Significance of ``hands-on training' in laparoscopic surgery

Background: The objective of this study is to investigate the role and significance of a hand-on program designed to teach laparoscopic skills. Methods: The course consisted of 3 half days. In vitro training in suturing and knot tying was covered on the 1st half day, and live animal surgery on the 2nd and 3rd half days, respectively. In vitro suturing and knot tying of the 15 course participants were video-recorded and analyzed four times during the course, basing on the time required to mount a needle in the needle driver (M), driving the needle in a rubber glove (D), and knot tying (T). Results: Laparoscopic skills which require two-hand coordination (M,T) were significantly improved by hands-on training. Needle driving skill appeared to be essentially the same as that needed for open surgery. Conclusion: Hands-on training is an effective format particularly for laparoscopic skills in which two-hand coordination is essential. Received: 3 April 1997/Accepted: 3 July 1997     

Optimal port locations for endoscopic intracorporeal knotting

Port location is crucial for endoscopic manipulations. The aim of the study was to investigate the influence of manipulation, azimuth, and elevation angles of instruments on endoscopic intracorporeal knotting. The standard task was tying a surgeon's knot. Manipulation angles of 30°, 45°, 60°, 75°, and 90° with equal and unequal azimuth angles and elevation angles of 0°, 30°, and 60° were investigated. The endpoints were the execution time and parameters of knot analysis. The execution time was shorter with 60° than with either 90° or 30° manipulation angles (p < 0.0001 and p < 0.01). Equal azimuth angles resulted in a shorter execution time than wide unequal angles (p < 0.001). A combination of 60° manipulation angle with 60° elevation angle had the shortest execution time (p < 0.001) and highest performance quality score (p < 0.02). A range of 45°–75° manipulation angles with equal azimuth angles is recommended. As the manipulation angle increases, the elevation angle has to increase accordingly. Received: 23 July 1996/Accepted: 4 October 1996     

Subfascial hemorrhage after endoscopic perforator vein ligation

Ligation of perforator veins in the lower extremity for the treatment of venous ulceration can be performed using a minimally invasive technique with endoscopic instruments. Several studies have documented that the endoscopic technique has a lower wound-related complication rate compared to open perforator vein ligation. We report the complication of postoperative subfascial hemorrhage requiring reexploration after subfascial endoscopic perforator vein ligation and describe a minimally invasive method for its control using balloon tamponade. Received: 15 January 1997/Accepted: 7 May 1997     

Endoscopic electrohydraulic lithotripsy in the management of pancreatobiliary lithiasis

Background: Clinical evaluation of intraoperative endoscopy with electrohydraulic lithotripsy (EHL) in the management of 13 patients with pancreatobiliary lithiasis was undertaken. Methods: Ten patients with chronic pancreatitis with intraductal lithiasis in the head and three with biliary lithiasis (one choledochal, one cystic, one right intrahepatic) underwent intraoperative endoscopy with EHL. Shock waves were applied by visual contact with a 3-Fr gauge EHL probe until all stones were fragmented and irrigated free. All pancreatitis patients had failed ERCP attempts to stent their pancreatic ducts secondary to ductal lithiasis. Patients with pancreatic stones underwent lateral pancreatojejunostomy. Biliary stone patients underwent laparoscopic cholecystectomy with common duct exploration (two cases) and open cholecystectomy with choledochoduodenostomy (one case). Results: Intraductal stone eradication was successful in all patients. Transampullary visualization of the duodenum was achieved in eight cases. Average EHL time was 65 min. There was no evidence of postoperative pancreatitis, cholangitis, or retained common duct stones. Conclusion: Intraoperative pancreatobiliary endoscopy with EHL is safe and effective in the eradication of pancreatic and bile duct stones. This novel technique represents a valuable adjunct in the management of chronic fibrocalcific pancreatitis with ductal lithiasis in the head region and in the open and laparoscopic management of intra- and extrahepatic bile duct stones. Received: 3 April 1997/Accepted: 25 September 1997     

Rocker handle for endoscopic needle drivers

Background: The design of the handle on instruments for endoscopic surgery determines comfort and efficiency of use by the surgeon. This applies particularly to needle drivers. Methods: A novel rocker handle was designed to provide holding comfort and intuitive function. This rocker handle was compared with a finger-loop handle in a study involving 10 surgeons who tied a total of 360 intracorporeal surgeons' knots in a random sequence. The end points in this study were the execution time, knot quality, and motion analysis parameters of the surgeon's elbow and shoulder joints. Results: Intracorporeal surgeon's knots tied with the rocker-handle driver exhibited a better knot quality, although this was not significant (p= 0.097). A significant improvement in the knot quality score (KQS) was observed between the first and the second sessions (p= 0.045) with the rocker handle, whereas no significant learning effect was observed for the finger-loop handle. During intracorporeal knot tying, the angular velocity at the elbow and shoulder joints was consistently lower with the rocker handle, suggesting that more controlled movements are enacted by the surgeon with this handle. Discomfort from finger-loop pressure on the thumb was reported by 3 of 10 surgeons with the finger-loop handle, whereas no discomfort was reported for the rocker handle. Conclusions: The new rocker handle improves the quality of task performance by eliminating discomfort and reducing angular velocities at the shoulder and elbow joints during use. Received: 26 May 1998/Accepted: 12 January 1999     

