Showing papers in "Surgical Endoscopy and Other Interventional Techniques in 1998"
TL;DR: In this paper, the authors compared the bursting strength of three hundred thirty-one arteries and veins sealed by application of precisely controlled electrothermal energy and physical pressure, allowing for brief cooling in compression, in experimental animals and fresh abattoir vessels.
Abstract: Background: The inherent tedium of intracorporeal knot tying has stimulated greater interest in energy-based and mechanical alternatives for hemostasis.
Methods: Three hundred thirty-one arteries and veins were sealed by application of precisely controlled electrothermal energy and physical pressure, allowing for brief cooling in compression, in experimental animals and fresh abattoir vessels. These seals were compared for bursting strength with occlusions by ultrasonic and bipolar coagulation, surgical clips, and ligatures.
Results: Ultrasonic and bipolar occlusions were significantly less likely to have burst strengths greater than 400 mmHg as compared with seals, clips, and ligatures (p < 0.001). Seal competence could be visually assessed by its translucence.
Conclusions: Precise energy control with physical compression, including a brief cooldown, produces a distinctive, translucent seal of partially denatured protein that can typically be transected after a single application. These seals have bursting strengths comparable to those of clips and ligatures and resist dislodgement because they are intrinsic to the vessel wall structure.
721 citations
TL;DR: Lamaroscopic surgery was associated with better cosmesis than open surgery and patients do not experience laparoscopic surgery any differently from open surgery.
Abstract: Background: The objectives of this study were to evaluate body image, cosmetic results, and quality of life in patients with Crohn's disease of the terminal ileum who had either laparoscopic-assisted or open ileocolic resection, and to determine how patients experienced the pre- and postoperative periods after both procedures. Methods: Thirty-four patients participated: 11 patients after open resection (OR), 11 patients after laparoscopic-assisted resection (LR), and 12 patients without resection (WR). Retrospectively, the patients filled out several questionnaires pertaining to body image, hospital experiences, and quality of life. One-way analysis of variance, Student's t-tests, and Pearson's correlation were used for statistical analysis. Results: The cosmetic score was significantly higher in the LR than in the OR group (p < 0.01). Body image correlated strongly with cosmesis and with quality of life. The hospital experiences of the laparoscopic and open groups were similar. Conclusions: Laparoscopic surgery was associated with better cosmesis than open surgery. Patients do not experience laparoscopic surgery any differently from open surgery.
319 citations
TL;DR: The author considers the one-trocar appendectomy an appropriate alternative procedure to other techniques of laparoscopic appendectomy.
Abstract: Laparoscopic appendectomy is a safe alternative to open appendectomy to treat appendicitis. The author reports his experience in performing laparoscopic appendectomy with the use of only one trocar in pediatric patients. Between 1 January 1994 and 30 October 1995 at the Department of General and Pediatric Surgery, Division of Pediatric Surgery of the ``Federico II'' University of Naples, we performed 51 laparoscopic appendectomies. Patient age varied from 4 to 16 years with a mean age of 7 years. In the last 25 patients of our series we performed the one-trocar appendectomy, positioning only one trocar infraumbilically with the use of a 10-mm operative telescope. The appendix is identified, dissected when necessary, grasped laparoscopically with a 450-mm operative atraumatic instrument introduced through the operative channel of the laparoscope, and then exteriorized through the umbilical cannula. The appendectomy was performed using traditional method outside the abdominal cavity. We had no intra- or perioperative mortality or morbidity. The mean overall hospitalization time was 2 days (1–4 days). At a maximal follow-up of 20 months the children have no clinical problems nor any visible scar related to the laparoscopic appendectomy. In conclusion, the author considers the one-trocar appendectomy an appropriate alternative procedure to other techniques of laparoscopic appendectomy.
308 citations
TL;DR: It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar to open surgery, but the rate of bile duct injuries and leaks is higher than in open choleCystectomy.
Abstract: Background: Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed A total of 114,005 cases were analyzed and 561 major bile duct injuries (050%) and 401 bile leaks from the cystic duct or liver bed (038%) were recorded Intraoperative cholangiography (IOC) was attempted in 415% of the laparoscopic cholecystectomies and was successful in 827% In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently injured (611%) and only 14% of the patients had complete transection
293 citations
TL;DR: The increased intraperitoneal pressure necessary to perform laparoscopic operations reduces substantially the portal venous flow, and this reduction of flow may depress the hepatic reticular endothelial function and enhance cryo-ablative effect during Laparoscopic cryosurgery for metastatic liver disease by diminishing the heat sink effect.
