Systems and instruments for laparoscopic surgery without pneumoperitoneum

The insufflation of carbon dioxide into the peritoneal cavity is a routine technique of abdominal exposure in laparoscopic surgery. Because of adverse physiological effects and technical disadvantages of the pneumoperitoneum, alternative methods of abdominal wall lifting have been explored recently. Two groups of retraction systems exist: intraabdominal lifting and subcutaneous lifting of the abdominal wall. Some systems require additional pneumoperitoneum, because the extent of intraabdominal exposure is not sufficient. Other systems are working completely without gas insufflation. Two systems combine abdominal wall lifting with pressure on the internal organs. Every method allows the use of standard laparoscopic instruments, which originally were designed for a regular pneumoperitoneum. The use of a low-pressure pneumoperitoneum in combination with mechanical augmentation of the peritoneal cavity reduces physiological disadvantages of laparoscopy. But technical advantages, such as combination of laparoscopic and open techniques, can be realized only without gas insufflation. Conventional instruments have been designed to fit the ergonomical needs of isopneumic laparoscopy and to be employed with simple valveless cannulae. Received: 19 November 1996/Accepted: 30 December 1997     

免气腹悬吊技术在腹腔镜手术中的应用

目的:探讨免气腹悬吊技术在腹腔镜手术中应用的可行性、安全性和优越性。方法:回顾分析2007年6月至2010年12月采用免气腹悬吊技术为49例患者行腹腔镜手术的临床资料,其中结节性甲状腺肿23例,原发性甲状腺功能亢进7例,胆囊结石12例,腹股沟疝7例。应用腹壁悬吊器,用2根骨科克氏针穿过皮下牵拉,悬吊颈前皮瓣或前腹壁形成手术空间完成腹腔镜手术。结果:49例均成功完成手术,无中转开放手术。其中一侧甲状腺次全切除术22例,双侧甲状腺次全切除术8例,胆囊切除术12例,完全腹膜外腹股沟疝修补术7例。手术时间20～125min,平均86min,术中出血<30ml。术后无声音嘶哑、胆漏、切口感染等并发症发生。术后住院5～7d,平均6d。术后随访3～38个月,中位随访时间21个月,无复发病例。结论:应用免气腹悬吊技术行腹腔镜手术避免了CO2气腹的相关并发症,吸引水雾、液体方便,手术空间较气腹稍小,但基本不影响手术的进行,是安全可行的。     

Laparoscopic cholecystectomy: an approach without pneumoperitoneum

Summary Diagnostic pneumoperitoneum, which has been considered the first step of any laparoscopic procedure, is no longer an absolute necessity. We devised an alternative to pneumoperitoneum or abdominal insufflation by upward and outward traction on the anterior abdominal wall with a hanger lifting method using subcutaneous wiring. Fairly good room was produced intraabdominally, which was enough in which to perform the cholecystectomy procedure. We have successfully performed 40 cases of laparoscopic cholecystectomy with this procedure. No complication was experienced with this method and, moreover, excess instrumentation and complications related to pneumoperitoneum were avoided.     

Initial experience in children using conventional laparoscopic instruments in single-incision laparoscopic surgery

Background

Single-incision laparoscopic surgery (SILS) has been successfully performed in children using 5-mm reticulating instruments. There are, however, few reports investigating the use of conventional instruments in SILS in the pediatric population.

Methods

We conducted a retrospective review of all consecutive children who underwent SILS from October 2009 to January 2010, with the procedure being solely performed by conventional 3- and 5-mm instruments through a standard access technique.

Results

A total of 19 SILS procedures were successfully performed in children aged 3 to 15 years. They included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). There was one conversion to conventional laparoscopic surgery, and that occurred in our first case of splenectomy. All the patients had smooth recovery from surgery without complications.

Conclusions

Using conventional instruments in SILS is technically feasible in children from simple to complex procedures and may have the potential to popularize this approach by eliminating the mandatory demand for specially designed instruments.     

经脐单孔腹腔镜在泌尿外科手术中应用的初步体会

目的 总结经脐单孔腹腔镜手术在泌尿外科应用的初步经验.方法 2010年2月至2011年3月,采用单孔三通道Triport建立操作通道,使用常规腹腔镜器械完成单孔腹腔镜手术21例,其中输尿管切开取石9例,输尿管狭窄切除吻合术5例,肾囊肿去顶术5例,无功能肾切除术2例,术前均明确诊断.依术式在脐部行长1.5 ～2.5 cm手术切口建立单孔操作通道,按普通腹腔镜手术步骤进行手术. 结果 21例手术均在经脐单孔腹腔镜操作下完成,无中转开放手术者.输尿管切开取石手术时间120～230 min,平均143 min;输尿管狭窄切开再吻合术手术时间120～180 min,平均157 min;肾囊肿去顶术手术时间95～132 min,平均110 min;无功能肾切除术分别为95、120min.患者术后1～2d恢复肠道功能,2～3d拔除引流管,术后住院4～7d.术后随访4～6个月,症状减轻或消失,未见明显并发症. 结论 经脐单孔腹腔镜手术安全可靠,具有手术创伤小、术后恢复快、手术切口美观等优点,适合逐步推广使用.     

