Laparoscopic versus open left lateral segmentectomy

Background

Pancreatic cancer is the fourth most common cause of cancer related death in Western countries. Advantages in surgical techniques, radiation and chemotherapy had almost no impact on the long term survival of affected patients. Therefore, the need for better treatment strategies is urgent. HER2, a receptor tyrosine kinase of the EGFR family, involved in signal transduction pathways leading to cell growth and differentiation is overexpressed in a number of cancers, including breast and pancreatic cancer. While in breast cancer HER2 has already been successfully used as a treatment target, there are only limited data evaluating the effects of inhibiting HER2 tyrosine kinases in patients with pancreatic cancer.

Methods

Here we report the design of a prospective, non-randomized multi-centered Phase II clinical study evaluating the effects of the Fluoropyrimidine-carbamate Capecitabine (Xeloda ^®) and the monoclonal anti-HER2 antibody Trastuzumab (Herceptin^®) in patients with non-resectable, HER2 overexpressing pancreatic cancer. Patients eligible for the study will receive Trastuzumab infusions on day 1, 8 and 15 concomitant to the oral intake of Capecitabine from day 1 to day 14 of each three week cylce. Cycles will be repeated until tumor progression. A total of 37 patients will be enrolled with an interim analysis after 23 patients.

Discussion

Primary end point of the study is to determine the progression free survival after 12 weeks of bimodal treatment with the chemotherapeutic agent Capecitabine and the anti-HER2 antibody Trastuzumab. Secondary end points include patient's survival, toxicity analysis, quality of life, the correlation of HER2 overexpression and clinical response to Trastuzumab treatment and, finally, the correlation of CA19-9 plasma levels and progression free intervals.     

Laparoscopic versus open left lateral segmentectomy

Background  

Laparoscopic liver surgery is becoming increasingly common. This cohort study was designed to directly compare perioperative outcomes of the left lateral segmentectomy via laparoscopic and open approach.     

Single-incision laparoscopic left lateral segmentectomy of colorectal liver metastasis

Laparoscopic surgery via a single port is an evolving technique being applied to an increasing variety of operations [1]. Multiple series over the past 3 years have shown single-incision laparoscopic cholecystectomy to be feasible and safe [2]. The ergonomic difficulties of single-port laparoscopy include a loss of instrument triangulation and operation with camera and instruments in parallel. Many different modifications of techniques and equipment have been used to compensate. Single-port techniques have been applied by a few authors to laparoscopic nephrectomy [3], splenectomy [4], and obesity surgery [5, 6]. Laparoscopic liver resection is well established and shown to be safe in multiple series [7]. The laparoscopic approach is accepted as the gold standard for resection of segments 2 and 3 [8]. To the authors’ knowledge, no reports of laparoscopic liver resection via a single port have been published. They report the use of their technique for single-incision laparoscopic left lateral segmentectomy in a patient with a solitary segment 2 colorectal liver metastasis. The authors maintained strict oncologic principles and adhered to their standard laparoscopic technique as far as possible. They used a TriPort (Advanced Surgical Concepts, Wicklow, Ireland) placed via a 12-mm incision at the umbilicus. Following diagnostic laparoscopy and intraoperative liver ultrasound, hepatic attachments were divided using electrocautery. Parenchymal transection and vascular control were achieved using an ultrasonic dissector and laparoscopic staplers. Standard straight laparoscopic instruments were used. A number of technical challenges were apparent. Movement of instruments was jerky at times, either because instruments were clashing with one another other or deflecting the camera. The multiport device can be stiff, requiring copious lubrication throughout surgery. Crossing hands facilitates internal triangulation of the operating instruments to allow retraction or to apply tension, for example, during the division of hepatic attachments. Control of minor hemorrhage is possible with judicious and patient application of pressure using small pieces of surgical gauze. An articulating laparoscopic stapler is useful to achieve the ideal angle of staple deployment during transection of vascular pedicles. The specimen was extracted by extending the umbilical incision. No complications occurred. The patient was able to resume an oral diet and full mobility free of opioid analgesia on the first postoperative day. The resection margin was clear. This video demonstrates that the authors’ technique is feasible and oncologically safe for selected patients requiring liver resection.     

Laparoscopic anatomical (hepatic) left lateral segmentectomy—technical aspects

Laparoscopic liver surgery is a tremendous challenge. The authors report a left liver lobectomy and removal by a total laparoscopic approach. Anatomical left lateral laparoscopic segmentectomy was performed on a woman who had a symptomatic hepatic adenoma. The patient was discharged after an uncomplicated postoperative recovery; the hospital stay and convalescence period were very short. The cosmetic result was good.     