Abstract: 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.
293 citations
TL;DR: Laroscopic skill can be measured objectively in a simulator, and performance improves progressively with practice, and these skills can be incorporated into the training and evaluation of residents in laparoscopic surgery.
Abstract: Background: Laparoscopic skill was measured objectively in a simulator Seven tasks were scored in terms of precision and speed These tasks included transferring, cutting, clip+ divide, placement of a ligating loop, mesh placement+ fixation, and suturing with intracorporeal and extracorporeal knot
289 citations
TL;DR: On March 3 1997, a telesurgical laparoscopic cholecystectomy was performed for the first time in history at the St. Blasius hospital in Dendermonde, Belgium using the Surgical Intuitive, Mountain View, California, USA device.
Abstract: On March 3 1997, a telesurgical laparoscopic cholecystectomy was performed for the first time in history at the St. Blasius hospital in Dendermonde, Belgium. The device used was the ‘‘Mona’’ from Surgical Intuitive, Mountain View, California, USA. After clearance from the local ethical committee and after informed consent had been obtained, the patient, a 72-year-old woman with a body mass index of 42 kg/m 2
252 citations
TL;DR: The laparoscopic approach has a recurrence rate similar to that for open procedures for colon cancer, however, additional follow-up of these patients is needed before it can be determined whether or not the laparoscope approach influences overall survival.
Abstract: Background: This study was performed to prospectively assess the impact of the laparoscopic approach to the patterns of port site metastases (PSM) and recurrence rate (RR) of resected colon carcinomas as compared with conventional colectomies. Methods: All patients were included in a prospective randomized trial comparing laparoscopic-assisted colectomy (LAC) versus open colectomy (OC) for colon cancer. The randomization was stratified for localization of the lesion. Patients with metastasic disease at the time of the surgery were excluded. Follow-up in the outpatient clinic was done every 3 months for a minimum of 12 months. Endpoints for the study were metastasis at port site and laparotomy incision as well as recurrence rate. Results: Of 91 segmental colectomies performed from November 1993 to January 1996, there were 44 LAC and 47 OC. Patient data were similar in both groups (age, sex, Dukes stage, type of operation). Mean follow-up was 21.4 months, with a range of 13 to 41 months. There were no wounds or PSM in those series. RR was similar for both groups. For LAC, it was five of 31 (16.1%); for OC, it was six of 40 (15%). Conclusions: The laparoscopic approach has a recurrence rate similar to that for open procedures for colon cancer. However, additional follow-up of these patients is needed before we can determine whether or not the laparoscopic approach influences overall survival.
231 citations
TL;DR: Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery, and appears safe, especially if an ePTFE mesh is used.
Abstract: Background: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias ≥4 cm2) is being used in a prospective, multicenter, long-term study.
224 citations
TL;DR: This study confirms that analgetic requirements are lower and pain is less intense after laparoscopic than after conventional colorectal resection, and patients also experience less fatigue after minimal invasive surgery.
Abstract: Background: Conventional colorectal resections are associated with severe postoperative pain and prolonged fatigue. The laparoscopic approach to colorectal tumors may result in less pain as well as less fatigue, and may improve postoperative recovery after colorectal resections.
223 citations
TL;DR: Transanal endoscopic microsurgery for the treatment of low-risk T1 carcinomas is associated with a significantly lower complication rate thanradical surgical therapy, and there is no difference in 5-year survival between local and radical surgical therapy in patients with low- risk T 1 carcinoma.
Abstract: Background: We compared the results of transanal endoscopic microsurgery and radical surgery in patients with T1 carcinomas of the rectum
TL;DR: There is a need to evaluate the ergonomic integration and suitability of the laparoscopic operating room environment to address the issues of efficiency, safety, and comfort for the operating team.
