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     

Minimally invasive parathyroid surgery

Background: Minimally invasive access for the treatment of primary hyperparathyroidism is becoming widespread, but several different approaches have been proposed in the literature. Methods: We describe the three main types of mini-invasive parathyroidectomy, with particular attention to the gasless video-assisted procedure, which is now routinely performed at our institution. Results: Eighty-nine patients with a preoperatively localized single adenoma were successfully treated. Operative time was 58 mins, and there were only five conversions. Discussion: After comparing the different approaches described in literature, we conclude that mini-invasive parathyroidectomy is feasible and can provide additional benefits not available with traditional surgery. At present, however, this operation can be recommended only for patients with sporadic disease, localized lesions, and absence of goiter and prior neck surgery. Received: 8 August 1999/Accepted: 13 December 2000/Online publication: 14 September 2000     

Minimally invasive surgical staging for esophageal cancer

Background: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. Methods: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. Results: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n= 1), I (n= 1), II (n= 23), III (n= 20), IV (n= 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. Conclusions: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer. Received: 5 April 1999/Accepted: 15 March 2000/Online publication: 12 July 2000     

Outcomes assessment and minimally invasive surgery

Background: Outcomes assessment is being used increasingly to shape practice patterns in all areas of medicine. Although outcomes assessment is not a new concept, the widespread application of outcomes measurement for modifying practice is novel. Instead of focusing on results of interventions in highly controlled environments, outcomes studies usually report results as they occur in uncontrolled, real-world environments. Recently, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has initiated a society-wide initiative to monitor outcomes in patients undergoing various laparoscopic operations. Methods: Pertinent literature is reviewed as it relates to outcomes assessment. The historical background underpinning the modern interest in outcomes is outlined. Definitions of terms useful for understanding outcomes research are given. The impact of outcomes assessment on minimally invasive surgery, both positive and negative, are examined. The SAGES outcome initiative is introduced. Conclusions: Although outcomes studies usually do not provide information on the causes of observations made, they have gained in popularity because they provide information about patient perceptions of disease, disability, and treatment. Minimally invasive surgical procedures often are reported in terms of outcomes assessment because a controlled clinical trial was rendered impossible by early and widespread application of laparoscopic surgery. The SAGES outcomes initiative will provide the necessary tools for the participation of surgeons in the process of practice profiling. Received: 17 December 1999/Accepted: 4 April 2000/Online publication: 29 August 2000     

Laparoscopy in the management of gastric submucosal tumors

Background: Gastric tumors, including early gastric cancers, can be safely removed laparoscopically. They do not require an open laparotomy. Methods: From March 1995 to December 1998, we used laparoscopy to resect gastric submucosal lesions in 32 patients. There were 22 men and 10 women. The patients ranged in age from 23 to 67 years (median, 51.4 yr). The lesions were located in the upper third in one patient, in the middle third in 20 patients, and in the lower third in 11 patients. The tumors ranged in size from 2 to 6 cm in diameter. The operative procedures were wedge resection in 19 patients, wedge resection with gastrotomy in two patients, intragastric surgery in nine patients, intragastric surgery with gastrotomy in one patient, and proximal gastrectomy in one patient, using a four- or five-port technique. The exophytic mass was resected with an Endo-GIA, and the tumors on the mucosal surface were exposed via a gastrotomy and excised. The gastrotomy was closed with an intracorporeal suture. In all cases, the operation was finished after the confirmation of tumor-free margins on frozen-section biopsy specimens. Results: The duration of the operation ranged from 80 to 180 mins. The final pathologic findings were leiomyoma in 24 patients, adenomyoma in three patients, hyperplastic polyp in two patients, lipoma in one patient, hamartoma in one patient, and leiomyosarcoma in one patient. One case (3.1%) was converted to a mini-laparotomy due to technical difficulty; in one other case, more margin was resected laparoscopically due to the tumor-positive margin; and in one further patient, leakage was repaired by laparoscopic suturing on the 1st postoperative day. There were no other major complications and no deaths. The hospital stay ranged from 6 to 7 days. The maximum follow-up to date in these patients, including a case of leiomyosarcoma, was 42 months. There has been no evidence of tumor recurrence. Conclusion: The application of laparoscopy to submucosal tumors of the stomach is technically feasible, safe, and useful. It should be considered a viable alternative to open surgery and gastroscopic management because of its low invasiveness and good postoperative results. Received: 10 May 1999/Accepted: 22 November 1999/Online publication: 13 June 2000     