免气腹与气腹腹腔镜胆囊切除术的临床对比分析

目的:探讨免气腹腹腔镜胆囊切除术(gasless laparoscopic cholecystectomy,GLLC)的应用、优点及可行性。方法:选取2009年3月至2012年6月60例GLLC(免气腹组)及60例气腹腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC,气腹组)患者进行回顾性对比分析,对比两组手术时间、术中出血量、术后肠道功能恢复时间、住院时间、术前与术后血气分析、术后并发症等指标。结果:两组均成功完成手术,无一例中转开腹,切口均甲级愈合。两组患者手术时间、术中出血量、肛门排气时间、住院时间差异均无统计学意义(P>0.05)。术前DBP、PaO2、PaCO2、SpO2、PETCO2、pH两组相比差异均无统计学意义(P>0.05),术前SBP、MAP两组相比差异有统计学意义(P<0.05)。两组患者术后PaCO2、SpO2、pH值差异均无统计学意义(P>0.05),DBP、SBP、MAP、PaO2、PETCO2差异有统计学意义(P<0.05)。结论:免气腹腹腔镜手术具有安全、微创、术后康复快等优点,无CO2气腹相关并发症发生,对人体血流动力影响小,具有较好的临床应用价值。     

腹腔镜下腹壁无切口直肠癌切除术

目的 探讨无切口腹腔镜下直肠癌切除术的临床应用价值.方法 对37例直肠癌患者行无切口腹腔镜下直肠癌切除术行回顾分析总结.结果 37例手术均成功,平均手术时间120 min,平均术中出血70 ml,术后平均胃肠蠕动恢复时间为38 h,平均住院时间为7d,无明显并发症.结论 无切口腹腔镜下直肠癌切除术安全可行,无腹部切口手术损伤小、恢复快,值得推广应用.     

Laparoscopy without pneumoperitoneum

Laparoscopic surgery with CO₂ insufflation is associated with adverse effects on hemodynamics and gas exchange. The abdominal wall retractor (AWR) is an alternative for pneumoperitoneum. Hemodynamics and gas exchange during the use of an AWR were compared to those of CO₂ pneumoperitoneum.In eight pigs subjected to 1 h of CO₂ pneumoperitoneum or abdominal wall retraction, hemodynamics, gas exchange, and oxygen transport were studied in a randomized cross-over study design.The only change observed during abdominal wall retraction was mild respiratory alkalosis. In contrast, during CO₂ pneumoperitoneum mean arterial blood pressure increased 13%, central filling pressures doubled, and a small increase in cardiac output was observed. Peak airway pressures increased 50%, end-tidal CO₂ increased 20%, and respiratory acidosis was induced (arterial pH from 7.46±0.07 to 7.31±0.06 and pCO₂ from 33±3 mmHg to 53±4 mmHg). Arterial PO₂ decreased but mixed venous oxygen saturation and oxygen consumption were unaffected.In contrast with CO₂ pneumoperitoneum, laparoscopy using abdominal wall retraction was not associated with adverse effects on hemodynamics or gas exchange.     

Laparoscopic surgery: Pitfalls due to anesthesia, positioning, and pneumoperitoneum

Background Laparoscopic procedures are increasing in number and extensiveness. Many patients undergoing laparoscopic surgery have coexisting disease. Especially in patients with cardiopulmonary comorbidity, pneumoperitoneum and positioning can be deleterious. This article reviews possible pitfalls related to the combination of anesthesia, positioning of the patient, and the influence of pneumoperitoneum in the course of laparoscopic interventions. Methods A literature search using Medline’s MESH terms was used to identify recent key articles. Cross-references from these articles were used as well. Results Patient positioning and pneumoperitoneum can induce hemodynamic, pulmonary, renal, splanchnic, and endocrine pathophysiological changes, which will affect the entire perioperative period of patients undergoing laparoscopic procedures. Conclusion Perioperative management for the estimation and reduction of risk of morbidity and mortality due to surgery and anesthesia in laparoscopic procedures must be based on knowledge of the pathophysiological disturbances induced by the combination of general anesthesia, pneumoperitoneum, and positioning of the patient.     

