Combined procedures in laparoscopic surgery

With advancements in minimal access surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies at the same surgery. In our center, we performed 145 combined surgical procedures from January 1999 to December 2002. Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures. The combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy, ovarian cystectomy, tubal ligation, urological procedures, fundoplication, splenectomy, hemicolectomy, and cystogastrostomy. In the same period, 40 patients who had undergone laparoscopic cholecystectomy and 40 patients who had undergone ventral hernia repair were randomly selected for comparison of intraoperative outcomes with a combined procedure group. All the combined surgical procedures were performed successfully. The most common procedure was laparoscopic cholecystectomy with another endoscopic procedure in 129 patients. The mean operative time was 100 minutes (range 30-280 minutes). The longest time was taken for the patient who had undergone laparoscopic splenectomy with renal transplant (280 minutes). The mean hospital stay was 3.2 days (range 1-21 days). The pain experienced in the postoperative period measured on the visual analogue scale ranged from 2 to 5 with a mean of 3.1. Of 145 patients who underwent combined surgical procedures, 5 patients developed fever in the immediate postoperative period, 7 patients had port site hematoma, 5 patients developed wound sepsis, and 10 patients had urinary retention. As long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery. Minimal access surgery is feasible and appears to have several advantages in simultaneous management of two different coexisting pathologies without significant addition in postoperative morbidity and hospital stay.     

Total laparoscopic aortic surgery versus minimal access techniques: review of more than 600 patients

In the following paper we describe our experience with a large number of patients in which either a laparoscopic assisted procedure or a total laparoscopic operation was performed. From 1996 until 2005 a total number of 638 aortic patients were operated on using a total laparoscopic or a laparoscopic assisted approach. A total laparoscopic operation was accomplished in 236 cases. A laparoscopic assisted aortic operation was performed in 402 patients. In aneurysm patients a tube graft was more frequently implanted. Thirty-day mortality was significantly higher in patients with a total laparoscopic abdominal aortic aneurysm repair (3.0%) compared to a laparoscopic assisted procedure (1.8%). There was no significant difference in mortality in patients with occlusive disease and a total laparoscopic aortofemoral bypass versus a laparoscopically assisted operation. The same tendency could be observed when analyzing the incidence of major perioperative complications. Again we found no significant difference in patients with occlusive disease yet more severe complications directly related to the operation in patients with a total laparoscopic aneurysm repair. There was a significantly increased complication rate in total laparoscopic aortoiliac repair with a bifurcated prosthesis compared to a tube graft repair: a tendency we could not observe in aneurysm patients with a laparoscopic assisted operation. Our data also show that there is a lot of room for technical improvements such as stapling devices or special grafts to reduce total operating times as well as the period of aortic crossclamping. The routine use of a minilaparotomy can hardly be a solution considering the technical drawbacks such as impaired vision and long term complications like ventral hernias. Compared to open surgery the midterm results of laparoscopic aortic procedures are promising. The time has come to prove that good results can be obtained in more than a few specialized centers.     

Level of evidence in minimal access pediatric surgery

INTRODUCTION: The use of minimal access techniques is rapidly expanding in pediatric surgery. Our aim was to answer two questions: (1) What is the current quality of evidence for minimal access pediatric surgery (MAPS)? and (2) Has the evidence for MAPS improved with respect to focus and methodology over a 12-year period (1995-2006)? METHODS: A systematic review was performed. Data collected included: study characteristics, methods, and outcomes recorded. Approval by a research ethics board (REB) was recorded, where applicable, and articles were assessed for the reporting of learning curves and study limitations. Studies were divided into two eras according to publication date. Data were compared by using correlation, chi-squares, and univariate analyses. RESULTS: Four hundred and ten studies met the inclusion criteria. Of those, 260 (63.4%) were published in the late era. Only 1.46% of studies were level 1, whereas level 4 evidence was predominant (71.46%). The two eras were comparable with regard to country of origin, single-institution studies, length of follow-up, and quality of outcomes reporting. More studies reported REB approval (P = 0.0001) and clearly documented limitation of study design (P = 0.03) in the late era. CONCLUSIONS: There has been a significant increase in the number of articles dealing with MAPS. Recent studies were more likely to report limitations of study design and REB approval, but overall, there was no increase in level of evidence in the MAPS literature over the past 12 years. Although more research is being published, more attention needs to be paid to producing higher quality evidence.     

胸腔镜辅助下小切口在胸椎前路手术的临床应用

目的探讨胸腔镜辅助下小切口行胸椎前路手术的可行性. 方法 2001年10月～2002年10月,我院在胸腔镜辅助下小切口行胸椎前路手术14例.其中6例胸椎转移瘤行病变椎体切除、钢板骨水泥椎体重建及前路针棒内固定;4例胸椎结核行病灶清除、植骨及前路钉棒内固定;2例胸椎间盘突出症行髓核摘除、椎间植骨融合;2例胸椎椎体骨折合并脱位行脱位椎体复位、椎管减压、椎体间植骨及前路钉棒内固定. 结果术后影像学显示病灶清除彻底,内固定效果确切.14例术后随访 4～12个月,14例胸背痛完全消失,13例脊髓压迫症中除1例转移瘤无改善外,其余12例肌力术前A～D级,术后恢复至C～E级. 结论胸腔镜辅助下小切口行胸椎前路手术方法可行,近期疗效满意.     