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     

Laparoscopic resection of large leiomyomas of the gastric fundus

Two patients with a large leiomyoma arising from the gastric fundus underwent laparoscopic resection. In case 1, the tumor was located in the anterior wall of the gastric fundus. To prevent stenosis and preserve the volume of the residual stomach, intragastric resection was adopted. The tumor was markedly and resected with laparosonic coagulating shears with a 1-cm safety margin. In case 2, a large tumor was detected in the duodenal bulb. Serious hemorrhage mandated emergency resection. The tumor originated from the posterior wall of the fundus. Attempts at reduction with the forceps failed. Reduction by digital manipulation via laparoscopic port sites was successful. An endostapler was used to resect the tumor and close the anterior wall. Both patients recovered uneventfully. Received: 15 November 1998/Accepted: 3 April 1999     

Minimally invasive surgery and clinical decision-making for pediatric malignancy

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

Minimally invasive adrenalectomy and malignant adrenal tumours

Summary   Background: Minimally invasive adrenalectomy is the standard procedure for the treatment of small benign adrenal neoplasms. The question of whether this technique is also suitable for treating adrenal malignancies has recently been discussed with controversy. Methods: A literature search was performed to gather published experience and opinions concerning the role of endoscopic adrenalectomy in the treatment of primary adrenal malignancies and adrenal metastases. Results: Adrenocortical carcinomas (ACCs) have been approached laparoscopically, and this technique has even been advocated for large tumours. Several small ACCs have been successfully removed laparoscopically. Oncological catastrophes with peritoneal carcinomatosis have been reported. Reoperation after laparoscopic adrenalectomy for unsuspected ACC was usually not performed. There are no data demonstrating a survival benefit of systematic lymphadenectomy. Adrenal metastases are firm and rarely penetrate the capsule of the adrenal gland. Several reports on endoscopic adrenalectomy for metastases have been published. Conclusions: Laparoscopic adrenalectomy for ACC should be considered with great reluctance. If ACC is diagnosed postoperatively upon histological examination after laparoscopic adrenalectomy for a presumably benign tumour, reoperation is not mandatory provided oncological principles were respected during the primary operation. Adrenal metastases confined to the adrenal gland can be removed laparoscopically.      

Skills evaluation in minimally invasive surgery using force/torque signatures

Background: One of the more difficult tasks in surgical education is to teach the optimal application of instrument forces and torques necessary to facilitate the conduct of an operation. For laparoscopic surgery, this type of training has traditionally taken place in the operating room, reducing operating room efficiency and potentially affecting the safe conduct of the operation. The objective of the current study was to measure and compare forces and torques (F/T) applied at the tool/hand interface generated during laparoscopic surgery by novice (NS) and experienced (ES) surgeons using an instrumented laparoscopic grasper and to use this data for evaluating the skill level. Methods: Ten surgeons (five-NS, five-ES) performed a cholecystectomy and Nissen fundoplication in a porcine model. An instrumented laparoscopic grasper with interchangeable standard surgical tips equipped with a three-axis F/T sensor located at the proximal end of the grasper tube was used to measure the F/T at the hand/tool interface. In addition, one axis force sensor located at the grasper's handle was used to measure the grasping force. F/T data synchronized with visual view of the tool operative maneuvers were collected simultaneously via a novel graphic user interface incorporated picture-in-picture video technology. Subsequent frame-by-frame video analysis of the operation allowed a definition of states associated with different tool/tissue interactions within each step of the operation. F/T measured within each state were further analyzed using vector quantization (VQ). The VQ analysis defines characteristic sets of F/T in the database that were defined as F/T signature. Results: The magnitude of F/T applied by NS and ES were significantly different (p < 0.05) and varied based on the task being performed. Higher F/T magnitudes were applied by NS than by ES when performing tissue manipulation, whereas lower F/T magnitudes were applied by NS than by ES during tissue dissection. Furthermore, the time to complete the surgical procedure was longer for NS by a factor of 1.5–4.8 when compared to the time for ES. State analysis suggests that most of this time is consumed in an [idle] state, in which movements of the surgeon make no tissue contact. Conclusions: Preliminary data suggest that F/T magnitudes associated with the tool/tissue interactions provide an objective means of distinguishing novices from skilled surgeons. Clinical F/T analysis using the proposed technology and methodology may be helpful in training, developing surgical simulators, and measuring technical proficiency during laparoscopic surgery. Received: 4 May 1999/Accepted: 1 April 2000/Online publication: 4 August 2000     

Laparoscopic treatment of gastric stromal tumors

Background: The laparoscopic resection of gastric stromal tumors (GST) is being performed with increased frequency. Methods: Between November 1993 and October 1998, nine consecutive patients with benign and low-grade gastric stromal tumors underwent laparoscopic resection using intraoperative endoscopy. For lesions located on the anterior wall (three cases), a direct approach was utilized. Lesions located on the posterior wall were resected via a transgastric approach (four cases) or through a small opening on the omentum or on the gastrocolic ligament (two cases). Excision of the lesions was performed manually by means of electrocautery and scissors in eight cases; the gastric incisions were closed by manual running suture. An endoscopic stapler device was used in one case only. Results: All patients were successfully treated laparoscopically; there were no conversions to open surgery. Operative time ranged from 75 to 120 min. There was one bleeding from the suture line of the gastric wall postoperatively that was treated conservatively. The average postoperative hospital stay was 4 days (range, 2–6). Conclusions: In light of the results reported in the literature and on the basis of the present work, it seems that laparoscopic resection of GST should be considered as the treatment of choice. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. In our opinion the direct approach should be reserved for lesions located on the posterior wall of the body, which can be easily reached through the greater omentum, while the transgastric approach should be preferred for lesions located on the fundus and antrum. Manual excision allows a tailored operation; hand-sewn sutures are always feasible, and they are cheaper than stapled ones. Received: 30 April 1999/Accepted: 7 October 1999/Online publication: 10 April 2000     

A 3-year experience with laparoscopic gastric banding for obesity

Background: The introduction of laparoscopic techniques—especially that of gastric banding—and the fact that conservative management does not provide satisfactory long-term results in patients with morbid obesity has resulted in a marked increase in the demand for bariatric surgery in our department since 1995. In this paper, we present our experience during the first 3 years with this approach. Methods: Data for all patients who had bariatric surgery at our institution were collected prospectively. They were analyzed for the purpose of this study. Results: A total of 150 patients were operated on between December 1995 and December 1998 (37 months). There were 130 women and 20 men, with a mean age of 37.5 years (range, 19–62). The mean initial excess body weight was 102.9% (range, 58–191%), and the mean initial body mass index (BMI) was 44.6 kg/m² (range, 35.1–64.1). A Lapband was used in 101 cases and a SAGB in 47 cases. In two patients in whom conversion was necessary, we performed a vertical banded gastroplasty. Duration of surgery decreased over time from 210 min (first 20 cases) to 73 min (last 20 cases). Six patients (4%) developed major complications, one of whom died. The median duration of postoperative hospital stay was 3 days. The mean follow-up was 17 months. In all, 24 patients (16%) developed late complications, and 22 (14.6%) required reoperation, mainly for band slippage and/or pouch dilatation (14 cases). An incorrect surgical technique used for the first 30 patients (Lapband within the lesser sac) was responsible for more than half of these complications. The mean excess weight loss was 34% at 6 months, 55% at 1 year, and 56% at 2 years. Compared to vertical banded gastroplasty (197 cases between 1981 and 1995), postoperative morbidity was greatly decreased, late morbidity was similar, and weight loss was equivalent. Conclusions: Laparoscopic gastric banding is followed by a weight reduction that is similar to that observed after vertical banded gastroplasty, with a much lower postoperative morbidity, a shorter hospital stay, and an earlier resumption of normal activities. If these results can be confirmed by long-term follow-up, laparoscopic gastric banding will be confirmed as the restrictive procedure of choice for morbid obesity. Received: 20 July 1999/Accepted: 16 December 1999/Online publication: 8 May 2000     

Laparoscopic resection of posterior gastric leiomyoma

Laparoscopic gastric surgery is gaining momentum, especially in the treatment of benign disease. Simultaneous endoscopy and laparoscopy allow precise localization of lesions. Because of the stomach's size, mobility, and distensibility, relatively large lesions can be safely excised. Wedge resection for anterior lesions and a transgastric or intragastric approach for posterior lesions are feasible laparoscopically. Two cases of posterior gastric leiomyomas successfully resected laparoscopically are presented. The use of stapling devices greatly facilitates this procedure. Received: 17 February 1995/Accepted: 7 September 1995     

Thoracoscopic enucleation of benign tumors of the esophagus under simultaneous flexible esophagoscopy