A safe and simple method for routine open access in laparoscopic procedures

Background: Access to the peritoneal cavity in laparoscopic procedures is generally achieved by means of a pneumoperitoneum, following introduction of a Veress needle. Because this procedure must be done blindly, it is not without visceral or vascular hazards. Therefore, we sought an alternative technique that might obviate these complications. Methods: In a series of 803 patients, a modified Hasson technique was used to obtain a pneumoperitoneum without risking the complications associated with the introduction of a Veress needle. Results: The modified Hasson technique proved to be feasible in all cases. No visceral or vascular complications resulted, but 10 patients had a transient serous discharge. Follow-up ranged between 5 and 52 months. Conclusion: The modified Hasson technique should always be used in laparoscopic procedures. Received: 17 December 1997/Accepted: 7 May 1998     

Totally endoscopic Ivor Lewis esophagectomy

Esophagectomy is associated with significant risks of perioperative morbidity and mortality, as well as prolonged convalescence due to effects of the incisions used for conventional surgical access. Because the outcome of this procedure is palliative in the majority of patients, it is possible that laparoscopic techniques could improve initial postoperative outcomes and therefore make surgery more acceptable for patients with esophageal cancer. A new technique is described for Ivor Lewis esophagectomy, which incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis. Initial experience in two patients has been encouraging, with postoperative hospital stay and convalescence shortened. Received: 17 December 1997/Accepted: 18 March 1998     

Laparoscopy-assisted jejunal resection for bleeding leiomyoma

We report a case of successful resection of a jejunal leiomyoma using a minimally invasive technique. By combining the procedures of push enteroscopy and laparoscopy, jejunal resection can be performed expeditiously without laparotomy. Received: 12 June 1997/Accepted: 14 July 1997     

Hepatic cryosurgery via minilaparotomy in a porcine model

Background: Cryosurgery of liver lesions is becoming increasingly accepted for the ablation of liver tumors. Attempts at laparoscopic cryosurgery have been very limited and often need to be converted to open laparotomy due to the complexity of the procedure. Methods: Seven domestic pigs were anesthetized, and 17 small (0.7 cm mean diameter) tumor mimicking agar ``lesions' were percutaneously placed in the liver. Two small subcostal incisions (∼2.0 cm) were placed, and an endocavitary ultrasound transducer (with a 2.4-mm cryoprobe mounted on it) was placed on the liver surface. Lesions were localized and directly punctured with one or two cryoprobes under ultrasound guidance, and a single 15-min freeze was undertaken. The animals were then killed, and their livers were removed and serially sectioned. Results: Total time for probe placement was approximately 10 min after incisions had been made. Animals tolerated the procedure well and all survived until they were killed. No intraabdominal complications were detected at exploration. Mean cryolesion dimensions were 3.0 cm (single probe) and 3.3 cm (dual probe) (p > 0.05). Positive margins were detected in one lesion treated with a single probe, and in none of the lesions treated with dual probes. Mean margins were 0.9 cm: 1.2 cm for the single probe and dual probe techniques, respectively. Liver surrounding control agar lesions demonstrated a thin rim of necrosis, approximately 0.5 mm wide. Conclusions: We conclude that minilaparotomy is an effective, safe, and simple method for performing hepatic cryosurgery in this animal model. This minimally invasive technique may benefit a subset of patients with lesions in accessible locations. Lesions in posterior locations may not be as amenable to this technique due to deterioration of ultrasound image quality in the far field. Received: 10 December 1997/Accepted: 27 March 1998     

Laparoscopic management of Tenchkoff catheters in continuous ambulatory peritoneal dialysis

We describe a one-port laparoscopic technique for assisting in Tenchkoff catheter placement and salvaging obstructed ones in patients requiring continuous ambulatory peritoneal dialysis (CAPD). This unique technique enables diagnostic laparoscopy, adhesiolysis, repositioning of catheters, and omentectomy to be performed without laparotomy. Six patients were treated. Only one 10-mm port was required, using an operating laparoscope and an instrument introduced through the working channel of the laparoscope. Adhesiolysis was performed under laparoscopic vision; omentectomy and flushing of blocked catheters were carried out extracorporeally. The catheters were then repositioned to the pelvic cavity under laparoscopic vision. All patients were followed up for 6–10 months. No mechanical problem was noticed. Our one-port laparoscopic technique is a simple and effective method for treating patients who have mechanical problems with their peritoneal dialysis catheters. Received: 14 January 1997/Accepted: 14 April 1997     

Two-trocar technique for terminal sigmoid colostomy in a patient with complex pelvic fracture

We report a multiple trauma case with complex pelvic fractures and perineal wounds. The patient had a laparoscopic abdominal exploration with a simultaneous laparoscopic colostomy using the same wounds. Only two trocars were needed to perform both procedures. The technique is detailed here. The procedures were performed in less than an hour, with excellent postoperative recovery, achieving complete diversion of the rectal fecal contents. Received: 3 April 1997/Accepted: 10 July 1997     

