwise undetectable disease.     

Anesthetic considerations during liver surgery

This article demonstrates the broad range of considerations that affect the outcome of patients undergoing hepatectomy. The progressive improvements in survival, despite the increasing complexity of the surgery, area testament to advances in both surgery and anesthesia. The key elements include careful patient selection, appropriate monitoring, and mechanical and pharmacologic protection of the liver and other vital organs.     

Technical considerations in revision anterior cruciate ligament surgery

Revision ACL surgery is a technically demanding enterprise that requires meticulous preoperative planning and tempered postoperative expectations on the patient's part. Despite the complexities of the procedure, it is becoming more common as an increasing number of primary ACL reconstructions are being performed, expanding the pool of patients at risk for failure. Candidates for revision surgery should be selected carefully, focusing on those patients with recurrent instability rather than pain as their primary complaint. A thorough history and physical examination is essential, taking care to identify additional patholaxity that might contribute to a failed ACL reconstruction. To optimize outcomes, surgeons must take care to avoid common pitfalls in index and revision procedures. Femoral and tibial tunnels should be positioned anatomically, and staged bone grafting procedures should be considered if revision graft fixation may be compromised by tunnel defects. The type of graft must be carefully selected, appropriately tensioned, and securely fixed. Surgeons should have a number of techniques and instruments at their disposal for performing each of these steps, as the highly variable presentation of failed ACL reconstructions demands a versatile approach. Ultimately, with cautious rehabilitation, these techniques will allow for restoration of knee stability and, in many cases, an improvement in activity level.     

Technical advances toward interactive image-guided laparoscopic surgery

Background: Laparoscopic surgery uses real-time video to display the operative field. Interactive image-guided surgery (IIGS) is the real-time display of surgical instrument location on corresponding computed tomography (CT) scans or magnetic resonance images (MRI). We hypothesize that laparoscopic IIGS technologies can be combined to offer guidance for general surgery and, in particular, hepatic procedures. Tumor information determined from CT imaging can be overlayed onto laparoscopic video imaging to allow more precise resection or ablation. Methods: We mapped three-dimensional (3D) physical space to 2D laparoscopic video space using a common mathematical formula. Inherent distortions present in the video images were quantified and then corrected to determine their effect on this 3D to 2D mapping. Results: Errors in mapping 3D physical space to 2D video image space ranged from 0.65 to 2.75 mm. Conclusions: Laparoscopic IIGS allows accurate (<3.0 mm) confirmation of 3D physical space points on video images. This in combination with accurately tracked instruments and an appropriate display may facilitate enhanced image guidance during laparoscopy. Received: 30 April 1999/Accepted: 10 November 1999/Online publication: 8 May 2000     

腹腔镜在肝脏外科中的临床应用

腹腔镜肝脏外科是微创外科的重要组成部分 ,是难度最大的腹腔镜手术之一。现就以下几个问题进行讨论。一、腹腔镜肝切除手术适应证并不是所有肝肿瘤患者均适合行腹腔镜手术 ,病例的选择直接影响手术的成败 ,经临床实践证明 ,肿瘤位于肝的Ⅱ、Ⅲ、Ⅳａ、Ⅴ、Ⅵ段的占位病变 ,直径不超过 10ｃｍ ,患者无重要脏器功能障碍 ,无明显黄疸、腹水及凝血功能障碍可作为选择对象。但肿块已与周围器官粘连或被包裹 ,不宜行腹腔镜肝切除。二、手术方法从创造操作空间上分类 ,腹腔镜肝切除主要可分为两大类 :一类是气腹下腹腔镜肝切除 ,另一类是免气腹腹…     

单孔腹腔镜技术在肝脏手术中的应用

近年来,随着微创理念和技术逐渐深入人心,腹壁无瘢痕（noscar）手术引起了腹部外科界医师的极大关注,其代表技术经自然腔道内镜手术     

Bleeding and hemostasis in laparoscopic liver surgery

Background

Minimally invasive liver resection is gaining acceptance worldwide. However, the laparoscopic approach often is reserved for small segmental resections due to the fear of significant blood loss. The expansion of laparoscopic liver surgery will depend on the ability of expert surgeons and technological advances to address the management of bleeding and hemostasis with any new approach. The 4½- year experience of a single center performing totally laparoscopic liver resections is presented, with special reference to the techniques the authors have developed to limit blood loss.

Methods

Between 2003 and 2007, 80 patients underwent laparoscopic liver surgery for benign and malignant conditions including colorectal cancer metastases (n = 31), hepatocellular carcinoma (n = 6), neuroendocrine tumor (n = 3), cystic lesion (n = 10), adenoma (n = 8), and focal nodular hyperplasia (n = 7). Totally laparoscopic resections included sectionectomy (n = 27), hemihepatectomy (n = 10), and single/multiple segmentectomies (n = 21). Data for all resections were recorded and analyzed retrospectively to assess blood loss, hospital stay, and morbidity.

Results

The median operative time was 150 min, and the median blood loss was 120 ml, with significantly more blood loss for right-sided transections than for the left liver surgery (821 vs 147 ml; p = 0.012). Four (57%) of seven resections converted to open procedures because of bleeding. No deaths occurred, and only two patients required intraoperative blood transfusions. There were eight complications and one bile leak. The median length of hospital stay was 3 days.