Abstract: Laparoscopic surgery provides patients with less painful surgery and a more rapid recovery, while requiring that surgeons work harder and in a more remote manner from the operating field. Cost-containment pressures on surgeons demand efficient surgery, whereas the increased technological complexity and sometimes poorly adapted equipment have led to increased complaints of surgeon fatigue and discomfort during laparoscopic surgery. There is, therefore, a need to evaluate the ergonomic integration and suitability of the laparoscopic operating room environment to address the issues of efficiency, safety, and comfort for the operating team. This approach is particularly important in the design of laparoscopic surgical instruments. A review of the literature on the biomechanics of laparoscopic surgical instrument use was combined with data from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Ergonomics Questionnaire and demonstration station. Laparoscopic instruments suffer from ergonomically inadequate handle designs and inefficient handle to tip force transmission, which lead to surgeon fatigue, discomfort, and hand paresthesias. Improvements in the design of laparoscopic instruments are needed to decrease the work and discomfort of tissue manipulation during video-endoscopic surgery.
TL;DR: The incidence of recurrence after laparoscopic hernioplasty performed by experienced surgeons was extremely low and that some causes could be corrected by experience, whereas others will require changes in technique or equipment.
Abstract: Background: To determine if there are common factors beyond the learning curve that lead to recurrence after laparoscopic hernioplasty, we analyzed failures seen in seven centers specializing in laparoscopic hernia repair.
TL;DR: Improved cholangiographic technique and interpretation should decrease injury severity, delays in diagnosis, and subsequent morbidity in Iatrogenic common bile duct injury.
Abstract: Background: Iatrogenic common bile duct injury is the worst complication of laparoscopic cholecystectomy. The goal of this study is to increase awareness of the problem and educate surgeons about the consequences of these injuries.
TL;DR: Electrosurgical smoke produced in a closed environment contains several toxic chemicals and the effects of these on cell viability, macrophage, and endothelial cell activation are not known but are being investigated.
Abstract: Background: High-frequency (HF) electrocoagulation and cutting procedures produce smoke by high-temperature pyrolysis of tissues. As distinct from the experience of conventional surgery, electrosurgical smoke is produced in a closed gaseous environment during laparoscopic operations. As a result, toxic chemicals may be absorbed into the circulation. The effects of this absorption are not known. Furthermore, the chemical composition of electrosurgical smoke produced in an anoxic environment may be different from that produced in air.
TL;DR: In this article, the technical aspects, intraoperative complications, morbidity, and mortality of laparoscopic cholecystectomy in a multi-institutional study representative of Switzerland were analyzed.
Abstract: Background: We set out to analyze the technical aspects, intraoperative complications, morbidity, and mortality of laparoscopic cholecystectomy in a multi-institutional study representative of Switzerland
TL;DR: Care may be needed with laparoscopy in patients at risk for increased ICP due to head injury or a space occupying lesion because of impaired venous drainage of the lumbar venous plexus at increased intraabdominal pressure.
Abstract: Background: Previous studies have documented an increase in intracranial pressure with abdominal insufflation, but the mechanism has not been explained. Methods: Nine 30–35-kg domestic pigs underwent carbon dioxide insufflation at 1.5 l/min. Intracranial pressure (ICP), lumbar spinal pressure (LP), central venous pressure (CVP), inferior vena cava pressure (IVCP), heart rate, systemic arterial blood pressure, pulmonary arterial pressure, cardiac output, heart rate, respiratory rate, temperature, and end-tidal CO2 were continuously measured. Mechanical ventilation was used to maintain a constant pCO2. Measurements were recorded at 0, 5, 10, and 15 mmHg of abdominal pressure with animals in supine, Trendelenburg (T), and reverse Trendelenburg (RT) positions. Prior to recording measurements, the animals were allowed to stabilize for 40 min after each increase in abdominal pressure and for 20 min after each position change. Results: The animals showed a significant increase in ICP (mmHg) with each 5-mmHg increase in abdominal pressure (0 mmHg: 14 ± 1.7; 5 mmHg: 19.8 ± 2.3, p < 0.001; 10 mmHg: 24.8 ± 2.5, p < 0.001; 15 mmHg: 29.8 ± 4.7, p < 0.01). The ICP at 15 mmHg abdominal pressure increased further in the T position (39 ± 4, p < 0.01). Insufflating in the RT position did not significantly reduce the increase in ICP. The IVCP (mmHg) increased with increased abdominal pressure (0 mmHg: 11.5 ± 6.2, 15 mmHg: 22.1 ± 3.5, p < 0.01). This increase correlated with the increase in ICP and LP (r of mean pressures ≥0.95). There was no significant change in CVP. Conclusions: This study suggests that care may be needed with laparoscopy in patients at risk for increased ICP due to head injury or a space occupying lesion. The mechanism of increased ICP associated with insufflation is most likely impaired venous drainage of the lumbar venous plexus at increased intraabdominal pressure. Further studies of cerebral spinal fluid movement during insufflation are currently underway to confirm this hypothesis.
