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 cecal ligation and puncture in the rat

Background: We describe a technique of laparoscopic cecal ligation and puncture (CLP) in the rat analogous to open CLP which may facilitate the study of minimally invasive surgery (MIS) and peritonitis. Methods: Forty-four rats were randomized to either laparoscopic or open CLP and their 3-day mortality was recorded. Autopsies were performed for peritoneal fluid cultures, measurement of the length of ligated cecum, and scoring of the degree of cecal necrosis. Results: Laparoscopic CLP required slightly longer operating times compared to open CLP (average 15.6 vs 13.1 min, p= 0.002). Three-day postoperative mortality was 36.4% and 22.7% for open and laparoscopic CLP, respectively (p= NS). There were no differences in the length of ligated cecum or the cecal necrosis score between the open and laparoscopic CLP groups. Conclusion: Laparoscopic CLP is feasible and produces a fecal peritonitis with similar characteristics to those of traditional open CLP. Received: 3 July 1996/Accepted: 7 January 1997     

The effect of immune enhancement and suppression on the development of laparoscopic port site metastasesrid=""id=""Presented at the 6th World Congress of Endoscopic Surgery, Rome, Italy, June 1998

Background: Recent clinical case reports and experimental studies have suggested that laparoscopic cancer surgery is associated with an increased risk of tumor spread to abdominal wall wounds. While the etiology of this problem was initially believed to be related to mechanical contamination of wounds, it is now recognized that there are other contributory factors, including disturbed immune function within the peritoneal cavity. To investigate this question further, we evaluated the effect of immune modulation within an established laparoscopic cancer model. Methods: Eighteen immune-competent syngeneic rats underwent modulation of their immune system, followed 18 h later by laparoscopy with the introduction of a suspension of adenocarcinoma cells into the peritoneal cavity. Rats were randomly allocated to receive either systemic cyclosporin (immune suppresser), intraperitoneal endotoxin (immune enhancer), or no agent (controls). Seven days later, all rats were killed and their peritoneal cavity was inspected for tumor implantation and port site metastases. Results: Cyclosporin did not influence the study outcome, but tumor growth (p= 0.008) and port site metastases (p < 0.0001) were less common following the administration of intraperitoneal endotoxin. Conclusion: The results of this study suggest that the immune system plays a role in the genesis of port site metastases. A preventive role for endotoxin in patients undergoing laparoscopic cancer surgery, however, remains speculative. Received: 22 July 1998/Accepted: 23 June 1999     

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     

Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve

Background: Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery. Methods: The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach, and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric bypass was performed. Results: The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of the stomach and surrounding upper abdominal organs. Conclusions: The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to decrease operation time. Received: 18 September 1996/Accepted: 26 December 1996     

The movement of mucosal cells of the gallbladder within the peritoneal cavity during laparoscopic cholecystectomy

Background: Tumor dissemination to trocar sites following the removal of a gallbladder malignancy by laparoscopic cholecystectomy is well documented. The mode of transfer of malignant cells to those sites remains unclear. Methods: The appearance and movement of gallbladder mucosal cells within the peritoneal cavity during laparoscopic cholecystectomy was prospectively studied in 15 patients. The appearance of cells on laparoscopic instruments, laparoscopic working ports, and also within a 5-μm polycarbonate filter, filtering exhaust carbon dioxide and attached to one of the main working ports, was noted. Results: Four out of 15 gallbladders were perforated during cholecystectomy. Operative choledochography was performed in 11 of the 15 cases. Glandular cells were found on instruments at the end of the procedure in six cases. Cells were also found in two of the 15 polycarbonate filters and on the laparoscopic ports in two of the 15 cases. Conclusion: These findings suggest that cellular contamination of the peritoneal cavity is frequent during laparoscopic cholecystectomy. This may occur when the gallbladder wall is macroscopically breached or when operative choledochography is performed, or by microperforation due to the application of crushing laparoscopic graspers to the gallbladder wall. Glandular cells adhere to instruments in 40% of the operative procedures and may be the main source of dissemination of malignant cells through the peritoneal cavity. Received: 29 January 1996/Accepted: 8 April 1996     

Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn's disease

Background: The objectives of this study were to evaluate body image, cosmetic results, and quality of life in patients with Crohn's disease of the terminal ileum who had either laparoscopic-assisted or open ileocolic resection, and to determine how patients experienced the pre- and postoperative periods after both procedures. Methods: Thirty-four patients participated: 11 patients after open resection (OR), 11 patients after laparoscopic-assisted resection (LR), and 12 patients without resection (WR). Retrospectively, the patients filled out several questionnaires pertaining to body image, hospital experiences, and quality of life. One-way analysis of variance, Student's t-tests, and Pearson's correlation were used for statistical analysis. Results: The cosmetic score was significantly higher in the LR than in the OR group (p < 0.01). Body image correlated strongly with cosmesis and with quality of life. The hospital experiences of the laparoscopic and open groups were similar. Conclusions: Laparoscopic surgery was associated with better cosmesis than open surgery. Patients do not experience laparoscopic surgery any differently from open surgery. Received: 29 September 1997/Accepted: 21 January 1998     

Intracorporeal colorectal anastomosis following laparoscopic left colon resection

Background: The aim of this study was to assess the impact of an intracorporeal double-stapled colorectal anastomosis upon the outcome of laparoscopic left colon resection. Methods: Fifty-four selected patients underwent elective laparoscopic left colon resection for benign disease. Once resection was completed, a 33-mm suprapubic port allowed insertion of the anvil of a circular stapler into the colon, which was closed by a handsewn purse-string suture using the T-needle technique. The circular stapler was passed transanally to perform a double-stapled anastomosis. Specimens were delivered in a plastic bag via the suprapubic port. Results: There were no deaths. Minor intraoperative and postoperative complications occurred in 3.7% and 9.2% of the patients, respectively. Median operating time was 125 min (range 80–210 min). Complete proximal and distal doughnuts were obtained in all patients and anastomoses were all methylene blue tight. Median hospital stay was 4 (range 3–7) days. Conclusions: Fashioning double-stapled colorectal anastomoses intracorporeally is feasable and safe. Received: 26 March 1996/Accepted: 9 September 1996     

Peritoneal response to a septic challenge

Background: Laparoscopic surgery has a lower incidence of surgical infection than open surgery. Differential factors that may modify the bacterial biology and explain this finding to some extent include CO₂ atmosphere, less desiccation of intraabdominal structures, fewer temperature changes, and a better preserved peritoneal and systemic immune response. Previous data suggest that the immune response and acute phase response are better preserved after laparoscopy. Therefore, we designed a study to evaluate the early peritoneal response to sepsis in an experimental peritonitis model comparing open surgery with CO₂ and abdominal wall lift laparoscopy. Methods: The study subjects comprised 360 mice distributed into the following four groups: group 1, n= 72 (controls); group 2, n= 96 (open surgery), 2–3 cm laparotomy, with abdominal cavity exposed to the air for 30 min; group 3, n= 96, CO₂ laparoscopy (5 mmHg pneumoperitoneum) for 30 min; group 4, n= 96, wall lift laparoscopy for 30 min. Intraabdominal contamination in the four groups was induced with 1 ml of E. coli suspension (1 × 10⁴ CFU/ml) 10 min before abdomen closure. Peritoneal fluid and blood samples were obtained 1.5, 3, 24, and 72 h after surgery, and TNF, IL-1, and IL-6 were measured (via ELISA), as well as quantitative culture. Results: The number of CFU (colony-forming units) obtained in peritoneal fluid and positive blood culture rates were significantly lower in the laparoscopic groups than in the open group. IL-1 peritoneal levels were significantly lower after 24 h and 72 h in the laparoscopy groups. IL-6 levels decreased sharply in the laparoscopy groups at 24 h and 72 h. There were no differences between the two types of laparoscopy models (CO₂ and wall lift). Conclusions: Peritoneal response to sepsis is better preserved after laparoscopy than after open surgery. CO₂ does not seem to influence bacterial growth. According to these findings, laparoscopy entails less local trauma and better preserved intraabdominal conditions. Received: 29 June 1998/Accepted: 25 August 1998     

