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Erratum

Surg Endosc (1997) 11: 1141

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

The sensitivity of new color systems in blood-flow diagnosis: the maximum entropy method and angiocolor comparative in vitro flow measurements to determine sensitivity, by C. Sohn and H.P. Weskott (Surg Endosc 11: 10401044) In this article that appeared in the October issue of Surgical Endoscopy, three figures that should have appeared in color appeared in black and white. The figures are reprinted here in color. The publisher apologizes for any inconvenience.

Fig. 1. Comparison of principle of power Doppler and conventional color Doppler imaging.

Fig. 2. A Color Doppler imaging: time and velocity of blood flow at one spatial point. B Spatial distribution of mean velocities depending from the time. Fig. 3. Autocorrelation.

Surg Endosc (1997) 11: 10841087

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Minimally invasive management of low-grade and benign gastric tumors


J. Buyske,1 M. McDonald,2 C. Fernandez,2 J. L. Munson,2 L. E. Sanders,2 J. Tsao,2 D. H. Birkett2
1 2

Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA Department of General Surgery, Lahey Hitchcock Clinic, 41 Mall Road, Burlington, MA 01805, USA

Received: 17 March 1997/Accepted: 28 May 1997

Abstract Background: Benign gastric tumors and tumors of lowgrade malignancy can be safely removed laparoscopically. Methods: Seven patients were considered candidates for laparoscopic resection of gastric tumors. Inclusion criteria included small tumor size (less than 6 cm), exophytic or endophytic tumor morphology, and benign characteristics. Indications for surgical intervention included bleeding, weight loss, and need for tissue diagnosis. Patients ranged in age from 38 to 70. There were five female and two male patients. All patients underwent preoperative upper GI endoscopy. The procedures were performed using a four- or five-port technique. An Endo-GIA (US Surgical Company, Norwalk, Connecticut) was used to amputate those tumors located on the serosal surface of the stomach. Tumors on the mucosal surface were exposed via a gastrotomy, then likewise amputated using an Endo-GIA. The gastrotomy closure was then either hand sewn or stapled. Operating time ranged from 95 to 225 min. Results: Final pathologic diagnoses included lipoma, lymphoma, leiomyoma, and leiomyosarcoma. There was a 28% conversion rate. There were no complications. Length of postoperative stay ranged from 4 to 7 days. There have been no tumor recurrences in 638-month follow-up. Conclusions: Minimally invasive management of benign and low-grade gastric tumors can be performed safely with excellent short- and long-term results. Key word: Gastric tumor Gastric resection Laparoscopy Minimally invasive surgery

Minimally invasive techniques have been applied to various disorders of the stomach and gastroesophageal junction, including laparoscopic myotomy for achalasia [3, 5, 16, 21], laparoscopic fundoplication for the treatment of reflux [4, 10, 11, 19], highly selective vagotomy for the treatment of peptic ulcer disease [2, 12], and formal gastric resection with reconstruction for both ulcer disease and tumor [9]. Patients requiring diagnostic or therapeutic excision of tumors of the stomach have traditionally required laparotomy. Such tumors are often adequately treated with wedge resection [20]. Several authors have presented case reports and small series of laparoscopic resection of such tumors [1, 68, 1315, 17, 18, 2224]. We here present our experience with a safe and simple approach to minimally invasive management of low-suspicion tumors of the stomach.

Methodology
From January of 1993 to October of 1995 seven patients were identified as candidates for laparoscopic wedge resection of gastric tumors. Patients ranged in age from 38 to 70 years. Five were female and two were male. Three patients presented with gastrointestinal (GI) bleeding, two with early satiety, one with epigastric pain, and one had a lesion discovered incidentally during a workup for bacterial endocarditis. A summary of this information is presented in Table 1. All patients underwent preoperative upper GI endoscopy. In two cases upper GI fluoroscopy was also performed, and abdominal computerized tomography (CT) for additional diagnostic information was used in four cases (Fig. 1). All patients underwent diagnostic laparoscopy; the plan was to perform a minimally invasive wedge resection of the tumor. The camera port was placed in the infraumbilical location. Two additional ports were placed in the upper abdomen to aid in identifying the location of the tumor by palpation with a closed grasping instrument. After identification of the tumor, one or two more ports were placed to allow for manipulation of the stomach and tumor with Babcock clamps. For access to the posterior wall of the stomach, and to allow for easier mobilization of the tumor, the stomach was divided from the greater omentum using either clips or the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio). Tumors located on the anterior wall of the stomach were resected by grasping and elevating the mass with a Babcock clamp and simultaneously stapling and dividing the base using and Endo-GIA. Tumors located on the posterior wall of the stomach were first exposed by

Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA 1922 March 1997 Correspondence to: J. Buyske

1085 Table 1. Laparoscopic gastric resections Presenting symptoms Early satiety Bleeding Incidental finding Epigastric pain Bleeding Bleeding Size tumor 3 cm 0.7 0.5 cm 4.2 3.4 cm 5 3 cm 5.5 2.0 cm 4.5 4.0 cm Operative time 95 135 115 110 110 225 Days nasogastric tube 3 1 2 3 3 3 In-hospital days 6 5 7 7 4 6

Age 1 2a 3 4 5 6
a

Sex M F F F F F

Diagnosis Leiomyoma Lymphoma Leiomyoma Lymphoma Lipoma Leiomyoma

61 49 38 62 70 66

Laparoscopically-assisted.

Fig. 2. An anterior gastrotomy is made using the electocautery and stapler.

Fig. 3. A posterior mass is elevated through the gastrotomy. Fig. 1. CT scans showing (a) an endophytic lesion and (b) an exophytic lesion that were removed by laparoscopic wedge resection. the nasogastric tube, and the staple lines were observed for any leak. In one case although there was no apparent leak, the stomach was felt to have an insecure closure. The staple line was exteriorized and oversewn through a 4-cm extension of a trocar site. The specimens were removed in a bag via one of the port sites. Margins as well as histology were evaluated with frozen section. Pathologic diagnoses included one lipoma, three leiomyomas, and two lymphomas. In one case the tumor was found to be a leiomyosarcoma, and the patient underwent conversion to laparotomy for further exploration, wide excision, and reconstruction. All patients were placed on nasogastric suction postoperatively. Nasogastric tubes were removed and feedings were initiated when clinical signs of peristalsis returned.

performing an anterior gastrotomy. An incision was made in the stomach immediately overlying the tumor using the electrocautery. The gastrotomy was then enlarged with the stapling device (Fig. 2). Stay sutures were placed to retract the edges of the stomach wall. The mass on the posterior wall was then grasped and elevated anteriorly through the gastrotomy (Fig. 3). At this point a stapler was fired across the tented-up posterior gastric wall, removing the tumor and simultaneously sealing the defect in the posterior wall (Fig. 4). The gastrotomy on the anterior wall was then closed using the stapler (Fig. 5). Integrity of the staple line was tested by submerging the stomach in irrigation fluid and then insufflating air via the nasogastric tube. In some cases methylene blue was also administered via

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Fig. 4. A stapler is fired across the tented-up posterior gastric wall.

available for all cases in the event that we had difficulty in locating the tumor, but we did not need to use this additional modality. Other authors have reported this to be useful [6, 18, 22]. The ability to obtain negative margins without compromising the lumen of the bowel was of preoperative concern. Intraoperative pathology consultation was used to assure negative margins, and in short-term follow-up there has not been any evidence of either tumor recurrence or gastric obstruction. One technical challenge that had not been anticipated was that it was frequently difficult to grasp and elevate these solid masses. Smaller instruments tended to slip off, and sharp graspers run the risk of violating the tumor. Although we were always successful in obtaining control of the tumor using simple grasping and retracting instruments, other authors have described the use of sutures through the stomach wall as well as T-fasteners to aid in elevating the involved area [17]. The technique of anterior gastrotomy for tumors located on the posterior wall has been recently described [8]. We independently arrived at this technique, and we agree that it provides excellent access to posterior tumors. All tumors resected in this manner were completely excised with negative margins. Conclusion A minimally invasive approach to benign tumors of the stomach appears to offer a safe and effective alternative to laparotomy. A high degree of suspicion for the presence of malignancy must be maintained. Should preoperative assessment or intraoperative pathology consultation reveal malignancy, then appropriate oncologic principles should be followed, including conversion to an open procedure where indicated. In the presence of benign disease a simple laparoscopic wedge resection is a viable option that is available to all laparoscopic surgeons. References
1. Abercrombie JF, McAnena OJ, Rogers J, Williams NS (1993) Laparoscopic resection of a bleeding gastric tumor. Br J Surg 80: 373 2. Cardiere GB, Himpens J, Bruyns J (1994) Laparoscopic proximal gastric vagotomy. Endosc Surg Allied Technol 2: 105108 3. Cuschieri A (1993) Endoscopic oesophageal myotomy for specific motility disorders and non-cardiac chest pain. Endosc Surg Allied Technol 1: 280287 4. Cuschieri A, Hunter J, Wolfe L, Swanstrom LL, Hutson W (1993) Multicenter prospective evaluation of laparoscopic antireflux surgery. Surg Endosc 7: 505510 5. Delgado F, Bolufer JM, Martinez-Abad M, Martin J, Blanes F, Castro C, Moreno-Osset E, Mora F, Benages A (1996) Laparoscopic treatment of esophageal achalasia. Surgical Laparosc Endosc 6: 8390 6. DiLorenzo N, Sica GS, Gaspari AL (1996) Laparoscopic resection of gastric leiomyoblastoma. Surg Endosc 10: 662665 7. Fowler DL, White SA (1991) Laparoscopic resection of a submucosal gastric lipoma: a case report. J Laparoendosc Surg 1: 303306 8. Geis WP, Baxt R, Kim HC (1996) Benign gastric tumors. Minimally invasive approach. Surg Endosc 10: 407410 9. Goh P (1995) Laparoscopic gastric resection. Bildgebung 62(Suppl 1): 43 10. Hinder R, Filipi C, Wetscher G, Neary P, DeMeester T, Perdikis G

Fig. 5. The gastrotomy is closed using a stapler.

Results Laparoscopic wedge resection of the tumor was completed in all cases. Tumors ranged in size from 0.7 cm to 5.5 cm in diameter. Two cases were converted to open or lap-assisted procedures, one to allow for wider excision in the case of a leiomyosarcoma and one to better secure the gastric staple line. This represents a conversion rate of 28%. There were no complications of bleeding, leakage of the suture line, obstruction, or infection. In 638-month followup there has been no evidence of tumor recurrence. The duration of nasogastric tube drainage ranged from 1 to 3 days. Time from surgery to discharge ranged from 4 to 7 days. These results are summarized in Table 1. Discussion A minimally invasive approach to benign and low-grade tumors of the stomach has allowed us to avoid unnecessary laparotomy in selected patients. In no case did we have any difficulty locating the tumor. In most cases the tumor was immediately visible by virtue of distorting the overlying collapsed stomach. Where this was not the case, we were able to palpate the tumor by running a closed instrument over the stomach. Intraoperative endoscopy was made

1087 (1994) Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 220: 472483 Jamieson G, Watson D, Jones-Britten R, Mitchell P, Anvari M (1994) Laparoscopic Nissen fundoplication. Advances in surgical techniques. Ann Surg 220: 137145 Kathouda N, Heimbucher J, Mouiel J (1994) Laparoscopic posterior vagotomy and anterior seromyotomy. Endosc Surg Allied Technol 2: 9599 Lacy AM, Tabet J, Grande L, Garcia-Valdecasas JC, Fuster J, Delgado S, Visa J (1995) Laparoscopic-assisted resection of a gastric lipoma. Surg Endosc 9: 995997 Llorente J (1994) Laparoscopic gastric resection for gastric leiomyoma. Surg Endosc 8: 887889 Lukaszczyk JJ, Preletz RJ Jr (1992) Laparoscopic resection of benign stromal tumor of the stomach. J Laparoendosc Surg 2: 331334 Oddsdottir M (1996) Laparoscopic management of achalasia. Surg Clinic North Am 76: 451458 Ohgami M, Otani Y, Kumai K, Kuboat T, Kitajima M (1996) Laparoscopic surgery for early gastric cancer. Nippon Geka Gakka Zasshi. J Japan Surg Soc 97: 279285 Payne WG, Murphy CG, Grossbard LJ (1991) Combined Laparoscopic and Endoscopic approach to resection of gastric leiomyoma. J Laparoendosc Surg 5: 119122 Peters J, Heimbucher J, Kauer W, Incarbone R, Bremner C, Demeester T (1995) Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Coll Surg 180: 385393 Sebastian MW (1997) Benign tumors of the stomach. In Sabiston, DC (Ed) Textbook of Surgery. 15th ed. WB Saunders, Philadelphia, PA. pp 871872 Swanstrom LL, Pennings J (1995) Laparoscopic esophagomyotomy. Surg Endosc 9: 286290, discussion 290292 22. Trias M, Targarona EM, Balague C, Bordas JM, Cirera I (1996) Endoscopically-assisted laparoscopic partial gastric resection for treatment of a large benign gastric adenoma. Surg Endosc 10: 344346 23. Watson DI, Game PA, Devitt PG (1996) Laparoscopic resection of benign tumors of the posterior gastric wall. Surg Endosc 10: 540541 24. Yamashita Y, Bekki F, Kakegawa T, Umetani H, Yatsuka K (1995) Two laparoscopic techniques for resection of leiomyoma in the stomach. Surg Laparosc Endosc 5: 3842

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

Discussion Dr. Hunter: Is there any way that you can tell preoperatively about the risk of leiomyosarcoma in your specimen. I would imagine that youre not going to want to take those on if there are features that might predict malignancy. Dr. Buyske: Most of the tumors underwent endoscopic biopsy. Two of the ones that were bleeding were not actually biopsied ahead of time. The leiomyosarcoma was biopsied, and retrieved only normal gastric mucosa as a submucosal lesion. I think both MRI and endoscopic ultrasound might help in distinguishing between benign and malignant lesions. That particular tumor was actually small, and had no features of malignancy. In all cases our margins were negative, including that case. In 6-38 month follow-up none of the tumors have recurred.

Surg Endosc (1997) 11: 10751079

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Production and systemic absorption of toxic byproducts of tissue combustion during laparoscopic surgery
J. S. Wu, D. R. Luttmann, T. A. Meininger, N. J. Soper
Department of Surgery, Washington University School of Medicine, Box 8109, Suite 6108, One Barnes Hospital Plaza, St. Louis, MO 63110, USA Received: 3 April 1997/Accepted: 22 May 1997

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.

Key words: Carbon monoxide Pneumoperitoneum Carboxyhemoglobin Methemoglobin Laparoscopic surgery Smoke

Presented at the annual scientific session of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA, 1922 March 1997 Correspondence to: N. J. Soper

Since its introduction in the United States in 1988, laparoscopic cholecystectomy has rapidly become the new gold standard therapy for uncomplicated cholelithiasis, replacing the traditional open operation in most patients. Other laparoscopic abdominal operations are also increasing in popularity due to their advantages for patients in terms of minimal abdominal wall trauma, decreased postoperative pain, shorter hospital stay, and earlier return to normal physical activities compared to their open counterparts [17]. However, among the disadvantages of laparoscopic surgery are the detrimental effects from the closed abdomen and CO2 pneumoperitoneum [6, 10, 19]. One theoretical disadvantage that has not been thoroughly investigated is that of smoke generated by electrocautery in the CO2 pneumoperitoneum. The gaseous products of tissue combustion in this setting could be dangerous to the patient as a result of transperitoneal absorption into the systemic circulation or dangerous to the operating room personnel as a result of smoke evacuated through trocar valves. Three studies have documented elevated intraperitoneal [CO] in patients undergoing laparoscopic operations using electrocautery. Two of those studies also found elevated systemic carboxyhemoglobin (COHb) levels due to transperitoneal absorption of CO [9, Ott personal communication] while one study did not [5]. In addition, Ott reported elevated systemic methemoglobin (MetHb) levels and detected 26 additional toxic chemical by-products resulting from pyrolysis of protein and lipids in the pneumoperitoneum during laparoscopic surgery [15]. The concentrations of these compounds were not measured and the significance of these findings and their risks are yet unknown. These phenomena were investigated using an animal preparation in which large amounts of smoke were produced in a CO2 pneumoperitoneum. In this porcine model,

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segments of liver were excised using monopolar electrocautery. The goals of this study were (1) to ascertain the relationship between intraperitoneal concentration of CO and blood levels of COHb and MetHb in pigs undergoing laparoscopic hepatic wedge resections and (2) to assess the presence and concentrations of three other potentially harmful gases that may be byproducts of incomplete tissue combustionhydrogen cyanide (HCN), acrylonitrile (Acr), and benzene (Bzn)in the pneumoperitoneum of these animals. Materials and methods
Seven domestic pigs, each weighing 3035 kg, underwent laparoscopic hepatic wedge resection using monopolar electrocautery for transection of the hepatic parenchyma. Since total uptake of CO is dependent on its concentration and the duration of exposure as well as FiO2 and ventilatory rate, the duration of the operation and the cumulative time of electrocautery use were recorded while maintaining FiO2 and end-tidal CO2 constant. Experimental procedures, animal care, and maintenance were approved by the Animal Studies Committee at Washington University School of Medicine in accordance with the Animal Welfare Act and the NIH Guide for the Care and Use of Laboratory Animals.

cedure at 1 min after insufflation (prior to electrocautery use), at 8 min, at 15 min, and every 15 min after initiating electrocautery intraoperatively, and then hourly postoperatively for 3 h. The blood samples were analyzed immediately for pO2 and SaO2 by Stat Profile 4 (Nova Biomedical, Waltham, MA). Total hemoglobin, oxyhemoglobin, MetHb, and COHb were analyzed immediately by the OSM3 Hemoximeter (Radiometer Copenhagen, Copenhagen, Denmark). The manufacturer lists the accuracy of this instrument as 1%. Intraperitoneal and exhaled [CO] were determined by SensidyneGastec detector tubes (Sensidyne, Inc., Clearwater, FL) by sampling 100 ml of gas from the side port of one of the laparoscopic trocars and from the endotracheal tube during exhalation with a Sensidyne-Gastec multistroke gas sampling pump. Analyses were performed intraoperatively simultaneous to the blood samples. Sensidyne-Gastec detector tubes use a colorimetric reaction with potassium polladosulfite so that the length of tubing stained corresponds to the concentration of CO in the sample. They detect CO concentrations between 1 and 4,000 parts per million (ppm) at an accuracy of 25% [4]. The intraperitoneal smoke was also analyzed for the concentrations of hydrogen cyanide, acrylonitrile, and benzene. For each gas, the technique was the same as that described above except that the detector tubes were specific for the type of gas analyzed. The lowest detectable concentrations for hydrogen cyanide, acrylonitrile, and benzene using this technique are 0.36, 0.125, and 0.125 ppm, respectively [4]. Determinations of intraperitoneal concentrations of these substances were performed intraoperatively simultaneous to the blood sampling.

Animal preparation
The animals were fasted and bowel prepped with magnesium citrate and Go-lytely (Braintree Lab, Inc., Braintree, MA) 10 h before surgery. The pigs were premedicated with ketamine 20 mg/kg, acepromazine 0.1 mg/kg, and atropine 0.04 mg/kg IM. After induction of anesthesia with pentobarbital 20 to 30 mg/kg IV, anesthesia was maintained with isoflurane. An endotracheal tube was inserted and connected to a ventilator with a tidal volume of 1520 ml/kg at a rate of 1216 breaths/min. Ventilatory rate was controlled to maintain end-tidal CO2 at 40 mmHg while FiO2 was maintained at 40%. Pulse oximetry was monitored throughout the study. An arterial line was placed via a cutdown in the femoral artery for frequent arterial blood samplings. Duration of cautery use was recorded by startstop cumulative arithmetic compilation.

