Hand-Assisted Laparoscopic Versus Standard Laparoscopic Colectomy: Are Outcomes and Operative Time Different?

Background

HAL colectomy is a technique perceived to provide the benefits of laparoscopic surgery while improving tactile feedback and operative time. Published data are largely limited to small, single-institution studies.

Methods

The 2012-2013 National Surgical Quality Improvement Program Participant Data Use File was queried for patients undergoing elective SL or HAL colectomy. Patients underwent 1:1 propensity matching and had outcomes compared. An additional subgroup analysis was performed for patients undergoing segmental resections only.

Results

13,949 patients were identified, of whom 6084 (43.6 %) underwent HAL colectomy. Patients undergoing HAL versus SL colectomy had higher rates of postoperative ileus (8.7 vs. 6.3 %, p?<?0.001), wound complication (8.8 vs. 6.8 %, p?=?0.006), and 30-day readmission (7.5 vs. 6.0 %, p?=?0.002), without any differences in operative time (156 vs. 157 min, p?=?0.713). Amongst segmental colectomies, HAL remained associated with higher rates of wound complications (8.6 vs. 6.5 %, p?=?0.016), postoperative ileus (8.9 vs. 6.3 %, p?<?0.001), and 30-day readmission (7.1 vs. 5.9 %, p?=?0.041) with no difference in operative time between HAL and SL (145 vs. 145 min, p?=?0.334).

Conclusions

Use of HAL colectomy is associated with increased risk of wound complications, postoperative ileus, and readmissions. Importantly, this technique is not associated with any decrease in operative time.

     

Laparoscopic Management of Lap-Band® Erosion

Background: Laparoscopic adjustable silicone gastric banding (LASGB) is the bariatric operation of choice in our institution for most morbidly obese patients. The advantage of LASGB is a minimally invasive procedure, with low systemic and operative complication rates. However this procedure is not free from significant postoperative problems that may arise at a later stage. Patients and Methods: 950 patients underwent LASGB between November 1996 and May 2000, with a median follow-up of 21 months. 3 patients (0.31%), developed band erosion 6 to 8 months following the original procedure. Laparoscopic band removal was attempted in all 3 patients. The charts of all patients were reviewed for the postoperative course of the original operation as well as the removal of the band. Results: 2 patients presented with abscess formation at the port site, and 1 patient suffered from a gastric fistula at the port site 6 months following surgery. In all patients the immediate postoperative course was not smooth; 2 patients developed a subphrenic collection drained percutaneously, and one patient had fever, treated empirically with intravenous antibiotics. In all 3 patients, no leak was demonstrated by CT and barium meal.The diagnosis of band erosion was confirmed by gastroscopy, which demonstrated part of the band eroding through the gastric wall. All patients were operated laparoscopically. The band was removed and the gastric wall was sutured. The postoperative course was uneventful and patients left the hospital within 3 days. Conclusion: LapBand erosion following LASGB is very rare and may occur months following the operation. The postoperative course suggests that the erosion is the consequence of a minute stomach wall injury during the primary operation. Diagnosis is essential and the treatment of choice is laparoscopic band removal with suturing of the stomach wall. It is possible that a minute injury to the gastric wall during the initial procedure is the underlying cause of this complication.     

Laparoscopic hernia repair--the best option?

For 100 years the Bassini-type repair for inguinal hernia was the standard method. The Lichtenstein "tension free" mesh repair replaced it on the grounds of much lower recurrence rates, < 5% vs approximately 15%. However, open procedures all have significant long-term discomfort rates of up to 53%. Laparoscopic repair has become a genuine option in the last 15 years and offers low recurrence (< 1%) and minimal long-term discomfort. However, it has not been widely taken up. There is a common misconception that it takes longer to perform, has more complications and is much more expensive. None of these caveats stand up under objective scrutiny. It is time that laparoscopic repair became the method of choice for most elective inguinal hernia repairs.     

Laparoscopic Italian Experience with the Lap-Band®

Background: An increasing number of surgeons with different levels of experience with laparoscopic surgery and open obesity surgery have started to perform laparoscopic implantation of the Lap-Band^?. Methods: An electronic patient data sheet was created and was mailed and e-mailed to all surgeons performing laparoscopic adjustable silicone gastric banding (LASGB) in Italy. Patients were recruited since January 1996. Data on 1,265 Lap-Band System^? operated patients (258 M / 1,007 F; mean BMI 44.1, range 27.0-78.1; mean age 38, range 17-74 years) were collected from 23 surgeons performing this operation. Results: Intra-operative mortality was absent. Post-operative mortality was 0.55% (7 patients) for causes not specifically related to LASGB implantation. The laparotomic conversion rate was 1.7% (22 patients). LASGB related complications occured in 143 patients (11.3%). Pouch dilatation was diagnosed in 65 (5.2%), and 28 (2.2%) of these underwent re-operation. Band erosion was observed in 24 patients (1.9%). Port or connecting tube-port complications occurred in 54 patients (4.2%), 12 of whom required revision under general anesthesia. Follow-up was obtained at 6, 12, 18, 24, 36 and 48 months, and mean BMI was respectively 38.4, 35.1, 33.1, 30.2, 32.1 and 31.5. The percentage of patients observed at each follow-up was >60%. There was no intra-operative mortality and no complication-related mortality, with acceptable weight loss. Conclusion: The LASGB operation is safe and effective, and deserves wider use for treatment of morbid obesity.     

