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Notizen: Abstract Background: During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided, the crura reapproximated, or the wrap sutured to the crus. Methods: Since first performing LNF, we have consistently utilized a 〈2.5-cm wrap performed over a 〉50 Fr dilator. Other technical details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF, two were converted to open operation (2%). In the remaining 103 patients with ≥3-month follow-up (mean 17 months), the initial 46 (group 1; 45%, mean age ± SEM = 47 ± 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients (65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the subsequent 57 LNFs (group 2; 55%, 47 ± 2 years), all patients underwent SGV division, posterior crural closure, and suture of the wrap to the crus. Results: Clinical outcome at ≥3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and 13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of these technical variables were significantly related to the improved outcome in group II. Conclusion: Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure of the crura, and fixation of the wrap to the crus during LNF.

Notizen: Abstract Background: Minimally invasive techniques offer theoretical advantages for treating resectable periampullary neoplasms. Laparoscopic pancreaticoduodenectomy (LPD) was first reported in 1992 and has been performed clinically despite lack of animal data to support the operation. The purpose of this study was to develop LPD in an acute porcine model and to assess safety and efficacy before considering clinical trials. Methods: LPD was initiated in six domestic pigs under general anesthesia. Once pneumoperitoneum was created, five 10-mm access ports were placed (one central and two in each flank). After cholecystectomy, the duodenum was mobilized and the proximal jejunum was divided distal to the ligament of Treitz. The neck of the pancreas was separated from the superior mesenteric vein, and the midstomach was divided by a stapler. Pancreaticojejunostomy (PJ), choledochojejunostomy (CDJ), and gastrojejunostomy (GJ) were performed using interrupted sutures. The animals were immediately sacrificed and the operative site was examined. Results: LPD was aborted in three animals due to complications: intestinal perforation with fecal contamination (one) and prolonged resection time ≥ 2.5 h (two). LPD was completed in three animals (operative time ranged from 5.0 to 7.5 h, blood loss 〈 200 cc); however, at sacrifice one PJ and two CDJs had small posterior leaks. The efferent loop of the GJ was narrowed by the staple line in one pig. All animals had extensive ecchymosis of the jejunal serosa due to excessive manipulation. Conclusion: Despite a significant number of anastomotic leaks in the immediate postoperative period, laparoscopic pancreaticoduodenectomy is feasible in a porcine model. Further studies and technical development are necessary before laparoscopic pancreatic resection can be performed on a more widespread basis.

Notizen: Abstract Background: Unlike sliding hiatal hernias, paraesophageal hiatal hernias (PEH) present a risk of catastrophic complications and should be repaired. To assess laparoscopic repair of PEH, we prospectively evaluated the outcome of 38 consecutive patients with type II (20 patients) or III (18 patients) PEH treated laparoscopically. Methods: With the use of 5 or 6 ports, laparoscopic PEH reduction and repair was attempted. One patient (3%) was converted to an open procedure. In the first 12 patients, the hiatus was closed using varying techniques including the placement of prothestic mesh in 6 patients, and the hernia sac was not routinely excised. In the next 25 patients, the hernia sac always was excised and the hiatus routinely sutured posteriorly to the esophagus. Twenty-nine patients also underwent either a Nissen (n= 27) or Toupet (n= 2) fundoplication, which is now performed routinely. Sutured anterior gastropexy was performed selectively in 10 of the first 20 patients, then routinely, using T-fasteners in the last 17 patients. Barium swallow studies were performed on all patients at 3 to 5 months postoperatively. Results: Mean ± standard error of the mean (SEM) age was 67 ± 2 year (range, 39–92 years; 11 men, 27 women), and the American Society of Anesthesia (ASA) score was 2.5 ± 0.1. The operating time was 195 ± 10 min: 244 ± 15 min in the first 12 patients and 170 ± 11 min in the last 25 patients (p 〈 0.001). There were three (8%) intraoperation complications, which were treated without sequelae, and four (11%) grade II postoperation morbidities. Median discharge was 3 days, and return to full activity was 14 days. Two patients (5%) died of cardiovascular disease after discharge. Barium swallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathoracic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but only 1 patient (4%) required medication for these symptoms. Conclusions: Laparoscopic PEH repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. Rapid recovery is achieved with acceptable morbidity and early outcome. Barium x-rays revealed hiatal abnormalities in a significant fraction of patients, many of whom were asymptomatic. Longer follow-up will be required to determine the ideal strategy for management of these patients.