A microprocessor-controlled psychomotor tester for minimal access surgery

Background: There is little reported information on psychomotor performance in relation to minimal access surgery (MAS). Methods: A microprocessor-controlled endoscopic psychomotor tester (the Dundee Endoscopic Psychomotor Tester—DEPT) has been developed to evaluate psychomotor aspects of MAS. Experiments were conducted on 20 medical undergraduates to evaluate accuracy and reliability of the tester. Results: The study demonstrated a significant difference between subjects (p < 0.01). It also identified three individuals who enacted 16, 22, and 40 errors while the majority (85%) sustained less errors with a median of 4.5. Conclusions: DEPT provides a standard, reproducible, objective real-time scoring system. It identifies individuals who cannot adjust to endoscopic viewing and therefore manipulate from endoscopic images.     

A new flexible videoendoscope for minimal access surgery

Summary This study was designed to evaluate the efficacy of a new flexible videolaparoscope. The Fujinon EVL-F has standard control knobs which deflect a flexible tip at the end of a rigid section. In addition, there are standard controls for irrigation and suction as well as an instrument channel. Twenty-eight procedures were performed on 22 patients. The advantages of this instrument include the ability to perform a more thorough exploration of the abdomen and improved image quality. In addition, the instrument channel provides the capability to irrigate, suction, perform cholangiograms, or pass dissecting instruments via the laparoscope, thus reducing the required number of trocar sites.     

The two-port laparoscopic retroperitoneal approach for minimal access pancreatic necrosectomy

IntroductionDespite advances in surgery and critical care, severe pancreatitis continues to be associated with a high rate of mortality, which is increased significantly in the presence of infected pancreatic necrosis. Controversy persists around the optimal treatment for such cases, with specialist units variously advocating open necrosectomy, simple percutaneous drainage or one of several minimal access approaches. We describe our technique and outcomes with a two-port laparoscopic retroperitoneal necrosectomy (2P-LRN).MethodsThirteen consecutive patients with proven infected pancreatic necrosis were treated by 2P-LRN over a three-year period in the setting of a specialist hepatopancreatobiliary unit. The median patient age was 46 years (range: 28–87 years) and 10 of the patients were male.ResultsThe median number of procedures required to clear the necrosis was 2 (range: 1–5), with a median time to discharge following the procedure of 44 days (range: 10–135 days). There was no 90-day mortality and the morbidity rate was 38%, consisting of pancreatic fistula (31%) and bleeding (23%).ConclusionsTwo-port laparoscopic retroperitoneal necrosectomy has been demonstrated to confer similar or better outcomes to other techniques for necrosectomy. It carries the additional advantages of better visualisation, leading to fewer procedures and the opportunity to deploy simple laparoscopic instruments such as diathermy or haemostatic clips.     

Management of primary hyperthyroidism: toward minimal access surgery

Fifteen years ago, bilateral exploration of the neck was dogma in parathyroid surgery. Now, less invasive procedures can be used to target lesions identified by new tests such as dual-phase Sestamibi scanning or intraoperative documentation of parathyroid hormone (PTH) level changes after removal of a parathyroid gland. A hand-held gamma probe can be used for intraoperative detection of high-uptake lesions, and video-assisted endoscopic surgery has been used successfully. With these new techniques, surgical exploration can be confined to one side of the neck through smaller incisions associated with better cosmetic results. The operating time is reduced, and in some cases the procedure can be done under local anesthesia. The objective of this article is to describe recent changes in the management of parathyroid adenoma requiring surgery.     

腹腔镜联合手术的应用

目的：探讨腹腔镜联合手术的临床应用价值。方法：回顾分析32例腹腔镜联合手术的临床资料。结果：32例均获成功,无并发症发生及中转开腹,术后3～7d痊愈出院。结论：腹腔镜联合手术能安全有效的处理多种腹部疾病,可在同一专科或多专科中联合应用,但需严格掌握手术适应证。     

Videotunneler for minimal and direct access aortoiliac reconstructive surgery

Despite improvements in surgical practice and postoperative care, the large vertical midline or transverse transperitoneal approaches used in abdominal aortic surgery are still associated with a relatively high perioperative morbidity and mortality rate even in patients who are considered good risks for undergoing aortic surgery. This significant perioperative morbidity is partly caused by the major surgical trauma. To decrease the surgical stress on these patients we have developed a less-extensive procedure for this type of vascular reconstruction. Technique: The abdominal aorta is explored using a special retractor through a short upper median minilaparotomy utilizing modified conventional surgical hand instruments. For an aortobifemoral graft implantation, a retroperitoneal tunnel is necessary. During the creation of this tunnel special care should be exercised to avoid troublesome hemorrhage with iliac and other vein lacerations. To overcome these difficulties, we have developed a new tunneling device, which allows us to have visual control of the tunneling procedure. This prototype device contains a semiflexible tube with an inflatable balloon and a flexible videoendoscope. It is introduced along the external iliac artery into the retroperitoneal space and creates a tunnel through step-by-step inflation of the balloon. After this, the graft is implanted in the usual manner. To date, 19 abdominal vascular reconstructions have been performed with this method.