Conclusions

The authors’ experience with 80 totally laparoscopic liver resections over a 4½-year period demonstrates that laparoscopic liver surgery is safe and effective in experienced hands for major resections. An intimate knowledge of the technology and techniques available for preventing and managing significant hemorrhage during laparoscopic liver resection is required for all surgeons performing laparoscopic liver surgery.     

Technical and technological skills assessment in laparoscopic surgery.

OBJECTIVES: Surgical appraisal and revalidation are key components of good surgical practice and training. Assessing technical skills in a structured manner is still not widely used. Laparoscopic surgery also requires the surgeon to be competent in technological aspects of the operation. METHODS: Checklists for generic, specific technical, and technological skills for laparoscopic cholecystectomies were constructed. Two surgeons with >12 years postgraduate surgical experience assessed each operation blindly and independently on DVD. The technological skills were assessed in the operating room. RESULTS: One hundred operations were analyzed. Eight trainees and 10 consultant surgeons were recruited. No adverse events occurred due to technical or technological skills. Mean interrater reliability was kappa=0.88, P=<0.05. Construct validity for both technical and technological skills between trainee and consultant surgeons were significant, Mann-Whitney P=<0.05. CONCLUSIONS: Our study demonstrates that technical and technological skills can be measured to assess performance of laparoscopic surgeons. This technical and technological assessment tool for laparoscopic surgery seems to have face, content, concurrent, and construct validities and could be modified and applied to any laparoscopic operation. The tool has the possibility of being used in surgical training and appraisal. We aim to modify and apply this tool to advanced laparoscopic operations.     

Impact of intraoperative ultrasonography in laparoscopic liver surgery

Background Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. This mainly includes diagnostic procedures, interstitial therapies, and treatment of liver cysts. However, the authors believe there is room for a laparoscopic approach to the liver in selected cases. Methods A prospective study of laparoscopic liver resections was undertaken with patients who had preoperative diagnoses of benign lesion and hepatocellular carcinoma with compensated cirrhosis. The inclusion criteria required that hepatic involvement be limited and located in the left or peripheral right segments (segments 2–6), and that the tumor be 5 cm or smaller. The location of the tumor and its transection margin were defined by laparoscopic ultrasound (LUS). Results From December 1996, 17 (5%) of 313 liver resections were included in the study. There were 5 benign lesions and 12 hepatocellular carcinomas in cirrhotic patients. The mean age of the study patients was 59 years (range, 29–79 years). The LUS evaluation identified the presence of new hepatocellular carcinoma nodules in two patients (17%). The resections included 1 bisegmentectomy, 8 segmentectomies, 3 subsegmentectomies, and 3 nonanatomic resections. The mean operative time, including laparoscopic ultrasonography, was 156 ± 50 min (median, 150 min; range, 60–250 min), and the perioperative blood loss was 190 ± 97 ml. There was no mortality. Conversion to laparotomy was necessary for two patients. Postoperative complications were experienced by 3 of 15 patients, all of them cirrhotics. One of the patients had a wall hematoma, and the remaining two patients had bleeding from a trocar access requiring a laparoscopic reexploration. The mean hospital stay for the whole series was 6.9 ± 4.9 days (median, 6 days; range, 2–25 days) and 5.6 ±1.4 days (median, 6 days; range, 2–8 days) for the 15 laparoscopic patients. Conclusion Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver. Evaluation by LUS is indispensable to guarantee precise determination of the segmental tumor location and the relationship of the tumor to adjacent vascular or biliary structures, excluding adjacent or adjunctive new lesions. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations.     

Technical considerations and laparoscopic bile duct exploration: transcystic and choledochotomy

Single-stage laparoscopic treatment of gallstones and common bile duct (CBD) stones is now challenging the traditional two-stage endo/laparoscopic approach. Many surgeons are reluctant to adopt this procedure because they believe this operation to be difficult and time-consuming. The aim of this report is to describe the technical details of the procedure and to demonstrate its effectiveness in a large series of unselected, consecutive patients. CBD stones were demonstrated in 301 unselected patients out of 2,894 undergoing laparoscopic cholecystectomy (10.4%) and were treated laparoscopically in 297 (98.6%), by the transcystic route in 185 patients (62.2%) and after choledochotomy in 112 patients (37.8%). Mean operative time was 119.2 minutes. Major complications were bile leakage (5 patients) and hemoperitoneum (4 patients) (3%). Retained CBD stones were observed in 14 patients (4.7%) and mortality in 1 high-risk patient (0.3%). Recurrent ductal stones occurred in 5 cases (1.6%) with dilated bile ducts, all after laparoscopic choledochotomy. Single-stage laparoscopic treatment of gallstones and CBD stones treats 2 problems during the same operation, avoids the additive complications of a second procedure (endoscopic sphincterotomy), and reduces hospital stay and costs. Laparoscopic management of ductal stones during laparoscopic cholecystectomy is the new "gold standard" for the treatment of gallstones and CBD stones.     

现代腹腔镜下肝脏手术的应用进展

经过20多年的发展,随着技术及外科医生对肝脏解剖和生理特征的认识提高,腹腔镜肝切除术有了质的飞跃,报道日益增多,成功有效的断肝是腹腔镜肝脏切除术的关键.术前选择好适应证,术中注意出血栓塞,借助于手助腔镜或中转开腹,恰当行肝血流阻断已达到精准肝切除.特作一综述.