Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentationrid=""id=""Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27 March 1999

Background: Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation. Methods: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation was performed in eight adult hydrocephalus patients from August 1996 to September 1998. All eight patients had undergone 1 to 18 prior shunt revisions. The procedures were performed with two 2-mm trocars. The instrumentation consisted of a 2-mm laparoscope, a 2-mm grasper, and 2-mm scissors. All shunts were placed in an area free of adhesions and checked for flow under direct vision. Four of the patients required a lysis of adhesions to create a space adequate for catheter placement. Results: All of the procedures were successful, with no operative complications. The operative times ranged from 29 to 99 min, (mean, 63 min). The blood loss in all of the procedures was minimal. At this writing, none of the patients have required subsequent distal shunt revisions. No conversions to larger instruments or an open procedure were required. Conclusions: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation is safe and effective, offering several advantages over the open procedure. This procedure is ideal for the use of 2-mm instruments. Received: 19 March 1999/Accepted: 23 June 1999/Online publication: 10 April 2000     

A laparoscopic approach to ventriculoperitoneal shunt placement in adults

Background: Ventriculoperitoneal shunts have been used for the treatment of hydrocephalus for years. In the past, the abdominal portion of this technique has required mini-laparotomy. We present a series of 10 consecutive patients in which ventriculoperitoneal (VP) shunts were placed with laparoscopic assistance. Materials and methods: At Lankenau Medical Center for July 1996 to January 1998, 10 patients (aged 22–81) with normopressure hydrocephalus underwent laparoscopic VP shunt placement. The neurologic portion of the procedure is begun simultaneously with the abdominal procedure. After pneumoperitoneum is established using a miniport disposable 2-mm introducer at the umbilicus, a 2-mm camera is introduced into the peritoneal cavity through the same port. A needle is introduced into the peritoneal cavity under direct visualization. Once the catheter is placed ventricularly, it is tunneled subcutaneously to the abdomen. Using the Seldinger technique, the VP catheter is introduced under direct visualization through a sheath into the peritoneal cavity toward the pelvis. Positioning and function are also confirmed under direct visualization. Results: All patients tolerated this procedure well, and there were no complications. The benefits of this procedure include direct visualization of catheter placement and smaller incisions than necessary for an open procedure. Conclusion: We recommend laparoscopic-assisted placement of the VP shunt in normopressure hydrocephalus patients as a good alternative to the open technique. Received: 30 June 1998/Accepted: 25 November 1998     

Primary laparoscopic placement of peritoneal dialysis catheters in children and young adults

Background: Primary placement of peritoneal dialysis catheters in children often requires suturing of the catheter into the pelvis. We describe our experience with a gasless laparoscopy technique in children and young adults. Methods: During an 18-month period, 12 patients (mean age, 14 years) underwent primary laparoscopic placement of peritoneal dialysis catheters. A single umbilical port was used for abdominal wall elevation, telescope, and catheter. A needleholder was introduced via an accessory port at the future catheter exit site or through the umbilical port. Omentectomy was performed through the umbilical incision. The catheter was tunneled to the lateral abdominal wall. Follow-up data (≥15 months) included time to initiation of dialysis, hospitalization, and outcome. End points were cure, transplantation, or death. Results: Diet was started on the day of surgery and dialysis on the following day. Four patients had seven complications, including leakage and entanglement of the catheter in tubal fimbriae. Long-term revision-free catheter survival was 67% at 24 months. Conclusions: This minimal access technique for primary placement of peritoneal dialysis catheters includes securing of the catheter tip in a dependent location and omentectomy. It allows nearly immediate use of the catheter, leads to a minimal hospital stay, and has acceptable long-term patency. Received: 24 December 1998/Accepted: 3 March 1999     