Statistical analyses
The InStat statistical computer software package (GraphPad Software, Inc., San Diego, CA) was used for data analysis. Statistical comparisons among the groups with respect to continuous variables were performed with the paired analysis of variance (ANOVA) test. Specific comparisons were made using Tukey-Kramer multiple comparisons test. When preoperative values were zero, intraoperative and postoperative continuous variables were analyzed using the two-tailed one-sample Students t-test. Summary values are expressed as mean SEM. Statistically significant differences were defined as p < 0.05.

Operative technique: hepatic wedge resection of the right medial lobe


The pig was placed in the supine position and the abdomen was prepped with Betadine and draped sterilely. A 14-gauge Veress needle was inserted infraumbilically, and the abdomen was insufflated with CO2 to create a pneumoperitoneum at a pressure of 15 mmHg. Four 10/12-mm trocars were used for access: an infraumbilical trocar for the video laparoscope, one trocar in the right flank for grasping forceps, and two lateral trocars right upper quadrant in the midclavicular line for electrocautery scissors and left upper quadrant in the midclavicular line for liver retraction. An electrocautery probe was used to incise Glissons capsule of the hepatic right medial lobe and then to divide the parenchyma. Three hepatic wedges, approximately 2 2 1 cm each, were resected. As the instrument progressively dissected deeper into the hepatic parenchyma, grasping forceps were used to hold the tissue and to separate the edges of the liver. Irrigation and aspiration of the operative field were used sparingly; enough to allow laparoscopic visualization while minimizing the loss of smoke to be tested. If the amount of smoke in the pneumoperitoneum obscured the surgeons view, smoke was vented until the field was visible. The number of times this was performed during each experiment was recorded. At the end of each operation, intraabdominal gas was evacuated through the ports. The total volume of CO2 insufflated and the cumulative duration of electrocautery during the procedure were also recorded, as was the mass of the resected liver. The animals remained anesthetized for 3 h postoperatively to facilitate blood drawings and were then euthanized.

Results Seven domestic female pigs, weighing 32 0.5 kg, underwent laparoscopic hepatic wedge resections. Duration of operation was 90 2 min, during which 99 12 l of CO2 (range 68140 l) were used for insufflation. Mean cumulative electrocautery time was 68 4 min. The smoke generated was often sufficient to interfere with visualization; this required a trocar to be opened for a 10-s venting on the average of six times per procedure (range 49). Each 2 2 1 cm hepatic wedge specimen weighed 1.8 0.3 g. No measurable [CO] could be detected in the animals exhaled gas. However, intraperitoneal [CO] rose significantly from 0 ppm prior to hepatic cauterization to 771 230 ppm (p < 0.02, range 2001900 ppm) at 30 min, peaked between 60 min (814 201 ppm, p < 0.01, range 5002,000 ppm) and 75 min (814 223 ppm, p < 0.02, range 200 1,600 ppm), and then declined to 557 100 ppm (p < 0.01, range 3001,000 ppm) at the end of the procedure (Fig. 1). COHb levels rose significantly from a preoperative value of 2.9% 0.1% to 3.3% 0.1% at 70 min and peaked to 3.5% 0.1% at the end of the procedure (p < 0.001; Fig. 2). During the first 3 h postoperatively, [COHb] steadily declined to baseline levels. MetHb level, however, did not change (preoperative range 0.40.7%; intraoperative and postoperative ranges 0.30.7%; Fig. 2).

Blood and gas sampling


For each animal, two arterial blood samples (3 ml each) were drawn in iced heparinized syringes 5 min prior to insufflation, during the surgical pro-

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Fig. 1. Intraperitoneal [CO] during laparoscopic hepatic wedge resections. Significant elevations occurred 8 min after initiation of hepatic electrocauterization and remained elevated throughout the procedure.

Fig. 3. Intraperitoneal concentrations of various toxic byproducts of laparoscopic hepatic combustion. Of the three gases, only [HCN] was significantly elevated intraoperatively from baseline. HCN; Acrnt; Bzn.

Fig. 2. Intra- and postoperative [COHb] and [MetHb] in the porcine model of laparoscopic hepatic resection using electrocautery. [COHb] was significantly elevated at 70 min after initiation of hepatic electrocauterization and remained elevated throughout the remainder of the procedure and for 2 h postoperatively. COHb; MetHb.

Figure 3 reveals intraoperative concentration of hydrogen cyanide, acrylonitrile, and benzene within the peritoneal cavity. Prior to hepatic cauterization, none of these gases were detected in the pneumoperitoneum. However, [HCN] rose significantly and peaked to 5.7 0.7 ppm at 15 and 30 min (p < 0.001, range 5.010.0 ppm) and remained elevated throughout the procedure. In contrast, acrylonitrile did not rise significantly from baseline values, with peak concentration of only 1.6 1.0 ppm at 15 min (range 07.5 ppm) and soon afterward declined to baseline value of zero. Benzene was undetectable throughout the procedures.

Discussion There are conflicting published data regarding the production and systemic absorption of toxic byproducts of tissue combustion in the pneumoperitoneum of humans during laparoscopic surgery, but no prior animal study has investigated this phenomenon. Since a major criticism of previous clinical studies investigating the production and effects of CO during laparoscopic surgery was the short duration of electrocautery use, we purposely created more smoke than during a procedure such as a routine laparoscopic cholecys-

tectomy. This was accomplished successfully since the average electrocautery time of 68 min more than tripled the longest mean electrocautery time in any previous study [5, 9, 15]. The density of smoke often obscured the surgeons view to the point that a trocar had to be vented repeatedly. The duration of CO2 pneumoperitoneum during the experiments was 90 min, similar to those in the aforementioned studies [5, 9, 15]. The current study clearly demonstrated that laparoscopic electrocautery of the porcine liver increased intraperitoneal concentrations of CO. The levels were slightly higher than those found in previous human studies. This was expected since the amount of tissue combustion in the animal model was much more than that in the clinical series. In Otts study of 25 patients undergoing laparoscopic-assisted hysterectomy or laparoscopic vaporization of endometriosis, with a mean time of tissue combustion of only 2.4 1.2 min, intraperitoneal [CO] increased to a mean of 425 ppm within 2 min of initiation of cauterization (range 115 2,100 ppm) [OtT personal communication]. Throughout the procedure, mean intraabdominal [CO] remained in the 500 535-ppm range. Others have reported similar increases of intraperitoneal [CO] in patients undergoing laparoscopic cholecystectomy [5, 9]. Although there are currently no known safety limits of intraperitoneal [CO], the Environmental Protection Agencys (EPA) maximum allowable 1-h exposure to ambient CO is 35 ppm with a ceiling concentration of 200 ppm [7, 8]. The maximum allowable concentration of ambient CO by the Occupational Safety and Health Administration (OSHA) is 50 ppm for 8 h of exposure or 400 ppm/15 min [9, 14]. Given the markedly elevated intraperitoneal [CO], transperitoneal absorption into the bloodstream could lead to toxic effects of end-organ hypoxia due to CO poisoning. If CO were absorbed systemically, one would predict either elevated levels of [COHb] or of exhaled [CO]. The basis for the generation of COHb is hemoglobins marked affinity for CO, approximately 200250-fold greater than that for O2 [11]. For nonsmokers, the normal baseline [COHb] is less than 1%, although the EPA has set the goal of maintaining nonsmokers [COHb] below 2% [8]. Smokers, however, often exhibit up to 8% hemoglobin saturation with CO.

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Above this level, one may suffer various symptoms (e.g., headaches, dizziness, nausea, dyspnea, palpitations, and impairment of manual coordination or judgement), and signs (e.g., tachycardia, tachypnea, and abnormal mental status) of CO toxicity [18]. A few studies, however, showed that [COHb] of only 24% significantly decreased the time of onset of angina in persons with coronary artery disease [1, 12] and decreased behavioral performance [13]. Previous studies of patients undergoing laparoscopic operations have shown variable COHb levels. In Otts series, all 25 patients showed elevated [COHb] after 10 min of cauterization, with a mean level of 10.5% (range 2.8 18.5%). The patients with the highest [COHb] were noted to suffer postoperative symptoms of dizziness, nausea, headache, and weakness [Ott personal communication]. Esper et al., however, found only a minimal but statistically significant increase in [COHb], from 0.7 0.6% to 1.2 0.7% (p < 0.01), in their study of 15 patients undergoing laparoscopic cholecystectomy [9]. In contrast, Beebe et al. demonstrated no significant elevation of [COHb] despite elevated intraperitoneal [CO] during laparoscopic cholecystectomy in nine patients [5]. This porcine study, with prolonged electrocautery time and constant bathing of the peritoneal cavity with smoke, showed statistically significant elevation of COHb to 3.5%. Since porcine hemoglobin may have different binding capability to CO than human hemoglobin, this absolute value is uninterpretable. However, comparing this peak concentration to the animals baseline of 2.9%, COHb only rose 0.6% (20%), which would probably be insignificant clinically. One possible explanation for the minimal elevation of [COHb] was that the animal was exhaling CO. However, CO was undetectable in the animals exhaled gas. The possibility of the development of methemoglobinemia during laparoscopic electrocautery was also explored after reports by Ott suggested elevation of [MetHb] to 23% from a baseline of <1% [15, 16]. Theoretically, elevations of MetHb (>2%) could produce the same symptoms and signs as COHb poisoning. However, MetHb was not elevated in the current study. Since many other compounds may be liberated during tissue combustion, levels of other potentially toxic gases were also assessed. Approximately 90% of the total weight of the smoke formed from combustion of tissue is in the gaseous phase, most of which is composed of nitrogen, O2, and CO2. The remaining gases and particulate matter are substances of potential toxicologic importance; these substances are physiologically active and may remain intraperitoneal or be absorbed. Ott identified 27 chemical byproducts of human tissue combustion resulting from laparoscopic electrocautery of the uterus and fallopian tubes [15]. He was, however, unable to quantify these substances. The current study assessed for the presence and quantity of only three of those substances due to technical limitations. HCN is a toxic, colorless gas that is easily absorbed through the lungs, gastrointestinal tract, and skin. The shortterm ambient concentration exposure limit according to the U.S. Department of Health and Human Services is 10 ppm [3]. Cyanide exerts its toxic effects by combining with ferric iron in cytochrome oxidase, inhibiting cellular oxygen utilization. Smoke-inhalation victims have experienced additive or synergistic effects from CO and cyanide, and only

recently has attention been focused on the potential for combined poisoning in victims of enclosed-space fires. In our study, [HCN] peaked to a mean of 5.7 ppm. However, in one animal, the [HCN] did reach 10 ppm, which is the short-term ambient exposure limit before toxic effects occur. Further studies are warranted to determine if intraperitoneal [HCN] poses a threat to human patients. Acrylonitrile is a colorless, volatile liquid that is easily absorbed through the skin and lungs and exerts its toxicity by liberating cyanide [2]. The upper limit of ambient exposure set by OSHA is 2 ppm [4]. Although our study found insignificant elevations of [HCN], the mean level at 15 min (1.6 1.0 ppm) was dangerously close to the OSHA limit. The significance of this finding, too, is unclear. The third potentially toxic gas that was assessed in the current study was benzene, which was not detected in the pneumoperitoneum of any of the experimental animals. In summary, the current study was designed to assess for the intraperitoneal presence and systemic absorption of toxic byproducts of tissue combustion in a porcine model of laparoscopic surgery using prolonged application of electrocautery. Whether the peritoneum of the pig has identical gas absorption characteristics to those of the human peritoneum is unknown, rendering translation to the clinical situation imprecise. In this model, intraperitoneal [CO] did reach levels above those established as safe for inhalation by the EPA and OSHA. There was also a statistically significant elevation of [COHb], but its magnitude does not seem to pose a clinical threat. Intraperitoneal gaseous hydrogen cyanide just reached the upper safety limit established for ambient concentrations, and small but potentially hazardous concentrations of acrylonitrile levels were detected. Intraperitoneal benzene and systemic methemoglobin were not elevated. Further investigation is required to determine the clinical relevance of hydrogen cyanide and acrylonitrile and to quantify the concentration of other potentially toxic chemical byproducts of laparoscopic tissue combustion.
Acknowledgment. The authors gratefully acknowledge the support from the Washington University Institute for Minimally Invasive Surgery as funded by a grant from Ethicon-Endosurgery, Inc. We also thank Alberto Rojales for his assistance in the care of the animals.

References
1. Allred EN, Bleecker ER, Chaitman BR, Dahms TE, Gottlieb SO, Hackney JD, Pagano M, Selvester RH, Walden SM, Warren J (1989) Short-term effects of carbon monoxide exposure on the exercise performance in subjects with coronary artery disease. N Engl J Med 321: 14261432 2. Anonymous (1984) Acrylonitrile. Lancet 1 (8338): 1221 3. Anonymous (1993) Cyanide toxicity. Agency for toxic substances and disease registry. Am Fam Physician 8(1): 107114 4. Anonymous (1987) Sensidyne gastec precision gas detector system manual. Sensidyne, Clearwater, FL 5. Beebe DS, Swica H, Carlson N, Palahniuk RJ, Goodale RL (1993) High levels of carbon monoxide are produced by electro-cautery of tissue during laparoscopic cholecystectomy. Anesth Analg 77: 338 341 6. Callery MP, Soper NJ (1993) Physiology of the pneumoperitoneum. Baillieres Clin Gastroenterol 7(4): 757777 7. Code of Federal Regulations, Title 40, Part 50 (40CFR50) (1994)

1079 National primary and secondary ambient air quality standards. US Environmental Protection Agency Environmental Protection Agency: Environmental Assessment and Criteria Office (1979) Air quality criteria for carbon monoxide. EPA, Washington, DC Esper E, Russell TE, Coy B, Duke BE 3rd, Max MH, Coil JA (1994) Transperitoneal absorption of thermocautery-induced carbon monoxide formation during laparoscopic cholecystectomy. Surg Laparosc Endosc 4(5): 333335 Hashikura Y, Kawasaki S, Munakata S, Hashimoto S, Hayashi K, Makuuchi M (1994) Effects of peritoneal insufflation on hepatic and renal blood flow. Surg Endosc 8: 759761 Kales S (1993) Carbon monoxide intoxication. Am Fam Physician 48(6): 11001104 Kleinman MT, Davidson DM, Vandagriff RB, Caiozzo VJ, Whittenberger JL (1989) Effects of short-term exposure to carbon monoxide in subjects with coronary artery disease. Arch Environ Health 44: 361 369 13. Masters RL (1971) Air pollutionhuman health effects. In: McCormac BM (ed) Introduction to the scientific study of atmospheric pollution. Reidel, Dordrech, Holland, pp 97130 14. National Institute for Occupational Safety and Health (1972) Occupational exposure to carbon monoxide. DHEW, US Government Printing Office, Washington, DC 15. Ott DE (1993) Smoke production and smoke reduction in endoscopic surgery: preliminary report. End Surg 1: 230232 16. Ott DE (1994) Laser smoke and hemoglobin oxidation at laparoscopy (abstract). Laser Surg Med 6: 17 17. Soper NJ, Brunt LM, Kerbl K (1994) Laparoscopic general surgery. N Eng J Med 330(6): 409419 18. Thom SR, Keim LW (1989) Carbon monoxide poisoning: a review. Epidemiology, pathophysiology, clinical findings, and treatment options including hyperbaric oxygen therapy. J Toxicol Clin Toxicol 27: 141156 19. Williams MD, Murr PC (1993) Laparoscopic insufflation of the abdomen depresses cardiopulmonary function. Surg Endosc 7: 1216

8. 9.

10. 11. 12.

Surg Endosc (1997) 11: 1135

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Endoscopic thyroid and parathyroid surgery


Having succeeded in doing hemithyroidectomies and also parathyroidectomies through an endoscopic approach, we are fully convinced that endoscopic neck surgery is set to open up new horizons in the ever-expanding field of minimally invasive surgery. Not only was the postoperative discomfort greatly reduced, but the cosmetic results, a primary concern in neck surgery, have been very satisfactory. Two technical points are conducive to smooth execution of endoscopic neck surgery. First, the operation is performed with the neck slightly flexed and the table tilted to the reverse Trendelenburg position (Fig. 1). An 11-mm incision is made just above the suprasternal notch. With the skin edges elevated, a plane is developed underneath the platysma muscle between the anterior border of the sternomastoid muscles. An 11-mm Endo-path trocar sleeve (Ethicon Endosurgery, Cincinnati) is fitted into the incision. This transparent cannula affords a wider field of vision. A pursestring suture picking up the platysma is tied around the cannula to achieve an air-tight seal. An end-viewing telescope is passed down the sleeve after the space is inflated with CO2 at 8 mmHg. A 5-mm trocar is introduced near the lower end of the anterior border of the sternamastoid muscle on the side opposite to the lesion. To ensure unimpeded movement of adjacent trocars, less bulky trocarsfor instance, Hunt/Reich Secondary Trocars (Apple Medical Corporation Massachusetts), are preferred. The trocar sheath can be maintained in position by screwing the cannula in a clockwise direction or by anchoring the stopcock with a skin stitch. These plastic cannulas have the added advantage of not interfering with cautery should they come into contact with the metallic part of the instruments during activation of the diathermy. A pair of endoscopic scissors inserted through this cannula is used to develop a plane between the sternomastoid and the strap muscles. Dissection should be kept in the right plane, care being taken not to wander onto the anterior surface of the sternomastoid, which would invite unnecessary bleeding and the belly of the sternomastoid would sag down. Another 5-mm trocar is then inserted 23 cm lateral to the midline incision, piercing through the lower sternomastoid belly on its way. Exposure of the carotid artery readily leads to the posterolateral border of the thyroid gland. Further dissection will mimic that in the open surgery. A third trocar of smaller size might be required higher up on the same side. Second, a clear field in the depths of the working space is essential. Oozing from small blood vessels can be troublesome and obscures the view. The usual laparoscopic technique of suction and irrigation is not too desirable for the following reasons: (1) Suction readily collapses the small space; (2) irrigation dilutes the blood and delays clotting; (3) suction is frequently accompanied by fogging of the lens; (4) it is not possible to suck clear all the fluid staining the local tissues. By contrast, the proper use of gauze swabs can provide a dry and clear field. When blood is blocking the view, the telescope is withdrawn. A piece of Nu-gauze (Johnson & Johnson Medical Incorporation, Arlington, Texas) 2 cm 2 cm in size is grasped by an endo-forceps and is passed all the way down the central cannula. With the camera in position again, the gauze swab is used to mop up the operative field. The gauze partially soaked with blood is tucked away from the operative site, ready to be used again. If required, compression by several pieces of Nu-gauze effects hemostasis. The fully soaked gauze swab can be easily removed by a grasping forceps while the flapper valve is kept open by depressing the desufflation lever. Despite encouraging early experience, the establishment of endoscopic thyroidectomy and parathyroidectomy as acceptable, if not better, alternatives to standard surgical treatment mandates a large prospective study comparing this technique with the classical open operation in a scientific manner. H. C. Yeung W. T. Ng C. K. Kong
Minimal Invasive Surgery Unit Department of Surgery Yan Chai Hospital 7-11, Yan Chai Street, Tsuen Wan Hong Kong (SAR), China

Fig. 1. An operative photograph showing the setup for endoscopic exploration of a parathyroid adenoma. Two working ports have been established on either side of the central camera port, which is also used for insertion of the Nu-gauze.

Editorial
Surg Endosc (1997) 11: 10631064

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Minimal access and open surgery


Competition or integration?

