Laparoscopic cryosurgery for hepatic tumors

Background: Hepatic cryosurgery has been shown to be a safe technique that may be well suited to a laparoscopic approach. Methods: The technical feasibility and safety of laparoscopic cryosurgery was explored first in a pig model. Thereafter we performed the first successful case of laparoscopic hepatic cryosurgery at our institution. Results: In the animal model, we found that it is possible to safely identify, target, and cryoablate specific lesions in the liver. Temperature in the peritoneal cavity remained above 35°C, and pathologic examination of the abdominal wall around the cryoprobe site revealed no damage. We also successfully treated a 62-year-old man with a metastatic colorectal carcinoma deep in the right lobe of the liver with laparoscopic cryosurgery using a transpleural approach. Conclusion: We conclude that laparoscopic cryosurgery is feasible for lesions anywhere in the liver. For lesions high on the dome of the liver, a transpleural approach may provide better access.     

The role of staging laparoscopy for multimodal therapy of gastrointestinal cancer

Background: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy. Methods: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally, 144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5 MHz). Results: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158 of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases—i.e., liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients. Conclusions: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on a stage-adapted surgical therapy. Received: 3 April 1997/Accepted: 26 September 1997     

Laparoscopic treatment of gastric stromal tumors

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

Laparoscopically assisted transsacral resection of rectal cancer with primary anastomosis

Background: The management of rectal cancer has been changing to include more sphincter-sparing procedures. We report our initial experience with a new technique incorporating laparoscopy and a transsacral approach for low or midlevel rectal cancer. Here, we tried to determine whether this sphincter-sparing method could produce acceptable morbidity and recurrence rates. Methods: Patients with rectal cancer 4 to 8 cm from the dentate line underwent laparoscopically-assisted transsacral resection (LTR) with primary anastomosis. With this technique, the rectosigmoid is mobilized via laparoscopy while the patient is in the supine position. Next, the patient is placed in the prone jackknife position, and a segment of rectum is resected by a transsacral approach. Age, estimated blood loss, length of time in the operating room, length of stay, and postoperative complications were noted. Aspects of the tumor pathology regarding stage, lymph nodes, tumor size, and presence of tumor at resection margins also were recorded. Results: A total of 13 patients, ages 26 to 70 years (mean, 52.5 years), underwent the procedure. No perioperative deaths occurred. The mean hospital stay was 9.6 days. The average size of the rectal lesion was 4.3 cm in the largest dimension. The average specimen contained 11.5 total, and 2.0 metastatic lymph nodes. Postoperative complications included two anastomotic breakdowns and two other wound complications. Late follow-up evaluation ranged from 10 to 30 months, with 11 of 13 patients alive (85% survival). Two local recurrences and three distant recurrences were noted at long-term follow-up assessment. Conclusions: In selected patients with low or midlevel rectal cancer, LTR may be a viable option. Further experience is necessary to define its oncologic efficacy and whether routine temporary diverting colostomy is indicated. Received: 16 June 1999/Accepted: 1 November 1999/Online publication: 12 July 2000     

Endothoracic sonography with color Doppler availability during video assisted thoracic surgery (videothoracoscopic operative staging with ultrasound color Doppler) for lung cancer staging

Background: The preoperative staging of lung cancer can be problematical when we attempt to evaluate T factor (T2–T3 versus T4) and N factor (N0 versus N1–N2). In some cases, radiology tests (CT scan, magnetic resonance imaging) cannot entirely dispel the possibility that the mediastinal structures have been infiltrated. N factor is evaluated mainly by dimensional criteria. However, mediastinoscopy and mediastinotomy do not allow the full exploration of all mediastinal mode stations. Method: Starting in 1995, we submitted 10 consecutive patients to videothoracoscopic operative staging with ultrasound color Doppler (VOS-USCD). In five cases, preoperative staging showed possible infiltration of the pulmonary artery (T4). In nine cases, we found involvement of the mediastinal nodes, seven patients were N2, and two were N3. Videothoracoscopy was performed under general anesthesia using a double-lumen endotracheal tube. The videothoracoscope and sonographic probe were inserted via three thoracoports placed in the axillary triangle. Results: Following the results of VOS-USCD, the staging and subsequently the therapeutic program were modified in seven of 10 cases (70%). Conclusions: Our preliminary experience indicates that VOS-USCD should be applied to the diagnosis of patients in stage IIIA (N2) and that it is particularly valuable for patients in stage IIIB. Received: 23 May 1997/Accepted: 28 October 1997     