Microlaparoscopic cholecystectomy

Background: We set out to compare a prospective evaluation of microlaparoscopic cholesystectomy (MLC) using 5-mm ports for the scope and operating ports and two 2-mm ports for retracting to the historic results of standard laparoscopic cholecystectomy (SLC). Methods: Fifty-six consecutive patients were operated electively for symptomatic gallstones between June 1997 and July 1998. Demographics, history of prior abdominal surgery, operative time, resident level, need to convert, length of stay, and postoperative analgesia were recorded for each case. In all, 43 women and 13 men aged 21 to 89 (average, 51 years) underwent MLC. Average weight was 78 kg (range, 48–119) and average height was 163 cm. Results: Operative time for MLC was 72 ± 25 min (range, 35–140), somewhat less than the referenced standard of 79 ± 27 min (p= 0.1). The skin-to-trocar time (6 ± 2 vs 13 ± 77 min) and intraoperative cholangiogram time (9 ± 8 vs 11 ± 6 min) were significantly shorter (p < 0.01 and p < 0.05, respectively) for MLC. Other partial times were not significantly different. PGY2 residents averaged 74 ± 21 min (range, 44–118) compared to 75 ± 27 min (range, 35–140) for PGY3 and 53 ± 5 (range, 43–59) for PGY5. Patient weight influenced time. Patients <65 kg averaged 56 ± 12 min; 66–80 kg, 72 ± 24 min; 81–95 kg, 78 ± 26 min; and >95 kg, 85 ± 22 min. Previous abdominal surgery did not affect operative time. Nine patients (16%) required conversion from 2- to 5-mm ports because of adhesions, wall thickening, or need for better retraction. Time in these patients was 95 ± 26 min vs 68 ± 21 min in other patients (p < 0.01). No patient was converted to an open procedure. Three patients (5%) had a positive cholangiogram and common bile duct exploration that required placement of an extra 5-mm trocar. Five patients (9%) required insertion of an additional 2-mm port. All patients received patient-controlled analgesia (PCA). Morphine use was 0.21 ± 0.19 mg/kg (range, 0–0.8). Hospital stay was 1.31 days (range, 0.5–4). Subjective satisfaction was excellent because of smaller incisions. No additional morbidity was seen with MLC. Conclusion: MLC is a feasible and safe approach that provides similar times to SLC with better cosmesis, a less painful recovery, and possibly an earlier return to normal activity. Received: 16 February 1999/Accepted: 8 October 1999     

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     

Laparoscopic placement of ventriculoperitoneal shunts: an innovative simplification of the existing techniques.

Ventriculoperitoneal shunting (VPS) remains one of the alternative choices for the surgical treatment of hydrocephalus. During the last two decades laparoscopy has been utilized to facilitate the placement of the abdominal portion of the shunt. We describe a minimally invasive laparoscopic technique, which facilitates the rapid, safe and direct placement of the peritoneal component of the VPS. A side frontal ventricular catheter is placed through a small burr hole and connected to the valve at the postauricular region. An infra-umbilical trocar is placed, using the Hasson technique, and after the pneumoperitoneum is established, a 10-mm laparoscope is introduced for identification of a VPS entry side free of adhesions. A 5-mm skin incision is made at the decided point of catheter insertion, usually at the right upper quadrant. Using a tunneler, the VPS catheter is placed subcutaneously from abdomen insertion point, to the postauricular region, where it is connected to the valve. A split type, 10-12 Fr and 12-15 cm long metallic puncture cannula, like those used for suprapelvic percutaneous bladder drainage, is introduced into the abdomen. Under direct laparoscopic vision the peritoneal portion of the VPS is passed into the abdomen through the cannula. The catheter is leaded to a desirable location by pointing the needle accordingly. Alteration of the position of the catheter can also be attained by entraining the catheter with the laparoscope and without using auxiliary graspers. The function of the VPS is confirmed under direct visualization. Suturing the abdominal and cranial incisions completes the procedure. We used this technique in a series of 12 patients with excellent outcome. There were no intra- or postoperative complications and no mortalities. Our technique is less invasive than a minilaparotomy, embraces all laparoscopic benefits and does not require auxiliary forceps or guidewires. It uses easy available materials with low cost, and attains an easy, rapid, and safe placement of the abdominal portion of the VPS.     