TL;DR: Spillage of gallstones after laparoscopic cholecystectomy is fairly common and occurs in about 6% of patients, however, abscess formation with subsequent surgical therapy remains a minor problem.
Abstract: Background: Spilled gallstones after laparoscopic cholecystectomy may cause abscess formation, but the exact extent of this problem remains unclear.
TL;DR: The first case reported of an endoscopic subtotal parathyroidectomy in a 37-year-old man with a history of severe pancreatitis and pancreatic calculi is performed, making us optimistic about the future of endoscopic neck surgery.
Abstract: Background: The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties.
TL;DR: The technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of a minimally invasive approach.
Abstract: Background: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In our experience, ∼20–25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap.
TL;DR: The natural history of gallstone disease during pregnancy is defined and laparoscopic cholecystectomy is evaluated to evaluate the safety of LC during pregnancy to find a feasible and safe method for treating severely symptomatic patients.
Abstract: Background: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy.
TL;DR: Elevated intraabdominal pressure (IAP) with CO2 insufflation may cause a decrease in hepatic blood flow and induce severe liver damage, especially in patients with poor liver function.
Abstract: Background: Laparoscopy under carbon dioxide (CO2) pneumoperitoneum has many advantages. However, the risks of CO2 pneumoperitoneum during laparoscopic hepatectomy (LH) have not been defined.
TL;DR: Currently, the voice control is more accurate and has the advantage of not requiring the surgeon to look away from the operative field, however, it is slower and may require more attention as an interface.
Abstract: Background: In order for robotic devices to be introduced successfully into surgical practice, the development of transparent surgeon/machine interfaces is critical. Methods: This study evaluated the standard foot pedal for the AESOP robot compared to a voice control interface. Speed, accuracy, learning curves, durability of learning at 2 weeks, and operator-interface failures were analyzed in an ex vivo model. Results: Foot control was faster and had less operator-interface failures. Voice control was more accurate as measured by ``pass points.'' The foot control learning curve reached a plateau at the third trial, while the voice control did not fully plateau. Durability of learning favored the foot control but was not significantly different. Conclusions: Currently, the voice control is more accurate and has the advantage of not requiring the surgeon to look away from the operative field. However, it is slower and may require more attention as an interface. As voice recognition software continues to advance, speed and transparency are anticipated to improve.
TL;DR: This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens and residual splenic tissue is detectable in half of the patients during the follow-up.
Abstract: BACKGROUND: The ultimate goal of surgery for hematological disorders is the complete removal of both the spleen and accessory spleens in order to avoid recurrence of the disease. Whereas splenectomy by open surgery provides excellent results, the validity of laparoscopic splenectomy in this regard remains unknown. OBJECTIVE: The purpose of this study was to evaluate the detection of accessory spleens during laparoscopic splenectomy for hematologic diseases. METHODS: We therefore evaluated the pre-, intra-, and postoperative detection of accessory spleens in a consecutive series of 18 patients treated by elective laparoscopic splenectomy for hematological diseases by using computed tomography (CT) and denatured red blood cell scintigraphy (DRBCS). RESULTS: Preoperative CT, DRBCS, and laparoscopic exploration detected 25%, 25%, and 75% of accessory spleens, respectively. At time of laparoscopy, 16 accessory spleens were detected in seven of the 18 patients (41%). In two patients (11%), laparoscopic exploration failed to detect accessory spleens, whereas preoperative CT (one case) and DRBCS (one case) did reveal them. Postoperatively, during a mean follow-up of 28 months (median, 24; range, 12-44 months), nine patients (50%) showed persistence of splenic tissue by DRBCS, and three of them had signs of disease recurrence. CONCLUSIONS: This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens. Moreover, after such a laparoscopic approach, residual splenic tissue is detectable in half of the patients during the follow-up.
TL;DR: This is the first report of an appendiceal mucinous tumor resected by laparoscopy associated with subsequent diffuse peritoneal carcinomatosis and reaffirms that dissemination of cancer may be associated with laparoscopic resection of structures containing a malignancy.