Minimal access surgery, with all its novelty, challenge, satisfaction, and seduction is now running the risk of being regarded as an entirely new technological field of medicine, competing with (some would say replacing) traditional open surgery. This mad dash to extol a new surgical tool or technique as the great salvation is not new. The evolution of cautery in surgery may well be a paradigm for us. In the Edwin Smith Papyrus the fire stick was used for the destruction of breast tumors. Hippocrates used cautery to open liver abscesses. For centuries cautery was regarded as an operation unto itself. Did not Albucassis suggest that cautery has universal application? Even then specialization developed to the extent that gold cautery was recommended for throat disorders and bronze for breast tumors. Celsus, Paulus Aeginetta, Avicennaall lauded cautery. It was not until the time of Ambroise Pare that it was recognized that unbridled heat application to tissue might often do more harm than good. Indeed Pare s influence at that time should give us food for thought. He not only tried to tame the overzealous use of cautery but also reintroduced into surgery an older but persistently useful techniquethat of ligating blood vessels. In the early days of laparoscopic cholecystectomy we almost fell into the same trap as surgeons did before Pare . Some early laparoscopic surgeons, recognizing that the laser was certainly a more refined and precise tool than the Egyptian fire stick or even Bovies later electrified loop, began to tout it as a preferred method of performing laparoscopic cholecystectomy. The term laser laparoscopic cholecystectomy was widely published [10]. And while the new stimulated appropriate questioning of the old, there were enough scholars among us to pick up the challenge and restudy the question. So it was that when Karl Semm raised some concerns about the use of electro-cautery during laparoscopic procedures there followed many studies attesting to the safety of high frequency currents as used in peritoneoscopy. One of the points I am trying to make with the curious title I have chosen, is that this same tide of educated change in how we utilize heat on tissue may be repeated many times over as minimal access surgery evolves. Even the concepts of access and exposure are in evolution and we have to acknowledge the current limitations of minimal access surgery, recognizing that many will be overcome in the near future.

For the safe performance of most, if not all operations, access, exposure, technique and judgement have long been regarded as important elements [7]. The development of changes and even improvement in access does not necessarily mandate changes in technique and judgement. It is difficult to understand the reluctance of many to combine what is feasible and superior about minimal access surgery with what is known and has worked well in traditional open surgery. Those who have not learned the lessons of the past are certainly doomed to repeat them. One of the stumbling blocks to the integration of minimal access surgery and open surgery is the concept of conversionan unfortunate term, since it suggests abandonment of one method for another. Another is the reluctance to continue handling tissues. Just as the lithotomists of a previous generation learned to put the well-lubricated (although, at that time, ungloved) finger of the left hand in the rectum to bring the bladder stone down to the perineum where the incision was made to deliver the stone, so also it is clear that some contemporary laparoscopic surgeons still find the surgeons hand useful in facilitating specific portions of an operation [2, 6, 14]. I submit that if one subscribes to the concept of integration rather than competition with respect to the place of minimal access surgery, various combinations, skills and strategies become available [1, 4, 11, 12]. For example, it is clear that there may be at times alternatives to blind trocar insertion. The Hasson technique still has a place. Even for pneumoperitoneum, recognizing the disadvantages of both carbon dioxide and nitrogen, other and friendlier gases are being evaluated [13]. Methods of separating viscera and maintaining exposure as alternatives to pneumoperitoneum are also being developed. The use of preformed balloons to maintain extraperitoneal spaces is an area in point. The reluctance to convert or the shame in having ones procedure regarded as laparoscopically assisted can be illustrated in the area of splenectomy for the large pathologic spleen [2]. Who can deny the superior ability to visualize and, with adequate training and experience to separate the pathologic spleen from surrounding viscera with minimal access techniques? However, have we proven that going to great effort, time and exposure to pulverize the specimen in order to avoid an incision larger than a trocar site is superior to an incision at

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that point in the procedure for safe, pure, total removal and adequate subsequent pathologic examination? The same may be true for other solid viscera [8]. Rather than deny the problem of lesion localization at minimal access surgery, those anxious to solve the problem of the inability to palpate it have been utilizing some other novel techniques such as ultrasound and, like Pare have found a previously described but incompletely utilized technique, namely, intraoperative flexible endoscopy to be of increasing value [3]. That these techniques may be joined with other modalities such as magnetic resonance imaging in the conduct of the operative procedure is one of the most satisfying developments. These, then, are but a few examples of the reasons we think integration superior to competition when we try to compare and contrast minimal access and open surgery. But what shall we do about conversion? It should be seen in terms of good judgement rather than failure. Making this choice will be helped immeasurably by incorporating basic surgical principles and techniques, with appropriate modern modifications, into the training of all surgeons. In fact, we need to do it for all would-be interventionists. References
1. Angelini L, Lirici MM, Papaspyropoulos V, Sossi FL (1997) Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum retractionrelated effects and needle and trocar injuries in laparoscopic surgery. Surg Endosc 11: 1006 1009 2. Ballaux KG, Himpens SM, Leman G, Van den Bossche MRP (1997) Hand-assisted laparoscopic splenectomy for hydatid cyst. Surg Endosc 11: 942943 3. Kim SH, Milsom JW, Church JM, Ludwig KA, Garcia-Ruiz A, Okuda

4. 5.

6. 7. 8.

9.

10.

11.

12. 13. 14.

J, Fazio VW (1997) Perioperative tumor localization for laparoscopic surgery. Surg Endosc 11: 10131016 Larson GM (1997) Combining minimal access procedures expands the potential of laparoscopic surgery (Editorial). Surg Endosc 11: 225 Melzer A, Schmidt A, Kipfmu ller, Gro nemeyer D, Seibel R (1997) Technology and principles of tomographic image-guided interventions and surgery. Surg Endosc 11: 946956 Naitoh T, Gagner M (1997) Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve. Surg Endosc 11: 830833 Paolucci V, Schaett B, Gutt CN (1997) Exposure of the operative field in laparoscopic surgery. Surg Endosc 11: 856864 Poulin C, Labbe (1997) Fully thoracoscopic pulmonary lobectomy and specimen extraction through rib resection: preliminary report. Surg Endosc 11: 354358 Read C, de La Torre RA, Scott JS (1997) Balloon dissection of the space of Bogros via the femoral canal for total extraperitoneal laparoscopic herniorrhaphy. Surg Endosc 11: 687692 Reddick ES, Olsen D, Alexander W, Bailey A, Baird D, Price N, Pruitt R (1990) Laparoscopic laser cholecystectomy and cholelithiasis. Surg Endosc 4: 133135 Simedh K, Skullman S, Kald A, Anderberg B, Nystrom P-O (1997) Laparoscopic bowel mobilization combined with intraoperative colonoscopic polypectomy in patients with an inaccessible polyp of the colon. Surg Endosc 11: 643644 Spivak H, Hunter JG (1997) Endoluminal surgery. Surg Endosc 11: 321325 Tsoi EKM, Organ CH (1996) Abdominal Access in open and laparoscopic surgery. Wiley-Liss, New York Watson DJ, Gaure PA (1997) Hand-assisted laparoscopic vertical banded gastroplasty: initial report. Surg Endosc (in press)

K. A. Forde
Department of Surgery Columbia University 161 Fort Washington Avenue New York, NY 10032 USA

News and notices


Surg Endosc (1997) 11: 11381140

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

New Address for the European Association for Endoscopic Surgery (E.A.E.S.)
Effective January 1, 1997, the new correspondence, telephone, and fax numbers of the E.A.E.S. office are: E.A.E.S. Office, c/o Mrs. Ria Palmen Luchthavenweg 81 Unit 1.42 5657 EA Eindhoven The Netherlands or: P.O. Box 335 5500 AH Veldhoven The Netherlands Tel: +31 40 2525288 Fax: +31 40 2523102

Essentials of Laparoscopic Surgery Surgical Skills Unit University of Dundee Scotland, UK


Under the direction of Professor A. Cuschieri the Surgical Skills Unit is offering a three-day practical course designed for surgeons who wish to undertake the procedures such as laparoscopic cholecystectomy. This intensely practical program develops the necessary operating skills, emphasizes safe practice, and highlights the common pitfalls and difficulties encountered when starting out. Each workshop has a maximum of 18 participants who will learn both camera and instrument-manipulation skills in a purpose-built skills laboratory. During the course there is a live demonstration of a laparoscopic cholecystectomy. The unit has a large library of operative videos edited by Professor Cuschieri, and the latest books on endoscopic surgery are on display in our Resource area. Course fee including lunch and course materials is $860. For further details and a brochure please contact: Julie Struthers, Unit Co-ordinator Surgical Skills Unit Ninewells Hospital and Medical School Dundee DD1 9SY Tel: +44 382 645857 Fax: +44 382 646042

Volunteer Surgeons Needed Northwestern Nicaragua Laparoscopic Surgery Teaching Program, Leon, Nicaragua
Volunteer surgeons are needed to tutor laparoscopic cholecystectomy for this non-profit collaboration between the Nicaraguan Ministry of Health, the National Autonomous University of Nicaragua, and Medical Training Worldwide. The program consists of tutoring general surgeons who have already undergone a basic laparoscopic cholecystectomy course. Medical Training Worldwide will provide donated equipment and supplies when needed. For further information, please contact: Medical Training Worldwide Ramon Berguer, MD, Chairman Tel: 707-423-5192 Fax: 707-423-7578 e-mail: berguer.r@martinez.va.gov

Advanced Endoscopic Skills Surgical Skills Unit University of Dundee Scotland, UK


Each month Professor Cuschieri Surgical Skills Unit offers a 412 day course in Advanced Endoscopic Skills. The course is intensely practical with hands on experience on a range of simulated models. The program is designed for experienced endoscopic surgeons and covers advanced dissection techniques, extracorporeal knotting techniques, needle control, suturing, internal tying technique, stapling, and anastomotic technique. Individual workstations and a maximum course number of 10 participants allows for personal tuition. The unit offers an extensive collection of surgical videos and the latest books and publications on endoscopic surgery. In addition, participating surgeons will have the opportunity to see live advanced laparoscopic and/or thoracoscopic procedures conducted by Professor Cuschieri and his team. The course is endorsed by SAGES. Course fee including lunch and course materials is $1850. For further details and a brochure please contact: Julie Struthers, Unit Co-ordinator Surgical Skills Unit Ninewells Hospital and Medical School Dundee DD1 9SY Tel: +44 382 645857 Fax: +44 382 646042

Fellowship in Minimally Invasive Surgery George Washington Medical Center Washington, DC USA
A one-year fellowship is being offered at the George Washington University Medical Center. Interested candidates will be exposed to a broad range of endosurgical Education and Research Center. Active participation in clinical and basic science research projects is also encouraged. For further information, please contact: Debbie Moser 202-994-8425 or, send curriculum vitae to: Dr. Jonathan M. Sackier Director, Washington Institute of Surgical Endoscopy George Washington University Medical Center Department of Surgery 2150 Pennsylvania Avenue, N.W. 6B-417 Washington, DC 20037, USA

The Practical Aspects of Laparoscopic Fundoplication Surgical Skills Unit University of Dundee Scotland, UK
A three-day course, led by Professor Cuschieri, designed for experienced laparoscopists wishing to include fundoplication in their practice. The

1139 course covers the technical details of total and partial fundoplication using small group format and personal tuition on detailed simulated models. There will be an opportunity to observe one of these procedures live during the course. Maximum course number is six. Course fee including lunch is $1850. For further details and a brochure please contact: Julie Struthers, Unit Co-ordinator Surgical Skills Unit Ninewells Hospital and Medical School Dundee DD1 9SY Tel: +44 382 645857 Fax: +44 382 646042 tomy (May 1516, August 1112, November 1011, 1997); Laparoscopic colon and rectal surgery (June 2021, September 1516, December 45, 1997). Also, courses for operating room nurses and technicians will be run on a monthly basis and personal instruction and preceptorship is available. For further information, please call: Debbie Moser Washington Institute of Surgical Endoscopy 2150 Pennsylvania Avenue, N.W. Washington, DC 20037 Tel: 202-994-9425

Courses at the Royal Adelaide Centre for Endoscopic Surgery


Basic and Advanced Laparoscopic Skills Courses are conducted by the Royal Adelaide Centre for Endoscopic Surgery on a regular basis. The courses are limited to six places to maximize skill development and tuition. Basic courses are conducted over two days for trainees and surgeons seeking an introduction to laparoscopic cholecystectomy. Animal viscera in simulators is used to develop practical skills. Advanced courses are conducted over four days for surgeons already experienced in laparoscopic cholecystectomy who wish to undertake more advanced procedures. A wide range of procedures are included, although practical sessions can be tailored to one or two procedures at the participants request. Practical skills are developed using training simulators and anaesthetised pigs. Course fees: $A300 ($US225) for the basic course and $A1,600 ($US1,200) for the advanced course. For further details and brochure, please contact: Dr. D. I. Watson or Professor G. G. Jamieson The Royal Adelaide Centre for Endoscopic Surgery Department of Surgery Royal Adelaide Hospital Adelaide SA 5000 Australia Tel: +61 8 224 5516 Fax: +61 8 232 3471

Call for Abstracts Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 1998 Annual Meeting April 14, 1998 Seattle, WA, USA
Abstract deadlines: Oral and Poster abstracts: September 12, 1997 Video Submissions: September 18, 1997 For further information, or to obtain an abstract form, please contact: SAGES Program Committee Society of American Gastrointestinal Endoscopic Surgeons Suite #3000 2716 Ocean Park Boulevard Los Angeles, CA 90405 Tel: (310) 314-2404 Fax: (310) 314-2585 e-mail: SAGESMail@AOL.com

Advanced Laparoscopic Suturing and Surgical Skills Courses MOET Institute San Francisco, CA, USA
Courses are offered year-round by individual arrangement. The MOET Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians and designates these CME activities for 2040 credit hours in Category 1 of the Physicians Recognition Award of the American Medical Association. These programs are also endorsed by the Society of Gastrointestinal Endoscopic Surgeons (SAGES). For further information, please contact: Wanda Toy, Program Administrator Microsurgery & Operative Endoscopy Training (MOET) Institute 153 States Street San Francisco, CA 94114, USA Tel: (415) 626-3400 Fax: (415) 626-3444

Eighteenth Annual Turnbull Symposium Important Issues in Colorectal Surgery November 21 and 22, 1997 Cleveland, OH, USA
Pre-symposium courses on laparoscopic colorectal surgery, office investigations in colorectal surgery, pelvic anatomy and live demonstrations of rectal surgery are offered to limited number of applicants.

Postgraduate Courses in Colorectal Surgery November 19, 20, 22, 1997 Cleveland, OH, USA
Laparoscopic intestinal surgery; techniques for investigation of the large bowel; endoscopy, intrarectal, and endoanal ultrasound, live surgery demonstrations, inherited colorectal cancer. Space for these courses is limited. For further information regarding the Turnbull Symposium or the Postgraduate Courses, please contact: J.M. Church, MD Department of Colon and Rectal Sugery Cleveland Clinic Foundation 9500 Euclid Avenue, A111 Cleveland, OH 44195 Tel: (216) 444-9052 Fax: (216) 445-8627 email: Churchj@cesmpt.ccf.org

Courses at WISE Washington Institute for Surgical Endoscopy Washington, DC, USA
The Washington Institute of Surgical Endoscopy is pleased to offer the following courses: Laparoscopic antireflux and hiatal hernia surgery (July 1415, 1997); Laparoscopic management of the common bile duct and difficult cholecystec-

1140

European Course on Laparoscopic Surgery (English language) November 1821, 1997 Brussels, Belgium
Course director: G.B. Cadiere For further information, please contact: Administrative Secretariat Conference Services s.a. Avenue de lObservatoire, 3 bte 17 B-1180 Bruxelles Tel: (32 2) 375 16 48 Fax: (32 2) 375 32 99

nationally represented and includes leading experts in the field. Simultaneous Spanish and Italian translation is available. For more information, please contact: Cleveland Clinic Florida Department of Education 2950 West Cypress Creek Road Fort Lauderdale, FL 33309-1743 Tel: 800-359-6101, ext. 6066 Fax: 954-978-5539

Second Asian Pacific Symposium and Workshop on Minimally Invasive Thoracic and Cardiac Surgery December 911, 1997 Taipei, Taiwan
The main themes are updates and live operative demonstrations of thoracoscopy and video-assisted thoracic surgery, minimally invasive cardiac surgery, and thoracoscopic spine surgery. For further information, please contact: Hui-Ping Liu, MD Division of Thoracic and Cardiovascular Surgery Chang Gung Memorial Hospital 199 Tun-Hwa N Rd. Taipai, Taiwan 10591 Tel: 866-3-3281200 Fax: 866-3-3285818

6th World Congress of Endoscopy Surgery Roma 98 6th International Congress of European Association for Endoscopic Surgery June 36, 1998 Rome, Italy
The program will include: the latest, original high quality research; symposia; plenary lectures; abstract presentations (video, oral, and posters); EAES and SAGES postgraduate courses, OMED postgraduate course on therapeutic endoscopy; working team reports; educational center and learning corner; meeting of the International Society of Nurses and Associates; original and non original scientific reports; and a world expo of new technology in surgery. For further information, please contact: Congress Secretariat: Studio EGA Viale Tiziano, 19 00196 Rome, Italy Tel: +39 6 322-1806 Fax: +39 6 324-0143

Tenth International Conference of the Society for Minimally Invasive Therapy September 35, 1998 London, England
Host Chairman: Mr. J. Wickham For further information, please contact: The Society for Minimally Invasive Therapy 2nd Floor, New Guys House Guys Hospital St. Thomas Street London, SE1 9RT, England Tel: +44 (0)171 955 4478 Fax: +44 (0)171 955 4477 email: j.wickham@umds.ac.uk

Colorectal Disease in 1998 February 1921, 1998 Fort Lauderdale, FL, USA Symposium Director: Steven D. Wexner, MD
Cleveland Clinic Florida presents its ninth annual postgraduate course. Provides an intensive, in-depth, analytical review of all aspects of colorectal disease, including laparoscopy; colorectal carcinoma screening and genetics, inflammatory bowel disease; and pouch surgery. There will be a review of both basic and advanced principles of diagnosis and management of disease. Video techniques will be shown as well. The faculty is inter-

Surg Endosc (1997) 11: 10681071

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Bedside percutaneous endoscopic gastrostomy


A safe alternative for early nutritional support in critically ill trauma patients
E. H. Carrillo,1 B. T. Heniford,2 D. L. Osborne,1 D. A. Spain,1 F. B. Miller,1 J. D. Richardson1
1

Department of Surgery, University of Louisville School of Medicine, and the Trauma Program in Surgery, University of Louisville Hospital, 530 South Jackson Street, Ambulatory Care Building, Louisville, KY 40292, USA 2 Department of General Surgery, Laparoscopic Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA Received: 5 March 1997/Accepted: 15 May 1997

Abstract Background: Percutaneous endoscopic gastrostomy (PEG) is a good alternative that provides long-term nutritional support and is associated with minimal morbidity. Methods: During a 24-month period, we studied 54 critically injured patients who underwent early PEG to provide enteral nutritional support. Patients were selected due to the inability to tolerate intake by mouth secondary to multiple associated injuries, especially to the central nervous system. Results: All patients sustained multiple injuries with an average Injury Severity Score of 27. The mean Glasgow Coma Scale at the time of admission was 7 and at the time of the PEG was 10. Eleven patients (20%) had an intracranial pressure (ICP) device, and there was no significant increase in the mean ICP before, during, or after the procedure. In 63% of patients, tube feedings were interrupted for a variety of problems in the 72 h preceding the PEG, and in 70% of patients an average of five radiographs were obtained to document tube position. In 95% of patients, the nutritional goal was achieved within 48 h of PEG placement. There were one immediate and two delayed complications after PEG placement. There were two deaths, neither related to the PEG placement. Conclusions: Early PEG in critically injured patients is a safe and effective method of providing access to the GI tract for nutritional support. In patients with significant brain injuries, adequate sedation and the presence of an ICP monitor help to minimize secondary insults to the brain. Key words: Percutaneous endoscopic gastrostomy (PEG) Nutrition Trauma

Presented at the annual scientific session of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA, 1922 March 1997 Correspondence to: E. H. Carrillo

Adequate nutritional support is a mainstay in the care of critically injured patients. Most patients receive nutritional support by either nasoenteric feedings or parenteral nutrition. Surgical gastrostomy is, in general, unacceptable in these patients as it typically requires general anesthesia and a laparotomy for placement, with their associated complications. Over the last two decades, the use of percutaneous endoscopic gastrostomy (PEG) has evolved as an excellent alternative to access the gastrointestinal (GI) tract for longterm nutritional support [5] with a very low morbidity and mortality [4, 10, 11]. Some clinicians propose the use of parenteral nutrition as the easiest way to achieve nutritional goals and minimize complications in the critically injured trauma patient; however, enteral feeding remains the primary choice for nutritional support when the GI tract is functional. Borzotta and associates have shown improved cognitive results in patients with head injuries when fed enterally compared to those receiving total parenteral nutrition (TPN) [2]. Recent studies have also shown that enterally delivered nutrients are better utilized and provide cytoprotection for the intestinal mucosa. Enterally fed patients experience fewer septic complications, presumably because of enhanced immunocompetence [9]. Historically, nasogastric (NG) tubes have been utilized to access the GI tract to provide nutritional support. These tubes are quite useful short term, but they are associated with complications such as esophagitis, aspiration pneumonia, sinusitis, pneumonia due to aspiration or otherwise, and erosion into and deformation of nasal cartilage [10]. Smaller, softer, and longer nasoenteric feeding tubes (NET) which can be advanced into the proximal jejunum have been proposed as an alternative to NG tubes to limit these adverse effects. Unfortunately, frequent dislodgements, obstruction of the lumen, and the cumbersome and time-consuming maneuvers to correctly place these tubes limit their clinical usefulness. Surgical gastrostomy is a time-tested and well-accepted technique to provide long-term access to the GI tract and

1069

Fig. 1. The push technique under endoscopic guidance. The needle is withdrawn; the flexible wire is secured and then pulled with a snare.