Intraperitoneal immunity and pneumoperitoneum

Background: Carbon dioxide (CO₂) pneumoperitoneum has been implicated as a possible factor in depressed intraperitoneal immunity. Using in vitro functional assays, CO₂ has been shown to decrease the function of peritoneal macrophages harvested from insufflated mice. However, an effective in vivo assessment is lacking. Listeria monocytogenes (LM), an intracellular pathogen, has served as a well-established in vivo model to study cell-mediated immune responses in mice. This study examines the immune competence of mice based on their ability to clear intraperitoneally administered LM following CO₂ vs helium (He) insufflation. Methods: Eighty-five mice (C57Bl/6, males, 4–6 weeks old) were divided between the following four treatment groups: CO₂ insufflation, He insufflation, abdominal laparotomy (Lap), and control (anesthesia only). Immediately postoperatively, each group was inoculated percutaneously and intraperitoneally with a sublethal dose (.015 × 10⁶ org) of virulent LM (EGD strain). Half of the animals were killed on postoperative day 3 and half on day 5. Spleens and livers (sites of bacterial predilection) were harvested, homogenized, and plated on TSB agar. The amount of bacteria (1 × 10⁶ LM/spleen and liver) from each group was then compared. Statistical significance was set at p≤ 0.05. Results: Control animals had nominal bacteria on day 3 (0.016 × 10⁶ LM/spleen and liver), and the bacterial burden remained low at day 5 (0.038 × 10⁶ LM/spleen and liver) postchallenge. On day 3, the bacterial burden was significantly higher in the CO₂ group (5.46 × 10⁶ LM/spleen and liver) as compared to He (0.093 × 10⁶ LM/spleen and liver) and controls. The Lap group (3.44 × 10⁶ LM/spleen and liver) had significantly more bacteria than the controls. There were no significant differences between any of the groups on day 5. Conclusions: In this animal model, CO₂ pneumoperitoneum impaired cell-mediated intraperitoneal immunity significantly more than He pneumoperitoneum and controls on day 3. Also on day 3, laparotomy caused impairment of intraperitoneal immunity when compared to controls. Finally, intraperitoneal immunosuppression resolved by day 5. Received: 22 July 1998/Accepted: 3 March 1999     

Port-site metastases

Background: Port-site metastases after laparoscopic procedures in patients with digestive malignancies have evoked concern. The pathogenesis of port-site metastases remains unclear. Two experiments in rats were performed to determine the impact of both tissue trauma and leakage of CO₂ along trocars (chimney effect) in the development of port-site metastases. Methods: Experiment I: Ten WAG rats had four 5-mm incisions in all abdominal quadrants. The incisions on the right side were crushed to induce tissue trauma. After inserting 5-mm trocars in all incisions, a pneumoperitoneum was created, and CC-531 tumor cells were injected intraperitoneally. CO₂ was insufflated for 20 min. Experiment II: Ten WAG rats had 5-mm incisions in the left and right abdominal upper quadrant. A 5-mm trocar was inserted in the incision in the left upper quadrant, and a 2-mm trocar was inserted in the incision in the right upper quadrant. After insufflating the abdomen, CC-531 tumor cells were injected intraperitoneally. Total leakage of CO₂ along the trocar in the right quadrant was 10 liters. After 4 weeks, in both experiments, the tumor deposits at the trocar sites were assessed. Statistical analysis was performed by the Wilcoxon matched-pairs test. Results: Experiment I: The median weight of tumor deposits at the trocar sites without induced tissue trauma was 22 mg. At the traumatic port sites, median weight of tumor deposits was 316 mg (p= 0.007). Experiment II: The median weight of tumor deposits at the leaking trocar sites was 478 mg and at the control sites 153 mg (p= 0.009). Conclusion: Tissue trauma at trocar sites and leakage of CO₂ along a trocar appear to promote implantation and growth of tumor cells at port sites. Received: 15 May 1997/Accepted: 3 March 1998     

Use of CT Hounsfield unit density to identify ablated tumor after laparoscopic radiofrequency ablation of hepatic tumorsrid=""id=""Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Atlanta, Georgia, USA, 29 March–1 April 2000

Background: When attempting to interpret CT scans after radiofrequency thermal ablation (RFA) of liver tumors, it is sometimes difficult to distinguish ablated from viable tumor tissue. Identification of the two types of tissue is specially problematic for lesions that are hypodense before ablation. The aim of this study was to determine whether quantitative Hounsfield unit (HU) density measurements can be used to document the lack of tumor perfusion and thereby identify ablated tissue. Methods: Liver spiral CT scans of 13 patients with 51 lesions undergoing laparoscopic RFA for metastatic liver tumors within a 2-year time period were reviewed. HU density of the lesions as well as normal liver were measured pre- and postoperatively in each CT phase (noncontrast, arterial, portovenous). Statistical analyses were performed using Student's paired t-test and ANOVA. Results: Normal liver parenchyma, which was used as a control, showed a similar increase with contrast injection in both pre- and postprocedure CT scans (56.4 ± 2.4 vs 57.1 ± 2.4 HU, respectively; p= 0.3). In contrast, ablated liver lesions showed a preablation increase of 45.7 ± 3.4 HU but only a minimal postablation increase of 6.6 ± 0.7 HU (p < 0.0001). This was true for highly vascular tumors (neuroendocrine) as well as hypovascular ones (adenocarcinoma). Conclusions: This is the first study to define quantitative radiological criteria using HU density for the evaluation of ablated tissues. A lack of increase in HU density with contrast injection indicates necrotic tissue, whereas perfused tissue shows an increase in HU density. This technique can be used in the evaluation of patients undergoing RFA. Received: 1 March 2000/Accepted: 4 April 2000/Online publication: 9 August 2000     

Laparoscopic insufflation of the abdomen reduces portal venous flow

Background: The adverse effects of sustained elevated intraperitoneal pressure (IPP) on cardiovascular, pulmonary and renal systems have been well documented by several reported experimental and clinical studies. Alteration in the splanchnic circulation has also been reported in animal experiments, but details of the exact hemodynamic changes in the flow to solid intraabdominal organs brought on by a raised intraperitoneal pressure in the human are not available. The aim of the present study was to estimate effect of increased IPP on the portal venous flow, using duplex Doppler ultrasonography in patients undergoing laparoscopic cholecystectomy. Methods: The studies were performed using the SSD 2000 Multiview Ultrasound Scanner and the UST 5536 7.0-MHz laparoscopic transducer probe. Details of the measurements were standardized in according to preset protocol. Statistical evaluation of the data was conducted by the two-way analysis of variance (ANOVA). Results: The flow measurement data have demonstrated a significant (p < 0.001) decrease in the portal flow with increase in the intraperitoneal pressure. The mean portal flow fell from 990 ± 100 ml/min to 568 ± 81 ml/min (−37%) at an IPP of 7.0 mmHg and to 440 ± 56 mmHg (−53%) when the IPP reached 14 mmHg. Conclusions: The increased intraperitoneal pressure necessary to perform laparoscopic operations reduces substantially the portal venous flow. The extent of the volume flow reduction is related to the level of intraperitoneal pressure. This reduction of flow may depress the hepatic reticular endothelial function (possibly enhancing tumor cell spread). In contrast, the reduced portal flow may enhance cryo-ablative effect during laparoscopic cryosurgery for metastatic liver disease by diminishing the heat sink effect. These findings suggest the need for a selective policy, low pressure or gas-less techniques to positive-pressure interventions, during laparoscopic surgery in accordance with the disease and the therapeutic intent. Received: 19 March 1996/Accepted: 4 July 1997     

Influence of High Impact Loading on Ultrasound Bone Measurements in Children: A Cross-Sectional Report

