Image-guided sinus surgery: lessons learned from the first 1000 cases.

OBJECTIVE: To study physician utilization and experience with image-guidance technology for sinus surgery. Study Design and Setting: Retrospective review of the first 1000 image-guided sinus operations performed by 42 surgeons at an academic medical center. RESULTS: Utilization of image-guidance systems showed a dramatic increase in both number of cases performed and surgeons who used this equipment (70.6% and 92.8%, respectively) during the first 2 years of its availability. Surgical volume subsequently decreased by a mean of 9.3% per year, whereas the number of surgeons using this technology plateaued. The majority of surgeons continued to perform image-guided surgery throughout the study period for selected cases. The knowledge base gained from this experience can best be summarized as a series of lessons learned. CONCLUSION: It is likely that the availability and utilization of image-guidance systems for sinus surgery will continue to increase in the future. Physicians who learn to use this new technology must do so with an appreciation for both its potential benefits and pitfalls.     

Hepatic surgery at a VA tertiary medical center: lessons learned

Background

The development of a hepatic surgery center within a US Department of Veterans Affairs hospital is dependent on proper training and institutional support, which can translate into low operative morbidity and mortality rates.

Methods

Patients who underwent hepatic procedures between 2003 and 2009 were retrospectively reviewed. A subset analysis of laparoscopic liver resections for patients with hepatocellular cancer (HCC) was performed. One hundred twenty-six patients underwent 130 hepatic procedures, 65% of which were hepatic resections. Ninety-seven percent of cases were for malignant disease, including HCC (70%).

Results

The morbidity and mortality rates were 15.5% and 2.4%, respectively. For patients with HCC there was no difference in operative outcomes or overall survival when procedures were performed laparoscopically.

Conclusions

A Veterans Affairs (VA) hospital specializing in hepatic surgery can achieve low complication rates comparable with those of high-volume centers. The numbers of patient referrals and hepatic resections and the proportion of laparoscopic operations increased after the creation of a dedicated hepatic surgery center within a single VA hospital.     

Laparoscopic adrenalectomy for large unilateral pheochromocytoma: experience in a large academic medical center

Background  

Laparoscopic adrenalectomy is the treatment of choice for most adrenal lesions. Concerns have persisted about its application to large pheochromocytomas due to reports of hemodynamic instability, difficult dissection, and tumor spillage.     

Gastric bypass revision: lessons learned from 920 cases

Roux-en-Y gastric bypass (RGB) is an accepted operation for the control of body weight in morbidly obese patients. Early technical complications and inadequate weight loss, well-known sequelae of this procedure, necessitated reoperation in 42 patients of 920 who underwent RGB in a 10-year period. Indications for reoperation included dilated gastrojejunal anastomosis (16), inadequate weight loss without demonstrable enlargement of the anastomosis (10), staple line breakdown (6), anastomotic obstruction (4), anastomotic leak (4), and enlarged proximal gastric pouch (2). Reoperation consisted of completely redoing the initial RGB in 20 patients, redoing the anastomosis alone in 17 patients, staple line revision in four patients, and intraoperative dilatation of the anastomosis in one patient. After initial RGB, 26 of the 42 patients (61.9%) experienced major complications. After revision of RGB, there were major complications in 21 patients (50%). In conclusion, major postoperative complications may contribute to RGB failure, RGB revision for early technical failure or inadequate weight loss is associated with a high incidence of major complications and, subsequently, negligible weight loss. Therefore repair of RGB for technical failure or complications is not recommended.     