Fig. 2. The tube is passed over a guidewire in a retrograde fashion. It is pushed into the stomach, exiting the abdominal wall until the tapered end of the PEG dilates the stoma tract through the abdominal wall.

PEG has become a popular minimally invasive alternative. The main advantages of this technique are that it is technically easier to perform, can be done under local anesthesia, involves little systemic stress, and is more cost effective [10]. The purpose of this study was to review our experience with PEG as a bedside technique in critically ill trauma patients and determine its safety and feasibility in a highrisk population. Materials and methods Patients
Over a 28-month period ending in July 1996, 54 consecutive critically injured patients admitted to the Trauma Service at the University of Louisville Hospital, underwent bedside PEG placement in the Surgical Intensive Care Unit (SICU). The procedure was completed in 53 patients (98%). Demographic information (age, gender, mechanism of injury, Glasgow Coma Scale [GCS], Injury Severity Score [ISS]) [1], procedure-related information (technical problems, monitoring abnormalities), and postoperative hospital outcome variables (nutritional goal achieved, pulmonary or other complicated wound problems, and mortality) were collected from each case and analyzed. During the review period, another 67 PEG placements were performed in the operating room or endoscopy suite.

Anesthesia
In all patients, 1% Xylocaine (lidocaine hydrochloride, Astra USA, Inc. Westboro, MA) was used as a local anesthetic. Intravenous sedation was provided with Versed (midazolam HCl, Roche Laboratories, Nutley, NJ). We considered it important to emphasize that proper sedation and local pain control should be obtained to minimize secondary trauma to patients with severe head injuries. Diprivan (propofol, Stuart Pharmaceuticals, Wilmington, DE) was also used as a rapidly acting intravenous anesthetic agent in severe closed-head-injury patients in order to avoid sudden increases in the intracranial pressure (ICP).

procedures. Optics included a flexible gastroscope (Olympus GIF V-10) attached to a high-resolution monitor. After a complete esophagogastroduodenoscopy (EGD), insufflation of the stomach and transillumination of the gastric and abdominal wall were performed as previously described [10, 11]. The lights in the room dimmed to facilitate location of the insertion site, which ideally should be 3 cm below the costal margin at the junction of a line drawn between the umbilicus and midclavicular line. In all cases, a MIC Removable OTW PEG Kit (Ballard Medical Products, Draper, UT) was utilized. The proper selection of the insertion site is critical for the success of this procedure. The chosen site of insertion, facilitated by the point of maximum transillumination in the abdominal wall, is depressed with a finger while the anterior gastric wall is observed with the endoscope. If the site depressed with a finger is a good location on the gastric wall, the skin is infiltrated with 1% lidocaine and a 1-cm skin incision is made. The site should be free of major vessels, viscera, and scar tissue. A needle is then placed through the incision, transabdominally into the stomach. An endoscopic snare is used to secure the needle, the stylet is removed, and a guidewire is passed through the needle (Fig. 1). Once the wire has been secured with the endoscopic snare, it is pulled against the end of the scope and then withdrawn as a unit. Tension is maintained at both ends of the guidewire and the gastrostomy tube is then loaded onto the guidewire with the tapered end first. The gastrostomy tube is pushed down the esophagus, into the stomach, exiting the abdominal wall at the site of needle insertion (Fig. 2). The PEG tube is then pulled through the abdominal wall until the button or bumper on the distal end of the tube appears to snugly approximate the stomach to the anterior abdominal wall. A repeat gastric endoscopy is performed to document position, the tube is secured with the external bolster under endoscopic control to avoid unnecessary tension, and finally a picture is obtained to document placement. We routinely leave the PEG to gravity drainage for 12 to 24 h before enteral feedings are started.

Results Fifty-four multiple trauma patients aged 1895 years (average 42 years) underwent PEG placement. There were 38 men and 16 women. The mechanism of injury was blunt trauma in 43 (motor vehicle accident in 32, fall in 11), gunshot wounds in four, and various other injuries in seven. Most procedures (56%) were carried out for low GCS or persistent vegetative state (PVS). Sixteen patients (30%) with predominantly orthopedic injuries underwent PEG as an adjunct to nutritional support. In four patients, aspiration and severe maxillofacial trauma were the indication for PEG. The mean ISS was 27 (range 842). Glasgow Coma

Surgical technique
All procedures were performed bedside in the SICU by a general surgery resident (postgraduate year [PGY]-2) or the trauma chief resident (PGY-5) under continuous supervision by the trauma attending staff. All patients were kept NPO for at least 6 h before the procedure. Universal precautions and sterile conditions were maintained. Blood pressure, pulse oximetry, end-tidal CO2, and cardiac activity were routinely monitored during all

1070 Table 1. Endoscopic findings during PEG Diagnosis Normal Gastritis Severe (5)a Mild (12) Reflux esophagitis Gastric ulcer Duodenal ulcer Number of Patients 24 17 6b 4c 3d

Specific treatment after PEG placement: a Four patients. b Three patients. c Three patients. d Two patients.

Scale score upon admission was 3 to 15 (mean 7) and on the day of the PEG was 3 to 15 (mean 10). Associated surgical procedures were performed in all patients with an average of 2.3 per patient (range 14); the most common operations were orthopedic and neurosurgical, which occurred in 32 patients, followed by maxillofacial in 20, vascular and thoracic in eight, and abdominal procedures in seven patients. In the 72 h prior to placement, 34 patients (63%) required interruption of their tube feeds for a variety of technical problems. In 38 patients, an average of five radiographs were obtained (range 116) to document the location of the feeding tube. Concomitant full EGD at the time of PEG placement revealed an unsuspected pathology in 30 patients (55%) requiring specific treatment in 12 patients (Table 1). The interval between admission and PEG averaged 7 days (range 212). At the time of the PEG placement, 40 patients (74%) were endotracheally intubated and required mechanical ventilation. In the last year of our experience, simultaneous percutaneous dilational tracheostomy (PDT) was performed in 14 patients with no complications. In 11 patients (20%) an ICP monitor was in place at the time of the PEG with no significant changes in ICP before or during the PEG (14 vs 16 cm H2O). Full enteral nutritional support was achieved within 48 h of PEG placement in 95% of patients. There were no significant complications related to the EGD, although three patients developed transient arterial oxygen desaturation which corrected after suctioning and repositioning the endotracheal tube. The procedure was converted, in one patient, to an open gastrostomy after bleeding at the entrance site in the stomach was noted, after the initial PEG placement. Two delayed complications were observed; one patient developed aspiration pneumonia, and in the second, the patient inadvertently pulled the tube, requiring surgical replacement. Two patients died in this series. Neither death was related to the PEG placement; each was the result of underlying associated injuries.

Discussion Adequate nutrition is an important part of the overall care of critically ill trauma patients. Unfortunately, it is too often neglected or relegated to a secondary role. PEG has been strongly advocated as a safe, reliable, and acceptable tech-

nique to provide adequate enteral nutrition [4, 810]. In general, our series confirms this; however, some points are important to emphasize. Monitoring the ICP is important during this procedure in patients with severe head injuries to minimize secondary insults to the brain. In our series, an ICP monitor was in place in 11 patients (20%) with minimal changes in the ICP. Adequate local anesthesia, IV sedation, and occasionally brief paralyzation are extremely important to avoid sudden elevation of the ICP. Despite concerns of endoscopic surgery in critically ill patients, PEG has been shown to be safe, reliable, and useful [4, 5, 9, 11]. Its use should be considered carefully for patients in whom it may not be possible because of (1) hemodynamic instability, (2) recent esophageal or gastric surgery, or (3) coagulopathy. Prior abdominal surgery has been mentioned as a relative contraindication. We performed PEG in six patients with prior abdominal surgery and agree that by following the technical steps carefully it can be performed without added risk to the patient [13, 15]. In this experience, we have shown that bedside PEG in critically ill trauma patients is a safe, reliable, and expeditious technique. In the two patients where an open G-tube had to be performed, better patient restraint and a conservative approach to the gastric bleeding possibly could have avoided the open procedure. The presence of a PEG tube is well tolerated by the patient; some in this series remained in place for over a year with no documented complications. Desired nutritional goals were achieved in 48 h in 95% of patients with minimal or no side effects. The delivery of feedings through a PEG is simple and easily implemented in the rehabilitation or home setting. This technique also facilitates transfers and discharges to and from long-term facilities. It is an effective method with which to maintain hydration and nutrition in the multiple trauma patient, and we believe it is the alternative of choice for long-term access to the GI tract. Physicians caring for these patients are encouraged to become familiar with this technique, which we believe is slightly more invasive than placing an NG tube. As part of the protocol of PEG placement, all patients are routinely fed in the 30 upright position, and tracheal secretions are routinely checked for the presence of dye or glucose. One potential advantage of PEG catheters is that since they do not cross the gastroesophageal junction and then stent it open, the incidence of reflux and aspiration is theoretically less that with NG tubes. The overall incidence of aspiration in patients with PEG tubes, however, ranges from 11 to 14% [9, 14]. The risk of aspiration is not decreased by placement of more distal tubes, as shown in this and other institutions [7, 12, 14]. This series of critically injured patients demonstrates that bedside PEG placement can be safely performed with minimal morbidity in the ICU by surgical residents with appropriate staff supervision. These patients, in general, do not tolerate general anesthetics and intrahospital transport well [6]. Currently, we routinely perform the push technique as described by Gauderer and Ponsky in 1980 [5] (Figs. 1 and 2). A potential complication of PEG tubes is extrusion of the tube out of the stomach. The literature suggests that it occurs secondary to pressure necrosis of the gastric wall when the fastener of the tube is positioned

1071

under excessive tension [3]. To avoid this complication, we position the external fastener ring of the PEG under endoscopic visualization of the bumper of the tube in the stomach to ensure that it is not left under undue traction. We do not routinely use prophylactic antibiotics with this procedure and wound infection was not a problem in any of these patients. In general, therefore, we believe that early bedside PEG should be considered in critically ill trauma patients for the following indications:

5.

6.

7.

8.

Patients with severe neurological injuries or PVS who are likely to need long-term enteral feedings Patients with multiple associated injuries who cannot tolerate adequate nutritional intake through the oral route Those patients with multiple and severe facial injuries who may be intolerant or have a contraindication to a NG tube

9.

10.

11. 12.

References
1. Baker SP, ONeill B, Haddon W Jr, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14: 187196 2. Borzotta AP, Osborne A, Bledsoe F, Paxton J, Mardesic S (1993) Enteral nutritional support enhances cognitive recovery after severe closed head injury. Surg Forum 44: 29 3. Chung RS, Schertzer M (1990) Pathogenesis of complications following percutaneous endoscopic gastrostomies (PEG). Am Surg 56: 134 137 4. DAmelio LF, Hammond JS, Spain DA, Satyak JP (1994) Tracheos13.

14.

15.

tomy and percutaneous endoscopic gastrostomy in the management of the head-injured trauma patient. Am Surg 60: 180185 Gauderer MWL, Ponsky JL, Izant RJ Jr (1980) Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 15: 872875 Indeck M, Peterson S, Smith J, Brotman S (1988) Risk, cost, and benefit of transporting ICU patients for special studies. J Trauma 28: 10201025 Kadakia SC, Sullivan HO, Starnes E (1992) Percutaneous endoscopic gastrostomy or jejunostomy and the incidence of aspiration in 79 patients. Am J Surg 164: 114118 Kelly KM, Lewis B, Gentili DR, Benjamin E, Waye JD, Iberti TJ (1988) Use of percutaneous gastrostomy in the intensive care patient. Crit Care Med 16: 6263 Moore FA, Haenel JB, Moore EE, Read RA (1992) Percutaneous tracheostomy/gastrostomy in brain-injured patientsa minimally invasive alternative. J Trauma 33: 435439 Ponsky JL, Gauderer MWL (1989) Percutaneous endoscopic gastrostomy: indications, limitations, techniques and results. World J Surg 13: 165170 Ponsky JL, Gauderer MW, Stellato TA, Aszodi A (1985) Percutaneous approaches to external alimentation. Am J Surg 149: 102105 Spain DA, DeWeese RC, Reynolds MA, Richardson JD (1995) Transpyloric passage of feeding tubes in patients with head injury does not decrease complications. J Trauma 39: 11001102 Stellato TA, Gauderer MWL, Ponsky JL (1987) Percutaneous endoscopic gastrostomy following previous abdominal surgery. Ann Surg 200: 4650 Strong RM, Condon SC, Solinger MR, Namihas BN, Ito-Wong LA, Leuty JE (1992) Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized prospective study. JPEN J Parenter Enteral Nutr 16: 5963 Townsend MC, Flancbaum L, Cloutier CT, Arnold MW (1992) Early postlaparotomy percutaneous endoscopic gastrostomy. Surg Gynecol Obstet 174: 4648

Surg Endosc (1997) 11: 10721074

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopy in the critically ill


R. Orlando, III, K. L. Crowell
Department of Surgery, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102-5037, USA, and University of Connecticut School of Medicine, Farmington, CT 06034, USA Received: 3 April 1997/Accepted: 19 May 1997

Abstract Background: Laparoscopy was evaluated in critically ill patients with suspected acute cholecystitis, mesenteric ischemia, or gastrointestinal perforation. We studied laparoscopy to assess its utility, accuracy, and effect on cardiopulmonary stability. Methods: Twenty-six surgical ICU patients with possible abdominal sepsis underwent laparoscopy. Nineteen were post cardiac surgery; the remainder had other diagnoses. Video laparoscopy was performed with hemodynamic monitoring and inotropic support as needed. Eight patients had bedside laparoscopy. Results: Fifteen patients had suspected acute cholecystitis. Laparoscopy was positive in 10; four had open cholecystectomy, four laparoscopic cholecystectomy, and two tube cholecystostomy. Nine patients had suspected mesenteric ischemia; laparoscopy was positive in five, revealing cirrhosis in two and ischemic bowel in three. Two patients had suspected perforated viscus with colonic perforation in one and one false negative. There were no adverse hemodynamic events. Conclusions: Laparoscopy can be performed safely in critically ill patients. It is useful in patients with acute cholecystitis and in patients who are post cardiac surgery with refractory lactic acidosis in whom a diagnosis of mesenteric ischemia is considered. Key words: Laparoscopy Critical illness Acute acalculous cholecystitis Mesenteric ischemia

emergent situations and in unstable patients are evolving. Critically ill patients often develop signs and symptoms of sepsis or the systemic inflammatory response syndrome (SIRS). Nonspecific findings such as fever, leukocytosis, abdominal distention, and metabolic acidosis raise concerns about possible intraabdominal sepsis. Acute cholecystitis, mesenteric ischemia, and gastrointestinal perforation are often difficult to diagnose with standard approaches such as physical examination, abdominal sonography, and computed tomography. Laparoscopic assessment of possible intraabdominal sepsis warranted investigation because it is minimally invasive, rapid, can be performed at the bedside in unstable patients, and had the potential to be highly accurate. We examined our experience with laparoscopy to assess its utility, diagnostic accuracy, effect on cardiopulmonary stability, and safety. Patients and methods
This study entailed a retrospective analysis of patients who had diagnostic or therapeutic laparoscopy while in the Surgical Intensive Care Unit (SICU) at Hartford Hospital, an 800-bed tertiary-care teaching institution. There are 24 SICU beds with approximately 1,700 admissions annually. Between July 1991 and June 1996, 26 SICU patients underwent laparoscopy. The study group included 17 males and nine females with a mean age of 69 years (range 5481). The mean SICU stay prior to laparoscopy was 10 days (range 033 days). The admitting SICU diagnoses are listed in Table 1. The cardiac, vascular, and two of the general surgery patients were all evaluated laparoscopically during the postoperative period. Three of the general surgery patients were admitted preoperatively with abdominal pain and sepsis. Eleven patients had a history of remote abdominal operations. Twenty patients (77%) were mechanically ventilated prior to contemplation of laparoscopy. The remainder were intubated just prior to the procedure. All patients had arterial lines in place and 21 (81%) had pulmonary artery catheters. Twenty-two patients were receiving vasoactive infusions at the time of the laparoscopy, ranging from renal-dose dopamine (seven patients) to high doses of dobutamine, amrinone, milrinone, phenylephrine, epinephrine, or norepinephrine (14 patients). All of the postoperative patients had an unstable course with clinical and laboratory findings suggestive of an intraabdominal source of sepsis. Twenty-two patients (85%) had abdominal exam findings suggestive of intraabdominal pathology and six (23%) were febrile. Nine (35%) had leukocytosis, 12 (46%) had elevated serum lactate levels, and 21 (81%) had abnormal liver chemistries and/or elevated serum amylase and lipase. Prelaparoscopy ultrasound was performed in 13 patients: It was positive in

During the past several years, laparoscopic techniques have been used in increasing numbers of elective surgical procedures. Laparoscopic approaches to diagnosis and therapy in
Presented at the annual scientific session of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA, 1922 March 1997 Correspondence to: R. Orlando, III

1073 Table 1. Admitting SICU diagnosis Type of surgery Cardiac Vascular General surgery No. patients 19 2 5 Table 2. Results of diagnostic laparoscopy in patient groups Suspected diagnosis Acute cholecystitis Mesenteric ischemia Perforated viscus No. patients 15 9 2 Positive 10 5 1 Negative 5 4 1

four, indeterminate in five, and negative in four. Abdominal computed tomography was performed in six patients and demonstrated ascites in two and portal venous air in one. These findings, often accompanied by low systemic vascular resistance, prompted the decision to perform laparoscopy. Indications for laparoscopy were categorized as suspected acute cholecystitis in 15, possible mesenteric ischemia in nine, and perforated viscus in two patients. Video laparoscopy was performed using open cannulation of the abdomen with a carbon dioxide pneumoperitoneum and hemodynamic monitoring and inotropic support as needed. Abdominal pressures were initiated at 1012 mmHg and increased to 15 mmHg if needed for visualization of the peritoneal cavity. Eight patients had diagnostic laparoscopy performed at the bedside. Patients treated in the operating room had general anesthesia with muscle relaxation. Patients undergoing laparoscopy in the SICU received sedation with intravenous narcotics, benzodiazepines, or propofol in addition to neuromuscular blockers. Two or three ports were employed for diagnostic laparoscopy. Peritoneal fluid was usually aspirated and sent for microbiologic analysis.

unstable. Only one of these patients, who had a colonic perforation, required transfer to the operating room for an open procedure. One operative complication occurred, a perforation of the small bowel secondary to manipulation of ischemic bowel with grasping forceps. At the time of the perforation and subsequent open small-bowel resection, enteric contents were spilled and the patient became hypotensive. This was treated with a single bolus of phenylephrine and represents the only hemodynamic compromise observed in this series. One patient developed a postoperative wound infection following open cholecystectomy. Overall, 11 patients (42%) survived to hospital discharge and 15 patients died (58%). None of the deaths were due to complications or laparoscopy or intraabdominal sepsis. Discussion Critically ill patients may develop acute abdominal conditions similar to those of ambulatory patients such as diverticulitis or they may develop intraabdominal catastrophes characteristic of the SICU population including acute acalculous cholecystitis and mesenteric ischemia. Diagnosis of these problems can be quite difficult: Physical findings are often unreliable due to altered mental status, laboratory findings are frequently confounded by coexisting disease processes, and radiologic studies may be impractical because of logistical and safety considerations in transporting unstable patients. The diagnosis of acute acalculous cholecystitis can be especially problematic. Laboratory findings are usually nonspecific (1). While bedside ultrasonography eliminates the need for transport, it is often inconclusive [4, 8, 13, 17]. Radionuclide hepatobiliary scans are of limited value in patients who are not receiving enteral nutrition. Morphine augmentation during cholescintigraphy was previously reported to improve accuracy in critically ill patients [9]; however, this finding has not been confirmed in a subsequent study [7]. Brandt et al. [5] and Sleeman et al. [18] have supported the utility of laparoscopy in trauma ICU patients with suspected acute cholecystitis. We advocate laparoscopic cholecystectomy when feasible but laparoscopic cholecystostomy is effective in the absence of gangrenous cholecystitis. Open cholecystectomy is required for gangrenous cholecystitis in situations not amenable to laparoscopic treatment. Suspected mesenteric ischemic is a difficult consideration in the critically ill because the only nonoperative diagnostic modality is mesenteric angiography. This requires transport of an unstable patient to the radiology department and involves the use of potentially nephrotoxic contrast agents [14]. Laparoscopy is now emerging as a diagnostic

Results Table 2 shows the results of laparoscopy in the three diagnostic categories which were considered. Among the 26 patients in the series, there were 16 positive and 10 negative examinations. There were no false positives and one false negative. The single false negative occurred in a patient with a suspected perforated viscus in the setting of peritonitis and SIRS. Laparoscopy documented patchy fat necrosis. Subsequent abdominal CT scan revealed severe pancreatic necrosis. Among patients diagnosed with acute cholecystitis, four had open cholecystectomy, four had laparoscopic cholecystectomy, and two had laparoscopic tube cholecystostomy. In patients with suspected mesenteric ischemia, the positive findings included mesenteric ischemia in three and unsuspected cirrhosis in two. One of the two suspected perforated viscus patients had a diverticular perforation of the colon and the other was the false negative mentioned above. In addition to the open cholecystectomies, conversions to open surgery were carried out for small-bowel resection in three cases, for Hartmann procedure in one, and for cecostomy in one. Analysis of preoperative laboratory tests including white blood cell count, liver chemistries, amylase, lipase, arterial blood gases, and serum lactate did not demonstrate any correlation with the presence or absence of intraabdominal pathology found at laparoscopy. Preoperative ultrasound was also poorly correlated with operative findings in the patients with suspected cholecystitis. All patients tolerated the pneumoperitoneum without adverse consequences. Hemodynamic stability was maintained in all but one case (see below) without the need for any increase in the level of inotropic support. There were no episodes of oxygen desaturation or ventilatory compromise. There were no complications observed in the patients undergoing bedside laparoscopy, who were generally more

1074

technique because of these uncertainties. One early case report described the use of laparoscopy to confirm the diagnosis of small-bowel infarction after abdominal aortic reconstruction [11]. Forde and Treat described the use of laparoscopy to determine the need for further evaluation with laparotomy in a series of 10 patients with clinical conditions similar to ours [10]. Bender and Talamini [3] and Brandt et al. [4] reported safety and utility of laparoscopy in critically ill patients. The single false negative in this experience demonstrates that diagnostic laparoscopy will not adequately evaluate the retroperitoneum. This patient had severe pancreatitis with necrosis and CT scanning remains the definitive diagnostic procedure. Despite known adverse physiologic effects of pneumoperitoneum, procedures were well tolerated in our patients. Respiratory effects of pneumoperitoneum include hypercarbia, respiratory acidosis, diaphragmatic elevation, reduced functional residual capacity, and ventilation perfusion mismatch. Cardiovascular alterations include elevated central venous pressure and pulmonary artery pressures, increased systemic vascular resistance and mean arterial pressure, and decreased stroke volume and cardiac output, especially in patients with limited cardiac reserve. These phenomena are dependent upon baseline cardiopulmonary function, intravascular volume status, and the magnitude of intraperitoneal pressure increases [1416,19]. Safran et al. [16] and Carroll et al. [6] described the safe and successful use of laparoscopy in high-risk patients with severe cardiac dysfunction. Careful physiologic monitoring is necessary to safely perform laparoscopy in this very ill group of patients. To minimize the risk of procedural complications, the Hasson technique of trocar introduction is advisable. Many of these patients have distended bowel, and the use of a Veress needle and blind trocar insertion can result in bowel injury. The inclusion of a Leukens trap in the suction tubing circuit is helpful for the collection of ascitic fluid for Grams stain and culture. We also advocate the gentle use of atraumatic grasping forceps to manipulate the bowel, preferring to grasp the mesentery rather than the often edematous, friable, and unforgiving bowel wall itself. Bedside laparoscopy is readily accomplished with all necessary equipment on a single rolling cart including camera, monitor, light source, and insufflator. The relative inflexibility of the ICU beds compared to an operating room table limits patient positioning and therefore is more suited to diagnostic rather than therapeutic procedures. This suggests that bedside procedures may be most appropriate when the clinicians guess is that the result of laparoscopy will be negative. Laparoscopic evaluation was clinically useful even when surgically remediable problems were not discovered. We believe that this approach is particularly useful in patients who are hemodynamically unstable following cardiac surgery. Low cardiac output is seen in conjunction with lactic acidosis, and mesenteric ischemia is difficult to exclude as a possible explanation. Diagnostic laparoscopy makes a rapid diagnosis and permits confident application of aggressive hemodynamic support when no abnormalities are identified in the abdomen. Three patients in this series who were evaluated due to a hyperdynamic, septic-

appearing state were discovered to have end-stage cirrhosis, which was completely unrecognized in two. This finding was influential in the assessment of prognosis and in subsequent decisions regarding withdrawal of support. Liver failure is known to produce a hyperdynamic state with increased cardiac output and decreased systemic vascular resistance, similar to the hemodynamic picture seen in sepsis [2], as well as predisposing to more severe hemodynamic and metabolic perturbations [12]. Laparoscopy can be performed safely in critically ill patients. It is a useful diagnostic procedure in patients with suspected acute cholecystitis, which is often difficult to diagnose in the critically ill. Cardiac surgical patients with refractory lactic acidosis in whom a diagnosis of mesenteric ischemia is considered and who are often unstable can also be accurately assessed with diagnostic laparoscopy. References
1. Babb RR (1992) Acute acalculous cholecystitis: a review. J Clin Gastroenterol 15: 238241 2. Baumgartner JD, Vaney C, Perret C (1984) An extreme form of the hyperdynamic syndrome in septic shock. Intensive Care Med 10: 245 249 3. Bender JS, Talamini MA (1992) Diagnostic laparoscopy in critically ill intensive care unit patients. Surg Endosc 6: 302304 4. Brandt CP, Priebe PP, Eckhauser ML (1993) Diagnostic laparoscopy in the intensive care patient. Avoiding the nontherapeutic laparotomy. Surg Endosc 7: 168172. 5. Brandt CP, Priebe PP, Jacobs DG (1994) Value of laparoscopy in trauma ICU patients with suspected acute acalculous cholecystitis. Surg Endosc 8: 361364 6. Caroll BJ, Chandra M, Phillips EH, Margulies DR (1993) Laparoscopic cholecystectomy in critically ill cardiac patients. Am J Surg 59: 783785 7. Fig LM, Wahl RL, Stewart RE, Shapiro B (1990) Morphine augmented hepatobiliary cholescintigraphy in the severely ill: caution is in order. Radiology 175: 467473 8. Flancbaum L, Majerus TC, Cox EF (1985) Acute posttraumatic acalculous cholecystitis. Am J Surg 150: 252256 9. Flancbaum L, Alden SM, Trooskin SZ (1989) Use of cholescintigraphy with morphine in critically ill patients with suspected cholecystitis. Surgery 106: 668674 10. Forde KA, Treat MR (1992) The role of peritoneoscopy (laparoscopy) in the evaluation of the acute abdomen in critically ill patients. Surg Endosc 6: 219221 11. Iberti TJ, Salky BA, Onofrey D (1989) Use of bedside laparoscopy to identify intestinal ischemia in postoperative cases of aortic reconstruction. Surgery 105: 686689 12. Moreau R, Hadengue A, Soupison T, Kirstetter P, Momzer MF, Janjack D, Vauquelin P, Assolis M (1992) Septic shock in patients with cirrhosis: hemodynamic and metabolic characteristics and intensive care unit outcome. Crit Care Med 20: 746750 13. Orlando R, Gleason E, Drezner AD (1983) Acute acalculous cholecystitis in the critically ill patient. Am J Surg 145: 472476 14. Reines HD (1992) Evaluating the acute abdomen in an ICU patient. In: Civetta JM, Taylor RW, Kirby RR (eds) Critical care. J B Lippincott, Philadelphia 15. Safran D, Orlando R III (1994) Physiologic effects of pneumoperitoneum. Am J Surg 167: 281286 16. Safran D, Sgambati S, Orlando R III (1993) Laparoscopy in high risk cardiac patients. Surg Gynecol Obstet 176: 548554 17. Savino JA, Scalea TM, Del Guercio LRM (1985) Factors encouraging laparotomy in acalculous cholecystitis. Crit Care Med 13: 377380 18. Sleeman D, Almeida J, Sosa JL, Puente I, McKenney M, Martin L (1995) Acalculous cholecystitis: the use of diagnostic laparoscopy. J Laparoendosc Surg 5: 227231 19. Wittgen CM, Andrus CH, Fitzgerald SD, Baudendistel LJ, Dahms TE, Kaminski DL (1991) Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 126: 9971001

Surg Endosc (1997) 11: 11021105

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy


A comparison of techniques
J. E. Korman, J. R. Hiatt, D. Feldmar, E. H. Phillips
Division of General Surgery, Department of Surgery, Room 8215, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA Received: 3 April 1997/Accepted: 3 July 1997

Abstract Background: Laparoscopic total extraperitoneal (TEP) hernia repair utilizes slit mesh that is placed around the spermatic cord to secure the prosthesis and prevent recurrence. Because of concern that encircling of the cord might increase pain and morbidity, we compared patients with mesh repairs using encircled and nonencircled techniques. Methods: The 191 male patients who underwent bilateral TEP repairs were divided into three groups. In 100 consecutive patients (group A), the slit mesh was closed around both spermatic cords; in 56 patients (group B), the slit mesh was tucked under the spermatic cords but not closed; in 35 consecutive patients (group C), the slit was closed around one cord and tucked under the other, in a randomized fashion. Results: The groups had similar operative times (A: 83 25 min; B: 79 21; C; 77 24), use of pain medication (A: 2.7 2.5 days; B: 2.4 1.9; C: 3.1 2.4), and recovery before return to work (A: 7.9 7.0 days; B: 8.2 6.1; C: 6.7 4.8). The incidence of indirect hernias was similar in all groups. Complication rate was 20% in A, 20% in B, and 14% in C (p NS). Chronic pain was more frequent in A (A: 6, B: 0, p 0.06). In group C, fluid collections were more common on the closed side (closed: 3, tucked: 0; p 0.08). There were no recurrences in any group. Conclusions: Closing the slit around the spermatic cord in laparoscopic inguinal hernia repair is not essential for prevention of early recurrence. Fluid collections tended to be more frequent when the mesh was closed around the cord, and chronic pain was more frequent in the group with closed mesh bilaterally. Key words: Hernia Laparoscopic total extraperitoneal hernioplasty TEP Laparoscopy Mesh

Extraperitoneal approaches to laparoscopic hernia repair have low recurrence rates and avoid both visceral contact with the prosthetic material and an incision in the peritoneum [8]. The total extraperitoneal (TEP) repair was developed by Phillips [8] and McKernan [6] to emulate the open preperitoneal repair of Stoppa [11], which had proven effectiveness. In many TEP repair techniques, a large piece of mesh is used to cover all of the potential defects, and the mesh is slitted and closed around the spermatic cord. Some surgeons have feared that unless the slit is closed snugly around the cord, making a new internal ring, recurrence is likely. Conversely, a too-tight closure could cause circumferential scarring, compression of the cord structures, and subsequent testicular pain, atrophy, and fluid collections. After an extensive experience with mesh closure around the cord structures, the authors adopted a technique in which the slit mesh is tucked under the spermatic cord, with the goal of decreasing postoperative pain. The present study was undertaken to compare various techniques related to slitting and closure of the mesh. Methods
This study analyzed the outcomes of 191 male patients who underwent bilateral laparoscopic inguinal hernia repair at Cedars Sinai Medical Center from July 1992 to February 1997. Patients were assigned to three groups chronologically. Group A included the first 100 consecutive patients of the study, in whom the slit mesh was closed around both the right and left spermatic cords (Fig. 1A). Group B included 56 consecutive patients in whom the slit mesh was tucked under the spermatic cords, but not closed around them (Fig. 1B). Group C included 35 consecutive patients who served as their own controls: The mesh was closed around one cord and tucked under the other (Fig. 2), with the sides chosen by random number assignment. There was no correlation between the side that the slit was closed on and presence of indirect hernias. Patients were allocated chronologically first to group A, then group C, and finally group B. All repairs were performed by the total extraperitoneal (TEP) approach as previously published [3, 4], and all aspects of the hernia repairs, other than handling of the slit in the mesh, were identical, including dissection, size of mesh, and stapling techniques. The data gathered included patient age, type of hernia defect (direct vs indirect), and type of repair (slit secured around cord vs slit tucked under the cord). Outcome measures included operative time (defined as time from Veress needle insertion to

Presented at the annual scientific session of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA, 1922 March 1997 Correspondence to: E. H. Phillips

1103

Fig. 1. A Rolled mesh with slit closed around spermatic cord and stapled to Coopers ligament (group A). B Rolled mesh with slit draped over spermatic cord. Lateral flap is tucked under cord, and medial segment is stapled to Coopers ligament (group B).

Fig. 3. Dimensions of mesh and orientation of slit. Top: closed technique. Bottom: tucked technique. Coopers ligament, the underside of the abdominal wall, the direct and indirect portions of the inguinal region. The spermatic cord, femoral canal, and aponeurotic sling are visualized bilaterally. If an indirect hernia is present, the sac is reduced and, if large, excised after ligation with an endoloop. Cord lipomas (preperitoneal fat herniated through the internal ring), if present, are reduced but not excised. After both inguinal regions are completely dissected, a 12 cm 12 cm sheet of mesh is fashioned for the repair. This mesh is prepared either with a 3-cm-long slit approximately 4 cm from one end (Fig. 3, top) or a key-like slit in the lateral third of the mesh (Fig. 3, bottom). The sheet is rolled and secured with an absorbable suture at each end, leaving unrolled the segment with the slit (Fig. 1A, B). If the slit is to be closed, the tongue of the mesh is placed under the testicular vessels and vas deferens from lateral to medial, with the medial segment of mesh secured onto Coopers ligament (Fig. 1A). Then the slit is closed to itself, creating a new internal ring. During this positioning, the surgeon must be careful not to place medial or lateral tension on the cord structures. In the tucked slit technique, the lateral segment is tucked under the testicular vessels, not quite reaching the vas deferens (Fig. 1B). After the contralateral mesh is placed, the stay sutures are cut; both sheets of mesh are unrolled superiorly and stapled to the anterior abdominal wall, medial to the epigastric vessels, and most important, the two pieces of mesh are stapled to each other in the midline.

Fig. 2. Bilateral repair (group C). Tucked technique on right side, closed on left. Mesh is unrolled, and the two pieces are stapled together in the midline. closure of wound), the presence of more prominent pain on one side (evaluated without knowledge of technique employed), number of days that oral pain medication was taken, number of days until the patient returned to work, complications (including groin fluid collections and testicular pain, swelling, or atrophy), and recurrence. Seromas, hematomas, and hydroceles of any detectable size were all considered to be fluid collections. Chronic pain was defined as frequent or daily pain that lasted longer than 6 weeks postoperatively.