Is it necessary to lift the abdominal wall when preparing a pneumoperitoneum?rid=""

Background: In order to create a pneumoperitoneum with the Veress needle, it is generally advocated that the abdominal wall should be lifted. Lifting is aimed at increasing the distance between the abdominal wall and the intraabdominal structures. This study was conducted to compare lifting (L) and nonlifting (NL) of the abdominal wall. Methods: All patients scheduled for laparoscopic surgery without previous abdominal surgery or morbid obesity were included in the study group. The number of attempts needed for proper positioning of the needle was assessed. Results: A total of 150 patients were randomized. There were no complications. The number of attempts needed for correct positioning of the Veress needle was significantly higher in the L group than in the NL group (31 of 75 vs nine of 75, p < 0.001). The body mass index (BMI) of patients in whom peritoneal entry needed more than one puncture was significantly higher than the BMI of patients with immediate proper placement (28.3 vs 24.7 kg/m², p < 0.05). Conclusion: Abdominal wall lifting is not necessary. Received: 20 September 1999/Accepted: 14 December 1999/Online publication: 8 May 2000     

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     

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     

Outpatient endoscopic thoracic sympathectomy using 2-mm instruments

Background: For a long time it has been known that sympathectomy is an effective treatment for hyperhidrosis and other conditions. The surgical options available until recently usually have required thoracotomy or large posterior incisions, and physicians generally have been reluctant to recommend surgery for most patients with ``benign' disorders. Recently, thoracoscopic techniques have allowed surgeons to offer these patients a permanent solution with minimal surgical trauma. Methods: In 20 patients, 30 endoscopic thoracic sympathectomies (ETS) were performed for several indications. Nine patients had bilateral sympathectomies. The procedures were performed on the day of admission, with the patient under general anesthesia using double lumen endotracheal intubation and hand temperature monitoring. Each lung was reinflated on completion of the sympathectomy, and residual pneumothorax aspirated before closure of the incisions. No placement of chest tubes was performed in the operating room. Results: All sympathectomies were completed thoracoscopically. There were no major complications, and 90% of the patients were discharged within 24 hours of admission. The average operative time was 69 min. Conclusions: Findings from this study show that ETS is a safe and effective procedure that can be performed routinely on an outpatient basis. The use of miniendoscopic (2-mm) instrumentation is safe and effective in most patients and a helpful adjunct in providing these patients with minimally traumatic surgery. Long-term results should be evaluated on the basis of specific indications for sympathectomy. Received: 1 March 1999/Accepted: 1 July 1999     

Surgical closure of atrial septal defect

Background: Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions. Methods: We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure. Results: The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 ± 12) and 14 to 158 min (27 ± 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt. Conclusion: Our results suggest that MICS is a good option for surgical closure of ASD. Received: 4 June 1997/Accepted: 29 October 1997     

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     

Laparoscopic ventriculoperitoneal shunt placement

Ventriculoperitoneal shunt (VPS) placement is an important therapeutic technique. Placement of the abdominal portion of VPS can be difficult in the setting of previous abdominal surgery, prior failure of VPS, or obesity. Even under ideal circumstances, standard mini-laparotomy does not allow precision in VPS positioning. We describe a single-port technique for VPS placement. While the neurosurgeon places a right frontal ventricular catheter and valve, an infraumbilical trocar is placed utilizing the open Hasson technique. A 12-mm operating laparoscope with an 8-mm channel is used to inspect the abdomen and identify the VPS entry site. Adhesions interfering with shunt placement can be lysed through the working channel of the laparoscope. Under laparoscopic visualization, an 18-gauge needle is introduced through a 5-mm incision in the right upper quadrant and the VPS tubing is tunneled to that site. A J-tipped guidewire is introduced, and the needle is exchanged for a dilator and peel-away sheath. The VPS is delivered through the sheath, which is sectioned and removed. An atraumatic grasper, placed through the laparoscope, directs the VPS to the desired intraabdominal location. Function of the VPS is assessed visually while compressing the valve. Suture closure of the trocar site and VPS entry site completes the procedure. We used this method successfully in a series of five patients with excellent outcome. A 14-month follow-up has revealed no failures or postoperative complications. This method is less invasive than mini-laparotomy, allows for precision placement of the abdominal portion of VPS, and confirms appropriate function.     