免气腹单孔腹腔镜阑尾切除69例

目的评价免气腹单孔腹腔镜阑尾切除术的可行性和效果。方法 2008年8月～2009年10月,对69例急性阑尾炎行免气腹单孔腹腔镜阑尾切除术。在硬膜外麻醉下,在右下腹麦氏点处做1.5～1.8 cm的切口,用免气腹悬吊装置,提起右下腹壁,建立腹腔镜操作空间。阑尾切除的方法有以下3种:完全腹腔外切除阑尾;腹腔内先游离阑尾,然后再在腹腔外切除阑尾;在腹腔内完成阑尾切除术所有的操作。如果有局限性腹膜炎,或阑尾残端炎症严重或残端处理不满意,则在右下腹放置引流管,并从切口处引出。结果 3例需要延长切口完成手术。免气腹单孔腹腔镜阑尾切除术成功66例,平均手术时间51 min(38～72 min),术中出血10 ml,无邻近肠管损伤。手术后24 h内均能下床活动。术后1例局限腹腔感染,1例切口感染,无腹腔出血。2例均经保守治疗痊愈。结论免气腹单孔腹腔镜阑尾切除术是一种安全可行的方法。     

Laparoscopic liver surgery

Background: An effort was made to evaluate the indications, safety, and therapeutic efficacy of laparoscopic liver surgery. Methods: Between 1989 and 1996, 28 patients, 23 to 88 years old were operated upon laparoscopically. Pathology consisted of simple cyst (ten), polycystic liver disease (seven), hydatid cyst (three, two of them calcified), abscess (one), focal nodular hyperplasia (six), and metastatic breast cancer (one). Results: Operations included 17 fenestrations, three pericystectomies, and eight resections (two lateral lobes). Operative time was 45 to 525 min with only four cases longer than 4 h. There was a 21% morbidity rate. There were no mortalities. Follow-up was 1–67 months with one asymptomatic recurrence. Conclusions: Laparoscopic hepatic surgery can be performed safely with good results by surgeons with hepatic and laparoscopic experience when careful selection criteria are followed. We advocate the ``four-hands technique' for simultaneous dissection and control of bleeding and bile ducts during resections. Received: 10 May 1996/Accepted: 26 July 1996     

Gasless laparoscopic assisted surgery for abdominal trauma

Background

Numerous studies have described the effectiveness of laparoscopy for trauma patients. In gas-filling laparoscopic surgery, most of the disadvantages are related to a positive pressure pneumoperitoneum that compromises the cardiopulmonary function. The main advantage of gasless laparoscopic assisted surgery (GLA) is that it does not affect the haemodynamic status, which is particularly critical for trauma patients. The purpose of this study was to investigate the feasibility and safety of GLA for abdominal trauma.

Materials and methods

This was a retrospective, 1:2 matched case–control study of all trauma gasless assisted laparoscopies performed from January 2010 until January 2013 in a Level I trauma centre. In total, 965 patients with abdominal trauma were admitted. According to the abdominal trauma protocol, a total of 93 hemodynamically stable patients required the operation; we selected fifteen patients to undergo GLA and matched 30 other patients to undergo laparotomy. Demographic information, perioperative findings, injury severity score, and postoperative recovery were recorded and analyzed.

Results

A total of fifteen patients (ten men, five women) with a mean age of 44.4, standard deviation (SD) 13.2 years underwent GLA for abdominal trauma. Eight patients had penetrating injuries, while seven had blunt injuries. Overall, 73% patients had multiple injuries. The mean time to the identified lesion was 23.1, SD 10.9 min, and the mean operative time was 109.7, SD 33.5 min. Most of the lesions were repaired concurrently by GLA. One conversion to laparotomy was done. The mean length of hospital stay (HLOS) was 9.1, SD 4.5 days. No mortality occurred in this series. The mean follow-up was 22.0, SD 7.9 months, and there were no significant events during this period. The mean operative times were comparable in the GLA and open surgery group (109.7, SD 33.5 vs. 131.2, SD 43.6 min; p = 0.076). Compared with the open surgery group, the HLOS was significantly shorter in the GLA group (9.1, SD 4.5 vs.16.3, SD 6.4 days; p = 0.030).

Conclusion

GLA offers both therapeutic and diagnostic advantages for patients with abdominal trauma. GLA shares the advantages of laparoscopy and prevents the cardiopulmonary function from being compromised due to pneumoperitoneum, which is especially critical for trauma patients.     