Laparoscopic Collis gastroplasty and Nissen fundoplication

Background: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In our experience, ∼20–25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap. Methods: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying the technique clinically in 1996. We performed 220 laparoscopic antireflux procedures between January 1996 and July 1997. Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy. Results: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed by patient-initiated symptom scores. Conclusions: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of a minimally invasive approach. Received: 8 September 1997/Accepted: 17 December 1997     

Prospective, multicenter study of laparoscopic ventral hernioplasty

Background: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias ≥4 cm²) is being used in a prospective, multicenter, long-term study. Methods: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7–10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. Results: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5–731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. Conclusions: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery. Received: 3 April 1997/Accepted: 10 August 1997     

Anaesthetic experience with laparoscopic cryotherapy

Background: Laparoscopic cryotherapy is a new technique for treating hepatic tumors that obviates the need for a laparotomy and may reduce the amount of surgical trauma and heat loss associated with the open technique. Liquid nitrogen is applied to the tumor via a cryoneedle probe introduced through a laparoscopic port. The aim of this study was to assess the effect on body temperature and the hematological and biochemical changes associated with this technique. Methods: Five patients who underwent this procedure were studied prospectively under a standardized general anaesthetic. Core and peripheral temperature were measured during the procedure, and blood samples were taken for hematological and biochemical analysis. Results: Freezing time ranged 19–57 min and measured blood loss 0–1000 ml. In one case, bleeding resulted from hepatic surface cracking. Three patients required a blood transfusion. The mean fall in both nasopharyngeal and right atrial temperature was 0.4°C. Postoperatively, all patients showed a large rise in alanine aminotransferase (ALT) and a fall in platelet count. A systemic inflammatory response syndrome was seen in some cases, but all patients survived to hospital discharge. Conclusions: Laparoscopic hepatic cryotherapy can be performed without significant temperature changes, but it entails significant morbidity. Received: 3 March 1997/Accepted: 28 April 1997     

Trocar fixation during endoscopic surgery in infants and children

The slipping of trocars is a major problem, especially in pediatric laparoscopic surgery. Although the suturing of a trocar, along with its valve housing, to the fascia or skin is common, this technique only serves to prevent the trocar from being pulled out. We have found that the simple procedure of winding a ±1-cm broad tape several times around the base of the trocar, which has been sutured to the fascia or skin, will prevent the trocar from being pushed in, even during lengthy operations. The tape that we use is derived from sterile disposable drapes and is therefore not only readily available but also an inexpensive solution to a chronic problem. Received: 17 March 1997/Accepted: 29 April 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     

A new technique for laparoscopic resection of a submucosal tumor on the posterior wall of the gastric fundus

Several reports have been published which describe the technique of using an Endo GIA to resect submucosal tumors on the anterior wall of the stomach. Lesions on the posterior wall, however, especially near the esophagocardiac junction (ECJ), are difficult to resect using these reported techniques. This is because the surgeon must divide the omentum and enter the omental bursa in order to use a similar extraluminal technique. Furthermore, special care must be taken to ensure that resections do not involve the ECJ and narrow the esophagus. In order to overcome these difficulties, we have proposed a new technique for the laparoscopic excision of a submucosal tumor located on the posterior wall of the gastric fundus. The principle of this procedure involves the intraluminal resection of the submucosal tumor, including the surrounding stomach wall, using the Endo GIA. This technique is safe, simple, and effective. We believe that we are the first to address the excision of a submucosal lesion by resecting the full thickness of the posterior gastric wall lesion intraluminally. Received: 11 November 1996/Accepted: 2 April 1997     

The pre-looped intracorporeal knot: a new technique for knot tying in laparoscopic surgery.

PURPOSE: Intracorporeal knot tying in laparoscopic surgery is time-consuming and difficult to learn. We present a new technique, that we call the pre-looped intracorporeal knot technique, which obviates the difficulties and saves time. MATERIALS AND METHODS: We devised a homemade suture ring that allows the introduction of the suture thread wrapped on the needle driver and ready for knot tying simply by pulling on both extremities of the thread. RESULTS: Our experience with this technique proved it to be easy to apply and to learn. CONCLUSIONS: The prelooped intracorporeal knot technique allies the sophistication of intracorporeal knot tying to the easiness and simplicity of the extracorporeal classic suturing. It renders intracorporeal knotting an easy and rapid task to achieve.     

A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit

Background: Laparoscopic hernia repair has often been criticized for its high costs. Methods: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. Results: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. Conclusion: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense. Received: 5 May 1997/Accepted: 28 October 1997     

Pneumoperitoneum from an eroded T-fastener

We present a case of late gastric perforation caused by retained T-fasteners after removal of a percutaneous endoscopic gastrostomy tube. We emphasize that timely removal of these fasteners is important in preventing this complication. Received: 25 September 1997/Accepted: 27 October 1997