Evidence suggests that weight-bearing exercise during the growing years may enhance peak bone mass. The purpose of this study was to compare ultrasound bone measurements, serum alkaline phosphatase (S-ALP), serum osteocalcin (S-OC), and dietary calcium in highly active and normal healthy male children. Subjects were 33 elite and subelite male gymnasts and 40 normoactive controls matched for age (9.4 ± 1.1 years), height (133.9 ± 5.9 cm), and weight (30.1 ± 3.8 kg). Measurements of broadband ultrasound attenuation (dB/MHz) through the calcaneus (CBUA) and ultrasound velocity (m/s) through the calcaneus (CVOS), distal radius (RVOS), and proximal phalanx of the index finger (PVOS) were performed using a Contact Ultrasonic Bone Analyzer (CUBA Research). Gymnasts had significantly greater CVOS (P < 0.001), RVOS (P < 0.0001), and PVOS (P < 0.05). There were no differences in CBUA, S-ALP, or S-OC between groups. RVOS correlated significantly with dietary calcium intake in all subjects (P < 0.05) and training time in the gymnasts (P < 0.05). Though gymnasts had significantly greater calcium intakes than controls (P < 0.05), whose mean value was below the RDA, after controlling for calcium intake in the gymnasts alone, RVOS was still significantly correlated with training time (P < 0.05). These preliminary results suggest that the heavy musculoskeletal loading inherent in gymnastics training produces positive adaptive responses in the growing skeleton. Furthermore, ultrasound appears to provide a safe, noninvasive means of comparing the skeletal status of exercising and normal healthy children, whereas single samples of biochemical markers did not discriminate between the groups. Received: 2 May 1996 / Accepted: 10 December 1996     

Geometry and reproducibility in 360° fundoplication

Background: In this study, we set out to precisely define two symmetrical points—a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or ``floppy') 360° fundoplication (FP). Methods: For the terms of this study, circumference =c; diameter =d; c/d=π; π= 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n= 5) and intraoperatively (n= 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c. Results: The smallest measured value for c was 7.5 cm (d= 2.39 cm); the largest value for c was 10.0 cm (d= 3.18 cm). The mean value was 8.35 cm (d= 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d= 2.66 cm. This technique creates a correctly oriented, symmetrical, ``floppy,' true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible. Conclusions: Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a ``floppy' 360° fundoplication. Received: 20 April 1999/Accepted: 15 February 2000/Online publication: 15 May 2000     

Development of a laparoscopic approach to neurolytic celiac plexus block in a porcine model

Background: Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control in cases of inoperable pancreatic cancer. This study was undertaken to evaluate the feasibility of a laparoscopic approach to NCPB in an experimental animal model. Methods: The laparoscopic technique for NCPB was developed in an acute study of six domestic swine followed by a chronic study of nine domestic swine that were monitored 3–21 days after surgery for adverse neurologic, gastrointestinal, or other sequelae. Using a four-port laparoscopic technique, the esophageal hiatus was dissected to expose the aorta at the level of the diaphragmatic crura. Under combined endoscopic and laparoscopic ultrasound (LUS) guidance, 5 ml of sclerosant dye (95% ethanol mixed with India ink) was injected into either side of the para-aortic soft tissue via a percutaneously placed 18-gauge spinal needle. After the animals were killed, the aorta and periaortic tissue were harvested from each animal for gross and histologic analysis. Results: Under LUS guidance, sclerosant was injected successfully into the para-aortic soft tissue in all animals. There were no intraoperative complications in the acute animal group. Placement of sclerosant injection was successful in all nine chronic cases. Two pigs in the chronic study group died in the immediate postoperative period secondary to pneumothorax. No adverse neurologic, gastrointestinal, or other sequelae were observed in the remaining seven animals at 3–21 days postoperatively. After the animals were killed, we found no injuries to the aorta or esophagus, and histologic analysis demonstrated good placement of dye-labeled sclerosant with no compromise of aortic structural integrity. Conclusion: A laparoscopic approach to the aortic hiatus and NCPB is feasible. Further studies are warranted to evaluate this approach in patients who undergo staging laparoscopy for pancreatic cancer and are found to have unresectable disease. Received: 19 March 1999 /Accepted: 18 November 1999 /Online publication: 26 July 2000     

Bone Metabolism in Endurance Trained Athletes: A Comparison to Population-Based Controls Based on DXA, SXA, Quantitative Ultrasound, and Biochemical Markers

In general, physical exercise appears to have favorable effects on the skeleton. However, a few recent reports have described negative effects, including reduced bone density (BMD) and high bone turnover in runners. The aim of our study was to compare endurance runners to controls with respect to BMD at different sites and ultrasound transmission through the peripheral skeleton, and to use PTH, total serum calcium, and biochemical markers of bone metabolism as a complement in evaluating the effects of endurance running on bone. Thirty runners (mean age 32 years, range 19–54 years) participated in the study. Their main form of training consisted of endurance running at moderate intensity for about 7 hours (range 2–12 hours) per week, and they had been active in their sport for about 12 years (range 1–21 years). For a comparison, 30 age- and sex-matched population based controls were investigated. BMD values, measured by dual energy X-ray absorptiometry (DXA), were higher in runners than in controls for the total body (3.6%; P= 0.03), legs (9.6%; P= 0.001), femoral neck (10.0%; P= 0.01), trochanter (9.9%; P= 0.01), and Wards triangle (11.8%; P= 0.02), but not in the lumbar spine or in the forearm measured by single energy X-ray absorptiometry (SXA). The quantitative ultrasound measurement of the calcaneus also revealed higher values in runners than in controls for both broadband ultrasound attenuation (9.2%; P= 0.002) and speed of sound (3.1%; P= 0.0001). At all sites, BMD was related to ultrasound measurements in controls, but no such relationship was evident in runners. Concentrations of parathyroid hormone (PTH) were lower (23.2%; P= 0.02) in runners than in controls, whereas total serum calcium concentrations were slightly higher (3.0%; P= 0.003). The levels of PICP (bone formation) and ICTP (bone resorption) in serum were lower (18.0%; P= 0.03 and 22.2%; P= 0.004, respectively) in runners than in controls, but no differences were seen for osteocalcin or bone specific alkaline phosphatase (b-ALP). In conclusion, BMD at the focus of strain for running, that is, the legs, is higher in endurance runners when compared to matched controls. Low bone turnover in runners, indicated by lower levels of PTH and biochemical markers of bone metabolism, point to an influence of endurance running at the cellular level. Received: 25 July 1996 / Accepted: 24 March 1997     

Ultrasonographic, Axial, and Peripheral Measurements in Female Patients with Benign Hypermobility Syndrome

Twenty-five female Caucasians, aged 19–57 years, with the hypermobility syndrome had bone density measurements using established noninvasive techniques such as dual X-ray absorptiometry (DXA), single photon absorptiometry (SPA), heel ultrasound (US), and peripheral computed tomography (pQCT) acquisitions of the radius. As a group, comparisons of the different bone indices with the corresponding age-matched reference population resulted in normal z-scores for the arial densities, however, values for the volumetric total and cortical bone at the radius measured by pQCT were significantly lower than expected (P < 0.0001). Spinal and femoral bone density results were significant after correction for body mass index (BMI). This cross-sectional study shows that the benign hypermobility syndrome patients have lowered t-scores for data reflecting bone structure and bone strength as measured with US and the tomographic technique. Received: 8 May 1999 / Accepted: 21 January 2000     

Thoracoscopic transdiaphragmatic microwave coagulation therapy for a liver tumor

Background: Microwave coagulation therapy (MCT) for hepatocellular carcinoma, which induces tumor coagulonecrosis, is now recognized as an efficient treatment. However, when a tumor is located just below the top of the diaphragmatic dome, laparotomical MCT requires a large incision, and percutaneous MCT is sometimes impossible. Patients and Methods: The patients were four men and two women. There were four cases of hepatocellular carcinoma and two cases of liver metastasis from colorectal cancer. All tumors were located below the top of the diaphragmatic dome. Thoracoscopic transdiaphragmatic MCT (TTMCT) was performed under general anesthesia using an endotracheal double-lumen tube. Identification of the tumor site in the liver was performed using an ultrasonic probe under thoracoscopic observation. After the diaphragm above the tumor was opened, a needle electrode to transmit microwaves was inserted directly into the tumor. Microwave irradiation was repeated to coagulate the entire lesion. After completion of TTMCT, the diaphragm was closed thoracoscopically. Results: TTMCT was successfully administered to cancerous lesions in all six patients. The postoperative course was uneventful, and the average postoperative hospitalization period was 10.5 days. None of the patients has shown any recurrence during a follow-up period of 4–23 months. Conclusions: TTMCT was performed without any difficulty using the thoracoscopic surgical technique, and its therapeutic outcome was satisfactory. This is effective for tumors located just below the top of the diaphragmatic dome.     