A comparison of surgeons' posture during laparoscopic and open surgical procedures

Background: There is increasing recognition of surgeons' physical fatigue in the new ergonomic environment of laparoscopic surgery. The purpose of this study was to determine what the differences are in the movement of the surgeon's axial skeleton between laparoscopic and open operations. Methods: Surgeons' body positions were recorded on videotape during four laparoscopic (LAP) and six open (OP) operations. The percent of time the head and back were in a normal, bent, or twisted position as well as the number of changes in head and back position were tabulated using a computer program. A separate laboratory study was performed on four surgeons ``walking' a 0.5-inch polyethylene tubing forward and backward using laparoscopic and open techniques. The movements of the surgeons' head, trunk, and pelvis were measured using a three-camera kinematic system (Kin). The center of pressure was recorded using a floor-mounted forceplate (Fp). Results: In the operating room surgeons' head and back positions were more often straight in laparoscopic procedures and more often bent in open operations. The number of changes in back position per minute were significantly decreased when the laparoscopic-only part of surgery was analyzed. In the laboratory the subjects' head position was significantly (p= 0.02) more upright and the anteroposterior (AP) and rotational range of motion of the head was significantly reduced during laparoscopy. Subjects' CP was more anterior and there was a significant reduction in the AP range of motion of the CP during laparoscopy. Conclusions: Our study suggests that surgeons exhibit decreased mobility of the head and back and less anteroposterior weight shifting during laparoscopic manipulations despite a more upright posture. This more restricted posture during laparoscopic surgery may induce fatigue by limiting the natural changes in body posture that occur during open surgery. Received: 3 March 1996/Accepted: 2 July 1996     

Transgastrostomal endoscopic surgery for early gastric carcinoma and submucosal tumor

Background: Laparoscopic intraluminal surgery of the stomach is now widely used for a lesion on the posterior wall. However, this procedure has some technical limitation related to the intricate introduction of the surgical instruments into the gastric lumen. In this article, we report our newly developed technique of transgastrostomal endoscopic surgery that overcomes this limitation and is also suitable for full-thickness gastric wall resection of a lesion in the wall. Methods: After making a 4-cm-long temporary gastrostomy, a Buess-type endoscope is inserted into the gastric lumen through the gastrostomy. The operation is performed inside the gastric lumen under video camera guidance using electrocautery, scissors, and forceps. After resection, the wound in the mucosa or the wound after full-thickness resection is endoluminally sutured. Mucosal resection was performed in six cases of early gastric carcinoma, two cases of atypical epithelium, and one case of ectopic pancreas. Full-thickness wall resection was performed in four cases of a leiomyoma. Results: In all 13 cases, the lesion could be precisely located by the video camera. All lesions were then resected endoluminally. The mean duration of the operation was 148 min. The postoperative course in all cases was uneventful. Conclusions: Transgastrostomal endoscopic surgery is minimally invasive and an efficient tissue-preserving technique for the removal of early gastric carcinoma or submucosal tumor. Received: 7 September 1996/Accepted: 27 January 1997     

Effect of surgical stress on endogenous morphine and cytokine levels in the plasma after laparoscopoic or open cholecystectomy

Background: Endogenous morphine in the brain leads to various biological responses after surgery. The aim of this study was to determine whether morphine levels in the plasma would be enhanced by open laparotomy rather than by laparoscopic procedures. Methods: We compared 19 patients who underwent laparoscopic cholecystectomy with five patients who underwent resection of the gallbladder by open laparotomy. Morphine levels in the plasma were measured by an electrochemical detection system. Results: Postoperative endogenous morphine levels were higher with open laparotomy than with the laparoscopic technique (three h after surgery: open, 200 ± 52.6 fmol/ml vs laparoscopy, 17.6 ± 3.7, p < 0.01). This morphine elevation accounted for higher levels of cytokine, greater pain scores, and longer duration of fasting in open laparotomized patients than in laparoscopic cholecystectomy patients. Stress hormone levels in the plasma were also higher with open laparotomy than with laparoscopy. Conclusion: Morphine synthesis was enhanced by open laparotomy, resulting in greater biological response postoperatively than that seen with laparoscopic cholecystectomy. Received: 21 October 1998/Accepted: 3 April 1999     

Postoperative complications of laparoscopic-assisted colectomy

Background: This study was performed to prospectively assess the complications of 118 consecutive patients who underwent laparoscopic assisted colorectal resections. Methods: The variables included were: indication for surgery, type of resection, duration of operation, duration of postoperative ileus, length of hospital stay, port-site recurrence, and complications in relation to the laparoscopic technique. Results: 118 Laparoscopic-assisted procedures were performed between July 1992 and October 1995. Surgical indications were: 106 patients for colonic malignancy, six for diverticulitis, two for Crohn's disease, two for benign polyps, one for endometriosis, and one for ischemic colitis. Fifteen patients required conversion to open techniques for completion of the operations (12.7%). The mean operating time was 168.8 min. The amount of operative blood loss was 98 ml. The mean time for passing flatus was 36 ± 16 h. Mean postoperative stay was 5.4 (range 3–13) days. Eight patients (6.8%) sustained complications: four unrelated to laparoscopy (three wound infection, one anastomotic leak); and four complications related to the laparoscopic approach: one small-bowel obstruction, one trocar injury, one rotation of the anastomosis, and one misdiagnosed synchronous adenocarcinoma. Conclusions: We suggest that with the development of improved technical devices and more experience, the indications for laparoscopic colectomy should continue to expand. The low incidence of infectious complications suggests an important role for the laparoscopic approach to colorectal surgery. Received: 25 March 1996/Accepted: 8 July 1996     

Laparoscopic vs open repair of gastric perforation and abdominal lavage of associated peritonitis in pigs

Background: Laparoscopy is increasingly used in conditions complicated by peritonitis, e.g., peptic ulcer perforation. Of some theoretical concern is the capnoperitoneum, which may aggravate peritonitis and induce septic shock due to increased intraabdominal pressure and distension of the peritoneum. This animal study was devised to analyze the effectiveness of laparoscopic versus traditional open repair of gastric perforation and abdominal lavage for associated peritonitis. Methods: To simulate gastric perforation, female Duroc pigs were subjects to standardized gastrotomy. Either 6 or 12 h after gastric perforation, the animals underwent either traditional open or laparoscopic repair of the gastric defect and peritoneal lavage. The subjects were divided into the following four groups: peritonitis for 6 h and open surgery (group I) or laparoscopic surgery (group II); peritonitis for 12 h and open surgery (group III) or laparoscopic surgery (group IV). After an observation period of 6 days, the surviving animals were killed. The main outcome criteria were survival, perioperative changes of hemodynamics suggestive for septic shock, bacteremia, and endotoxemia. Results: There were no significant differences between group I and II. Mortality was 22% in group III, as compared to 78% in group IV (p= 0.045). In group IV, the incidence of perioperative bacteremia and plasma endotoxin concentrations were significantly higher than in group III. Concomitantly, decreased mean arterial pressure and systemic vascular resistance, and increased cardiac output suggested a higher incidence of septic shock in group IV. Conclusion: Critical appraisal of laparoscopic surgery is warranted in conditions associated with severe, longstanding peritonitis. Received: 28 February 1997/Accepted: 1 July 1997     

Early international results of laparoscopic gastrectomies

Background: The first totally laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world and the laparoscopic approach has been extended to Billroth I and total gastrectomy. The aim of this study is to review the state of laparoscopically performed gastrectomies in the international scene. Methods: Questionnaires were prepared and sent to every surgeon in the world known by the authors or their contacts to have performed a laparoscopic gastrectomy. A questionnaire survey was started in July 1994 and completed by November 1994. Data collected included age, sex, type of gastric resection, technique of reconstruction after resection, average duration of surgery, time to liquid and solid intake, postoperative hospital stay, complications, and opinions of the surgeons. Results: Sixteen surgeons contributed to this study. A total number of 118 cases of laparoscopic gastrectomies, comprising Billroth I (11), Billroth II (87), vagotomy and antrectomy (10), and total gastrectomy (10) had been performed. The indications were gastric and/or duodenal ulcers and benign and malignant gastric tumors. Conclusions: Laparoscopic gastrectomy was found to be superior to the open technique by 10 of 16 surgeons because of faster recovery, less pain, and better cosmesis. The procedure was an expensive and long operation according to four. Two surgeons were uncertain of any benefit because of limited experience. Received: 7 August 1996/Accepted: 28 October 1996     

Effects of laparoscopic vs laparotomy treatment of E. coli peritonitis on hemodynamic responses in a porcine model

Background: Laparoscopic surgery is being used now for increasingly diverse clinical applications, including diagnosis and treatment of appendicitis and bacterial peritonitis. However, some concerns and controversies exist regarding the effectiveness of laparoscopic irrigation of the abdominal cavity compared with that achieved during laparotomy. Of no less importance is concern that establishing a CO₂ pneumoperitoneum in patients with cardiopulmonary insufficiency or endotoxemic shock may compromise hemodynamic function. The objective of this randomized, controlled study was to determine the effects of laparoscopic versus laparotomy intervention on hemodynamic and outcome measurements using a porcine model of Escherichia coli peritonitis. Methods: For this study, 24 specific pathogen-free Hanford pigs underwent surgical placement of carotid, Swan-Ganz, and peritoneal catheters. After a 24-h recovery period, one subset of pigs (n= 12) received a bolus infusion of 9 × 10⁸ CFU/kg E. coli intraperitoneally (septic) and intravenous fluid resuscitation. The remaining 12 pigs were not challenged with E. coli (control). Twenty-four hours later, all 24 pigs underwent either laparoscopic or open peritoneal irrigation with saline, then were reevaluated 48 h after surgical intervention. Standard cardiopulmonary, hematologic, and bacteriologic assessments were obtained both perioperatively and 48 h after surgical intervention. Results: Pigs given E. coli exhibited significantly elevated heart rates and core temperatures and decreased O₂ saturation during the initial 6 h. Within 24 h, these pigs exhibited respiratory alkalosis, altered blood leukocyte profiles, and E. coli–infected peritoneal fluid. Random blood samples from the septic pigs tested negative for E. coli. Mean pulmonary artery and capillary wedge pressures were lower (p < 0.05) in septic than in control pigs before and after surgical intervention. Septic pigs that underwent laparoscopy had significantly lower (p < 0.05) arterial pH and higher arterial pCO₂ levels than septic pigs after laparotomy. Other cardiopulmonary responses were similar irrespective of the surgical modality used. One of six septic pigs from each surgical group still had E. coli growth in its peritoneal fluid 48 h after surgical intervention. Conclusion: Laparoscopic intervention demonstrated effectiveness equal to that of laparotomy for treating acute E. coli peritonitis in pigs without septic shock. Received: 26 June 1998/Accepted: 12 January 1999     

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     

Increased tumor establishment and growth after open vs laparoscopic bowel resection in mice

Background: Surgery can suppress immune function and facilitate tumor growth. Several studies have demonstrated better preservation of immune function following laparoscopic procedures. Our laboratory has also shown that tumors are more easily established and grow larger after sham laparotomy than after pneumoperitoneum in mice. The purpose of this study was to determine if the previously reported differences in tumor establishment and growth would persist in the setting of an intraabdominal manipulation. Methods: Syngeneic mice received intradermal injections of tumor cells and underwent either an open or laparoscopic cecal resection. In study 1, the incidence of tumor development was observed after a low dose inoculum; whereas in study 2, tumor mass was compared on postoperative day 12 after a high-dose inoculum. Results: In study 1, tumors were established in 5% of control mice, 30% of laparoscopy mice, and 83% of open surgery mice (p < 0.01 for all comparisons). In study 2, open surgery group tumors were 1.5 times as large as laparoscopy group tumors (p < 0.01), which were 1.5 times as large as control group tumors (p < 0.02). Conclusion: We conclude that tumors are more easily established and grow larger after open laparoscopic bowel resection in mice. Received: 27 October 1997/Accepted: 19 January 1998     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996