Abstract: Indications and contraindications to laparoscopic surgery continue to be refined. Laparoscopic appendectomy for acute appendicitis is frequently selected by patients and surgeons, and clinical studies show it to be a reasonable alternative. In this case study, laparoscopic surgery was used to resect an appendiceal mucocele caused by a nonperforated mucinous adenocarcinoma. Implants of mucinous tumor were found widely disseminated on peritoneal surfaces at laparotomy 9 months later. As a result of this case study, the authors suggest that when an appendiceal mucinous tumor is encountered at laparoscopy, a special situation requiring totally atraumatic appendectomy is indicated. This clinical situation should be considered an indication for conversion to open appendectomy. All appendiceal tumors, including the most benign-appearing adenomas, can result in diffuse peritoneal implantation. This is the first report of an appendiceal mucinous tumor resected by laparoscopy associated with subsequent diffuse peritoneal carcinomatosis. This patient presentation reaffirms that dissemination of cancer may be associated with laparoscopic resection of structures containing a malignancy.
TL;DR: Laroscopic colectomy for benign colorectal diseases was associated with significantly less disability than was laparotomy in terms of length of hospitalization as well as return to baseline partial and full activity and employment.
Abstract: Background: The aim of this study was to evaluate disability after laparoscopic colectomy in patients with benign colorectal disease. Methods: Patients who underwent laparoscopic colectomy for benign colorectal diseases were matched with patients who underwent laparotomy for the same diseases by the same surgeons during the same time period. A standardized questionnaire used to assess disability included days until return to partial activity, full activity, and work. Results: Seventy-one patients who underwent laparotomy were compared with 71 patients who underwent laparoscopy. Pathology included 26 patients with adenoma, 23 with Crohn's disease, 13 with diverticulitis, and 9 with reversal of Hartmann's procedure in each group. Procedures were partial colectomy with ileocolostomy, colocolostomy, or colorectostomy. There were no significant differences (p > 0.05) in age (55.8 vs. 59.7 years) or in the incidence of perioperative complications (25% vs. 29%) between the laparoscopy and laparotomy groups, respectively. The operative time was longer in the laparoscopic group than in the laparotomy group: 165 versus 122 min (p < 0.001). However, length of hospitalization, return to partial and full activity, and time off of work were significantly shorter in the laparoscopy than in the laparotomy group: 6.3 versus 9.0 days, 2.1 versus 4.4 weeks, 4.2 versus 10.5 weeks and 3.8 versus 7.5 weeks, respectively (p < 0.01 for all). Conclusions: Laparoscopic colectomy for benign colorectal diseases was associated with significantly less disability than was laparotomy in terms of length of hospitalization as well as return to baseline partial and full activity and employment.
TL;DR: The current state of the art of common bile duct stones management is summarized, including principal guidelines and an extensive review of the literature, according to an international panel of experts.
Abstract: Background: Common bile duct stones (CBDS) are a frequent problem (10–15%) in patients with symptomatic cholecystolithiasis. Over the last decade, new diagnostic and surgical techniques have expanded the options for their management. This report of the Consensus Development Conference is intended to summarize the current state of the art, including principal guidelines and an extensive review of the literature.
Methods: An international panel of 12 experts met under the auspices of the European Association of Endoscopic Surgery (EAES) to investigate the diagnostic and therapeutic alternatives for gallstone disease. Prior to the conference, all the experts were asked to submit their arguments in the form of published results. All papers received were weighted according to their scientific quality and relevance. The preconsensus document compiled out of this correspondence was altered following a discussion of the external evidence made available by the panel members and presented at the public conference session. The personal experiences of the participants and other aspects of individualized therapy were also considered.
Results: Our panel of experts agreed that the presence of common bile duct stones should be investigated in all patients with symptomatic cholecystolithiasis. Based on preoperative noninvasive diagnostics, either endoscopic retrograde cholangiopancreaticography (ERCP) or intraoperative cholangiography should be employed for detecting CBDS. Eight of the 12 panelists recommended treating any diagnosed CBDS. For patients with no other extenuating circumstances, several treatment options exist. Stones can be extracted during ERCP, or either before or (in exceptional cases) after laparoscopic or open surgery. Bile duct clearance should always be combined with cholecystectomy. Evidence for further special aspects of CBDS treatment is equivocal and drawn from nonrandomized trials only.
Conclusions: The management of common bile duct stones is currently undergoing some major changes. Many diagnostic and therapeutic strategies need further study.
TL;DR: Tissue trauma at trocar sites and leakage of CO2 along a trocar appear to promote implantation and growth of tumor cells at port sites.
Abstract: 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.
TL;DR: LC can be performed safely under epidural anaesthesia in patients with severe COPD and can be effectively controlled with small doses of opioid analgesia.
Abstract: Background: Laparoscopic cholecystectomy (LC) has become firmly established as a procedure of choice for gallstone disease. The procedure usually necessitates general anaesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment secondary to the induction of pneumoperitoneum. There is a paucity of data in the literature on the procedure being performed under regional (epidural) anaesthesia, especially in patients with coexisting pulmonary disease and pregnancy, who are deemed high risk for general anaesthesia. We report our preliminary experience with LC using epidural anaesthesia in patients with chronic obstructive pulmonary disease (COPD). Methods: We performed LC in six patients (one man and five women), with a median age of 56 years (range, 38–74), under epidural anaesthesia over an 8-month period. All patients were ASA grade III/IV and the mean FEV1/FVC was 0.52 (range, 0.4–0.68), due to chronic asthma (two cases) and COPD (four cases). They were admitted a day prior to surgery for pulmonary function tests, nebulisers, and chest physiotherapy. An epidural catheter was introduced at T10/11 intervertebral space, and a bolus of 0.5% Bupivacaine was administered. Depending on the patient's pain threshold and the segmental level of analgesia achieved, incremental doses of 2 ml of 0.5% Bupivacaine along with boluses of intravenous 100 mcg Alfentanil was given to each patient. The patients were breathing spontaneously. No nasogastric tube was inserted, and a low-pressure (10 mmHg) pneumoperitoneum was created. LC was performed according to the standard technique. Results: All the patients tolerated the procedure well and made an uneventful postoperative recovery. Median operating time was 50 min; average length of hospital stay was 2.5 days (range, 2–4). The epidural catheter was removed the morning after the operation. Only one patient required postoperative opioid analgesia. Two patients complained of persistent shoulder tip pain during surgery and required intraoperative analgesia (Alfentanil). There was no change in the patient's cardiorespiratory status, including pO2 and pCO2, and no complications occurred either intra- or postoperatively. Conclusions: LC can be performed safely under epidural anaesthesia in patients with severe COPD. Intraoperative shoulder tip or abdominal pain does not seem to be a major deterrent and can be effectively controlled with small doses of opioid analgesia.
TL;DR: Laroscopic colorectal operations are still rare (about 1% of all coloreCTal operations in Germany).
Abstract: Background: Prospective randomized multicenter studies comparing laparoscopic with open colorectal surgery are not yet available. Reliable data from prospective multicenter studies involving consecutive patients are also lacking. On the basis of the personal caseloads of specialized surgeons or of retrospective analyses, it is difficult to judge the true effectiveness of this new technique. This study aims to investigate the results of laparoscopic colorectal surgery in consecutive patients operated on by unselected surgeons. Methods: This observational study was begun August 1, 1995, in the German-speaking part of Europe (Germany and Austria) and 43 centers initially agreed to participate. All consecutive cases were documented. All data were rendered anonymous. Analysis was performed on an intention-to-treat basis. The study committee was blinded to the participating center. Results: By the end of the 1st year, 500 patients (M:F ratio 0.83, mean age 62.9 years) had been treated by 18 centers; 269 operations were performed for benign indications and 231 for cancer (palliative and curative). Most operations were done on the distal colon or rectum. An anastomosis was performed in 84%, with an overall leakage rate of 5.3% (colon 3.6% and rectum 11.8%), which required surgical reintervention in 1.7%. The mean operating time was 176 min and showed a decreasing tendency over the period under study. The conversion rate was 7.0% and the overall complication rate 21.4%. The reoperation rate was 6.6%; the most common cause was bleeding. There was one ureteral lesion (0.2%), but urinary tract infections were fairly common (4.8%). A postoperative pneumonia was diagnosed in 1.6% of the cases. No thromboembolic complications were reported. The 30-day mortality rate was 1.4% and overall hospital mortality 1.8%. Conclusions: Laparoscopic colorectal operations are still rare (about 1% of all colorectal operations in Germany). Laparoscopic procedures are more common on the left colon and rectum than on the right colon. The surgical complication rate is acceptable, comparable with rates reported by others for open surgery. Cardiopulmonary and thromboembolic complications were rarely seen. Mortality and surgical morbidity rates do not differ significantly among participating centers. A learning curve, reflected by a shortening of the operating time and a somewhat lower conversion rate, was observed over the observation period.