Analysis of risk factors for infection in coplacement of percutaneous endoscopic gastrostomy and ventriculoperitoneal shunt

Patients with severe neurological impairment requiring tube feeding may have concomitant hydrocephalus. Coplacement of percutaneous endoscopic gastrostomy (PEG) and ventriculoperitoneal (VP) shunting is currently standard in such cases. The present study investigated the risk factors for shunt infection in such patients. The medical records of 23 patients with PEG and VP shunting were retrospectively reviewed. Correlations between shunt system infection and potential risk factors were analyzed including order of PEG and VP shunting, position of abdominal shunt catheter, diabetes mellitus, tracheostomy, and activities of daily living. Twelve patients underwent VP shunting after PEG and 11 underwent PEG after VP shunt placement. Four patients experienced shunt infection, and three required shunt revision. Three of these four patients underwent VP shunting after PEG. The period between PEG and VP shunt placement was 18, 19, and 25 days, shorter than the mean period of 29.3 days. VP shunting can be combined with PEG, but a larger study is required to clearly identify the risk factors. Administration of prophylactic antibiotics and a period of at least 1 month between the procedures are recommended, particularly if the shunt is placed after the PEG tube.     

Laparoscopy-assisted ventriculoperitoneal and lumboperitoneal shunt surgery

Recently, laparoscopy (also referred to as minimally invasive surgery) has been used during peritoneal catheter implantation in shunt placement for hydrocephalus; however, the procedure and devices for this technique have not yet been well established. We adopted umbilical and paraumbilical laparoscopy for peritoneal catheter insertion. In this paper, we describe the technique we used and its clinical results and benefits. Ten consecutive patients with hydrocephalus who underwent laparoscopic shunt surgery (6 cases of ventriculoperitoneal shunt and 4 of lumboperitoneal shunt) were enrolled for this study. The follow-up period ranged from 21 to 434 days (mean, 263 days). After a standard cranial/spinal procedure, an approximately 5-mm incision was made in the lateral side of the umbilicus, where the abdominal catheter was introduced subcutaneously. Thereafter, we inserted a laparoscope into the peritoneal cavity via a small incision beneath or just on the umbilicus. A shunt catheter was laparoscopically inserted through a peel-off cannula and placed after taking note of the outflow of cerebrospinal fluid (CSF) from the catheter tip. In all patients, the shunt was inserted with no complications, and good patency was achieved. Laparoscopy allows implantation of the catheter into the peritoneal cavity, and the outflow of CSF can be confirmed intraoperatively. Furthermore, the abdominal surgical wounds are minimal, even for obese patients, and fascia/muscle incisions are not needed. Laparoscopy-assisted shunt surgery for hydrocephalus is effective and safe and also has cosmetic advantages.     

Frameless stereotactic ventricular shunt placement for idiopathic intracranial hypertension