Systematic laparoscopic left lateral segmentectomy of the liver for hepatocellular carcinoma

A systematic technique for the resection of hepatocellular carcinoma (HCC) prevents the dissemination of cancer cells through the portal vein of the remnant liver. We successfully performed a systematic laparoscopic left lateral segmentectomy in a 62-year-old man with HCC. The tumor was located in the left lateral segment of the liver, and measured approximately 4 cm in diameter. Since no other tumors were detected in the liver or in any distant organs, the patient was considered to be a candidate for surgery. A laparoscopic hepatic resection was selected as the procedure of choice. Prior to dissection of the liver parenchyma, the arteries and branches of the portal vein feeding the left lateral segment were divided and dissected, together with the branches of the biliary tree in the umbilical portion of the left pedicle of Glisson's capsule. The liver parenchyma was then dissected and the left hepatic vein divided and dissected, and transection of the left lateral segment was completed. The patient's postoperative course was uneventful and he was discharged on postoperative days 14. No evidence of recurrence has been noted in the 22 months after surgery (the time of this report). This less invasive surgery, taking into consideration the pathogenesis of HCC, may be a useful new approach in selected patients with this tumor. Received for publication on Sept. 1, 1997; accepted on Dec. 26, 1997     

Laparoscopic stapled left lateral segment liver resection—Technique and results

Because of the favorable anatomy of the left lateral segment of the liver, a totally laparoscopic approach to resection is feasible. Herein we describe a technique for laparoscopic stapled resection of the left lateral segment of the liver, including the necessary anatomic criteria for a safe operation and data on clinical outcome. Five patients at our center underwent laparoscopic exploration, ultrasound examination, and resection of segments II and III. After complete mobilization of the left lateral segment and minimal portal dissection, the totally laparoscopic resections were performed with two endoscopic staple loads (4.5 mm Χ 60 mm) applied sequentially across the portal pedicle and the left hepatic vein. The mean operative time was 182 minutes (range 130 to 240 minutes), blood loss was 41 ml (range 25 to 50 ml), and length of hospital stay was 2.2 days (range 1 to 3 days). All three patients with malignancy had negative surgical margins. All five patients returned to normal activity or work by 1 week postoperatively. There were no complications. Patients with isolated malignant and benign diseases of the left lateral segment of the liver are candidates for totally laparoscopic resection, if evaluation demonstrates a normal liver character and hepatic parenchymal thickness less than 3 cm overlying the ligamentum venosum groove. Such patients benefit from the minimally invasive approach, with no compromise in the surgical result as compared to the open approach. Presented at the Fourth Biennial Americas Hepato-Pancreato-Biliary Congress, Miami Beach, Florida, February 28, 2003. Supported in part by a Minnesota Medical Foundation Laparoscopy Training Grant (T.D.S.) and the Richard Lewis Varco Surgical Research Award (B.C.L.).     

Laparoscopic hysterectomy: technique, indications

Today, hysterectomy is, after caesarean section, the most frequent surgical intervention performed in fertile women. Introduced in 1989, laparoscopic hysterectomy remains poorly diffused: today, less than 5% of all hysterectomies remain done by laparoscopy. Nevertheless after a correct learning curve, laparoscopic hysterectomy finds perfect indications in benign and even some malignant indications. In these conditions, the complication rate is similar to those of the other surgical routes. Currently the limitations of this technique are the very bulky uterus, contraindicated uterine morcellation, the lengthening of the operative time potentially generated by this technique, and the lack of experienced instructors.     

完全腹腔镜下肝左外叶解剖性切除七例

目的探讨完全腹腔镜下肝脏左外叶解剖性切除手术的方法和适应证。方法在不阻断全肝血流的情况下 ,应用多种器械于完全腹腔镜下进行解剖性肝左外叶切除 7例 (男 3例 ,女4例 ) ,其中原发性肝癌 2例 ,肝脏血管瘤 5例 (2例为多发 )。术前 3例行超声和CT检查 ,4例行超声、CT和MRI检查。结果 7例手术均在完全腹腔镜下顺利完成 ,平均手术时间 2 10min ,平均出血量70 0ml,平均输血量 343ml。术后平均住院 5 7d ,腹腔引流管放置时间 2～ 4d。未发生胆漏、出血、感染等并发症。结论在现有的手术器械条件及在不阻断全肝血流的情况下 ,可安全地进行腹腔镜肝左外叶解剖性切除。     

Hand-assisted laparoscopic left lateral segmentectomy of the liver for hepatocellular carcinoma with cirrhosis

Background/Purpose. Despite recent progress in trials with laparoscopic hepatectomy, it is still necessary to develop safe and stable techniques. We have performed laparoscopic hepatic resection for 30 patients with liver tumors to date. We have recently been applying a hand-assisted laparoscopic surgical technique for greater safety. Methods. In the present study, we report techniques using a hand-assisted laparoscopic anatomical left-lateral segmentectomy for hepatocellular carcinoma with liver cirrhosis. Results. Direct feeling with the surgeons hand makes possible a procedure that is almost identical to open surgery in which there is better visualization of the surgical field and transected margin, and immediate hemostasis is also achieved by manually depressing the bleeding point. Conclusions. With this method, laparoscopic anatomical hepatectomy can be performed more safely for patients with cirrhosis than by the fully laparoscopic method, although a larger incision is necessary.     