Laparoscopic Witzel gastrostomy—a reappraised technique

Background Laparoscopic gastrostomy is the best alternative for long-term enteral feeding when percutaneous endoscopic gastrostomy is not possible. The aim of the present study was to determine the feasibility, complications, adequacy of feeding support, and tolerability of laparoscopic Witzel gastrostomy (LWG) in head and neck cancer patients. The initial results and the results of extended follow-up were evaluated. Methods A consecutive series of 48 patients with stenotic head and neck or esophageal cancer were referred for laparoscopic gastrostomy. The patients consisted of 42 men and 6 women aged 36 to 82 years (mean, 54 years). After laparoscopic placement of a Foley catheter of 16 F into the stomach, a seromuscular tunnel 4 cm in length is created, embedding the catheter by interrupted sutures. Three stay sutures for gastropexy are fixed and tied on the abdominal skin at the end of the procedure. The mean duration of the procedure was 62.4 ± 11 min (52–124 min). Results Laparoscopic Witzel gastrostomy could be performed successfully in all patients with aerodigestive cancer. None of the laparoscopic gastrostomy tube placement procedures was converted to an open surgery, and none of the 48 patients in this series died as a result of the laparoscopic procedure. All LWG complications (11%) were minor, consisting of superficial wound infections, balloon rupture, and chronic granulation. No major complications were encountered. The mean usage time of gastrostomy was 6.3 ± 5.3 months. Conclusions Current techniques of LWG could be an alternative to percutaneous endoscopic gastrostomy (PEG) for long-term enteral access, because it has proved to be safe and reproducible with relatively few complications.     

Are Laparoscopic Gastric Bypass After Gastroplasty and Primary Laparoscopic Gastric Bypass Similar in Terms of Results?

Background  

This retrospective study compares the results of primary gastric bypass (PGB) versus secondary gastric bypass (SGB) performed after gastroplasty.     

Is Laparoscopic Appendectomy an Effective Procedure ?

Aim: To compare the results of open and laparoscopic appendectomy and to determine if the laparoscopic approach might be more effective for some subgroups of patients.

Material and methods: We retrospectively analysed the computerised data of 326 consecutive adult patients operated on for suspected appendicitis between 2001 and 2005. The series consisted of 166 men and 160 women with a mean age of 32 ± 16 years and a mean Body Mass Index (BMI) of 24 ± 4. There were 265 ASA I, 46 ASA II and 5 ASA III patients. According to the surgeon’s preference, 176 patients had an open appendectomy (OA) and 150 a laparoscopic appendectomy (LA).

Results: The mean operative time and hospital stay were equivalent in the two groups: respectively 49 ± 19 min. and 4.1 ± 2.5 days in OA and 50 ± 16 min. and 3.5 ± 1.8 days in LA. However, subgroup analysis revealed that overweight (BMI > 25) patients (n=102) and patients with ectopic appendices (n=86) had an obvious benefit from LA. In cases of OA, operative time and hospital stay were longer in overweight patients than in normal weight patients: respectively 63 ± 20 min. and 5.3 ± 2.9 days versus 44 ± 16 min. (p < 0.01) and 3.7 ± 2.2 days (p < 0.01). On the contrary, no difference was observed in the lA group. Operative time and hospital stay were also longer in patients with ectopic appendices submitted to OA than in patients with an appendix in the normal position: respectively 60 ± 18 min. and 4.7 ± 2.7 days versus 45 ± 18 min. (p < 0.01) and 3.9 ± 2.4 days (p < 0.01). Again, such a difference was not observed in cases of LA. We noted no mortality, but 24 patients (7%) developed an abdominal complication: 18 wound infections and 6 intra-abdominal abscesses. Wound infections were more common in the OA than in the LA group: 7.3% (13/176) versus 3.3% (5/150) (p = 0.1). In the LA group, 4 wound infections were observed in our early experience, at a time where no endoscopic bag was used for the removal of the appendix. The rate of intra-abdominal abscesses was similar: 1.7% (3/176) in the OA group and 2% (3/150) in the LA group.

Conclusions: LA is an effective procedure with a reduced risk of developing wound infection. The laparoscopic approach is particularly effective for overweight patients and/or patients with ectopic appendices as far as shortening the operative time and hospital stay are concerned.     

Laparoscopic splenectomy: what barriers remain?

Conditions that once were considered either relative or absolute contraindications for laparoscopic splenectomy have become fewer and less significant in the overall assessment of candidates for this procedure. Advances in surgical technique, operative conduct, and instrumentation have made it feasible to perform splenectomy laparoscopically with good outcomes and minimal morbidity in a variety of different pathologic conditions. Obesity, malignancy, pregnancy, and splenomegaly are assessed here in detail.     

Can Laparoscopic Pancreaticoduodenectomy Be Safely Implemented?

Introduction  

The implementation of laparoscopic pancreaticoduodenectomy (LPD) has been appropriately met with apprehension, and concerns exist regarding outcomes early in a program’s experience. We reviewed our early experience and outcomes of LPD.     

Laparoscopic live donor nephrectomy--is it safe?

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney donation. Concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in LDN transplant recipients. METHODS: Between October 1997 and May 1999, 80 LDNs were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These LDNs were compared with 50 ODN performed from January 1996 to October 1997. RESULTS: LDN procedures took significantly longer than ODN (4.6 vs. 3.1 hr). However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. Of the 80 LDN procedures, a total of 75 (94%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for complex vascular anatomy. ODN conversion was associated with large donor body habitus and/or obesity. Seven LDN patients had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery, and 1 aortic injury). All patients made complete recoveries. All LDN kidneys functioned immediately posttransplant. We have observed 100% patient and 97% 1-year actuarial graft survival in LDN transplant recipients. There have been no short-or long-term urologic complications in this series. CONCLUSION: With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.     

Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band—a Systematic Review

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9 % in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7 % and long-term complications in 8.9 and 2.5 %. Reoperation was performed in 6.5 and 3.5 %. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.     

Who Should Be Doing Laparoscopic Bariatric Surgery?

Background: The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. Methods: Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. Results: 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do >25 open before laparoscopic ones; and 3) clinical trials are needed (P<0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P<0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P<0.008). Conclusions:There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships.The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.     

Laparoscopic ileocecal resection in Crohn’s disease

Background: Despite some encouraging preliminary results, the role of laparosropic surgery in the treatment of Crohns disease (CD) is a subject of controversy and still under evaluation. The aim of this case-matched study was to compare the postoperative course of laparoscopic and open ileocecal resection in patients with CD in order to define the potential role of laparoscopic surgery in CD. Methods: From 1998 to 2001, 24 consecutive patients with isolated Crohns terminal ileitis treated by laparoscopic ileocecal resection (laparoscopy group) were compared with 32 patients matched for age, gender, duration of disease, preoperative steroid treatment, fistulizing disease, and associated surgical procedure, and treated by open resection (open group). Results: In the laparoscopy group, four procedures (17%) were converted. There were no deaths. The morbidity rate was 20% in the laparoscopy group and 10% in the open group (NS). There was no significant difference between the two groups in operating time, size of bowel resection and resection margin, postoperative morphine requirement, resumption of intestinal function, tolerance of solid diet, or length of hospital stay. Conclusions: Laparoscopic ileocecal resection in CD is safe and effective, even for fistulizing disease. There are no significant differences between laparoscopic and open ileocecal resection, especially in terms of the mortality and mortality rates. Consequently, because laparoscopic surgery seems to offer cosmetic advantages, it should be considered the procedure of choice for patients with ileocecal CD.     

Laparoscopic cholecystectomy. The new 'gold standard'?

Laparoscopic cholecystectomy has rapidly been adopted by surgeons, but concerns remain about its safety, the management of common bile duct stones, and the means of appropriate training. Of 647 patients referred for cholecystectomy, preoperative endoscopic retrograde cholangiography was performed in 49 (7.6%), with 27 patients (4%) undergoing sphincterotomy and stone extraction. Traditional cholecystectomy was performed in 29 patients (4.5%). Laparoscopic cholecystectomy was attempted in 618 patients and completed successfully in 600 (97.1%). Surgical trainees functioned as the primary surgeon in 70% of cases. Technical complications occurred in three patients (0.5%), including one patient with a common bile duct laceration (0.2%). Major complications occurred in 10 patients (1.6%), with no perioperative mortality. Mean postoperative hospital stay was 1 day, with return to work or full activity a mean of 8 days after surgery. Two cases of retained common bile duct stones (0.3%) were identified. We now regard laparoscopic cholecystectomy as the "gold standard" therapy for management of symptomatic cholelithiasis.     

Complicated Appendicitis: Laparoscopic or Conventional Surgery?

Background The surgical treatment of complicated appendicitis remains controversial. The aim of this study was to evaluate the role of laparoscopic appendectomy in the treatment of complicated appendicitis in comparison with open surgery. Methods We reviewed the medical records of all patients who underwent an appendectomy for complicated appendicitis between January 2001 and August 2005. Results We identified 98 patients with complicated appendicitis. Forty-eight patients underwent open appendectomy, 42 laparoscopic appendectomy, and 8 initial laparoscopy with conversion to open surgery. Older patients, patients with comorbidities, and female patients were more likely to have been offered a laparoscopic appendectomy. Operating time, time to solid oral intake, and time of hospital stay were prolonged in the laparoscopic group but not significantly. There was no mortality observed in either group, and the complication rate was similar in both groups. Conclusions Laparoscopic appendectomy is an acceptable procedure for complicated appendicitis, with the same rate of infectious complications as the conventional approach.