Complications of surgical endoscopy

Background: This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe. Methods: We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications and deaths occurring up to 30 days following the procedures. Results: The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication. Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period. Conclusions: Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of common complications and application of appropriate precautions and instruction are critical for minimizing complications. Received 25 March 1996/Accepted: 24 April 1996     

Minimally invasive surgery and clinical decision-making for pediatric malignancy

Background: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS. Methods: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed. Results: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS. Conclusion: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques. Received: 19 March 1999/Accepted: 27 August 1999     

Prehensile atraumatic grasper with intuitive ergonomics

Background: Minimal access surgery (MAS) procedures that require tissue to be grasped are impeded by the design of current instruments. The use of graspers and forceps can result in tissue damage and is highly inappropriate when handling larger organs such as the bowel, liver, and spleen. In addition, current instruments have unnatural handling characteristics. A new type of tissue grasper is presented as a solution to these problems. Methods: The new grasper design was evolved through a process of setting basic requirements and proceeding through cycles of design, construction, evaluation, and redesign. Results: The main features of the new device are prehensile grasping by finger-like jaws, which retain tissue by `capture,' and a novel handle design with intuitive ergonomics. The jaws are interchangeable to suit differing surgical tasks and the handle and trigger mechanism are designed so that the surgeon's forefinger movement mirrors the instrument jaw action. The grasper has been used in 32 MAS procedures with no indications of trauma. Conclusions: A grasper that functions by capture has been demonstrated to be an effective solution for atraumatic tissue handling during many MAS procedures. Received: 3 February 1997/Accepted: 28 February 1997     

The clinical impact of warmed insufflation carbon dioxide gas for laparoscopic cholecystectomy

Background: Reports suggest that the insufflation of cold gas to produce a pneumoperitoneum for laparoscopic surgery can lead to an intraoperative decrease in core body temperature and increased postoperative pain. Methods: In a randomized controlled trial with 20 patients undergoing laparoscopic cholecystectomy, the effect of insufflation using carbon dioxide gas warmed to 37°C (group W) was compared with insufflation using room-temperature cold (21°C) gas (group C). Intraoperative body core and intra-abdominal temperatures were determined at the beginning and end of surgery. Postoperative pain intensity was evaluated using a visual analog scale and recording the consumption of analgesics. Results: There were no significant group-specific differences during the operation, neither in body temperature (group W: 36.1 ± 0.4°C vs group C: 35.7 ± 0.6°C) nor in intra-abdominal temperature (group W: 35.9 ± 0.3°C vs group C: 35.6 ± 0.6°C). Postoperatively, the two groups did not differ in pain susceptibility and need of analgesics. Conclusion: The use of carbon dioxide gas warmed to body temperature to produce a pneumoperitoneum during short-term laparoscopic surgery has no clinically important effect. Received: 13 August 1999/Accepted: 24 September 1999/Online publication: 9 August 2000     

Laparoscopic management of ovarian tumors

Background: Laparoscopy can be used with minimal operative morbidity to evaluate adnexal masses. We report our experience with the endoscopic approach to the diagnosis and treatment of ovarian tumors. In particular, we describe 11 patients who incidentally underwent laparoscopy and in whom the ovarian masses were found to be malignant. Methods: Between September 1994 and September 1996, 292 patients with 316 ovarian tumors were treated laparoscopically in the Department of Obstetrics–Gynaecology, University of Ulm. We assessed vaginal ultrasonography, clinical assessment, the tumor marker CA 12-5, and the intraoperative low-power magnification for their value in predicting the final diagnosis in all laparoscopically treated ovarian tumors. Results: From a total of 292 patients with ovarian tumors, 11 were diagnosed, intraoperatively or after final histologic examination, as having a malignant or borderline ovarian tumor. All applied pre- and intraoperative diagnostic procedures were by themselves too unreliable to exclude early stages of ovarian carcinoma exactly. Conclusions: On the basis of the present findings, we are tempted to conclude that laparoscopic surgery is justified in the management of ovarian tumors. Even with an accurate preoperative selection of suitable patients for laparoscopic surgery, the presence of an undetected ovarian carcinoma cannot be entirely excluded. Received: 23 September 1997/Accepted: 4 December 1997     

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     

The role of staging laparoscopy for multimodal therapy of gastrointestinal cancer

Background: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy. Methods: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally, 144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5 MHz). Results: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158 of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases—i.e., liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients. Conclusions: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on a stage-adapted surgical therapy. Received: 3 April 1997/Accepted: 26 September 1997     

Laparoscopic cryosurgery for hepatic tumors

Background: Hepatic cryosurgery has been shown to be a safe technique that may be well suited to a laparoscopic approach. Methods: The technical feasibility and safety of laparoscopic cryosurgery was explored first in a pig model. Thereafter we performed the first successful case of laparoscopic hepatic cryosurgery at our institution. Results: In the animal model, we found that it is possible to safely identify, target, and cryoablate specific lesions in the liver. Temperature in the peritoneal cavity remained above 35°C, and pathologic examination of the abdominal wall around the cryoprobe site revealed no damage. We also successfully treated a 62-year-old man with a metastatic colorectal carcinoma deep in the right lobe of the liver with laparoscopic cryosurgery using a transpleural approach. Conclusion: We conclude that laparoscopic cryosurgery is feasible for lesions anywhere in the liver. For lesions high on the dome of the liver, a transpleural approach may provide better access.     

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     

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     

Analysis of complications of endoscopic sphincterotomy for biliary stones in a consecutive series of 546 patients

Background: Endoscopic sphincterotomy (ES) plays an important role in treatment of biliary stones; however, there remain some controversies concerning complications of ES, which in most cases seem not to be predictable. Methods: The aim of this study was a retrospective analysis of complications in 546 consecutive patients (267 males, 279 females, average age 63.7 years) who underwent endoscopic retrograde cholangiography (ERCP) for biliary stones from 1988 to 1995. Results: ES was performed in 535 patients (98%), and extraction of stones was successful in 493 (92%). In all, 29 complications (5.4%) were observed, including bleeding 13, cholangitis seven, cholecystitis four, pancreatitis three, retroduodenal perforation two; of these, four (14%) required an operation. Overall mortality was 0.3%. Conclusion: While a significant decrease of the incidence of complications was observed in the course of the study, due to constantly improving experience, no correlation between risk factors and complications was identified. Received: 27 March 1996/Accepted: 16 July 1996     

Primary laparoscopic placement of gastrostomy buttons for feeding tubes

Background: During a 4-year period, 240 gastrostomy buttons were placed in children, as the initial surgical feeding tube, using laparoscopic techniques. Materials and methods: The technique requires the use of a minilaparoscope (1.6-mm) and a single 5-mm trocar placed at the exit site for the gastrostomy button. It can also be performed in addition to a laparoscopic fundoplication using the same trocar sites. The technique requires no special instrumentation or kits. When performed alone, operative times average 15 min. When performed with fundoplication, it adds ∼5–10 min to the time for the procedure. Results: There were no intraoperative complications and five (2.1%) postoperative complications. Conclusions: This technique has proven to be simple and effective. It allows primary placement of a gastrostomy button that is cosmetically and functionally superior to a gastrostomy tube. Received: 11 February 1999/Accepted: 27 April 1999     

Methods for improving performance under reverse alignment conditions during endoscopic surgery

Background: There are times during endoscopic procedures when the surgeon has to operate ahead of the camera/telescope assembly. As a result, the image displayed on the monitor will be an inverted mirror image of the operative field (reverse alignment). The present study addresses the extent of these difficulties and suggests some techniques that may be used to overcome the problem. Methods: Eight specialist registrars participated in experiments involving the execution of a simulated dissection task under 12 different imaging conditions. These conditions included normal alignment, reverse alignment, total or partial digital correction of reverse alignment (about the horizontal and vertical axes independently and together), and a simple rotation of the camera through 180°. Normal, reverse, and corrected reverse alignment were also tested with optical axes of 45° and 60°. The endpoints were the task execution and the errors rate. Results: A marked deterioration in execution time was observed when the surgeons worked under reverse alignment rather than under normal viewing (p= 0.036). Significant improvement in execution-time errors rate was found when both the horizontal and vertical axes were digitally corrected simultaneously (p= 0.27) and when the camera was rotated 180° with respect to the telescope during reverse alignment (p= 0.28). Conclusions: The effect on performance produced by reverse alignment of the endoscope and instruments can be overcome by means of digital electronic processing, or simply by turning the camera through 180°. Received: 22 July 1998/Accepted: 13 October 1998     

Pain after laparoscopy

Background: In the context of the much-heralded advantages of laparoscopic surgery, it can be easy to overlook postlaparoscopy pain as a serious problem, yet as many as 80% of patients will require opioid analgesia. It generally is accepted that pain after laparoscopy is multifactorial, and the surgeon is in a unique position to influence many of the putative causes by relatively minor changes in technique. Methods: This article reviews the relevant literature concerning the topic of pain after laparoscopy. Results: The following factors, in varying degrees, have been implicated in postlaparoscopy pain: distension-induced neuropraxia of the phrenic nerves, acid intraperitoneal milieu during the operation, residual intra-abdominal gas after laparoscopy, humidity of the insufflated gas, volume of the insufflated gas, wound size, presence of drains, anesthetic drugs and their postoperation effects, and sociocultural and individual factors. Conclusions: On the basis of the factors implicated in postlaparoscopy pain, the following recommendations can be made in an attempt to reduce such pain: emphathically consider each patients' unique sociocultural and individual pain experience; inject port sites with local anesthesia at the start of the operation; keep intra-abdominal pressure during pneumoperitoneum below 15 mmHg, avoiding pressure peaks and prolonged insufflation; use humidified gas at body temperature if available; use nonsteroidal anti-inflammatory drugs at the time of induction; attempt to evacuate all intraperitoneal gas at the end of the operation; and use drains only when required, rather than as a routine. Received: 26 May 1998/Accepted: 30 June 1998     

An ergonomic comparison of in-line vs pistol-grip handle configuration in a laparoscopic grasper

Background: Laparoscopic instruments incorporate both in-line and pistol-grip handle configurations, yet it is unclear which design is most advantageous for surgeons, particularly when operating at angles perpendicular to the surgeon's position. We present a detailed electromyographic (EMG) comparison of these handle configurations under different force and angle conditions. Methods: Nine general surgeons used a Microsurge grasper with the handle in an in-line (MS-IL) and pistol (MS-PS) configuration, as well as a standard hemostat (HE), to grasp and close two spring-loaded metal plates. The task was performed randomly by each subject with the three instrument configurations at two forces levels (0.7 N, 4.2 N) and at three angles to the surgeons' body (0, 45, and 90°). Surface EMG was measured from the flexor carpi ulnaris (FCU), flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), extensor carpi ulnaris (ECU), extensor digitorum comunis (EDC), and thenar compartment (TH). The peak root mean squared (RMS) EMG voltage was calculated for each instrument, force, and angle condition. Statistical comparison was carried out by ANOVA. Results: Both laparoscopic handle configurations required significantly higher contractions of all muscle groups compared to the hemostat at the high force level. TH was not affected by laparoscopic handle configuration. MS-IL required higher FCU, ECU, and EDC contractions at 45° compared to MS-PS. However, MS-IL decreased the flexor compartment muscle contractions (FDP, FDS, FCU) at 90° compared to MS-PS. Conclusions: Laparoscopic grasping requires higher forearm and thumb muscle contractions compared to the use of a hemostat. The in-line handle configuration is no better than the pistol configuration except when grasping at 90° to the surgeon, where rotation of the handle and wrist back toward the surgeon significantly decreases forearm flexor compartment muscle contractions. Received: 3 April 1997/Accepted: 10 August 1997     

Incidence and significance of pneumomediastinum after laparoscopic esophageal surgery

Background: Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery, the mediastinum is exposed to carbon dioxide gas under pressure that can cause pneumomediastinum. Methods: Forty-five patients undergoing laparoscopic esophageal procedures had erect, inspiratory, single-view chest radiographs (CXR) performed in the recovery room (RR). Patients with extraabdominal gas underwent daily erect, inspiratory, single-view CXR until resorption of the gas or discharge from the hospital. Insufflation time and pressure were recorded, and morbidity was evaluated. Results are expressed as mean ± SEM. Results: Twenty-five mens (56%)and 20 women (44%) aged 33.0 ± 2.9 years underwent 10 Heller myotomies (22.2%), 27 Nissen fundoplications (60.0%), six Toupet fundoplications (13.3%), and two paraesophageal hernia repairs (4.4%). Twenty-four patients (53.3%) had normal CXR in RR, and 21 (46.7%) had extraabdominal gas. Eighteen (85.7%) of the 21 had pneumomediastinum, three (14.3%) had pneumothorax, and 12 (57.1%) had subcutaneous emphysema in RR. Sixteen of these 21 remained hospitalized and had repeat CXR on postoperative day 1. Of these 16, five (31.3%) had normal CXR, 11 (68.8%) had pneumomediastinum, and seven (43.8%) had subcutaneous emphysema. There were no esophageal perforations and no chest tube insertions, and there was no morbidity related to pneumomediastinum. Conclusion: Pneumomediastinum is observed frequently following laparoscopic esophageal operations and often persists past 24 h. After these operations, pneumomediastinum is not necessarily indicative of esophageal perforation. In this group, it caused no clinically significant events that altered the course of the patients. Received: 30 April 1999/Accepted: 24 February 2000/Online publication: 8 May 2000     

Ergonomic problems associated with laparoscopic surgery

Background: The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Task Force on Ergonomics conducted a subjective and objective assessment of ergonomic problems associated with laparoscopic instrument use. The goal was to assess the prevalence, causes, and consequences of operational difficulties associated with the use of laparoscopic instruments. Methods: A questionnaire was distributed asking respondents to rate the frequency with which they experienced pain, stiffness, or numbness in several body areas after laparoscopic operations. An ergonomics station was assembled to quantify forearm and thumb muscle workload. Processed electromyogram (EMG) signals were acquired from 27 volunteer surgeon subjects while they completed simulated surgical tasks using a hemostat and an Ethicon® laparoscopic grasper, with the aid of an endoscopic trainer and video monitoring system. Results: Of 149 surgeons responding to the questionnaire, 8% to 12% reported frequent pain in the neck and upper extremities associated with laparoscopic surgery. The ergonomics station demonstrated that the peak and total muscle effort of forearm and thumb muscles were significantly greater (p < 0.01) when the grasping task was performed using the laparoscopic instrument rather than the hemostat. Conclusion: These findings indicate that laparoscopic surgical technique is more taxing on the surgeon.     

A reliable and efficient technique for laparoscopic needle positioning

Needle positioning can be a difficult, frustrating, and time-consuming step during laparoscopic suturing. Utilizing the reliable and efficient technique described in this article, needle positioning is expedited. This technique is applicable for any type of needledriver or suture. Received: 1 October 1998/Accepted: 7 April 1999     

Ultrasonography of the ureter after surgical trauma

Background: The purpose of the study was to discover whether ultrasonography can be used in diagnosing ureteral complications during surgery. Methods: The study consisted of an animal experiment with five pigs, that underwent laparotomy. The right ureter was electrocauterized and transsected, and the left ureter was ligated. The type and frequency of peristaltic waves and the diameter of the ureter were recorded by perioperative ultrasonography. Four patients with ureteral trauma during gynecologic surgery were also examined. Results: In the animal study six out of nine ureters dilated after the procedure. In seven ureters the contraction segment became smaller, and the lumen did not close properly during the peristaltic wave. The frequency of peristalsis diminished in all cases after ligation. Human ureters showed similar changes when examined 1.5–48 h after surgical trauma. Conclusions: Perioperative ultrasonography has great diagnostic potential as a method for noninvasive evaluation of ureteral conditions during both laparoscopy and laparotomy. Received: 16 June 1997/Accepted: 4 December 1997     

Short-stay laparoscopic adrenalectomy

Background: We performed a consecutive series of unilateral laparoscopic adrenalectomies (LA) with the expectation of short (less than 24 h) hospital stay. Results were compared with those from laparoscopic cholecystectomy (LC) and unilateral open adrenalectomy (OA). Methods: A combination of chart review and patient questionnaires was used to compare LA (n= 19) to LC (n= 20) regarding length of stay (LOS), narcotic requirements, and time to full recovery. Chart reviews also were used to compare LA to OA (n= 48) regarding operating room time (OR time), LOS, and surgical morbidity. Results: All of the LC patients as compared with 47% of the LA patients were discharged within 24 h. The reason for additional hospitalization in the LA group was pain control. After discharge, the narcotic requirement lasted 6.6 days in the LA group as compared with 3.4 days in the LC group (p < 0.01), but the times until full recovery were not significantly different (12.2 vs 11.3 days respectively). Operating room times did not differ significantly between the LA and OA groups (3.3 and 3.8 h, respectively), but there were fewer postoperative complications and much shorter LOS in the LA group (1.5 vs 6.3 days; p < 0.001), a difference that remained significant even when cases from the same time period were compared. Conclusions: Increased pain in LA as compared with LC patients may result in a slightly longer LOS and higher narcotic requirement during the early postoperative period, but time to full recovery between the two groups is the same. As compared with its open counterpart, LA offers a significant reduction in LOS and morbidity with no increase in OR time. Received: 12 February 1999/Accepted: 24 October 1999/Online publication: 28 April 2000