La resección laparoscópica de los segmentos del lóbulo hepático izquierdo debe ser el abordaje inicial en centros con experiencia

Introduction

The resection of tumours of the anatomical left lobe is normally straightforward using either left lateral sectionectomy (LLSEC) or segmentectomy II or III. Our objective is to present the results of the laparoscopic approach and to consider whether this could be the “ideal technique” in liver surgery units where the surgeons have experience of laparoscopic liver surgery (LLSURG).

Patients and methods

We have studied patients with resected solid tumours of the anatomical left lobe using LLSURG (n=18): 10 cases with LLSEC and 8 cases with segmentectomy II or III. We carried out a comparative study with a control group of 18 patients operated on using the same surgical technique using open surgery (OS).

Results

There were no cases of mortality in either of the 2 groups (n=36). Morbidity was similar (5.5% per group). For LLSEC, the LLSURG group (n=10) had a shorter hospital stay (p=0.005) and less surgical time (141 vs. 159 min) (differences not significant.), than the OS group. For segmentary resections II or III, in the LLSURG group (n=8) there was greater use of the Pringle manoeuvre (p=0.05), greater surgical time (p=0.05) and a shorter hospital stay (4.8 vs. 5.6 days) (differences not significant), than in the OS group.

Conclusions

LLSEC should be carried out by laparoscopy in centres where they have considerable experience. The patients may have a shorter hospital stay and spend less time in surgery than when OS is performed, with the same morbidity and mortality rates. Segmentectomy resections II or III carried out by laparoscopy involve a shorter hospital stay but longer surgery time and therefore the advantages are not as evident as they are for LLSEC.     

Estudio comparativo prospectivo aleatorizado entre apendicectomía laparoscópica por puerto único y apendicectomía laparoscópica convencional

Introduction

Laparoscopic appendectomy is probably the technique of choice in acute appendicitis. Single port laparoscopic surgery (SILS) has been proposed as an alternative technique. The objective of this study is to compare the safety and efficacy of SILS against conventional laparoscopic appendectomy (LA).

Material and methods

From January 2011 to September 2012, 120 patients with acute appendicitis were prospectively randomized; 60 for SILS and 60 for LA. Patients between 15 to 65 years were selected, with onset of symptoms less than 48 h. We compared BMI, surgery time, start of oral intake, hospital stay, postoperative pain, pathology and costs.

Results

The median age, BMI, sex and time of onset of symptoms to diagnosis were similar. There were no statistically significant differences in the operative time, start of oral intake or hospital stay. There was a significant difference in postoperative pain being higher in SILS (4 ± 1.3) than in LA (3.3 ± 0.5) with a P=.004. Flemonous appendicitis predominated in both groups in a similar percentage. A total of 3 cases with intra-abdominal abscess (SILS 2, LA 1) required readmission and resolved spontaneously with intravenous antibiotic treatment. One case of SILS required assistance by a 5 mm trocar in the RLC for drainage placement. The cost was higher in SILS due the single port device.

Conclusion

SILS appendectomy is safe, effective and has similar results to LA in selected patients, and although the cost is greater, the long term results will determine the future of this technique.     

Resultados de las 100 primeras colecistectomías por puerto único en un hospital de segundo nivel

Introduction

Despite the excellent results obtained with standard laparoscopic cholecystectomy, the efforts for minimizing the ports needed to reduce postoperative pain, for a quicker recovery and to improve the patient's cosmetics continue. The aim of this study is to report the results of the first 100 cases of single port laparoscopic cholecystectomy performed in a secondary care hospital.

Material and methods

Prospective, observational and unicentric study including 100 patients between January 2010 and April 2012. Inclusion criteria: symptomatic cholelythiasis patients over 16-years of age on whom a single port laparoscopic cholecystectomy was performed. Exclusion criteria: history of acute cholecystitis, pancreatitis or suspected choledocholithiasis, Endoscopic retrograde cholangiopancreatography, BMI > 35 and previous laparotomies. We studied epidemiological, surgical and safety variables.

Results

The mean patient age was 39,89 ± 11,5 years. The mean time of the surgical procedure was 67,94 ± 25,5 min. There were 2 cases of postoperative complications. A non-infected seroma and a biliar leak. In 2 cases the use of an accessory trocar was needed. The mean hospital stay was 1,13 ± 0,8 days. A total of 35% patients were included in the major ambulatory surgery programme.The overall patient satisfaction survey rating showed a high level of cosmetic satisfaction in 100% of patients.

Conclusions

Single port laparoscopic cholecystectomy is a good technique when performed in selected cases by expert surgeons. It is feasible to include the single port laparoscopic cholecystectomy in a major ambulatory surgery programme. We have not had serious complications. There is a high cosmetic satisfaction index with this technique.     