Notizen: Abstract Background: To date, there have been only a few anecdotal reports of laparoscopic hepatectomy, most of which are limited to wedge resections. The aim of this study was to assess the feasibility of laparoscopic hepatic lobectomy in a porcine model. Methods: Eight pigs were anesthetized before placement of an abdominal wall lift device and five laparoscopic ports. With the porta hepatis clamped, the left lateral hepatic lobe was divided with an ultrasonic dissector. Small vessels and ducts were clipped, larger vascular structures were transected with staplers, and surface hemorrhage was controlled with an argon beam coagulator. Serum liver enzymes (LFTs) and blood counts were drawn pre- and postoperatively. All animals were killed after 1 week. Results: Mean ± SEM operating and clamp times were 131 ± 8 and 39 ± 2 min, respectively. There were four intraoperative complications in three animals (three lacerations of the hepatic vein and one tear of the splenic capsule), all of which were controlled at surgery. Mean blood loss was 189 ± 52 ml, and the mass of the resected specimen was 139 ± 11 g. There were no postoperative complications or deaths. White blood cell count, hematocrit, and LFTs did not change postoperatively, except for aspartate aminotransferase (AST), which was elevated transiently. There were no bile leaks or intraabdominal abscesses. Conclusions: Laparoscopic left hepatic lobectomy was technically feasible in the porcine model using an abdominal wall lift device for exposure. Clinical trials are needed to assess its feasibility and limitations before laparoscopic hepatic lobectomy is deemed safe for human use.

Notizen: Abstract Background: Among the potential hazards of laparoscopic surgery using electrocautery is the intraperitoneal release and subsequent absorption of byproducts of tissue combustion. In a porcine model of laparoscopic surgery with smoke production, our aims were to assess (1) the relationship between levels of intraperitoneal carbon monoxide (CO) and systemic carboxyhemoglobin (COHb) and methemoglobin (MetHb), and (2) intraperitoneal concentrations of other noxious gases, including hydrogen cyanide (HCN), acrylonitrile (Acr), and benzene (Bzn). Methods: Seven pigs underwent laparoscopic resection of three hepatic wedges using monopolar electrocautery in a CO2 pneumoperitoneum. Sequential arterial samples were drawn to measure [COHb] and [MetHb] perioperatively, while gaseous intraabdominal [CO], [HCN], [Acr], and [Bzn] were assayed intraoperatively. Results: The mean ± SEM duration of operation was 90 ± 2 min, and electrocautery was used for 68 ± 4 min. Intraabdominal [CO] rose from 0 to 814 ± 200 ppm (p 〈 0.01) while [COHb] increased from 2.9 ± 0.1% to 3.5 ± 0.1% (p 〈 0.001). Systemic [MetHb] remained unchanged intra- and postoperatively, ranging from 0.3 to 0.7%. Intraperitoneal [HCN] rose from 0 to 5.7 ± 0.7 ppm (p 〈 0.001). [Acr], however, did not change significantly from preoperative values, ranging from 0 to 1.6 ± 1.0 ppm, and [Bzn] was undetectable. Conclusions: Laparoscopic tissue combustion increases intraabdominal [CO] to ``hazardous'' levels leading to minimal, yet significant, elevations of [COHb]. Systemic [MetHb] and intraabdominal [HCN], [Acr], and [Bzn] are not elevated to toxic levels. Production of intraperitoneal smoke during laparoscopic electrosurgery therefore may not pose a significant threat to the patient.

Notizen: Abstract Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients.