Port-site metastases after CO2 laparoscopy

BACKGROUND: Animal experiments have shown that carbon dioxide (CO(2)) laparoscopy results in more port-site recurrences than gasless laparoscopy. Possible transport of aerosolized tumor cells by CO(2) was investigated in rats. METHODS: Abdominal cavities of 15 pairs of Wistar Agouti (WAG) rats were connected and 2 x 10(6) or 16 x 10(6) CC 531 cells were injected in the first (donor) rat of each pair. Then 10 l of CO(2) were allowed to flow from the first (donor) to the second (recipient) rat. RESULTS: No tumor was found in the recipients after injection of 2 x 10(6) cells in the donors. Injection of 16 x 10(6) cells in the donors resulted in very limited tumor growth in the recipients. CONCLUSIONS: Aerosolization of tumor cells occurs, but the number of intraperitoneal tumor cells required for metastases to occur by this mechanism is extremely high. Therefore, aerosolization of tumor cells appears not to be of major relevance in the pathogenesis of port-site metastases.     

腹腔镜术术后戳孔疝一例报道

病例:男,76岁,发现左腹部戳孔处可复性肿块1年余.3年前在外院行腹腔镜右斜疝修补术,术后1年余左腹壁脐周戳孔处,有一半球形包块突出,大小7.0 cm×8.0 cm,无红肿及压痛,触之柔软,可回纳入腹腔,拟诊为戳孔疝(trocar site hernia).入院行疝无张力修补术.手术探查证实为腹壁戳孔疝,疝环口直径约3 cm,疝囊大小7.0 cm×8.0 cm,疝内容物为大网膜,回纳后置入补片,皮下放置负吸球.术后5 d痊愈出院,无明显并发症,术后随访恢复好,无复发.     

Port-site metastasis after laparoscopic surgery for gastrointestinal cancer

Although the incidence of port-site metastasis after laparoscopic surgery for colorectal cancer has markedly decreased since laparoscopic colectomy was first reported in 1991, it still has not reached zero. In colorectal cancer, the safety of laparoscopic surgery, including the low incidence of port-site metastasis, has been proven in large, randomized trials. In gastric cancer, reports of port-site metastasis are extremely rare, but we should await the results of ongoing trials. This brief review summarizes the current knowledge regarding port-site metastasis after laparoscopic surgery for colorectal and gastric cancer.     

Port-site complications after pediatric urologic robotic surgery

The incidence of port-site hernia development after adult laparoscopic surgery is reported to be between 0.1% and 3.0%. There are no published reports concerning hernia incidence or related factors after pediatric urologic laparoscopic interventions. We present our experience with port-site complications following pediatric urologic robotic surgery (PURS). From July 2005 to June 2009 we prospectively followed the first 200 PURS cases performed at Children’s Hospital of Philadelphia. All cases had follow-up available for at least 2 months postoperatively. The data collected allowed for evaluation of the outcomes for each port site separately and compared its size, location, and fascial closure status. Median age was 3.2 years (0.4–18.8 years). All 200 patients had follow-up with median of 11 months (0.2–83.4 months). There were 600 port sites analyzed in the 200 cases. Of the 600 port sites, 200 were umbilical. The other 400 port sites were lateral to the rectus muscle, either subcostal or at the level of the anterior superior iliac spine. There was no wound irrigation prior to closure on any sites. All the patients received perioperative antibiotics. One umbilical port had a hernia diagnosed 2 weeks postoperatively. Four of the 600 ports (0.6%) developed skin dehiscence secondary to superficial wound infection within 1 week postoperatively. At our institution, the overall incidence of port-site complications after PURS was 0.83%. This is slightly lower than the published incidence in adults undergoing conventional laparoscopy. Due to the low incidence of complications it is difficult to draw conclusions on contributing factors.     

Port-site metastases

Background: Port-site metastases after laparoscopic procedures in patients with digestive malignancies have evoked concern. The pathogenesis of port-site metastases remains unclear. Two experiments in rats were performed to determine the impact of both tissue trauma and leakage of CO₂ along trocars (chimney effect) in the development of port-site metastases. Methods: Experiment I: Ten WAG rats had four 5-mm incisions in all abdominal quadrants. The incisions on the right side were crushed to induce tissue trauma. After inserting 5-mm trocars in all incisions, a pneumoperitoneum was created, and CC-531 tumor cells were injected intraperitoneally. CO₂ was insufflated for 20 min. Experiment II: Ten WAG rats had 5-mm incisions in the left and right abdominal upper quadrant. A 5-mm trocar was inserted in the incision in the left upper quadrant, and a 2-mm trocar was inserted in the incision in the right upper quadrant. After insufflating the abdomen, CC-531 tumor cells were injected intraperitoneally. Total leakage of CO₂ along the trocar in the right quadrant was 10 liters. After 4 weeks, in both experiments, the tumor deposits at the trocar sites were assessed. Statistical analysis was performed by the Wilcoxon matched-pairs test. Results: Experiment I: The median weight of tumor deposits at the trocar sites without induced tissue trauma was 22 mg. At the traumatic port sites, median weight of tumor deposits was 316 mg (p= 0.007). Experiment II: The median weight of tumor deposits at the leaking trocar sites was 478 mg and at the control sites 153 mg (p= 0.009). Conclusion: Tissue trauma at trocar sites and leakage of CO₂ along a trocar appear to promote implantation and growth of tumor cells at port sites. Received: 15 May 1997/Accepted: 3 March 1998     

Port-site metastasis after laparoscopic cholecystectomy for benign disease.

We describe the case history of a patient presenting with a port-site metastasis from an occult pancreatic malignancy after laparoscopy for benign gallbladder disease. While port-site recurrence is well recognized after laparoscopy for malignant disease, its presentation after laparoscopy for benign disease is rare, this being only the third such case to be reported in the literature. It emphasizes that all pathology localizing to port sites after surgery should be investigated, as it may represent the earliest sign of a hitherto occult intra-abdominal malignancy.     

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     

Pitfalls of diagnostic laparoscopy in abdominal tuberculosis

Background  

Diagnostic laparoscopy currently is emerging as an important tool in the diagnostic armamentarium for abdominal tuberculosis (TB). However, the laparoscopic view may be deceiving even to the most experienced eyes, and it is not uncommon for TB to be diagnosed erroneously before the final histologic confirmation is received.     

腹腔镜胆囊切除术戳孔并发症48例临床分析

目的　探讨腹腔镜胆囊切除术戳孔并发症发生的原因及其预防措施。方法　回顾性分析我院 1 992年 1 0月～ 2 0 0 3年 6月行腹腔镜胆囊切除术 (LC)出现戳孔并发症 4 8例的诊治经过。结果　 4 8例中 ,发生戳孔感染 1 9例 ,戳孔出血 9例 ,戳孔异物残余 1 1例 ,戳孔疝 7例 ,戳孔肿瘤种植 2例。结论　LC戳孔并发症不容忽视     

Port-site metastasis after laparoscopic resction of a duodenal stromal tumor]

Gastro-intestinal stromal tumors are rare and their evolution is dubious. This observation of port site metastasis after laparoscopic resection of a small duodenal stromal tumor would be, to our knowledge, the first case reported in the literature. Several direct and indirect mechanisms were supposed to be involved in the appearance of metastases after laparoscopic surgery, but the risk of dissemination remains badly evaluated on its frequency as well as on its mechanisms.     

Port-site recurrence after laparoscopy-assisted gastrectomy: report of the first case

In advanced gastric cancer, laparoscopic management has been associated with trocar-site recurrence, even though laparoscopy-assisted gastrectomies have reported positive results to treat early-stage gastric cancer in the world. There are no reports of port-site recurrence after laparoscopic gastrectomy in the literature. In this paper, we present a case report of advanced gastric cancer with port-site recurrence 12 month after the initial operation. A wide excision of this recurrence was performed. Otherwise, the evaluation of metastasis in other sites remained negative at 18 months after the original operation. The laparoscopic surgeon should be aware of trocar-site recurrence when dealing with advanced gastric cancer.     