Resección hepática por laparoscopia: lecciones aprendidas tras 132 resecciones

Introduction

After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc.

Aim

To report our experience in laparoscopic liver resections (LLRs).

Patients and method

Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS. Surgical technique: 6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections.

Results

There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150 min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively.

Conclusion

LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.     

Trasplante ortotópico de hígado en la poliquistosis hepática

Introduction

There is currently no effective medical therapy for polycystic liver (PCL). Cyst puncture and sclerotherapy, cyst fenestration, or partial hepatic resections have been used as palliative treatments. Orthotopic liver transplantation (OLT) has become the treatment of choice for terminal PCL, being indicated in patients with limiting symptoms not susceptible to any other medical treatment. It is also difficult to determine the priority on the waiting list using the Model for End-Stage Liver Disease (MELD).

Methods

A retrospective analysis of OLT for PCL was conducted in our centre. Inclusion criteria were patients with limiting symptoms, bilateral cysts liver, and insufficient remaining liver. In all cases a deceased donor liver transplantation with piggy-back technique without veno-venous bypass was performed.

Results

Six patients underwent liver transplantation for PCL between April 1992 and April 2010, one of them a combined liver-kidney transplantation. The mean intraoperative packed red blood cell transfusion was 3.25 L and fresh frozen plasma was 1.200 cc. Mean operation time was 299 min, and 498 min in the liver-kidney transplantation. There was no peri-operative mortality. The mean hospital stay was 6.5 days. All patients are healthy after a mean follow-up of 71 months.

Conclusion

OLT offers an excellent overall survival. Results are better when OLT is performed early; thus these patients should receive additional points to be able to use the MELD score as a valid prioritisation system for waiting lists.     

25 años de cirugía laparoscópica en España

Introduction

The introduction of laparoscopic surgery (LS) can be considered the most important advancement in our specialty in the past 25 years. Despite its advantages, implementation and consolidation has not been homogenous, especially for advanced techniques. The aim of this study was to analyse the level of development and use of laparoscopic surgery in Spain at the present time and its evolution in recent years.

Material and methods

During the second half of 2012 a survey was developed to evaluate different aspects of the implementation and development of LS in our country. The survey was performed using an electronic questionnaire.

Results

The global response rate was 16% and 103 heads of Department answered the survey. A total of 92% worked in the public system. A total of 99% perform basic laparoscopic surgery and 85,2% advanced LS. Most of the responders (79%) consider that the instruments they have available for LS are adequate and 71% consider that LS is in the right stage of development in their environment.

Conclusions

Basic laparoscopic surgery has developed in our country to be considered the standard performed by most surgeons, and forms part of the basic surgical training of residents. With regards to advanced LS, although it is frequently used, there are still remaining areas of deficit, and therefore, opportunities for improvement.     

Estudio prospectivo, aleatorizado: cirugía laparoscópica con asistencia robótica versus cirugía laparoscópica convencional en la resección del cáncer colorrectal

Introduction

Robotic-assisted surgery is playing an increasingly important role in the last few years in the treatment of colorectal oncological disease. However, there are still no studies that objectively demonstrate the advantages of this type of surgery.We present a prospective randomised study in order to compare the short-term results between colorectal robotic surgery and laparoscopic surgery.

Material and method

A total of 56 patients diagnosed with colorectal cancer between January 2008 and January 2009, were randomised and assigned to the robotic or laparoscopic group. Age, body mass index, tumour location, conversions in each group, complications during and after surgery, and histological characteristics of the specimens obtained, were all compared.

Results

There were no significant differences between age (P=.055), body mass index (P=.12), or tumour location (P=.91). Only one patient in the robotic group required a transfusion and none in the laparoscopic group. The percentage of conversions was the same in both groups, however, the preparation times and operating times were significantly longer in patients intervened using the robotic device (P=.0001 and P=.017, respectively). There were no differences as regards the rate of complications or in the percentage of re-interventions (14.2% and 7.1%). The mean hospital stay of the patients was 9.3 (8.1) days in the robotic group and 9.2 (6.8) days in the laparoscopic (P=.79). The distal resection margin was greater in the specimen obtained using robotic surgery (P =.003) as well as the number of lymph nodes obtained in the specimen (P =.23).

Conclusion

Robotic colorectal was performed safely and effectively, and with similar clinical results.International Trial Number for this study is: ISRCTN60866560.     

Resultados del abordaje laparoscópico en el tratamiento de la obstrucción aguda del intestino delgado por adherencias y hernias internas

Introduction

Laparotomy is the standard approach for the surgical treatment of acute small bowel obstruction (ASBO).

Patients and methods

From February 2007 to May 2012 we prospectively recorded all patients operated by laparoscopy in our hospital because of ASBO due to adhesions (27 cases) and/or internal hernia (6 cases). A preoperative abdominal CT was performed in all cases. Patients suffering from peritonitis and/or sepsis were excluded from the laparoscopic approach. It was decided to convert to laparotomy if intestinal resection was required.

Results

The mean age of the 33 patients who underwent surgery was 61.1 ± 17.6 years. 64% had previous history of abdominal surgery. 72% of the cases were operated by surgeons highly skilled in laparoscopy. Conversion rate was 21%. Operative time and postoperative length of stay were 83 ± 44 min. and 7.8 ± 11.2 days, respectively. Operative time (72 ± 30 vs 123 ± 63 min.), tolerance to oral intake (1.8 ± 0.9 vs 5.7 ± 3.3 days) and length of postoperative stay (4.7 ± 2.5 vs 19.4 ± 21 days) were significantly lower in the laparoscopy group compared with the conversion group, although converted patients had greater clinical severity (2 bowel resections). There were two severe complications (Clavien-Dindo III and V) in the conversion group.

Conclusions

In selected cases of ASBO caused by adhesions and internal hernias and when performed by surgeons highly skilled in laparoscopy, a laparoscopic approach has a high probability of success (low conversion rate, short hospital length of stay and low morbidity); its use would be fully justified in these cases.     

Quimioembolización previa a la resección hepática laparoscópica en el carcinoma hepatocelular precoz en pacientes cirróticos

Objective

To assess whether preoperative transarterial chemoembolisation (TACE) reduces haemorrhage during laparoscopic resection, thus making the Pringle manoeuvre unnecessary and avoiding any subsequent complications.

Patients and methods

We present 3 cirrhotic Child A patients with early hepatocellular carcinoma, all of whom had been given the same treatment involving resection by laparoscopy and preoperative TACE of the segments to remove. All the nodules were located in the right hepatic lobe. One case was treated using total laparoscopic surgery and the two remaining cases were converted to the hand-assisted technique. In the first case we carried out bisegmentectomy VI-VII; in the second, segmentectomy VI plus radiofrequency of a second nodule in segment VII, and in the third case, segmentectomy V.

Results

There was no morbidity or mortality. Blood transfusion was not required by any of the patients; in fact blood losses were 100, 50 and 150 ml, respectively, and it was not necessary to carry out the Pringle manoeuvre. Surgical margin was greater than 1 cm in the three cases and hospital stay was less than 3, 3 and 4 days, respectively.

Conclusion

TACE prior to early hepatocellular carcinoma resection in cirrhotic patients seems to improve surgical safety with low blood losses without the use of the Pringle manoeuvre. Prospective random studies should be carried out on a larger number of patients in order to assess this technique.     

Derivación biliopancreática laparoscópica: técnica quirúrgica en nuestra curva de aprendizaje

Background

We present our initial experience with the laparoscopic BPD technique for super-obese patients. Recommended tips on the technique are summarized.

Methods

A total of 35 super-obese patients were submitted to BPD by laparoscopy in November 2009 and June 2010 for the treatment of morbid obesity.

Results

All operations were performed by laparoscopy with no need to convert to laparotomy. No mayor complications and mortality related to surgery were observed.

Conclusion

The Scopinaro technique can be safely performed in super-obese patients by surgeons with special dedication for bariatric surgery and advanced skills in intracorporeal suturing and knot-tying.     

Resultados tras resección hepática laparoscópica: una opción adecuada en patología maligna

Introduction

The laparoscopic approach is not yet widely used in liver surgery, but has proven to be safe and feasible in selected patients even in malignant disease. The experience and results of a hepato-pancreato-biliary (HPB) surgery unit in the treatment of malignant liver disease by laparoscopic approach is presented.

Material and methods

Between February 2002 and May 2011, 71 laparoscopic liver resections were performed, 43 for malignant disease (only patients with more than one year of follow-up were included). Mean age was 63 years old and 58% of the patients were male. Forty-nine per cent of the lesions were located in segments ii-iii. Thirty segmentectomies were performed, 7 limited resections and 6 major hepatectomies.

Results

The median operative time was 163 min. There were 3 conversions. Five cases (11%) required blood transfusion. The oral intake began at 32 h and the median hospital stay was 6.7 days. There were no reoperations and there was one case of mortality. Nine patients (21%) had postoperative complications. The mean number of resected lesions was 1.2, with an average size of 3.5 cm. All resections were R0. The median survival after resection of colorectal liver metastases (CLM) was 69% and 43.5% at 36 and 60 months, respectively, and 89% and 68% at 36 and 60 months, respectively, in hepatocellular carcinoma (HCC).

Conclusion

The laparoscopic liver resection in malignant disease is feasible and safe in selected patients. The same oncological rules as for open surgery should be followed. In selected patients it offers similar long-term oncological results as open surgery.     

Colecistectomía laparoscópica en pacientes mayores de 80 años

Introduction

The increasing aging of the population also increases the prevalence of symptomatic gallbladder diseases. It is important to analyse their surgical treatment in the elderly.

Methods

All the laparoscopic cholecystectomies performed in our surgery department on patients aged 80 years-old or over from 1992 to 2007 were included in this study.

Results

Laparoscopic cholecystectomy was performed on 133 patients 80 years-old and over, with 63% of them women, and an average age of 83.23 years. Biliary colic (29%) and acute pancreatitis (44%) were the main reasons for surgery. Associated diseases were found in 73% of them. Only 7.5% needed urgent surgery, even although 71% were admitted urgently. There were 13.5% conversions to open surgery, 17% morbidity and 2.3% mortality.

Conclusions

Laparoscopic cholecystectomy can be recommended in symptomatic gallbladder disease in the elderly.     

Programa de formación del residente de cirugía en un laboratorio experimental de cirugía minimamente invasiva (CENDOS)

Introduction

The rapid development of laparoscopic surgery makes resident training programmes necessary.

Objective

To analyse the results of a structured programme of laparoscopic training in an experimental laboratory.

Material and method

From 2003 until 2007, we trained 11 general surgery residents for 20 h every 3 months, for three years. The practice consisted of suture and anastomosis in Endo-Trainer with animal organs, as well as laparoscopic techniques in live animals. In the Endo-Trainer practice we evaluated the time and quality of anastomosis performance. In laparoscopic techniques (cholecystectomy and anti-reflux surgery) a task table was evaluated, from 0 (no errors) to 100 (severe lesion).

Results

In total, 314 anastomosis were performed by the 11 residents, with a median of 28.5 per resident (24-42). The mean time for the first gastro-jejunal anastomosis was 135 min (100-140) and 65 min (57.5-105) for the first jejunal-jejunal anastomosis. Maximum learning was achieved after 45 training hours. There wer no appreciable ifferences between both types of anastomosis. There was inadequate anastomosis quality due to leakage in 17.1% during the learning period and 13.7% during the consolidation period. In the animal, 172 procedures were performed. In cholecystectomy and anti-reflux surgery the mean scores were 2.4 and 5.6 points, respectively. In the remaining procedures, subjectively evaluated by the monitors, the quality was adequate in 65%, deficient in 22% and highly deficient in 13%.

Conclusions

This structured programme of laparoscopic skills based on intestinal anastomosis allows for quicker resident training.     

Divertículos epifrénicos: ¿cuándo y cómo operar?

The majority of epiphrenic diverticula arise due to a peristaltic mechanism caused by an oesophageal motor disturbance that establishes a barrier effect and causes mucosal and submucosal herniation through a weak point in the muscular layer. Intraluminal oesophageal manometry and video-radiology are important in assessing these patients, since they define the characteristics of the functional disorder, as well as the true relationship between the symptoms of the patient and the diverticulum.Surgical treatment is indicated in symptomatic patients, more so if there are respiratory complications. Left posterolateral thoracotomy followed by diverticulotomy, oesophageal cardiomyotomy and anti-reflux have been considered the surgery technique of choice. Oesophageal myotomy must go beyond, in a proximal direction, the neck of the diverticulum, and, in a distal direction, must progress 1-2 cm into the gastric wall. The laparoscopic approach has won many followers since it has been shown to be both safe and effective as open surgery, adding to the advantages of minimally invasive surgery.     

Single incision transumbilical laparoscopic appendectomy: initial experience

Introduction

Appendicitis is the most common abdominal emergency. The treatment is surgical and single incision laparoscopic surgery (SILS) involves performing laparoscopic surgery through a single transumbilical point, in an attempt to improve the results of laparoscopic surgery.

Material and method

A total of 73 patients with suspected acute appendicitis were operated on using the SILS technique between June 2009 and August 2010. All patients were operated on by the same surgical team, and the navel was the only point of entrance. Post-surgical pain was assessed using a numerical scale at the time of discharge.

Results

None of the patients required conversion to conventional laparoscopy. The mean surgical time was 40 ± 14 (16-80) minutes. There were no complications during or after the surgery. The mean post-surgical pain score was 3 ± 1 (1-7) and the mean hospital stay was 18 ± 7 (9-42) hours.

Conclusion

SILS is a safe and effective technique for appendicitis. In the future, the most common surgical procedures could be performed through the navel. This would be by surgeons, highly experienced in advance laparoscopic surgery in order to introduce this new technique safely without increasing morbidity and mortality.     

Estudio prospectivo controlado y aleatorizado sobre la necesidad de la preparación mecánica de colon en la cirugía programada colorrectal

Introduction

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

Material and method

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The “Preparation” group (MPC) received MPC and the “non-preparation” group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

Results

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of “no preparation” as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

Conclusions

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.