Technique
The preperitoneal space is accessed by blunt dissection as previously published [3, 4]. Under direct vision, the preperitoneal tissue is dissected from

1104 Table 1. Comparison of groups A n Average age, years Mean followup, months Indirect hernia, n (%) Operative time, min. Pain medication, days Return to work, days Complications, n (%) Recurrence * p 0.03 (A vs B) 100 52 12* 40 118 (59) 83 25 2.7 2.5 7.9 7.0 20 (20) 0 B 56 41 13* 15 60 (54) 79 21 2.4 1.9 8.2 6.1 11 (20) 0 C 35 54 16 35 35 (50) 77 24 3.1 2.4 6.7 4.8 5 (14) 0 Table 2. Complications A (n 100) Chronic pain (6) Hydrocele (5) Hematoma (4) Persistent lipoma Bradycardia Urinary retention Seroma Testicular pain B (n 56) Seroma (5) Urinary retention (3) Nausea/vomiting Hydrocele Thigh numbness C (n 35) Hematoma (2) Seroma Chronic pain Retroperitoneal bleeding

Results There were 100 patients in group A, 56 in group B, and 35 in group C (Table 1). Patients in group B were younger than in group A. Frequency of indirect hernias, operative times, use of pain medication, recovery before return to work, and complication rates were similar in all groups. There were no recurrences in any group. Specific complications are shown in Table 2. Groin fluid collections and chronic pain accounted for the majority of complications. When complications were compared for groups A and B (Table 3), there was a greater incidence of chronic pain in the former, which approached statistical significance. Testicular pain and groin fluid collections occurred with similar frequency. In group C, the closed and tucked sides were compared (Table 4). There were no differences in the frequency of indirect hernias, testicular pain, or increased pain on one side relative to the other. In four patients, pain was greater on one side (two on the closed side and two on the tucked side; p 1). Fluid collections were more common on the closed side, approaching statistical significance. There were no recurrences on either side. Discussion The extraperitoneal approaches (TAPP or TEP) depend upon the use of a large piece of mesh to cover all potential hernia sites and to overlap normal abdominal wall. In a multi-institutional review of laparoscopic hernia repair [9] use of mesh that was too small was the most common reason for early recurrence. Regarding technical aspects of TEP, some authors report no need to slit the mesh [12] instead draping it over the spermatic cords, while others maintain that securing the mesh around the cord will prevent recurrences and migration of the prosthesis [1]. Various techniques and outcomes are compared in Table 5. No reports have analyzed results based upon differing configurations of the mesh prosthesis. Our analysis showed that a new internal ring, created by closing the mesh around the cord (group A), was not needed to prevent recurrence. Although the numbers were relatively small, and follow-up was limited, most recurrences after the TEP repair occur within the first 2 years [9]. Though there was no difference in the duration before return to work or use of pain medication, groin fluid collections and chronic pain were somewhat more frequent in patients with mesh closed around the cord. In group C, the two methods were compared in indi-

Table 3. Complications: groups A and B compared A n Testicular pain, n (%) Fluid collection, n (%) Chronic pain, n (%) 100 1 (1) 10 (10) 6 (6) B 56 0 6 (11) 0 p value 0.4 0.9 0.06

Table 4. Complications: closed and tucked sides (group C) compared Closed Indirect hernia, % Difference-side of pain, n (%) Testicular pain, n (%) Fluid collection, n (%) 46 2 (6) 1 (3) 3 (9) Tucked 54 2 (6) 0 0 p 0.5 1 0.3 0.08

Table 5. Comparison of laparoscopic herniorrhaphy techniques Author Deans [2] Payne [7] Stoker [10] Vellasco [14] Swanstrom [12] Arregui [Personal Communication 3/10/97] McKernan [6] Liem [5] Vanclooster [13] Phillips Techniquea TAPP TAPP TAPP TAPP TAPP/ TEP TEP TEP TEP TEP TEP Use of slit None ND ND Horizontal slit closed None None Vertical slit closed None None Oblique slit closed n 150 48 75 25 158 300 200 120 195 172 Recurrence (%) 0 1 0 6 2 0.7 0 8 0 0

TAPP Transabdominal preperitoneal repair; TEP Totally extraperitoneal repair; ND No data

vidual patients. We found no difference in pain between the two sides, no significant difference in the occurrence of testicular pain, and no recurrences. However, there was a difference in the incidence of groin fluid collections on the closed side that approached statistical significance. In summary, closure of the slit mesh around the spermatic cord is not essential to prevention of recurrence in

1105

TEP laparoscopic herniorrhaphy. Moreover, this additional maneuver, which some surgeons find tedious, may be associated with a greater frequency of fluid collections and chronic pain. These data may not be applicable to unilateral repairs or to repairs that do not include mesh fixation to Coopers ligament. It is important to emphasize that our techniques employed large pieces of mesh which were fixed to Coopers ligament bilaterally and to one another in the midline. Utilizing these technical principles, results have been excellent. References
1. Avery C, Foley RJE, Prasad A (1995) Simplifying mesh placement during laparoscopic hernia repair. Br J Surg 82: 642 2. Deans GT, Wilson MS, Royston CMS, Brough WA (1995) Laparoscopic bikini mesh repair of bilateral inguinal hernia. Br J Surg 82: 13831385 3. Fallas MF, Phillips EH (1995) Laparoscopic near-total preperitoneal hernia repair. In: Phillips EH, Rosenthal RJ (eds) Operative strategies in laparoscopic surgery. Springer Verlag, Berlin, pp 8892 4. Friedman RL, Phillips EH Extraperitoneal laparoscopic hernioplasty. In: Maddern G, Hiatt JR, Phillips EH (eds) Hernia repair: open vs. laparoscopic approaches. Churchill-Livingstone, London (in press) 5. Liem MSL, van Steensel CJ, Boelhouwer RU, Weidema WF, Clevers GJ, Meijer WS, Vente JP, de Vries LS, van Vroonhoven TJMV (1996) The learning curve for totally extraperitoneal inguinal hernia repair. Am J Surg 171: 281285 6. McKernan JB, Laws HL (1993) Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 7: 2628 7. Payne JH, Grininger LM, Izawa MT, Podoll EF, Lindahl PJ, Balfour J (1994) Laparoscopic or open inguinal herniorrhaphy? Arch Surg 129: 973981 8. Phillips EH, Carroll BJ, Fallas MF (1993) Laparoscopic preperitoneal inguinal hernia repair without peritoneal incision: technique and early results. Surg Endosc 7: 159162 9. Phillips EP, Rosenthal R, Fallas MJ, Carroll BJ, Arregui M, Corbitt J, Fitzgibbons R, Seid A, Schultz L, Toy FK, Wadell RL, McKernan B (1995) Reasons for early recurrences following laparoscopic hernioplasty. Surg Endosc 9: 140145 10. Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM (1994) Laparoscopic versus open inguinal hernia repair: randomised prospective trial. Lancet 343: 12431245 11. Stoppa RE (1995) The preperitoneal approach and prosthetic repair of groin hernias. In: Nyhus LM, Condon RE (eds) Hernia. JB Lippincott, Philadelphia, pp 188210 12. Swanstrom LL (1996) Laparoscopic herniorrhaphy. Surg Clin North Am 76(3): 483491 13. Vanclooster P, Meersman AL, de Gheldere CA, Van de Ven CK (1996) The totally extraperitoneal laparoscopic hernia repair: preliminary results. Surg Endosc 10: 332335 14. Vellasco JM, Gelman C, Vallina VL (1996) Preperitoneal bilateral inguinal herniorrhaphy: evolution of a technique from conventional to laparoscopic. Surg Endosc 10: 122127

Discussion Dr. Dudai: Id like to know whether you have any idea, or tried to investigate, about the effects of the fibrosis that create the mesh around the vas deferens, or the motility of the sperm in the vas deferens. Dr. Korman: Thats a good question. That was also one of the main factors in our undertaking this study. We were concerned that this fibrosis, encircling the vas, would contribute to more testicular pain. We dont have any answers on the motility of the sperm. Dr. Dudai: A very important issue, especially in bilateral hernia in young patient. Dr. MacFadyen: Any other comments? Well, I think

youve answered a question that all of us have had, as to the importance of whether that slit was an important issue or not, and it appears from your paper that it is not. That will probably expedite the procedure for some people who have found that to be complicated. Could you comment on that a little bit, about the technical aspect of slipping that around? Dr. Korman: Certainly I think that devoting time to bringing the flap all the way around and closing it is cumbersome. With our slit we use it to actually help us. We drape the slit over the cord. It helps in positioning the mesh in the right spot, so it doesnt drift too far medially, too far laterally, and, as it is well placed, we then anchor it to Coopers ligament. We drape the mesh over the cord while its rolled up, and that was shown in one of our illustrations. That also helps in placing the mesh and making the mesh much easier to handle. Dr. Felix: In our large series we did see hernias actually through the slit. Has your group seen that as a problem? Some of us have covered the slit, and tried to avoid that hernia by covering the slit itself, and Id be interested to see if that was a cause of recurrence in your larger series of hernias that youve done. Dr. Korman: We have no recurrences to date. There are times, if we feel that our slit perhaps is too big, well just lay another piece of mesh over it. We certainly dont rule out putting in other smaller pieces of mesh, even laterally, if there are indirect hernias, well put another piece of mesh out laterally to basically cover any potential defect that we might be concerned about. Dr. Phillips: I did want to add that we have had one recurrence. What had happened is that the stapling technique had not gone through both pieces of meshwas inadequately fixed to itself in the midline, bilateral, and inadequately fixed to Coopers ligament. But, most importantly, the mesh had blown out bilaterally into both direct hernias, so the lateral parts were absolutely still there, so I was a little surprised by the comment about lateral recurrences that had been seen. This recurrence was definitely a failure of the mesh being fixed to itself in the midline. We have to look at our report here about the slit, nor not to slit, not to close. We did this in bilateral repairs. Im not 100% sure that we can apply this to unilateral repairs, but in bilateral repairs it seems, because the only place we fixed the mesh was to Coopers ligament and to the two prostheses to themselves in the midline, and no staples lateral at all, and we have not had any lateral recurrences. Dr. MacFadyen: Certainly it seems that the mesh itself seems to fixate within a very short period of time. My impression is it tends to fix within probably about 710 days, or do you think its even shorter? Dr. Phillips: Well, certainly in 24 hours I think the platelet aggregation is there, so thats its fixed, but its not securely enough fixed that it, you know, would stay there. I think one of the reasons that the TEP repair doesnt have any trocar site hernias is because the peritoneum is covering the trocar sites and allowing the wound to heal without intrusion of intra-abdominal organs up into the defect, so I think the same thing occurs by having the intact peritoneum, allowing the mesh to stay where it is, and then, in 14 days, I think it probably has about 7585% of its strength adherence.

Surg Endosc (1997) 11: 11151117

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic cryosurgery for hepatic tumors


Experimental observations and a case report
V. R. Tandan,1 D. Litwin,2 M. Asch,2 M. Margolis,2 S. Gallinger2
1 2

Department of Surgery, McMaster University, St. Josephs Hospital, Room G815, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada Department of Surgery, The University of Toronto, Mt. Sinai Hospital, Toronto, Ontario, Canada

Abstract 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 35C, 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. Key words: Cryosurgery Laparoscopic ultrasound Liver tumors Laparoscopy

esized immune response to the frozen tumor [3]. With advances in surgical technique and the use of intraoperative ultrasound, hepatic cryosurgery is being used routinely in many centers throughout the world for a variety of indications, including primary hepatocellular carcinoma and metastatic colorectal cancer. Recent advances in technology for laparoscopic surgery have made it technically possible for almost any abdominal surgical procedure to be performed via the laparoscope. Hepatic cryosurgery is a procedure that lends itself well to the laparoscopic approach because the cryoprobes can be passed through incisions of 12 mm and no specimen is removed. There are several technical aspects that make laparoscopic hepatic cryosurgery challenging. We addressed these questions first in a pig model, and we can now report the first successful case of laparoscopic hepatic cryosurgery performed at our institution.

Materials and methods

Animal experiments
The first experiment was performed on two pigs to determine the technical feasibility and safety of creating a cryosurgical lesion in the liver laparoscopically. Under general anesthesia, a standard Veress needle technique was used to create a pneumoperitoneum using CO2 to a pressure of 15 mm Hg. A 10-mm port was created at the umbilicus and a 30 telescope inserted. A second 10-mm port was created in the left upper quadrant, and the laparoscopic ultrasound probe (B&K model no. 3535) was introduced (Fig. 1). After performing a laparoscopic ultrasound examination of the liver, we made a 10-mm incision in the right upper quadrant. Under direct vision, a Teflon sheath specially designed to accommodate the 5-mm cryoprobe was placed into the abdomen (Fig. 2). An L hook was passed through this port with minimal loss of pneumoperitoneum, and the liver capsule was scored over the mid right lobe using electrocautery. The 5-mm cryoprobe was then passed through the Teflon sheath and introduced into the liver parenchyma. There was no significant loss of pneumoperitoneum from this setup. With intermittent ultrasonographic monitoring, a 4-cm freezeball was created. Intraabdominal temperature was continuously monitored during freezing. The goal of the second experiment was to demonstrate our ability to identify, target, and accurately freeze a preexisting lesion in two pigs. The

Cryosurgery, a treatment in which tumors are frozen and then left in situ to be reabsorbed, was first applied to the liver by Cooper in 1963 [1]. Cryosurgery has the advantage of being a focal treatment that causes little hepatic parenchymal loss; thus, lesions in multiple sites in the liver can be treated. In addition, lesions adjacent to large blood vessels can be frozen without damage to the vessels, since the flowing blood acts as a heat sink to protect them [2]. There are also some animal data to suggest that cryosurgery may provide added benefits over resection as a result of a hypoth-

Correspondence to: V. R. Tandan

1116

Fig. 1. Port positions used for laparoscopic hepatic cryosurgery (right lobe lesion).

initial anesthesia and port placement was identical to experiment 1. Under the guidance of the intraoperative ultrasound, a 2-cm lesion was created by percutaneously injecting saline mixed with India ink into the liver parenchyma. The right upper quadrant Teflon sheath was then introduced in the same fashion as experiment 1. The lesion was then identified with the laparoscopic ultrasound by a blinded team. With the help of our interventional radiologist, who is an integral part of the cryosurgical team, the cryoprobe was passed into the center of the lesion and the freezeball was created. Intraabdominal temperature and pressure were monitored continuously during freezing. After a 4-cm iceball had been generated, the probe was warmed and removed. A 5-mm forceps was used to pack the probe tract with surgicel before thawing was complete. The animals were then killed and the livers harvested and sent for pathologic examination. The skin and abdominal wall around the Teflon sheath were also excised and submitted for pathological examination.

Fig. 2. Cryoprobe inserted in Teflon sheath used as a laparoscopic port.

Case report
A 62-year-old man with a histologically proven advanced adenocarcinoma of the rectum was found on helical CT of the abdomen to have a 2-cm metastasis in the middle of the right lobe of the liver. Because the patient required preoperative radiation and attempted pelvic exenteration to treat the rectal tumor, we concluded that a formal right hepatic lobectomy was unwarranted and thus opted for cryosurgery. The laparoscopic approach was taken in order to allow the patient to proceed with his radiotherapy and pelvic surgery as soon as possible. Under general anesthesia, a pneumoperitoneum was created using the standard Veress needle technique. Ports were then placed, as shown in Fig. 1. The abdomen was inspected for evidence of spread of the rectal cancer. The liver was then carefully examined using the laparoscopic ultrasound through ports A and B to provide both transverse and sagittal images. The liver was quite coarse and nodular. The original 2-cm lesion was identified as well as several other suspicious lesions in both the left and right lobes. Using a Truecut needle, all suspicious lesions, including the original

one, were percutaneously biopsied twice under the direction of the laparoscopic ultrasound. All of the biopsies were done from one skin site in the 7th interspace in the anterior axillary line. Frozen-section examination of all biopsy specimens revealed no evidence of malignancy, except in the original lesion, which was confirmed as malignant. The Teflon sheath described in the animal experiments was then introduced under direct visualization through a 10-mm skin incision at the site used for the needle biopsies. The liver capsule was scored with electrocautery, and with the aid of our interventional radiologist, the cryoprobe was passed into the lesion under the guidance of the laparoscopic ultrasound. Two freeze/thaw cycles of 8 min each were performed, producing freezeball measuring 38 mm in diameter. Patient core temperature and intraabdominal temperature were continuously monitored during the freezing process. After the probe was warmer than 20C, it was removed and the tract was packed with surgicel.

Results Animal experiments In the first animal experiment, we were able to generate a 4-cm iceball with no difficulty. The animals remained hemodynamically stable throughout the procedure, and the temperature in the peritoneal cavity did not drop below 35C.

1117

In the second animal experiment, we generated 4-cm iceballs in the two pigs. Again, the animals remained stable throughout and the intraabdominal temperature did not drop below 35C. After 20 min of observation, there was no significant bleeding from the probe site. Pathologic examination of the liver revealed that the cryoablation was centered on and encompassed the entire lesion in both cases (the lesion was grossly visible to the pathologist as a result of the India ink). Histologic examination of the abdominal wall, including skin from around the Teflon port, demonstrated no injury. Clinical case Intraoperative laparoscopic ultrasound demonstrated clearly that the original lesion had been encompassed in the iceball with a minimal 8-mm margin. While waiting for the biopsy results, we noted that the central venous pressure (CVP) was increasing markedly and that air entry on the right side was absent (the patient remained stable with no tachycardia, hypotension, or difficulty with oxygenation). A diagnosis of a pneumothorax was made, and a 20 F chest tube was inserted in the 5th interspace without incident. The core temperature remained above 35C and the intraabdominal temperature did not drop below 35C. Estimated blood loss was <100 cc. The patient spent 1 h in the post-anesthetic care unit (PACU) and was returned to the surgical ward. He was ambulatory the following morning and resumed a regular diet on the 1st postoperative day. The chest tube was removed on the 1st postoperative day. The preoperative platelet count was 179; it fell to a low of 115 on the 1st postoperative day and returned to 137 on the 2nd postoperative day. Urine was examined for the presence of myoglobin, which has been reported as a possible complication of cryosurgery, but none was detected [4]. The patient was discharged home in excellent condition on the 4th postoperative day with plans to proceed with treatment of his rectal tumor in the near future. Discussion We have demonstrated the technical feasibility and safety of localizing, targeting, and cryoablating tumors in the liver using a laparoscopic approach. Cooling of the peritoneal cavity and damage to the skin from the probe site do not appear to be problems, and the procedure offers the advantages of decreased postoperative pain and a shorter hospital stay than with open cryosurgery. The complication of the pneumothorax is predictable in high right lobe lesions ne-

cessitating a transpleural probe placement. For these cases, a double lumen endotracheal tube to allow collapse of the lung and a prophylactic chest tube may be warranted. Skill in the use of laparoscopic ultrasound techniques is essential to this procedure. There are few data available to compare laparoscopic to conventional intraoperative ultrasound, but our experience with this new technology since January 1994 in >30 patients booked for liver resection suggests that laparoscopic ultrasound is close to but not as sensitive as open intraoperative ultrasound [5]. Whether this result is due to the learning curve or is a limitation of the current technology remains to be seen. We have found that our multidisciplinary approach, including the employment of an interventional radiologist who is scrubbed as part of the surgical team, has been extremely helpful in targeting lesions deep in the liver. Although hepatic cryosurgery is used in many centers throughout the world for various indications, there have not been any controlled trials comparing this therapy to resectionor any other treatment, for that matter. Surgical resectionthe current standard therapy for resectable primary liver cancers, as well as for hepatic metastases from specific primary tumors such as colorectal, adrenal, and neuroendocrine tumorshas not been compared with nonsurgical management in a controlled trial. At the same time, >40 years experience on thousands of patients has led to the accumulation of a large body of evidence demonstrating that resection can provide 5-year survival rates of 2550% in properly selected patients. We now practice in an era of evidence-based medicine, so cryosurgery must be compared to resection in a controlled clinical trial. Until it is, cryosurgery should be reserved for patients deemed to have unresectable disease by virtue of the anatomic location of the tumor, hepatic functional reserve, or comorbid conditions. References
1. Cooper IS (1963) Cryogenic surgery. N Engl J Med. 268 743749 2. Gage AA, Fazekas G, Riley E (1967) Freezing entry to large blood vessels in dogs. Surgery 61(5): 748754 3. Jacob G, Li AK, Hobbs KE (1984) A comparison of cryodestruction with excision or infarction of an implanted tumor in rat liver. Cryobiology 21: 148156 4. Onik G, Rubinsky B, Zemel R, Weaver L, Diamond D, Cobb C, Porterfield B (1991) Ultrasound-guided hepatic cryosurgery in the treatment of metastatic colon carcinoma: preliminary results. Cancer 67: 901907 5. Tandan V, Asch M, Margolis M, Page A, Gallinger S (1997) Laparoscopic versus open intra-operative ultrasound of the liver: a controlled study. J Gastrointest Surg 1: 146151

Surg Endosc (1997) 11: 10801083

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux
B. A. Jobe,1 J. Wallace,1 P. D. Hansen,1,2 L. L. Swanstrom1,2
1 2

Department of Surgery, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201, USA Minimally Invasive Surgery Department, Legacy Portland Hospitals, 501 North Graham Street, Suite 120, Portland, OR 97227, USA