腹腔镜肝切除术

目的展示应用腹腔镜肝切除手术治疗肝脏左外叶肿瘤的1个病例。方法该患者为41岁女性,肝左外叶肿瘤直径为5．5cm,肝功能检测为Child—PughA级,吲哚氰绿15min潴留率（ICG15）为8．9％。术前手术方案评估表明为腹腔镜肝切除手术的适应证。患者术中采用仰卧位,共应用5个troear（即5个穿刺孔）。手术的初始操作为游离肝周韧带,肝实质的离断应用超声刀和可吸收血管夹来完成。结果手术时间为115min,出血量为110ml,除了常规进行预存式自体输血外,无需额外输血。病理结果提示为肝脏囊腺瘤。患者术后恢复良好,无手术并发症发生,术后第8天出院。结论对于具备肝胆手术以及腹腔镜手术操作经验的外科医生而言,腹腔镜肝切除手术是治疗肝脏外科疾病的一种安全、有效的方法。     

Laparoscopic left lateral hepatic lobectomy: a safer and faster technique

Background/Purpose Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. At present, a limited number of laparoscopic anatomical left lobectomies have been reported in the literature, but we believe that the use of stapling devices has made this technique safer and faster. Methods From January 2000 to May 2005, eight patients (five men, three women; mean age, 60.5 years) underwent laparoscopic anatomical left lobectomy at our department. Seven patients presented with hepatocellular carcinoma and cirrhosis, while one patient had a large symptomatic angioma. The average size of the lesions was 4.18 cm (range, 3.6–7.1 cm); all the lesions were localized in the anatomical left lobe (segments II–III). Transection of the liver parenchyma, together with sectioning of the vascular pedicle for segment II and III and of the left hepatic vein, was obtained by the use of stapling devices. Results The mean operative time was 142 min (range, 120–180 min). There were no intraoperative or postoperative complications, and blood transfusions were not required. The mean postoperative hospital stay was 5.75 days. Conclusions The key points of the technique are: late mobilization of the liver; no transection of the round ligament; no surrounding or taping of the portal pedicles or of the left hepatic vein; and the use of three consecutive linear staplers, turned to the left for transecting the liver parenchyma and vascular pedicle together. This technique, in our opinion, should be considered a new good option for patients with isolated lesions of the left lateral segments, but it must be performed by surgeons trained in both liver and advanced laparoscopic surgery.     

Laparoscopic pyelolithotomy: indications and technique

BACKGROUND AND PURPOSE: Laparoscopic pyelolithotomy, although uncommonly performed, may be considered in patients who have renal anomalies, are poorly compliant, and have a large single renal-pelvic calculus. We present our experience with this procedure in five patients. PATIENTS AND METHODS: Three patients underwent laparoscopic pyelolithotomy because of a horseshoe kidney, one for a pelvic kidney, and one for a large renal-pelvic calculus. All stones were solitary with a mean size of 2280 mm2 (range 540-8200 mm2). All were approached transperitoneally with passage of a flexible cystoscope through a laparoscopic port to aid in stone extraction. RESULTS: All cases were completed laparoscopically. The length of surgery was 74, 92, 134, 158, and 159 minutes. There were no minor or major complications, and the estimated blood loss was <50 mL in all cases. All patients were discharged on postoperative day 1 with the drains removed. Four patients were stented for 4 to 6 weeks. The remaining patient was not stented because of poor compliance. The stents were removed with office cystoscopy. All patients were stone free on follow-up imaging. CONCLUSIONS: Laparoscopic pyelolithotomy can be done safely, effectively, and efficiently with proper patient selection and adherence to standard laparoscopic surgical principles.     

Roux-en-Y gastrojejunostomy: indications,technique, results

61 gastrojejunostomies were constructed between 1981-1999 in 58 cases (43 cases were operated between 1991-1999). 30 cases have previously suffered various gastric operations; in 28 cases the Roux-en-Y was the first gastric operation (27 operated on between 1991-1999). Radiologic and endobioptic studies were routine for diagnostic and follow-up evaluation, but various scintigraphic studies were performed in selected cases. The surgical technique was tailored for each case, according to the preoperative strategy. The indications for surgery were the following: 19-reflux disease; 14-severe peptic disease (9-reccurence, 3-postbulbar lesion, 2-juxtacardial ulcer); 8-peptic disease associated to reflux disease; 8-gastric cancer; 8-various early or late complications after gastrectomy; 1-lymphocytic gastritis. There were 4 early reoperations and 3 deceased. In 3 cases late reintervention was mandatory (for Zollinger-Ellison syndrome, peptic ulcer secondary to gastrectomy for cancer, Roux-stasis syndrome) and the Roux pattern was preserved; in 2 cases the antireflux effect of the operation was lost after the reoperation.     

Mini-laparoscopic cholecystectomy: indications, technique and results

The improvement of results and patients quality life is the aim of surgical technique. Mini-laparoscopic cholecystectomy brings not only to a better cosmetic results, but also to a decrease of post operative pain, analgesic use, hospital stay and an early return to normal activities. In this study, Authors report their own experience about mini-laparoscopic cholecystectomy using 5 mm and 3 mm trocar. Patients suffering from biliary sludge, microscopic lithiasis and mild or moderate gallbladder inflammation can undergo this procedure.