Pneumothorax after diagnostic laparoscopy

A case of laparoscopic-induced asymptomatic pneumothorax (PTX) is presented. Six hours postoperation, a chest x-ray revealed no evidence of PTX. The patient subsequently had a routine postoperation course. As the number of laparoscopic cases performed each year continues to rise, the surgeon must remain cognizant of all possible major and minor complications to keep laparoscopic surgery safe and effective. Received: 15 September 1998/Accepted: 25 November 1998     

Neuromuscular recovery after laparoscopy

Vecuronium bromide, 0.045 mg X kg-1, was compared with pancuronium, 0.07 mg X kg-1, when used to provide muscle relaxation for tracheal intubation and abdominal relaxation for outpatient gynecologic laparoscopy. Both drugs provided adequate intubating conditions within 5 min and satisfactory abdominal relaxation. Because spontaneous recovery from vecuronium was more rapid, either with inhalational or nitrous oxide-narcotic techniques, pharmacological reversal with edrophonium and atropine was either not necessary or more easily accomplished after vecuronium, as shown by the train-of-four. All patients receiving pancuronium required reversal of the blockade, and in a few patients reversal was difficult. Tests of muscle power and coordination performed 30 and 60 min postoperatively showed no difference between the drugs. There were no postoperative complications related to muscle relaxants and all patients met our discharge criteria the day of surgery. Given the conditions observed at the end of the procedure, we would choose vecuronium for muscular relaxation in laparoscopic surgery.     

Port-site metastasis after laparoscopic partial nephrectomy: Case report and literature review

Local recurrence and port-site metastasis remain a concern in urologic laparoscopic oncologic surgery. Portsite recurrence of renal-cell carcinoma after retroperitoneal and transperitoneal radical nephrectomy has been well documented. We report the first case of a port-site metastasis secondary to a partial nephrectomy and perform a literature review of this subject.     

Port-site metastasis after CO<Subscript>2</Subscript> pneumoperitoneum

Background Port-site metastasis is a continuing problem in laparoscopic cancer surgery. To clarify the role of adhesion molecules in the development of port-site metastasis, particularly with regard to prevention, we performed experiments in which port-site metastasis was inhibited using antibodies against extracellular matrix proteins or the active Arg–Gly–Asp (RGD) peptide after CO₂ pneumoperitoneum in a murine model.Methods We examined the development of port-site metastasis under the following conditions: (1) CO₂ pneumoperitoneum with or without hyaluronic acid and anti-integrin or anti-CD44 antibody and (2) CO₂ pneumoperitoneum and a RGD peptide or pseudo-RGD sequence peptide (FC-336). BALB/c mice (n = 130) were injected with 5 × 10⁵ human gastric cancer cells (MKN45) and either antibody or peptide, treated with CO₂ pneumoperitoneum, and injected intraperitoneally with antibody or peptide for 5 days. Three weeks after CO₂ pneumoperitoneum, the frequency and weight of port-site metastatic tumors were determined.Results Anti-integrin antibody significantly decreased the weight of port-site metastatic tumors without hyaluronic acid (control vs anti-integrin: 8.2 ± 7.1 vs 3.6 ± 4.5 mg; p < 0.05) but not the frequency of port-site metastases. With hyaluronic acid, the frequency of port-site metastasis and the weight of port-site metastatic tumors were significantly decreased both by anti-integrin and by anti-CD44 antibody (control vs anti-integrin and anti-CD44; 95% and 8.5 ± 7.2 mg vs 50% and 3.1 ± 4.3 mg and 55% and 3.3 ± 5.1 mg, respectively; p < 0.05). RGD peptide and FC-336 also inhibited port-site metastasis in a dose-dependent manner.Conclusion Cell adhesion molecules integrin and CD44 play an important role in the development of port-site metastasis after laparoscopic cancer surgery. Intraperitoneal injection of RGD peptide or pseudo-RGD sequence peptide (FC-336) can prevent port-site metastasis.     

Port-site recurrence following video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery (VATS) is an established modality in the management of pleural diseases. We report a case of port-site recurrence following management of malignant pleural effusion in an elderly patient with extensive pleural metastasis from adenocarcinoma of the lung. Although her shortness of breath was relieved following VAT decortication and talc insufflation, at 3 months she was found to have a 2.5-cm subcutaneous nodule at the camera port site which on biopsy was confirmed to be metastatic in nature. Even though the nodule was asymptomatic and the patient prognosis was not affected, it is important that both the surgeon and future patients should be aware of this potential complication.