Received: 24 March 1997/Accepted: 28 May 1997

Abstract Background: This prospective study assesses the outcome results in 100 consecutive patients with gastroesophageal reflux disease (GERD) treated with a laparoscopic Toupet fundoplication. Methods: GERD was confirmed by 24-h pH study and/or esophagogastroduodenoscopy (EGD). Pre- and postoperative symptoms, operative times, and perioperative complications were recorded on standardized data forms. Early follow-up was at 3 months and late follow-up, including 24-h pH, manometry, and EGD was at 22 months. Results: Preoperative symptoms included heartburn (92%), regurgitation (58%), water brash (39%), and dysphagia (39%). Mean operative time was 3.2 hours. There were no conversions to celiotomy and there were no mortalities. The perioperative complication rate was 14%; 6% (5/83) of patients reported heartburn at 3 months and 20% (15/74) at 22 months. Early and late dysphagia was 20% (17/83) and 9% (7/74), respectively; 24-h pH testing was abnormal in 90% of symptomatic patients (9/10), 39% of asymptomatic patients (12/31), and 51% overall. Conclusions: Despite early improvement in reflux symptoms following laparoscopic Toupet fundoplications, there is a high incidence of recurrent GERD. Symptomatic follow-up underestimates the true incidence of 24-h pHdocumented reflux. Based on these results we cannot recommend the laparoscopic Toupet repair for GERD patients with normal esophageal motility. Key words: Toupet Fundoplication Laparoscopic Gastroesophageal reflux disease Antireflux surgery Prospective

Correspondence to: L. L. Swanstrom

Gastroesophageal reflux disease (GERD) is very common in western countries. If inadequately treated, patients may develop complications with serious morbidity. Antireflux surgery has recently been advocated as a means of treating medically refractive GERD successfully and with low morbidity [35]. The advantages of a surgical approach include eliminating the need for life-long medical therapy, improving the quality of life, and minimizing the incidence of adverse sequelae such as Barretts esophagus and stricture formation [2]. The laparoscopic Nissen fundoplication is probably the current gold standard for surgical treatment of GERD. This procedure is, however, associated with several side effects, including transient or persistent dysphagia, inability to belch or vomit, and gas bloat [10]. Partial fundoplications, as exemplified by the Toupet, have been suggested as an alternative procedure because they do not hyperaugment the lower esophageal sphincter (LES) to the same degree as the Nissen and thus have fewer postoperative side effects. Several reports in the literature also suggest that the Toupet is equivalent to the Nissen in the elimination of GERD symptoms [1, 7, 8]. Many of these reports have limited long-term objective follow-up. The introduction of laparoscopic approaches to antireflux surgery may have created a paradigm shift with respect to indications and expectations for surgical treatment of GERD and for the acceptance of postoperative symptoms amongst patients, referring physicians, and surgeons alike. Prior to the introduction of laparoscopic antireflux surgery, postoperative side effects related to the fundoplication were more likely to have been accepted as a necessary nuisance, requisite to the elimination of a potentially life-threatening condition. Perhaps because of a lower threshold for surgery, the low morbidity, and the minimal convalescence associated with laparoscopic surgery, the side effects caused by a fundoplication have been magnified. This may be driving surgeons to look for the perfect repair, a repair that would both prevent acid reflux and limit postoperative fundoplication-related side effects. Toupet-type fundoplica-

1081

tions have been advocated as such a repair. Although this procedure has been traditionally reserved for patients with esophageal motility abnormalities or an anatomy that did not permit a complete wrap, it is possible that the Toupet is effective as a primary treatment for all patients with GERD requiring surgery. This prospective study was performed to determine whether the laparoscopic Toupet fundoplication is, in fact, a preferable repair for all patients with GERD, irrespective of their esophageal motility. Methods Patient selection
All patients were referred to the senior investigator for surgical evaluation of medically refractive GERD. After objective determination of reflux, the patients were asked to participate in the study. One hundred consecutive patients were treated with laparoscopic Toupet fundoplications. Patients with type 2, 3, or 4 paraesophageal hernias were excluded.

Evaluation
Patients were entered into a prospective database that included pre- and postoperative symptom assessment, 24-hr pH monitoring, esophageal manometry, and esophagogastroduodenoscopy (EGD). Radionucleotide studies were performed if it was suspected that delayed gastric emptying was the cause of reflux. Intraoperative hospital data were recorded during the hospital stay and included operative time, blood loss, perioperative complications, and length of hospital stay. Follow-up 24-h pH monitoring, esophageal manometry, and EGDs were performed by our lab or by the referring gastroenterologist. All data were collected on standardized forms and entered into a computerized database.

Surgical procedure
All patients underwent a modified laparoscopic Toupet fundoplication performed by or under the direction of the senior investigator. The procedure has been described elsewhere [11]. The key elements include a thorough dissection of the esophageal hiatus, mobilization of the gastroesophageal junction so that at least 3 cm of distal esophagus is below the diaphragm without tension, and routine division of the short gastric vessels. The hiatal defect is closed loosely by reapproximation of the crura posteriorly. The fundic wrap is fixed posterolaterally to both the right and left crura and a 56F bougie is passed through the gastroesophageal junction. The wrap is then sutured to the right and left sides of the esophagus at the 2 and 10 oclock positions. This creates a 270 wrap with posterior abdominal fixation.

Follow-up
Complications were recorded as they occurred. At 3 months postoperatively patients were asked to complete a symptom assessment form. Approximately 2 years postoperatively patients were recalled and once again asked to complete the symptoms assessment form and all patients were asked to undergo repeated pH testing and manometry. Upper endoscopy was performed when clinically indicated.

Results The patients were 62% male and 38% female with a mean age of 49 years (2583). The mean short- and long-term follow-up was at a mean of 3 and 22 months, respectively.

Primary preoperative symptoms included heartburn (92%), regurgitation (57%), water brash (39%), and dysphagia (39%). Ninety percent of patients were on proton-pump inhibitors prior to surgery. Eight patients had had previous antireflux procedures; 100% of patients had preoperative 24-h pH and manometry studies. The presurgical LE pressure was a mean of 10.75 mmHg (040) and the length was a mean of 1 cm (04). Abnormal motility was present in 8.4% of patients as evidenced by low-amplitude (<40 mmHg) contractions, dropped peristalsis, or tertiary contractions; 24-h ambulatory pH monitoring was abnormal in 91% of patients and the mean DeMeester score was 46.5 (1281). Endoscopically confirmed esophagitis was present in 29% of patients at their most recent EGD. Six patients were thought to have alkaline reflux. There were 11 patients with Barretts esophagus. Operations averaged 3.2 h (16.5) with a mean blood loss of 133 cc (30680). There were no mortalities and no procedures were converted to celiotomy. There were six complications during surgery. Two of these complications required second laparoscopic operations: a posterior esophageal perforation found by EGD on postoperative day 1 and a delayed small-bowel perforation from adhesiolysis. Mean length of hospital stay was 2.8 days (144). One patient developed adult respiratory distress syndrome after an apparently uncomplicated operation and required supportive care for 44 days. Post hospitalization one patient required readmission for nasogastric decompression to treat symptoms of gas bloat. Operative, early, and late postoperative complications are listed in Table 1. Some 83 patients returned for follow-up at 3 months and 74 patients at 22 months. Six percent (5/83) and 20% (15/ 74) of patients complained of recurrent heartburn at early and late follow-up, respectively. Dysphagia, which was defined as any difficulty swallowing liquids or solids, was 20% at 3 months and 9% at 22 months. One patient required esophageal dilation secondary to persistent dysphagia. The preoperative, early postoperative, and late postoperative reflux symptoms are displayed in Fig. 1. Of the 74 patients who followed up at 22 months, 32 (43%) underwent repeat manometry. The mean postoperative LES pressure was 23.45 mmHg (6100), which confers a 130% increase in peak LES pressure after Toupet fundoplication. The mean postoperative LES length was 2 cm, a 100% increase from preoperative. Forty-one of 74 patients (55%) underwent repeat pH testing at late follow-up. Ten of these patients were symptomatic and 31 were asymptomatic. Abnormal pH studies were defined as an elevated DeMeester score; 90% (9/10) of symptomatic patients had an elevated DeMeester score and 39% (12/31) of asymptomatic patients had an elevated DeMeester score. Overall, 51% of patients had an elevated DeMeester score at 22-month follow-up. The average was 39.8 (1212), a decrease of 6.7 points from preoperative values. Thirty-three of 74 patients (45%) underwent late followup endoscopy; 18% (6/33), or 8% overall (6/74), revealed esophagitis. All six patients were symptomatic. Overall, 60% of patients had late objective data, either pH testing, manometry, or EGD. Pre- and postoperative pH, manometry, and EGD data are summarized in Table 2.

1082 Table 1. Intraoperative and postoperative complications Complication Intraoperative complications Enterotomy Pericardial tear Esophageal perforation Bougie injury to esophageal mucosa ARDS, etiology undetermined Delayed gastric emptying Dislodged gastrostomy tube Pleural effusion Nausea/vomiting Candida empyema Gas bloat URI Treatment Laparoscopic repair Laparoscopic repair Mediastinal drainage Blood transfusion Supportive Supportive Subfascial abscess drainage Thoracentesis Supportive Chest tube drainage Nasogastric decompression Antibiotics n 3 1 1 1 6 (6%) 1 1 1 1 4 (4%) 1 1 1 1 4 (4%) Total 14 (14%)

Postoperative complications (in hospital)

Postoperative complications (after discharge)

Table 2. Preoperative and postoperative (22-month) objective evaluationa Test 24-hour pH studies: DeMeester score % with pH <4 greater than 5% of the time Manometry: LES length (cm) LES pressure (mmHg) EGD % with esophagitis
a

Preoperative 46.5 (1281) 91 1 10.75 29%

Postoperative 39.8 (1212) 51 n 41 2 23.45 n 32

18% n 33

Numbers are given as a mean value

Fig. 1. Reflux symptoms.

Seven patients were deemed complete surgical failures. This was defined as symptoms severe enough to cause employment of proton pump inhibitors (four patients) or a repeat fundoplication (three patients). The mean time to postoperative resumption of medical therapy was 8 months. EGD revealed obvious wrap disruption in only two of the patients who underwent repeat fundoplication. There were no cases of thoracic herniation. Therefore, five patients were refluxing through intact wraps. Discussion Nissen fundoplication has been the most widely accepted procedure for the treatment of medically refractive GERD

in patients with good esophageal motility. Partial wrap procedures have generally been reserved for patients with impaired esophageal motility [6, 7, 13]. There has been a recent growth in interest, however, in using partial wrap procedures as an alternative to the Nissen. This was based on reports which suggested a lower incidence of postoperative wrap-related complications and a similar success rate in preventing reflux symptoms when compared to Nissen fundoplications [7, 8, 13]. In fact, several studies have supported partial fundoplications as a primary surgical treatment for all GERD patients requiring operative management. Two randomized prospective trials carried out by centers experienced in partial fundoplication techniques compared open Nissen repairs to the Toupet and Lind fundoplications and found equivalent or superior results with respect to both prevention of reflux and postoperative symptoms [7, 8]. Follow-up in the study comparing Nissen to Toupet fundoplication was 5 years and included objective testing. There are no such studies which demonstrate similar long-term follow-up with laparoscopic procedures. There have also been reports which contradict this and show a higher recurrence rate with partial fundoplications. The results of this study show that perioperative morbidity is low and short-term resolution of reflux symptoms

1083

is high following laparoscopic Toupet fundoplications. These are, in fact, very well tolerated repairs, physiologically. We have also shown, however, a progressive failure in reflux control with a symptomatic recurrence rate of 20% at 22 months follow-up. This high rate is partially explained by the fact that we had a broad definition of heartburn (any substernal burning) and made no attempt to grade its severity. This finding, however, remains worrisome, as our follow-up is still early, and this number can be expected to increase. Even more concerning to us was the 51% reflux rate at late follow-up based on 24-h pH testing. While this may be overstating the true incidence of reflux if one assumes a negative bias in follow-up (i.e., the patients with reflux would be the ones that return for testing), the minimum reflux rate would still be 21%, even if all of the abnormal patients were in the tested group. In fact, we suspect that 51% is probably relatively accurate, as over one-half of the tested patients were asymptomatic and, therefore, unlikely to have returned only because of surgical problems. The 39% incidence of abnormal 24-h pH studies in asymptomatic patients is of concern and the significance of this finding is currently unclear. Longer follow-up on these patients, including endoscopy, will be required to look for objective evidence of reflux-related esophageal injury. These patients are probably at risk of eventually developing reflux-related symptoms or complications. Our results are particularly discouraging when compared to our experience with laparoscopic Nissen fundoplications. Currently we have an 8% symptomatic failure rate and 4% recurrence rate with objective testing (n 225). We have not found a greatly increased incidence of postoperative wrap-related side effects. Our incidence of late dysphagia is only 3%. It is unclear why our recurrence rates for documented reflux and reflux symptoms after laparoscopic Toupet fundoplications are higher than demonstrated with open Toupet fundoplication. It is possible that we are not replicating the open repair laparoscopically, although every effort is made to do so. In fact, we feel that laparoscopic fundoplication techniques offer improved visualization of the hiatus, easier and safer dissection, and more accurate suture placement compared to the open counterpart and, therefore, should provide the best results. We have shown that laparoscopic Toupet fundoplica-

tions have a high rate of symptomatic failure at 2-year follow-up. This high failure rate is confirmed by objective testing. We have also demonstrated that there is a substantial number of asymptomatic patients who have demonstrable esophageal reflux by objective tests. Though the implications of this asymptomatic reflux are currently unclear, it is likely that many of these patients will go on to have reflux related problems in the future. We believe that this information contraindicates the use of laparoscopic Toupet fundoplications for patients with GERD and normal esophageal motility.

References
1. Boutelier P, Gosta J (1982) An alternative fundoplicative maneuver for gastroesophageal reflux. Am J Surg 143: 260264 2. Crookes P, DeMeester T (1996) The diagnosis and treatment of gastroesophageal reflux disease in a managed care environment. Arch Surg 131: 10211023 3. Cuschieri A, Hunter J, Wolfe B, Swanstrom L, Hutson W (1993) Multicenter prospective evaluation of laparoscopic antireflux surgery. Surg Endosc 7: 505510 4. DeMeester T, Bonavina L, Albertucci M (1986) Nissen fundoplication for gastroesophageal reflux disease. Ann Surg 204: 920 5. Hunter J, Trus T, Branum G, Waring J, Wood W (1996) A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 6: 673684 6. Kahrilas P, Clouse R, Hogan W (1994) An American Gastroenterological Association Medical Position Statement on the clinical use of esophageal manometry. Gastroenterology 107: 18651884 7. Kjell T, Silander T (1989) A long term randomized prospective trial of the Nissen procedure versus a modified toupet technique. Ann Surgery 210: 719724 8. Lundell L, Abrahamsson H, Ruth M, Rydberg H, Lonroth H, Olbi L (1996) Long-term results of a prospective randomized comparison of total fundic wrap (Nissen-Rossetti) or semifundoplication (Toupet) for gastro-oesophageal reflux. Br J Surg 83: 830835 9. Mosnier H, Leport J, Aubert A, Kianmanesh R, Sbai Idrissi M, Guivarch M (1995) A 270 degree laparoscopic posterior fundoplasty in the treatment of gastroesophageal reflux. J Am Coll Surg 181:1088 1094 10. Negre J, Markkula H, Keyrilainen O, Matikainen M (1983) Nissen fundoplication. Am J Surg 146: 635638 11. Swanstrom L (1996) Laparoscopic Partial Fundoplications. Problems in General Surgery 13: 7584 12. Swanstrom L, Wayne R (1994) Spectrum of gastrointestinal symptoms after laparoscopic fundoplication. Am J Surg 167: 538541 13. Walker S, Holt S, Sanderson C, Stoddard C (1992) Comparison of Nissen total and Lind partial transabdominal fundoplication in the treatment of gastro-oesophageal reflux. Br J Surg 79: 408412

Surg Endosc (1997) 11: 11361137

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Importance of transesophageal echocardiography in directing the surgical approach to atrial myxomas


The optimal operative approach to an atrial myxoma should provide good exposure for complete resection of the tumor and its attachment, allow inspection of heart chambers for multiple tumors, and be safe and efficacious [2]. There is still controversy concerning the best surgical approach to achieve this, and various incisions have been used including left atriotomy, biatrial, transseptal, and the superior transseptal approach. Each of these approaches has its drawbacks; for example, a left atriotomy alone may impede obtaining adequate excisional margins [3] while the biatrial approach is responsible for a high incidence of arrhythmias and conduction disturbances [2]. Furthermore, although the superior transseptal approach allows good visualization of the interatrial septum, it is associated with an increased risk of postoperative bleeding and of damage to the blood supply to the sinus node [5]. It is the variability in the attachment point of atrial myxomas that offers a challenge to the surgeon. While almost every approach can provide adequate access to myxomas that arise from the interatrial septum, difficulties in surgical exposure can arise in the 15% to 40% of the atrial tumors that are attached elsewhere [2]. Clearly, therefore, there is no single approach that is ideal for every situation, and the technique may have to be individualized for each case. Intraoperative transesophageal echocardiography (TEE) has become an integral part of cardiac surgical practice, and its application continues to evolve as more data become available [4]. TEE plays an important role in the diagnosis of atrial myxomas as well as in confirming the complete removal of the tumor before closing the chest [1, 4]. However, the importance of TEE in directing the surgical approach to an atrial myxoma has not received enough emphasis. Intraoperative TEE can be used to localize the site of origin of the tumor; thus, the most appropriate line of incision is selected so that this can be excised. This is illustrated by the following examples: In case 1, a 65-year-old man was diagnosed to have an atrial myxoma by transthoracic echocardiography. On intraoperative TEE (Fig. 1), the transverse plane of the left atrium showed a pedunculated left atrial myxoma arising via a narrow stalk from the interatrial septum. Therefore, this tumor was easily excised through the right atrium by excising a disc of the interatrial septum completely with the stalk and the tumor attached to it. In case 2, however, intraoperative TEE (Fig. 2) in a 71-year-old woman demonstrated a myxoma that had a broad-based attachment to the roof of the left atrium, immediately posterior to the superior vena cava and the aorta. The tumor had to be removed en bloc together with the full thickness of the atrial wall. This was performed through a vertical left atriotomy anterior to the right pulmonary veins, extended superiorly behind the superior vena cava, anterior to the tumor attachment. The roof of the left atrium was excised as a whole with the myxoma and was repaired with a Dacron patch. In both cases histological examination documented complete excision of the tumor. Another advantage of intraoperative TEE is that it is no longer necessary for the surgical incision to provide access to all heart chambers. With TEE, all four chambers can be accurately inspected, which obviates the need for a visual inspection. This is particularly beneficial if a minimally invasive approach (for example, through a parasternal incision) is elected. TEE has been established as a useful tool which can significantly enhance the cardiac surgeons diagnostic and

Fig. 1. Transesophageal echocardiography in transverse plane demonstrating a left atrial pedunculated myxoma (Mx) prolapsing into left ventricle (LV) during diastole. The tumor is attached to the interatrial septum (arrows) via a narrow stalk.

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References
1. Joffe II, Jacobs LE, Lampert C, Owen AA, Loli AW, Kotler MN (1996) Role of echocardiography in perioperative management of patients undergoing open heart surgery. Am Heart J 131: 162176 2. Jones DR, Warden HE, Murray GF, Hill RC, Graeber GM, Cruzzavala JL, Gustafson RA, Vasilakis (1995) Biatrial approach to cardiac myxomas: a 30-year clinical experience. Ann Thorac Surg 59: 851856 3. Kabbani SS, Jokhadar M, Meada R, et al. (1994) Atrial myxoma: report of 24 operations using the biatrial approach. Ann Thorac Surg 58: 483488 4. Reeder GS, Khandheria BK, Seward JB, Tajik AJ (1991) Transesophageal echocardiography and cardiac masses. Mayo Clin Proc 66: 1101 1109 5. Vigano M, Grande AM, Gaeta R (1995) Superior transseptal approach to left atrial myxomas. Ann Thorac Surg 60: 18601861

Fig. 2. Transesophageal echocardiography in transverse plane demonstrating a broad-based myxoma (Mx) attached to the roof of the left atrium (LA), immediately posterior to the superior vena cava (VC) and the aorta (Ao).

