Laparoscopic vs. Hand-Assisted Laparoscopic Sigmoidectomy for Diverticulitis

Introduction Sigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left-lower quadrant and pelvis. We hypothesized that hand-assisted laparoscopic technique may facilitate laparoscopic completion of this surgery while retaining the short-term benefits associated with “pure” laparoscopic surgery, in which an incision is made only for extracting the specimen. This study was designed to compare the outcomes of patients who underwent totally laparoscopic or hand-assisted laparoscopic sigmoidectomy for diverticulitis. Methods We reviewed our prospectively collected patient database from July 2001 to June 2004 and compared the intraoperative data and postoperative outcomes of patients who underwent elective laparoscopic or hand-assisted laparoscopic sigmoidectomies for diverticulitis. Complicated patients (with abscess or fistulas) also were separately analyzed. Results The hand-assisted laparoscopic (mode age, 57 years; 48 percent male) and laparoscopic sigmoidectomy (mode age, 56 years; 90 percent male) groups were similar with regard to age and gender. Overall, patients who underwent laparoscopic (n = 21) vs. hand-assisted laparoscopic (n = 21) sigmoidectomies had a significantly longer operative time (197 ± 42 vs. 171 ± 34 minutes, P = 0.04) and shorter incision length (5 ± 2.1 vs. 9.3 ± 4.1 cm, P = 0.0001). Patients with complicated diverticulitis (n = 14; abscess, colovesical fistula, enterocolic fistula) who underwent laparoscopic sigmoidectomies (n=4) had a significantly longer operative time compared with hand-assisted laparoscopic sigmoidectomy (n = 10) group (255 ± 18 vs. 177 ± 34 minutes, P = 0.001). Conversion rate for the laparoscopic group was significantly higher (3/4 vs. 1/10, P = 0.04, Fisher exact) when complicated diverticulitis was present. There were no differences in postoperative outcomes or incision lengths in thecomplicated group. Conclusions Outcomes after hand-assisted laparoscopic sigmoidectomy for diverticulitis are similar to those seen in the pure laparoscopic method, with lower conversion rates and shorter operative times. Hand-assisted laparoscopic sigmoid resection for diverticulitis is an attractive alternative to a “pure” laparoscopic method in complicated cases. Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Reprints are not available.     

Ileocolic intussusception due to intestinal metastatic melanoma. Case report and review of the literature

The small intestine is a frequent site of melanoma metastases and the most common cause of secondary intestinal tumors. Even though, its presentation with intestinal obstruction due to intussusception is very rare. We present a 47-year-old woman with a medical history of facial melanoma operated 17 years ago and recently diagnosed of cervical recurrence who complained of abdominal pain of one week duration accompanied with vomiting and abdominal distension. Computed tomography (CT) scan revealed marked distension of the small intestine with features suggesting intussusception of the distal ileum. At laparoscopic exploration a massive ileocolic intussusception was found with invagination of the last 60 cm of ileum inside the cecum and ascending colon. Surgical reduction revealed a tumor of approximately 2 cm in the distal end of the intussuscepted intestine acting as the lead point. Resection of non-viable ileum along with the tumor and end-to-end anastomosis was performed. Many other lesions of smaller size were found distantly in the proximal small bowel but were not treated. The patient had a full recovery and was discharged three days after surgery. Pathological examination showed metastatic melanoma and a positron emission tomography (PET) scan confirmed disseminated disease with brain metastasis. The patient died three months after surgery. Intestinal occlusion due to metastatic disease is a rare condition but should be taken into account particularly in patients with history of cancer. Surgical intervention with a mini-invasive laparoscopic approach is feasible. Intestinal resection and anastomosis is mandatory for either curative or palliative intentions providing a satisfactory treatment.     

Hand-assisted laparoscopic surgery of abdominal large visceral organs

AIM: To design a hand-assisted laparoscopic approach in an attempt to provide an option for laparoscopic resection of abdominal large viscera. METHODS: A 5-6 cm incision (for HandPort) and 2 trocars were employed. The main vessel of the target organ was taken as a "core", and all tissues around the core were taken as peripheral structures. The peripheral structures were dissected first, and the core vessels were treated last. Twenty-six patients underwent laparoscopic deroofing of the hepatic huge cysts, resection of the segments lying at the outer edge of the liver (segments 2 to 6), splenectomy, hemicolectomy, ileocecectomy and subtotal gastrectomy with HandPort device, harmonic scalpel, or Ligasure. RESULTS: The duration of the procedure was within 2 hours. Blood loss amounted to 8-120 mL. The conversion rate was 3.8% (1/26). All patients had uneventful postoperative courses with less pain, earlier oral intake, and faster recovery, compared with conventional surgery. CONCLUSION: This method combines the advantages of both open and laparoscopic techniques, achieving better hemostasis effect, shortening the operative time, and is beneficial to the patients.     

Evaluation of serum cytokine release in response to hand-assisted, laparoscopic, and open surgery in a porcine model

Background

Although the immunologic benefits of laparoscopic surgery have been established, effects from hand-assisted (HA) surgery have not been investigated thoroughly. We hypothesized that the HA approach maintains the immunologic advantage of laparoscopic surgery compared with the open (O) approach.

Methods

Six O, HA, and laparoscopic (L) transabdominal left nephrectomies were performed on pigs. Blood samples were taken preoperatively, perioperatively, and postoperatively, and serum interleukin-6 and C-reactive protein levels were measured.

Results

At 24 hours after surgery, interleukin-6 levels were significantly higher in the O group vs the HA and L groups (82.2 vs 37.5 and 29.9 pg/mL, respectively; P < .05). Similar trends were seen at all time periods for both IL-6 and C-reactive protein. No significant differences in postoperative cytokine levels were detected between the HA and L groups.

Conclusions

The HA approach mimics the immunologic effects of laparoscopic surgery. These data suggest that the HA technique resulted in a reduced systemic immune activation in the early perioperative period when compared with open surgery. In addition to clinical benefits of minimal access, the HA approach also may afford patients an immunologic advantage over laparotomy.     

手助腹腔镜改良Sugiura 术治疗门静脉高压症的临床分析

目的：比较手助腹腔镜与开腹改良Sugiura术治疗门静脉高压症的近期临床疗效。 方法：2011年1月—2012年3月,将需行改良Sugiura术的56例门静脉高压症患者随机分为手助腹腔镜组和开腹组,每组28例,比较两组术中及术后各项临床指标。 结果：两组患者手术均获成功,无术中并发症发生。两组手术时间和术后并发症发生率差异无统计学意义（均P>0.05）,而手术切口、术中出血量、肛门排气时间、腹腔引流液量、术后住院天数比较,手助腹腔镜组均低于开腹组,差异均有统计学（均P<0.05）。术后随访1~13（平均7.32）个 月,两组食管胃底曲张静脉消除率均为100%,均未出现上消化道再出血。 结论：手助腹腔镜行改良Sugiura术既具有与开腹改良Sugiura术相同的临床疗效,又具有腹腔镜手术微创的优点。     

手辅助腹腔镜治疗胰腺实性假乳头状肿瘤一例

胰腺实性假乳头状肿瘤（SPN）是一类多为单发的罕见低度恶性肿瘤,以手术治疗为主。该文报道了1例应用手辅助腹腔镜技术治疗SPN的诊疗经过,该例为29岁女性患者,因胸骨后疼痛伴憋闷不适3个月余入院,行腹部增强CT提示为脾胰间隙囊性占位,约5.4cm×3.7cm,予手辅助腹腔镜下胰尾联合脾切除术,术后病理示SPN,患者术后3...     

Hand-assisted laparoscopic surgery for a large gastrointestinal stromal tumor of the stomach

We report two cases of large gastrointestinal stromal tumor (GIST) of the stomach that were successfully treated by hand-assisted laparoscopic surgery (HALS). Two patients, a 56-year-old woman and a 60-year-old man, were admitted to our department for the treatment of a large submucosal tumor of the stomach. After gastrointestinal endoscopy, ultrasonography, computed tomography, and magnetic resonance imaging, we suspected that the masses, measuring 7.0 cm and 8.0 cm in diameter, respectively, were GISTs in the stomach. However, preoperatively, we could not rule out the possibility of malignant neoplasms, because they had been bleeding or gradually growing. Hand-assisted laparoscopic wedge resection was safely performed for the diagnosis and treatment of the submucosal tumor of the stomach. The immunohistochemical diagnosis in both patients was GIST of the stomach with intermediate-grade malignancy. HALS may be a good indication for large GISTs of the stomach that are difficult to diagnose preoperatively, whether they are malignant or benign, because it is safe and minimally invasive, promoting rapid recovery.     

手辅助腹腔镜胃癌根治术的疗效及对患者CEA、CA199的影响

目的研究手辅助腹腔镜胃癌根治术的临床治疗效果以及对患者血清CEA和CA199的影响。方法对采用手辅助腹腔镜胃癌根治术治疗的58例患者临床资料进行回顾性分析,并对治疗效果及治疗前后患者血清肿瘤标记物CEA和CA199变化情况进行比较。结果采用手辅助腹腔镜胃癌根治术治疗的58例患者无手术死亡病例,发生胃无力2例、切口感染1例,经治疗均痊愈。患者CEA水平从术前的(20.4±2.1)ng/ml降低至术后的(4.3±1.8)ng/ml、患者CA199水平从术前的(63.1±28.9)U/ml降低至术后的(23.6±11.2)U/ml,手术前后差异均有统计学意义(P<0.05)。结论手辅助腹腔镜胃癌根治术操作难度小,疗效确切,血清肿瘤标记物CEA和CA199降低明显,术后并发症少,可作为胃癌治疗的新术式。