Laparoscopic gastric resection for benign and malignant conditions: lessons learned from 35 consecutive cases

INTRODUCTION: Despite significant advances in laparoscopy, gastric surgery is still generally carried out by conventional open techniques. The aim of the study was to report the short- and medium-term outcomes of gastric surgery when carried out laparoscopically for a variety of benign and malignant conditions. METHODS: A retrospective review was carried out for all patients who underwent a laparoscopic gastric resection between January 2000 and September 2006. Follow up was carried out at the private consulting rooms and by telephone interview. RESULTS: Thirty-five consecutive laparoscopic gastric resection were carried out in 31 patients for a variety of benign lesions, six early gastric cancer and 13 adenocarcinomas. The totally intracorporeal laparoscopic procedures included four total, eight distal and 21 partial gastrectomies. There were two open conversions (6%). There was one in-hospital mortality (3%) and one non-fatal anastomotic leak. Median operative duration and length of stay were 75, 205 and 252 min and 5, 6.5 and 8 days for laparoscopic partial, distal and total gastrectomy, respectively. After malignant resections, there were six recurrences; however, 15 patients remained disease-free at up to 60 months follow up. CONCLUSION: Laparoscopic gastric resection is feasible with good short- and medium-term results and may be an appropriate treatment option in selected cases.     

Laparoscopic pyeloplasty: an analysis of first 100 cases and important lessons learned

Aim  

Laparoscopic pyeloplasty (LP) is a minimally invasive approach that is becoming a standard treatment of ureteropelvic junction obstruction (UPJO). It is providing similar results when compared with open surgery. We here present our technique and analyses of experience of our first 100 cases.     

Laparoscopic cholecystectomy in children: lessons learned from the first 100 patients.

BACKGROUND/PURPOSE: Laparoscopic cholecystectomy is a very common operation in adults but is relatively infrequently required in children. A retrospective review of 100 consecutive infants and children undergoing laparoscopic cholecystectomies from 1990 to 1998 was performed to see what lessons have been learned from this relatively large population of pediatric patients. RESULTS: The patients ranged in age from 25 to 230 months, with a mean of 105 months. Only 19 patients had hemolytic disease as the etiology for their cholelithiasis. Two patients had biliary dyskinesia. Seventy-eight patients underwent an elective operation. Twenty-two children required urgent hospitalization because of complications from their cholelithiasis: acute cholecystitis (n = 7), jaundice and pain (n = 6), gallstone pancreatitis (n = 5), acute biliary colic (n = 4). All 6 patients who presented with jaundice underwent endoscopic retrograde cholangiopancreatography (ERCP) before their laparoscopic cholecystectomy. Two patients required laparoscopic choledochal exploration. The operating time and postoperative hospitalization were significantly longer (P = .0005) in the complicated group when compared with the elective patients. No significant complications such as the need for reoperation, injury to the choledocuhus or to other viscera, bile leak, or retained choledocholithiasis occurred. CONCLUSIONS: Laparoscopic cholecystectomy is a safe, effective procedure in children for removal of the gallbladder. The exact role of routine cholangiography and ERCP remains unclear.     

Laparoscopic repair for choledochal cyst: lessons learned from 190 cases

Objective

The aim of this study is to report the technical details, early outcomes, and lessons learned from laparoscopic repair of 190 cases of choledochal cyst.

Method

The operation was performed using 4 ports. The cystic duct was identified and divided. The liver was elevated by 2 stay-sutures: one on the round ligament and the other on the distal cystic duct. The choledochal cyst was isolated and removed completely, and then biliary-digestive continuity was reestablished.

Results

From January 2007 to April 2009, 190 patients were operated on. There were 144 girls and 46 boys. Ages ranged from 2 months to 16 years (mean, 46.9 ± 29.3 months). Cyst diameter ranged from 10 to 184 mm. A total of 106 patients were classified as Todani type I cysts, and 84 were type IV. Cystic excision and hepaticoduodenostomy were performed in 133 patients and hepaticojejunostomy in 57 patients. The operating time varied from 70 to 505 minutes (mean, 186 minutes). Conversion to open surgery was required in 2 patients. Intraoperative blood transfusion was required in 4 patients. There were no perioperative deaths. Postoperative anastomotic leakage occurred in 7 patients, resolving spontaneously in 6 and requiring a second operation in 1. Postoperative hospital stay ranged from 5 to 27 days (mean, 7.2 ± 3.3 days). Follow-up occurred between 1 and 24 months postdischarge (mean, 9 ± 2.2 months) and was obtained in 161 patients (84.7%). Of these patients, cholangitis occurred in 4 patients (2.4%).

Conclusion

Laparoscopic repair is a safe and effective procedure for choledochal cyst.     

Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases

BACKGROUND: In this study of laparoscopic splenectomy (LS), we evaluate prospectively gathered perioperative patient data and review lessons learned in the evolution of this procedure. METHODS: At 2 university medical centers between November 1993 and March 2000, there were 203 patients (122 female patients and 81 male patients) who underwent LS after preoperative evaluation. RESULTS: LS was successfully completed in 197 patients (97%). The mean operative time was 145.5 minutes and the length of stay averaged 2.7 days with 143 (70.4%) staying less than 48 hours. The most common indication was idiopathic thrombocytopenic purpura (ITP). Six patients required conversion to open splenectomy (OS), with only 2 conversions in the last 163 cases. No deaths were attributed to the procedure. Complications occurred in 19 patients (9.3%). Thirty accessory spleens were identified in 25 patients (12.3%). Seventeen patients (8.4%) underwent concomitant procedures, most commonly cholecystectomy. CONCLUSIONS: LS by the lateral approach is both safe and feasible in patients of all ages.     

A critical analysis of laparoscopic colectomy at a single institution: lessons learned after 1000 cases

BACKGROUND: A critical outcome analysis of a large, single-institution experience provides a better frame of reference for an assessment of the role of laparoscopic colectomy for colorectal pathology. METHODS: Review of a prospectively gathered database was performed of a consecutive series of laparoscopic colectomy patients who were operated on by 2 surgeons at a single institution (tertiary referral center) using standardized techniques and care plans. Patients were assessed for operative indications, type of resection, operative time, conversion, complications, duration of stay, and readmission within 30 days. RESULTS: One thousand consecutive patients undergoing laparoscopic colectomy from January 1999 thru June 2004 were analyzed. The types of resections were right colectomy = 314, left/sigmoid colectomy/anterior resection = 435, total colectomy = 61, total proctocolectomy = 14, and other = 176. The indications for surgery were diverticular disease = 285, colorectal neoplasia = 285, inflammatory bowel disease = 172, rectal prolapse = 81, and other = 177. The conversion rate was 11.4%. The mean operative time was 112 +/- 45 minutes for all resections. The mean duration of hospitalization for all patients was 3.7 +/- 3.8. The overall complication rate was 9.9%, with the most frequent complications being ileus 2.8%, pulmonary 1.6%, cardiac 1.4%, and wound infection 2.6%. The 30-day readmission rate was 9.1%, and the most frequent reasons for readmission were ileus/small-bowel obstruction, intra-abdominal infection, and anastomotic leak. CONCLUSIONS: This largest single-institution experience with laparoscopic colectomy confirms the benefits of a standardized approach including shorter hospital rehabilitation and low rates of cardiopulmonary and wound complications. Efforts must be directed at improving access to training in laparoscopic colectomy techniques so that patients can benefit from this new technology.     

Laparoscopic donor nephrectomy 1997 to 2003: lessons learned with 500 cases at a single institution

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to traditional open nephrectomy that has several potential advantages. However, there have been few large series reports describing the complications of LDN and the details of their management. METHODS: We performed a retrospective review of 500 LDNs performed at our center between October 1997 and September 2003. We evaluated preoperative donor characteristics, intraoperative parameters and complications, and postoperative recovery and complications. A modification of the Clavien classification was developed and used to grade the severity of all complications. RESULTS: The overall rate of intraoperative complications was 2.8%. There were 9 open conversions (1.8%), of which 6 were in the first 100 cases. Six of the 9 open conversions were for management of complications; 3 were elective. Seven renovascular incidents (1.4%) all required open conversion except one. The overall rate of postoperative complications was 3.4%. Thirty of 500 patients in our LDN series experienced an intraoperative or procedure-related complication (6.0%). When graded by severity, 18 of 31 (58.1%) of all complications were grade 1, 11 of 31 (35.4%) grade 2, and 2 of 31 (6.5%) grade 3. Only 1 recipient experienced delayed graft function, and only 1 recipient had a urologic complication. CONCLUSIONS: Our series supports the safety and efficacy of LDN with very low intraoperative complication and conversion rates. Most of the intraoperative complications can be managed laparoscopically. Readmissions are extremely rare (1.5%). Aberrant vascular anatomy and obesity are not contraindications to LDN, but they require experience. With careful surgical technique, delayed graft function and urologic complications in recipients can be avoided. A graded classification scheme for reporting complications of donor nephrectomy might be useful for maintaining registry information on donor outcomes and when informing potential donors about the risks and benefits of this procedure.     

Laparoscopic radical prostatectomy: the lessons learned

PURPOSE: To evaluate the operative, oncologic, and functional results of laparoscopic radical prostatectomy based on an initial series of 350 patients. PATIENTS AND METHODS: Between January 1998 and May 2000, 350 consecutive patients underwent laparoscopic radical prostatectomy according to our technique. The study of operative morbidity was based on all intraoperative and postoperative complications. The oncologic assessment was based on clinical, laboratory, and intraoperative and postoperative pathological data. Postoperative functional results were assessed by the ICS-male self-administered questionnaire. RESULTS: No deaths were observed in this series. Conversion was required in seven cases, exclusively among the first 70 patients. The mean operating time was 217 +/- 59 minutes, including the lymphadenectomy phase that was considered necessary in 21.4% of patients, and 195 +/- 56 minutes for the most recent 200 patients. The mean intraoperative blood loss was 354 +/- 250 mL. The overall transfusion rate was 5.7% and 2.8% in the last 250 patients. Intraoperative complications were reported in 14 patients (4%), and the reoperation rate was 3.7%. The mean postoperative bladder catheterization time was 5.8 +/- 3.3 days, and the catheter could be removed before the 5th day in 41% of patients. The mean hospital stay was 6 +/- 3.9 postoperative days (range 2-33 days). By pathologic stage, the positive surgical margin rate was 3.6% for pT2a specimens (3 patients), 14% for pT2b specimens (29 patients), 33% for pT3a specimens (12 patients), and 43.5% for pT3b specimens (10 patients). In the first 75 patients with pT2N0/Nx negative-margin specimens and a follow-up of >12 months, the PSA concentrations was <0.2 ng/mL in 92% of patients. The continence rate (no protection necessary either during the day or at night) among the first 133 patients was 85.5% and the postoperative erection rate was 59% among 22 selected consecutive patients. CONCLUSIONS: This study confirms the value, in our experience, of the laparoscopic approach to radical prostatectomy, which allows satisfactory cancer control associated with low perioperative morbidity and encouraging functional results in terms both of continence and erectile function.     

Laparoscopic splenectomy for ruptured spleen: lessons learned from a case

Splenic rupture is a frequent consequence of blunt abdominal trauma. When nonsurgical management is not indicated, splenic rupture is usually an emergency requiring surgery. Removal of the spleen (splenectomy) or alternative conservative procedures (splenorraphy, partial splenectomy, and hemostatic collagen application) are surgical treatment options. Recently, laparoscopic conservative techniques have been proposed. Laparoscopic splenectomy for a ruptured spleen has been reported only in a single case, in which a hand-assisted technique was used. We present the first reported case, to our knowledge, of successful removal of a ruptured spleen by means of a totally laparoscopic technique. Adequate technical instrumentation, such as the endostapler, harmonic scalpel, and red cell-saving machine, in addition to extensive experience with routine splenectomy, were essential factors to ensure a safe and effective procedure.     

Laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs and high-volume academic facilities: a comparison of institutional outcomes

BACKGROUND: Outcomes of bariatric surgery have been linked to institutional case volume. The objective of our study was to compare outcome of laparoscopic Roux-en-y gastric bypass (RYGB) in 2 settings: a low-volume Veterans Affairs (VA) and a high-volume university hospital (UH). METHODS: Over a period of 27 months, 140 patients underwent RYGB (137 laparoscopic, 3 open) performed by 1 surgeon. Fifty-five were performed at a VA and 85 at a UH with an annual caseload close to 300. RESULTS: The body mass index in both groups was similar, but patients at the VA were older, mostly men, and more likely to have hypertension (HTN), obstructive sleep apnea, and diabetes mellitus (DM). Operative and anesthesia times were significantly longer at the VA. There were no differences in 30-day mortality (none), major morbidity, conversion rates, or reoperation rates. CONCLUSION: Laparoscopic RYGB can be performed safely at a VA facility despite a higher risk population and low annual volume.     

On the road to single-site laparoscopic adjustable gastric banding: lessons learned from 60 cases

Background  

Single-site laparoscopic surgery is a promising emerging technique with potential to decrease postoperative pain, reduce port-site complications, and improve cosmetic results. Laparoscopic adjustable gastric banding (LapGB) is a procedure that lends itself well to single-site laparoscopic surgery because the surgery is confined to a single region of the body, the need for a larger incision for port implantation and the fact that bariartric patients are more likely to be body image conscious. The procedure is, however, technically challenging and potentially more time consuming and hazardous. To simplify learning, a hybrid technique that used multiple conventional trocars and laparoscopic equipment through a single periumbilical incision while retaining the use of the Nathanson retractor via a separate epigastric incision was developed. The authors’ experience and results with this technique are described.     

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures.

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE: The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA: Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS: One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS: Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION: Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.     

Pediatric snakebites: lessons learned from 114 cases

Purpose

Evidence-based guidelines for the treatment of pediatric snakebite injuries are lacking because they occur infrequently in most centers.

Methods

We reviewed our experience treating snakebites from January 1995 through December 2005. Demographic (eg, age, sex, geographic location) and clinical information (eg, location of bite, species of snake, vital signs, laboratories, treatment, hospital length of stay) were obtained.

Results

Over the last decade, we have treated 114 children with confirmed snakebites. Mean age was 7.3 ± 4.2 years (range, 1-17 years), and snakebites were more common in males (n = 68, 60%). All bites occurred on the extremities, and lower extremity bites were more common (n = 71, 62%). Copperheads inflicted the most bite injuries (n = 65, 57%), followed by rattlesnakes (n = 9, 8%) and cottonmouths (n = 7, 6%). The snake was not identified in 33 (29%) cases. Seven (6%) children were treated with Crotalidae antivenin. Of the children treated with antivenin, only 4 met criteria for treatment, and 1 had an anaphylactic reaction. If compartment syndrome was suspected based on neurovascular examination, compartment pressures were measured. Only 2 (1.8%) patients required fasciotomies. Over the last 2 years, we have stopped empiric treatment with antibiotics and have not observed any infectious complications. Average hospital length of stay was 30 ± 25 hours.

Conclusions

Most children bitten by pit vipers can be managed conservatively with analgesics and elevation of the affected extremity. Treatment with Crotalidae antivenin, antibiotics, and fasciotomy is rarely indicated.     

Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program

HYPOTHESIS: Laparoscopic Roux-en-Y gastric bypass is a complex procedure performed on a high-risk patient population. Good results can be attained with experience and volume. DESIGN: Retrospective study. SETTING: Tertiary care academic hospital. PATIENTS: Seven hundred fifty consecutive morbidly obese patients undergoing surgery from March 1998 to April 2004. INTERVENTIONS: All patients underwent laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOME MEASURES: Perioperative deaths and complications. RESULTS: The patient population was 85% women and had a mean body mass index of 47 kg/m2 (range, 32-86 kg/m2). The overall complication rate was 15% and the mortality was 0.3%. For the first 100 cases, the overall complication rate was 26% with a mortality of 1%. This complication rate decreased to approximately 13% and was stable for the next 650 patients. The incidence of major complications has also decreased since the first 100 cases. Leak decreased from 3% to 1.1%. Small-bowel obstruction decreased from 5% to 1.1%. Overall mean operating time was 138 minutes (range, 65-310 minutes). It decreased from 212 minutes for the first 100 cases to 132 minutes for the next 650 and 105 minutes (range, 65-200 minutes) for the last 100 cases. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically difficult operation. This review of a large series in a high-volume program demonstrated that the morbidity and mortality could be reduced by 50% with experience. The results are similar to those reported from other major centers. In addition, as reported elsewhere, the learning curve for this procedure may be 100 cases.