Comparison of immune preservation between CO2 pneumoperitoneum and gasless abdominal lift laparoscopy.

OBJECTIVE: Carbon dioxide (CO2) pneumoperitoneum has been implicated as a possible factor in early immune preservation in laparoscopic surgery. Although the current analysis was not adequate to clarify this issue, the aim of this study was to compare CO2 insufflation laparoscopic cholecystectomy to gasless abdominal wall lift laparoscopic cholecystectomy with respect to preservation of the immune system. METHOD: An analysis of the temporal immune responses was performed in 2 similar groups of patients (n = 50) who were divided randomly into the categories of gas or abdominal wall lift laparoscopic cholecystectomy. The patients were matched with respect to age, weight, and operation time. The immune parameters (serum white blood cell count, cortisol, erythrocyte sedimentation rate [ESR], tumor necrosis factor-alpha [TNF-alpha], interferon-y [INF-gamma], interleukin-6 [IL-6], interleukin-8 [IL-8]) were assessed at preoperative 24 hours and at postoperative 24 and 72 hours for the 2 groups. During the operation, the levels of cytokines that were cultured in the peritoneal macrophages were also checked. RESULTS: The serum white blood cell count, cortisol, and ESR levels were not statistically different in either of the 2 groups. Further, the serum TNF-alpha, INF-gamma, IL-6, and IL-8 levels in both groups were not significantly different from each other at preoperative 24 hours, and postoperative 24 and 72 hours. However, an immediate decrease in the cytokine levels at 24 hours after the operation was significant in both groups. The cytokine levels were particularly higher in the cultured peritoneal macrophages than in the serum, but were not statistically different between the 2 groups. CONCLUSION: Our results showed that the beneficial immune response obtained in the CO2 gas insufflation laparoscopic procedure could also be obtained in the gasless abdominal wall lift laparoscopic procedure. An immediate preservation of the immune functions in the postoperative period was detected similarly in the 2 groups.     

Gasless laparoscopy in abdominal surgery

Pneumoperitoneum, as a necessary precondition of laparoscopic procedures, represents a restriction of the surgeon's freedom of movement and can lead to rare but typical complications. We describe our first experiences with laparoscopic surgery without using pneumoperitoneum. Under direct vision and digital control a fan-formed wall retractor, which is attached to an electric lift arm, is introduced into the abdominal cavity. After raising the abdominal wall, the scope is introduced through the same access and the laparoscopic procedure can be started without the technical and physiopathological problems which may occur using a pneumoperitoneum. In this gasless laparoscopic procedure, simple valveless trocars and instruments can be used. Furthermore, an unlimited suction can be obtained without a loss of exposure. During anesthesia, neither increased ventilation nor increased ventilation pressure is necessary, and the surgeon has increased freedom of action. Not only special laparoscopic instruments, but the conventional instruments, used in open surgery, can also be employed in gasless laparoscopy. In this way we performed gasless laparoscopic surgery on 54 patients: cholecystectomy (n=37), abdominal exploration for NSAP (n=5) or tumor staging (n=4), fenestration of liver cysts (n=5), and appendectomy (n=3). We did observe three wound infections as related complications. Six times, we had to change the surgical procedure. Compared to the traditional procedure with a CO₂ pneumoperitoneum, the results of the first gasless procedures demonstrate potential advantages.     

免气腹腹腔镜用于妇科手术的临床价值

目的:探讨免气腹腹腔镜在妇科手术领域的应用价值。方法:回顾分析2006年以来在妇科领域施行免气腹腹腔镜手术的疗效,并与同期气腹法腹腔镜对比。结果:两种方法的手术时间、术中出血量、术后肛门排气时间、体温及腹胀时间差异有统计学意义。结论:免气腹腹腔镜手术在术中通气、血液动力学及术后疼痛等方面均明显优于气腹法,可作为腹腔镜手术发展的一个方向。     

Fishing-rod-type abdominal wall lifter for gasless laparoscopic surgery

We have designed a new abdominal wall lifter for gasless laparoscopic surgery which consists of stainless steel rods and iron lifters. They elevate the abdominal wall up like a dome-type camping tent, which does not disturb any manipulation of scope or X-ray camera. We received a good view of the peritoneal cavity without CO₂ gas insufflation in ten patients with cholecystitis. This will be helpful for general laparoscopic surgery or laparoscopic assisted surgery with the use of conventional forceps or extracorporeal suturing through a valveless trocar.     