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     

Initial experience with stereoscopic visualization of three-dimensional ultrasound data in surgery

Initial in vivo and in vitro experiments were performed to evaluate the feasibility of stereoscopically displaying three-dimensional (3D) ultrasound data from neurosurgery, laparoscopic surgery, and vascular surgery. Stereoscopic visualization was illustrated by four video sequences, which can be downloaded from http://www.us.unimed.sintef.no/. These sequences show a brain tumor, hepatic arteries in relation to the gallbladder, a model that mimics a neuroendoscope in a cyst, and a ``flight' into model of an artery with an intima flap. The experiments indicate that stereoscopic display of ultrasound data is feasible when there is sufficient contrast between the objects of interest and the surrounding tissue. True 3D vision improves perception, thus enhancing the ability to understand complex anatomic structures such as irregular lesions and tortuous vessels. Received: 5 August 1999/Accepted: 14 October 1999/Online publication: 22 May 2000     

Outpatient endoscopic thoracic sympathectomy using 2-mm instruments

Background: For a long time it has been known that sympathectomy is an effective treatment for hyperhidrosis and other conditions. The surgical options available until recently usually have required thoracotomy or large posterior incisions, and physicians generally have been reluctant to recommend surgery for most patients with ``benign' disorders. Recently, thoracoscopic techniques have allowed surgeons to offer these patients a permanent solution with minimal surgical trauma. Methods: In 20 patients, 30 endoscopic thoracic sympathectomies (ETS) were performed for several indications. Nine patients had bilateral sympathectomies. The procedures were performed on the day of admission, with the patient under general anesthesia using double lumen endotracheal intubation and hand temperature monitoring. Each lung was reinflated on completion of the sympathectomy, and residual pneumothorax aspirated before closure of the incisions. No placement of chest tubes was performed in the operating room. Results: All sympathectomies were completed thoracoscopically. There were no major complications, and 90% of the patients were discharged within 24 hours of admission. The average operative time was 69 min. Conclusions: Findings from this study show that ETS is a safe and effective procedure that can be performed routinely on an outpatient basis. The use of miniendoscopic (2-mm) instrumentation is safe and effective in most patients and a helpful adjunct in providing these patients with minimally traumatic surgery. Long-term results should be evaluated on the basis of specific indications for sympathectomy. Received: 1 March 1999/Accepted: 1 July 1999     

Laparoscopy in the management of gastric submucosal tumors

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

The use of intraoperative ultrasound in laparoscopic adrenal surgery

Background: Laparoscopic adrenalectomy has been shown to be a safe and effective therapy for benign adrenal lesions. We review our experience with this procedure, including the use of laparoscopic ultrasound. Methods: We retrospectively reviewed our experience with 36 patients who underwent resection of 42 adrenal glands. Data gathered included preoperative evaluation and diagnosis, operative time, blood loss, complications, and follow-up status. Laparoscopic ultrasound was used to guide dissection and characterize a variety of adrenal lesions. Results: Thirty-five of 36 patients underwent successful laparoscopic adrenalectomy. There was one conversion to the open procedure in a patient with bilateral adrenal metastases from an endometrial cancer. For the bilateral laparoscopic procedure, the operative time averaged 262 mins, blood loss was 160 cc, and hospital stay was 3.0 days. For unilateral cases, operative time averaged 193 min, blood loss was 108 cc, and hospitalization was 1.1 days. Six patients experienced perioperative complications, most of which were minor and transient. Laparoscopic ultrasound was useful to define anatomy and to identify the adrenal vein, especially on the left side. Conclusions: Laparoscopic adrenalectomy is the procedure of choice for benign adrenal disease. Laparoscopic ultrasound is useful to localize and aid in the dissection of the left adrenal vein. Received: 24 December 1998/Accepted: 12 February 1999