INTRODUCTION: Cerebrospinal fluid (CSF) shunting effectively reverses symptoms of idiopathic intracranial hypertension (IIH). Lumboperitoneal (LP) shunts have traditionally been used in patients with IIH due to a frequently undersized ventricular system. However, the advent of image-guided stereotaxis has enabled effective ventricular catheter placement in patients with IIH. We describe the first large series of frameless stereotactic ventriculoperitoneal (VP) shunting for patients with slit ventricles and IIH. METHODS: We describe the frameless stereotactic VP shunting technique for IIH in 32 procedures. Outcomes following shunt placement, time to shunt failure, and etiology of shunt failure are reported. RESULTS: A total of 21 patients underwent 32 ventricular shunting procedures (20 VP, 10 ventriculoatrial, 2 ventriculopleural). One hundred percent of shunts were successfully placed into slit ventricles, all requiring only one pass of the catheter under stereotactic guidance to achieve the desired location and CSF flow. There were no procedure-related complications and each ventricular catheter showed rapid egress of CSF. All (100%) patients experienced significant improvement of headache immediately after shunting. Ten percent of ventricular shunts failed at 3 months after insertion, 20% failed by 6 months, 50% failed by 12 months, and 60% failed by 24 months. Shunt revision was due to distal obstruction in 67%, overdrainage in 20%, and distal catheter migration or CSF leak in 6.5%. There were no shunt revisions due to proximal catheter obstruction or shunt infection. CONCLUSIONS: In our experience treating patients with IIH, frameless stereotactic ventricular CSF shunts were extremely effective at treating IIH-associated intractable headache, and continued to provide relief in nearly half of patients 2 years after shunting without many of the shunt-related complications that are seen with LP shunts. Placing ventricular shunts using image-guided stereotaxis in patients with IIH despite the absence of ventriculomegaly is an effective, safe treatment option.     

Laparoscopic management of mechanical small bowel obstruction

Background: Laparoscopy is used increasingly for the management of acute abdominal conditions. For many years, previous abdominal surgery and intestinal obstruction have been regarded as contraindications to laparoscopy because there is an increased risk of iatrogenic bowel perforation. The role of laparoscopy in acute small bowel obstruction remains unclear. Methods: Since 1995, data from patients undergoing laparoscopic surgery have been entered prospectively into a database. Patients who underwent surgery before 1995 were added retrospectively to the same database. The charts of all patients treated surgically for mechanical small bowel obstruction were reviewed. Univariate analysis was performed to identify factors associated with success or failure, especially intraoperative complications, conversion, and postoperative morbidity. Stepwise logistic regression was used to assess for independent variables. Results: This study included 83 patients (56 women and 27 men) with a mean age of 56 years (range, 17–91 years). Conversion was necessary in 36 cases (43%). Laparoscopy alone was successful in 47 patients (57%). Intraoperative complications were noted in 16% and postoperative complications in 31% of the patients. Eight reoperations (9%) were necessary. Mortality was 2.4%. Duration of surgery (p < 0.001) and a bowel diameter exceeding 4 cm (p= 0.02) were predictors of conversion. No risk factor for intraoperative complication was identified. Accidental bowel perforation (p= 0.008) and the need for conversion (p= 0.009) were the only independent factors associated with an increased risk of postoperative complications. Conclusions: Laparoscopic management of small bowel obstruction is possible in roughly 60% of the patients selected for this approach. Morbidity is lower, resumption of a normal diet is faster, and hospital stay is shorter than with patients requiring conversion. No clear predictor of success or failure was identified, but intraoperative complications must be avoided. If the surgeon is widely experienced in advanced laparoscopic surgery and there is a liberal conversion policy, laparoscopy is a valuable alternative to conventional surgery in the management of acute small bowel obstruction. Received: 20 July 1999/Accepted: 22 November 1999/Online publication: 17 April 2000     

Recent experience with percutaneous endoscopic gastrostomy/jejunostomy (PEG/J) for enteral nutrition