普通微创器械下的腹腔镜脾切除术

目的总结使用普通微创手术器械行腹腔镜脾切除术中的临床经验,探讨其可行性与安全性。方法对26例患者行腹腔镜脾切除术,应用一般电刀、分离钳、持针器、无损伤胃肠钳、钛夹,使用单人双手缝扎法、电凝热烫法、喷射电凝止血法等手段处理脾蒂、脾周韧带血管、脾窝创面完成脾切除术。结果26例手术全部成功,手术时间80～420min,平均120min,术中出血量100—1000ml,平均200ml。无严重并发症发生,患者术后恢复良好。术后住院4～7d,平均5d。结论普通微创器械在腹腔镜下行脾切除术是可行的,并且成本低,副损伤小,具有一定的临床应用价值。     

前腹壁悬吊腹腔镜辅助下婴儿先天性巨结肠根治术的研究

目的 探讨前腹壁悬吊（免气腹）腹腔镜辅助下婴儿先天性巨结肠（HD）根治术的特点。方法 用气囊导尿管充生理盐水1．5～2．0ml前腹壁悬吊行13例前腹壁悬吊腹腔镜辅助下婴儿HD根治术，比较了13例免气腹组和17例CO2气腹组手术中血流动力学参数和量化手术效果参数。结果 气腹组在术中因腹内压增高可以致血流动力学参数平均动脉压（MAP）、PaCO2、心脏指数（CI）、HCO3^-发生显著性变化，前腹壁悬吊组则保持稳定的参数值。两组在手术效果上差异无统计学意义。结论 前腹壁悬吊腹腔镜辅助下HD根治术其前腹壁提拉装置构思新颖。实用性强，具有安全性，可行性，大大减少了由于腹内高压对血流动力学参数的影响，该手术方法值得在临床上推广。     

无气腹皮下悬吊式腹腔镜与传统气腹腹腔镜子宫肌瘤剔除术的临床比较

目的探讨无气腹皮下悬吊式腹腔镜子宫肌瘤剔除术的应用价值。方法对比分析2006年10月～2008年2月我院同期施行无气腹与气腹腹腔镜子宫肌瘤剔除术的手术情况,比较两者手术时间、术中出血量、排气时间、住院时间、并发症及相关费用情况。结果2组患者均无术中、术后并发症发生。无气腹组手术时间（99.2±35.4）min,气腹组（102.7±28.8）min,2组比较差异无显著性（t=-0.411,P=0.682）。无气腹组术中出血量（77.0±48.3）ml与气腹组（89.6±53.8）ml相比,差异无显著性（t=-0.940,P=0.351）。无气腹组排气时间（1.8±0.5）d与气腹组（2.1±0.3）d相比,差异有统计学意义（Mann-WhitneyU=304.000,P=0.013）。无气腹组住院时间（8.7±2.9）d显著短于气腹组（10.3±3.1）d（t=-2.031,P=0.047）。无气腹组住院总费用（6372.8±784.7）元,显著少于气腹组（7984.6±1048.7）元（t=-6.657,P=0.000）。结论无气腹腹腔镜子宫肌瘤剔除术更适于剔除大直径肌瘤,而手术时间与术中出血量未增加,患者术后恢复快,住院时间缩短,住院费用降低,在妇科手术中值得推广。     

Laparoscopically assisted retroperitoneal spinal surgery.

BACKGROUND: Laparoscopically assisted spinal surgery has been reported in several series to be safe and effective. We completed a retrospective chart review of patients who underwent laparoscopically assisted retroperitoneal spinal surgery. METHODS: Between April 1996 and June 2004, 124 patients underwent laparoscopically assisted anterior spinal fusion with a retroperitoneal and gasless approach with a variety of orthopedic devices. Sixty patients were male, 64 were female, and the mean age was 40. Access to the retroperitoneal space is obtained using a balloon dissector and midline trocars, similar to that for TEP hernia repairs. An additional trocar is placed laterally to complete the dissection along the anterior spine. The procedure is then converted to a gasless technique using wound protectors in the midline and laterally. The laparoscope, a balloon retractor, and a lifting device are placed through the lateral incision. The orthopedic instrumentation is placed through the midline incision. RESULTS: Mean operative time and estimated blood loss were 165 minutes and 205 mL, respectively. The conversion rate was 8.9% (6/11 occurred in the first 20 cases). Mean length of stay was 3.0 days. The complication rate was 5.6%, and included iliac vein injury (3), postoperative ileus (2), and need for posterior fusion during the same hospital stay (2). CONCLUSION: Laparoscopically assisted retroperitoneal spinal surgery is safe and reproducible. This technique allows for the benefits of a minimally invasive approach, but also for multi-level exposure, complete discectomy, endplate removal, and placement of conventional orthopedic devices.