Background: Benign tumors of the esophagus are very rare, accounting for only 0.1–2% of all esophageal tumors. Conventional treatment consists of thoracotomy adapted to the location of the tumor, followed by enucleation of the lesion. This approach, however, involves major surgery. Minimally invasive surgery represents a viable therapeutic alternative, in particular for benign tumors. Methods: In four patients with a benign tumor of the esophagus, we carried out thoracoscopic enucleation under simultaneous esophagoscopy. Results: Using this combination of endoscopic procedures, the tumors were removed reliably and safely. Two of the lesions were intramural leiomyomas, and two were intramural myxoid cysts. Conclusion: This combination of endoscopic procedures represents a minimally invasive approach with correspondingly minor surgical trauma. Using simultaneous esophagoscopy and transillumination (diaphanoscopy) of the esophageal wall, the safety and accuracy of the dissection is increased, and the risk of mucosal perforation minimized. Received: 10 January 2000/Accepted: 30 March 2000/Online publication: 29 August 2000     

Indications for endo-organ gastric excision

Intragastric surgery for benign and malignant conditions is a new form of minimally invasive surgery, to which the term endo-organ gastric surgery has been applied. This procedure may provide improved results for patients, but reported studies are small, and follow-up evaluation is limited. The indications for endo-organ surgery are evolving as technology and operative expertise begin to meet the need for continued advancements in miniaturized surgery. This new approach is applied primarily to the removal of gastric neoplasms poorly positioned or too large for standard transoral endoscopic excision. Gastric polyps, benign gastric wall tumors such as leiomyomas and carcinoids, and low-grade as well as high-grade malignancies can be removed. The history of endo-organ surgery, the background technology, and surgical experience are reviewed. In addition, current indications for endo-organ surgery and the rationale for algorithms are included. Intraluminal gastric surgery is not widely performed or studied, therefore a further understanding of its role is provided. Received: 7 April 1999/Accepted: 18 August 1999     

Minimally invasive surgical biopsy confirms PET findings in esophageal cancer

This report describes our initial experience using positron emission tomography (PET) scanning in esophageal cancer patients. In two patients PET identified distant metastatic disease missed by conventional staging. Laparoscopic biopsy provided histological confirmation of metastases. In the third patient, locoregional lymph nodes were identified by PET and confirmed by surgical staging. In this preliminary report, PET appears to be a promising new noninvasive modality for staging patients with esophageal cancer. Received: 6 December 1997/Accepted: 14 January 1997     

Minimally invasive pancreatic surgery

Robotic surgery remains in its infancy, and little experience has been reported, as surgeons carefully explore the application of this type of technology to diseases of the pancreas. While challenging and controversial, Dr. Zollinger would most likely support the ongoing research in the techniques of pancreatic surgery that can lead only to an improvement in the outcomes of our patients.     

Minimally invasive repair of congenital diaphragmatic hernia

Purpose

Operative approach, including minimally invasive surgery (MIS) in the repair of congenital diaphragmatic hernia (CDH), is variable among institutions. The short-term recurrent hernia rate is not well described. We evaluated the in-hospital recurrence rate of MIS repairs of infants with CDH from the Congenital Diaphragmatic Hernia Registry.

Methods

Prospectively collected data from infants with CDH were analyzed from the Congenital Diaphragmatic Hernia Registry from January 1995 to January 2010. Recurrent hernia was defined as reoperations during initial hospitalization. Operative approaches included abdominal, thoracic, laparoscopic, and thoracoscopic techniques.

Results

Five thousand four hundred eighty infants with CDH were identified, of which 4516 (82.4%) were repaired. Operative data were available in 4390 infants. One hundred fifty-one infants (3.4%) underwent MIS repairs with 12 reported recurrences (7.9%) compared with 114 for open techniques (2.7%, P < .05). Minimally invasive surgery demonstrated a significant increased odds for recurrence (odds ratio, 3.59; 95% confidence interval, 1.92-6.71) after adjusting for gestational age, birth weight, patch repair, and extracorporeal membrane oxygenation.

Conclusion

Minimally invasive techniques appear to have a significant higher recurrent hernia rate, with thoracoscopy being the highest. Although adjusted for patch repair, other factors with regard to disease severity may contribute to differences in outcomes among centers. This study is limited to short-term recurrence during initial hospitalization.     

Laparoscopic management of ovarian tumors

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

Minimally invasive management of anastomotic leaks in colorectal surgery

Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient's quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.