Background: Enteral feeding is the preferred means of nutritional support in patients unable to eat orally. Jejunal-placed feeding tubes are often considered optimal for this purpose. Successful administration of such tube feedings depends on the method of placement and the size of the tube. Herein we review our experience with endoscopically placed jejunal feeding tubes. Methods: Thirteen percutaneous endoscopic gastrostomy/jejunostomy (PEG/J) tubes were placed in 13 patients at the Emory University hospital by one surgeon. Indications for jejunal placement included aspiration in five patients and suspicion of increased reflux susceptibility in eight patients. Insertion of an 8.5-Fr nasobiliary tube was attempted in nine patients using the technique described by Coates and MacFadyen. A 12-Fr tube was placed in four patients using a technique that took advantage of previously placed PEG tubes. Results: Initial placement was successful in all but one patient. Nine tube-related complications occurred in seven patients. These included six tube occlusions, one tube site infection, one peristomal leak, and one tube perforation that required replacement. Five of six tube occlusions (83%) occurred in the smaller 8.5-Fr. tubes. There was one non–tube-related death. Conclusions: PEG/J insertion can be performed successfully and safely in most patients. Long-term tube patency is, however, dependent on the use of tubes with a large diameter; thus, modalities that enable placement of larger-sized tubes are preferable. Further technical developments are needed to facilitate the endoscopic insertion of larger jejunostomy tubes. Received: 1 May 1999/Accepted: 14 March 2000/Online publication: 25 April 2000     

Infectious risk to ventriculo-peritoneal shunts from gastrointestinal surgery in the pediatric population

Purpose

The infectious implication of abdominal surgeries on ventriculo-peritoneal (VP) shunts, including simultaneous shunt placement and management of shunt infections, has been ill defined in children.

Methods

We conducted a 9-year retrospective review of pediatric patients with VP shunts who underwent abdominal surgeries.

Results

Forty-two patients fit criteria. The median age at shunt placement was 1.75 years, and the median time between shunt placement and abdominal surgery was 24 days. The most common procedures included gastrostomy (17), fundoplication (15), and appendectomy (3). Seven patients had simultaneous abdominal surgery and shunt placement. All patients received preoperative antibiotics. Two children developed shunt infections, both occurred after appendectomy. Both were treated with antibiotics, with one requiring shunt removal. Median length of stay was 24 days but 28 days for those with infections. Thirty-eight patients were discharged home, 3 to chronic care facilities, and 1 died.

Conclusions

Infections did not occur in children with VP shunts undergoing elective abdominal procedures or procedures simultaneously with shunt insertion. Infections were seen only with emergent appendectomies, suggesting that performing gastrointestinal procedures at the time of VP shunt insertion is safe. Children with VP shunts undergoing emergent surgery for peritoneal infection warrant close observation for shunt infection.     

Laparoscopic cholecystectomy performed by a single surgeon using a visual field tracking camera

Background: This report describes a visual field tracking camera for laparoscopic surgery that allows the visual field to be changed without moving the laparoscope. We also report on our early experience with this camera for single-surgeon laparoscopic cholecystectomy. Methods: The visual field tracking camera has a tracking mechanism (composed of a zoom lens and a charge-coupled device [CCD] slide mechanism) built into the camera head. The 80° visual field observed with the laparoscope can be expanded using the zoom lens, and the field can be shifted by changing the size of the area being viewed by the CCD. This is accomplished by pushing a switch on the forceps or by verbal command. Cholecystectomy was carried out on 12 patients with gallstones using this camera. The operations were performed by either a single surgeon or two surgeons. Forceps held with a forceps holder were inserted through the right port to lift the fundus of the gallbladder. The single surgeon used the other two ports to resect the gallbladder by the two-handed technique. Results: In all cases, cholecystectomy was completed without any need to move the laparoscope at any point during the operation. Seven operations were performed by a single surgeon. Mainly for education purposes, five other operations were performed by a pair of surgeons. The mean time required for surgery was 76 ± 17 min. This time did not differ from that of laparoscopic cholecystectomy performed during the same period on 22 patients by teams of three surgeons using conventional cameras. Conclusions: Using the visual field tracking camera, laparoscopic cholecystectomy can be performed without any need to touch the laparoscope. This camera allowed laparoscopic cholecystectomy to be performed by a single surgeon. Received: 30 April 1999/Accepted: 10 January 2000/Online publication: 4 August 2000