M. Bashar Izzat A. P. C. Yim


Division of Cardiothoracic Surgery Department of Surgery The Chinese University of Hong Kong Hong Kong

therapeutic accuracy and, in this context, direct the surgical approach to atrial myxomas.

Surg Endosc (1997) 11: 10911094

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Initial results of a prospective trial of outpatient laparoscopic cholecystectomy


P. K. Narain, E. J. DeMaria
Department of Surgery, Box No. 980475, Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, VA 23298-0475, USA Received: 3 April 1997/Accepted: 10 June 1997

Abstract Background: Whether or not laparoscopic cholecystectomy may be performed safely as an outpatient procedure is controversial. In 1993, a protocol for outpatient laparoscopic cholecystectomy was instituted to determine the benefits and safety of discharging patients within several hours of surgery. Methods: The initial 60 outpatient laparoscopic cholecystectomies performed by one surgeon in a hospital-based outpatient teaching facility between February 1993 to June 1996 were prospectively studied. Results: Fifty-eight (97%) patients were discharged successfully after an average stay in the recovery room of 3 h. There were no deaths. Two patients required overnight observation and three patients required readmission. Two patients (3%) had cystic duct leak. The average hospital stay for all patients undergoing laparoscopic cholecystectomy at the institution (inpatient and outpatient) decreased from 3.2 to 1.5 days and the average hospital cost decreased from $7,800 to $4,600 during this period. Conclusion: Laparoscopic cholecystectomy in an outpatient setting is safe and cost-effective in healthy patients. Key words: Laparoscopic cholecystectomy Ambulatory surgery Outpatient

smaller scars, earlier discharge from hospital, shorter convalescence, and less cost. Initially, articles on laparoscopic cholecystectomy contained a long list of absolute and relative contraindications. With increasing experience these have changed dramatically. Increase in confidence has led to laparoscopic cholecystectomy being performed in the outpatient setting. Although outpatient laparoscopic cholecystectomy has been reported since 1990 [8, 9] many of the so-called outpatient procedures included patients observed overnight [6]. Concerns have been raised in the literature about the safety of the procedure being performed on a true outpatient basis [11]. A protocol for outpatient laparoscopic cholecystectomy was instituted at the Medical College of Virginia hospitals in 1993 to ascertain the feasibility, safety, and benefits of discharging patients several hours after surgery. Materials and methods
The first 60 laparoscopic cholecystectomies that were performed in a dedicated outpatient facility affiliated with the Medical College of Virginia (MCV) hospitals between February 1993 and June 1996 were studied prospectively. The indications for surgery were symptomatic cholelithiasis; acute, chronic, and acalculous cholecystitis; and biliary dyskinesia. Relative contraindications to outpatient laparoscopic cholecystectomy were common bile duct dilatation, coagulopathy, pregnancy, cirrhosis, ASA grade III and IV, and inadequate family support for the patient to be sent home. Patients were screened preoperatively by the surgeon and the anesthesiologist. Laboratory tests included complete blood count and liver function tests. Other tests like coagulation profile, serum chemistry, chest x-ray, and EKG were performed if indicated. Patient education regarding the outpatient nature of the procedure was initiated by the surgeon during the first clinic visit. The participation of a responsible adult identified as the care giver for the early postoperative period was strongly encouraged. Patients arrived an hour before surgery on the day of operation. The outpatient aspect of the procedure was further reinforced by the surgical staff at this time. Surgery was performed using intravenous induction and general inhalation anesthesia with muscle relaxants. All patients received prophylactic antibiotics. The standard four-port technique was used. Later on this was modified to a 10-mm subcostal port and three 2-mm ports, using a 2-mm laparoscope and instruments in a few patients. The open (Hassan) tech-

After first being performed by Phillipe Mouret of France in March 1987, laparoscopic cholecystectomy was introduced in the United States in 1988. Of the approximately 700,000 cholecystectomies performed in the United States every year, now more than 80% are performed laparoscopically [15]. This rapid shift from open to laparoscopic cholecystectomy has been driven mainly by public demand. The reasons for its universal acceptance include reduced pain,

Correspondence to: E. J. DeMaria

1092

Fig. 1. Operation time for outpatient laparoscopic cholecystectomy performed at MCV hospitals between February 1993 and June 1996.

Fig. 2. Time spent in recovery room after outpatient laparoscopic cholecystectomy performed at MCV hospitals between February 1993 and June 1996.

nique was utilized to enter the peritoneum in patients with prior laparotomy. Operative cholangiogram was performed selectively. All wounds were infiltrated with a 50:50 mix of 0.25% bupivacaine and 1% lidocaine with 1:100,000 epinephrine. Patients were given preemptive antiemetics in the preoperative period and analgesics prior to the end of operation. They were discharged when they were tolerating fluids orally and when they were able to ambulate and void spontaneously. They were given a prescription for hydrocodone with acetoaminophen (Percocet) for pain in the postoperative period. Patients were kept in hospital for overnight observation if there were technical concerns, unstable vital signs, excessive pain, nausea or vomiting, or urinary retention. All patients were contacted by telephone on the 1st postoperative day by a nurse and were seen by the surgeon in a week. In order to assess the overall impact of this outpatient protocol the results of outpatient surgery were compared to inpatient laparoscopic cholecystectomy performed at the institution. Procedures done by other surgeons were included in studying the quarterly demographics of all outpatient and inpatient laparoscopic cholecystectomy patients. The average hospital cost and charges to the patient for all laparoscopic cholecystectomies performed in the ambulatory and inpatient settings were similarly analyzed.

Table 1. Procedures performed simultaneous with outpatient laparoscopic cholecystectomy 1. 2. 3. 4. 5. 6. Liver biopsy Appendectomy Bilateral tube ligation Ovarian cystectomy Inguinal hernia repair Incisional hernia repair 1 1 1 1 1 1 6

Total

Results The average age of the initial consecutive 60 patients was 38.5 years. The range was 19 years to 63 years. The male to female ratio was 1:5. Nine patients (15%) had had previous laparotomy. The average operating time was 1.5 h, with a range between 0.5 and 3.3 h (Fig. 1). The average recovery room stay was 3 h, range 1.58.25 h (Fig. 2). No patient required conversion to open procedure. Eleven patients (18%) underwent cholangiography during surgery. Other procedures performed simultaneous with the laparoscopic cholecystectomy are listed in Table 1. No mortality occurred postoperatively. Fifty-eight patients (97%) were discharged home after meeting discharge criteria. Of the two patients admitted for overnight observation, one had excessive nausea and pain but was discharged uneventfully the next morning. The second patient had a cystic duct leak that necessitated an ERCP and stent procedure, following which she made an uneventful recovery. Fifty patients (83%) did not require any medical attention from the time of discharge to their routine follow-up

appointment. Six patients (10%) made an unscheduled visit to the emergency room or to their primary care doctor and three of them (5%) were readmitted. One patient had a cystic duct leak and went on to develop pancreatitis from endoscopic stent placement that eventually resolved with conservative management. Two patients were admitted for management of pain. Altogether, eight patients (13%) suffered 10 minor complications (Table 2). Two complications were identified at the patients scheduled visit to the clinic. One patient had scrotal ecchymosis after having undergone an inguinal hernia repair simultaneous with the laparoscopic cholecystectomy. Another patient complained of nausea for a few days after surgery. There were no bile duct or bowel injuries in this series. Outpatient status did not appear to compromise the safety of the patients, even in the few who suffered a complication. Early in 1993, laparoscopic cholecystectomy was performed only in the inpatient facility at our institution. By 1996, approximately 50% of all laparoscopic cholecystectomies were performed on an outpatient basis (Fig. 3). The average length of stay for all patients having laparoscopic cholecystectomy between June 1993 and June 1996 decreased from 3.2 days to 1.5 days (Fig. 4). The hospital charged an average of $5,811 for an outpatient laparoscopic cholecystectomy during this period. This was in contrast to the $12,390 charged for an average inpatient laparoscopic cholecystectomy. The average hospital cost for all patients undergoing laparoscopic cholecystectomy decreased during the protocol from $7,800 in the third quarter of 1993 to $4,600 in the second quarter of 1996 primarily as a result of the shift toward the outpatient facility (Fig. 5).

1093 Table 2. Complications after outpatient laparoscopic cholecystectomy Major: 1. Cystic duct leak Minor: 1. Pain 2. Nausea 3. Urinary tract infection 4. Rash 5. Scrotal ecchymosis Total 2 4 3 1 1 1 10 (in 8 patients)

Fig. 5. Average combined cost of all laparoscopic cholecystectomies performed at MCV hospitals over the 3-year study period. The primary cause of decreased procedure cost was a shift to the outpatient facility.

Fig. 3. The number of outpatient laparoscopic cholecystectomies performed at MCV hospitals increased progressively during the study period.

Fig. 4. Mean stay in hospital after all laparoscopic cholecystectomies (inpatient and outpatient combined) performed at MCV hospitals decreased over the course of study.

Discussion Laparoscopic cholecystectomy has rapidly emerged as the standard of care for symptomatic cholelithiasis. It is cost effective and safe and can be performed with morbidity and mortality rates similar to those for the open procedure [13, 15]. There have been concerns, however, about it being performed as an outpatient procedure. Although same-day discharge has been reported even after open cholecystectomy [10], there has been a reluctance to perform laparoscopic cholecystectomy on an ambulatory basis [11]. The present study was undertaken to assess the safety of performing laparoscopic cholecystectomy in the outpatient

setting. Although small in size, the study was done prospectively on the first 60 consecutive patients. In this relatively healthy population group, more than 95% of the patients were discharged home within 5 h of surgery and only two patients required overnight admission. More than 80% of the patients did not require any unscheduled medical attention in the postoperative period. Of those patients who went home, only one had a serious complication. Some complications following laparoscopic cholecystectomy, like bleeding and pneumothorax, are detected early in the recovery room, whereas others, like biliary leak, tend to go undetected for a few days. Saunders et al. found that patients with cystic stump leak presented anywhere between postoperative day 1 and 7 [11]. Therefore even a hospital stay of 24 h or more would not obviate the risk that the complication would develop following discharge [8, 14]. Two cystic duct leaks occurred in the current series and both patients were managed with endoscopic stent placement. One was reoperated to place a drain. She developed significant pancreatitis after the stent that resolved slowly over time. There are no data on the incidence of cystic duct leak in outpatient laparoscopic cholecystectomy. Wherry et al. reported 0.53% bile leak rate in their large audit of military institutions [15]. In an equally large audit, Scott et al. had shown the biliary leak rate to be 0.4% [12]. Saunders et al. reported 7 (1.2%) cystic duct leaks in 506 patients [11]. Our experience was similar to that of Albasini et al., who reported a 2% cystic stump leak with no bile duct injuries [1]. The small size of our series makes it difficult to draw any meaningful conclusions. However, the outpatient nature of the procedure did not seem to affect the outcome adversely. Our operating time was similar to that reported by others [8, 14]. The time spent in recovery room after surgery was, however, less than that reported by other authors. We had a mean recovery time of 180 min, which was a much quicker discharge than in other series which purportedly show outpatient procedure results. Reddick reported a mean stay of 222 min [8], Farha et al. reported a mean recovery time of 252 min [2], and Voitk had a mean recovery period of 7.5 h [14]. Despite our earlier discharge, only three patients were readmitted, one for biliary leak and two for pain and nausea. The readmit rate was similar to the 2% readmission

1094

rate reported by Voitk [14], Farha et al. [2], and Saunders et al. [11]. Reddick, however, did not report any readmissions [8]. Greenburg et al. reported a similar 1.5% readmission rate after both open and laparoscopic ambulatory general surgery procedures. Twenty-five percent of the admissions were due to pain and 12% due to nausea and vomiting [4]. Fiorello et al. found that the only significant factor in predicting successful early postoperative discharge was the duration of the procedure. The ambulatory group had a mean operating time of 62 min compared to 82 min for the group that stayed overnight in their series [3]. They theorized that longer operations meant the need for longer recovery periods with higher incidence of nausea, drowsiness, and atelectesis. We did not observe this difference. In our series, more than 75% of patients had an operation time greater than 60 min, but only two patients required overnight admission. The addition of cholangiography or an additional procedure which prolonged the operation did not increase the likelihood of the patient staying overnight. One 55-year-old patient in our series was able to go home 5 h after a 3.2-h surgery. Another patient was discharged 1.8 h after a 3.3-h surgery. While the metabolic and stress hormonal responses are similar for open and laparoscopic cholecystectomy [7], the earlier recovery seen in laparoscopic surgery is likely to be due to less pain. Strategies for pain control in our protocol included local infiltration of the wounds, preemptive antiemetics, and adequate postoperative analgesia. Preemptive antiemetics and analgesia are routinely used in our ambulatory patient population with good results. Fiorello et al. similarly suggested the possible relation of local infiltration of trocar sites to successful early discharge [3]. Over the 3-year period, the average stay in hospital after laparoscopic cholecystectomy (inpatient and outpatient combined) has gradually decreased at our institution. During this period the mean cost of the procedure has also decreased by 40%. This could partly be attributed to a higher percentage of patients being operated on as outpatients. Whereas in 1993 all laparoscopic cholecystectomy procedures were done as inpatients, at present 50% of the patients undergoing laparoscopic cholecystectomy have their surgery in the outpatient facility. In 1990, Reddick and Olsen reported that only 45% of the patients they selected to undergo laparoscopic cholecystectomy could be discharged on an outpatient basis [9]. Better results were reported by Fiorello et al., who successfully discharged 61% of their unselected patients within several hours after surgery [3], but they did not gather data prospectively. In our prospective trial, we sent 95% of selected patients home and 75% of them within 4 h of surgery. Greenberg et al. emphasized the importance of good patient selection and adequate support systems for successful ambulatory surgery [4]. Although age per se was not one of our exclusion criteria (our oldest patient was 63 years old), patients with significant comorbidities were excluded from ambulatory surgery, including patients with ASA grade III and IV. Careful screening at various levels in the preoperative evaluation allowed inappropriate patients to be excluded. Patient education and adequate support at home is integral to good patient selection. Outpatient laparoscopic cholecystectomy is a relatively new concept and we found that many patients initially had doubts about the adequacy

of postoperative support with such early discharge. We believe that education of the patients and their families in the preoperative period, reassurance, and close postoperative contact with the physician and nurses played a key role in the success of our outpatient laparoscopic cholecystectomy program. Our data suggest that it may be reasonable to do laparoscopic cholecystectomy in a freestanding outpatient center utilizing a carefully designed program such as ours to ensure a high likelihood of successful early discharge and the safety of the patient. Conclusion Outpatient laparoscopic cholecystectomy can be safely performed in a select group of patients with a high likelihood of success using our selection criteria and protocol. Careful patient selection, patient education, and dedicated health professionals are paramount for the safe practice of outpatient laparoscopic cholecystectomy [2, 14]. Diverting healthy patients undergoing elective procedures to our outpatient facility appeared to significantly decrease costs without compromising safety. References
1. Albasini JLA, Aledo VS, Dexter SPL, Marton J, Martin IG, McMohan MJ (1995) Bile leakage following laparoscopic cholecystectomy. Surg Endosc 9: 12741278 2. Farha GJ, Green BP, Beamer RL (1994) Laparoscopic cholecystectomy in a freestanding outpatient surgery center. J Laparoendosc Surg 4: 291294 3. Fiorello MA, Davidson PG, Fiorello M, DAnna JA Jr, Sithian N, Silich RJ (1996) 149 ambulatory laparoscopic cholecystectomies. Surg Endosc 10: 5256 4. Greenberg AG, Greenberg JP, Tewel A, Breen C, Machin O, Mcrae S (1996) Hospital admissions following ambulatory surgery. Am J Surg 172: 2123 5. Mckernnan JB, Stuto A, Champion JK (1996) New applications of bipolar coagulation in laparoscopic surgery. Surg Laparosc Endosc 6(5): 335340 6. Moving to outpatient surgery: how do you compare? 1994 Ontario Ministry of Health and Ontario Hospital Association Joint policy and Planning Committee, document 1-3, Don Mills, Ontario 7. Ortega AE, Peters JH, Incarbone R, Estrada L, Ehsan A, Kwan Y, Spencer CJ, Moore-Jeffries E, Kuchta K, Nicoloff JT (1996) A prospective randomized comparison of the metabolic and stress hormonal responses of laparoscopic and open cholecystectomy. J Am Coll Surg 183: 249256 8. Reddick EJ (1992) Laparoscopic cholecystectomy in freestanding outpatient centers. J Laparoendosc Surg 2: 6567 9. Reddick EJ, Olsen DO (1990) Outpatient laparoscopic laser cholecystectomy. Am J Surg 160: 485487 10. Saltzstein EC, Mercer LC, Peacock JB, Dougherty SH (1992) Outpatient open cholecystectomy. Surg Gynecol Obstet 174(5): 173175 11. Saunders CJ, Leary BF, Wolfe BM (1995) Is outpatient laparoscopic cholecystectomy wise? Surg Endosc 9: 12631268 12. Scott TR, Zucker KA, Bailey RW (1992) Laparoscopic cholecystectomy: a review of 12,397 patients. Surg Laparosc Endosc 2: 191198 13. Shea JA, Healey MJ, Berlin JA, Clarke JR, Malet PF, Staroscik RN, Schwartz JS, Williams SV (1996) Mortality and complications associated with laparoscopic cholecystectomy: a meta-analysis. Ann Surg 224: 609620 14. Voitk AJ (1995) Routine outpatient laparoscopic cholecystectomy. CJS 382 (3): 262265 15. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, Rich NM (1996) External audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense. Ann Surg 224(2): 145154

Surg Endosc (1997) 11: 11291130

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic management of lumbar hernia


A. Bickel, M. Haj, A. Eitan
Department of Surgery, Western Galilee Hospital, Nahariya, P.O. Box 21, 22100 affiliated to the Rappaport Faculty of Medicine, the Technion, Israel Institute of Technology, Haifa, Israel Received: 10 November 1996/Accepted: 20 December 1996

Abstract. We describe (for the first time) a laparoscopic approach to repair an acquired superior triangle lumbar hernia in a morbidly obese woman by using prosthetic mesh. Such a technique provides an excellent anatomic view, thus avoiding injury to structures in proximity to the hernia during repair; eventually the well-known advantages of such approach result. Key words: Lumbar hernia Laparoscopy Prosthetic mesh

entered, while the left colon was easily mobilized medially, assisted by the gravitational force, due to the patients right decubitus position. The psoas muscle was identified, and the left ureter was dissected and isolated. A 3 3 cm round defect was discovered in proximity to the ureter, between the level of the iliac crest and the 12th rib (Fig. 2). An incarcerated retroperitoneal fat was reduced and the borders of the opening were cleared. A fourth sleeve (12 mm) was introduced at the anterior axillary line near the iliac crest for the introduction of an hernia stapler. A 7 11 cm piece of Prolene mesh was used to occlude the hernia defect, and was fixed to the lumbar abdominal wall by the hernia staples, carefully avoiding the ureter. The postoperative sequelae were uneventful, and she was discharged asymptomatic on the 3rd postoperative day. During 8 months of follow-up, neither recurrence of hernia nor any related complaints were recorded.

Discussion Hernias in the lumbar region are relatively rare; they vary in etiology, exact anatomic location, and method of surgical repair [19]. Numerous open procedures for lumbar hernia repair have been suggested, depending on the size and etiology of the abdominal wall defect [2, 4, 5, 7, 9]. We present a case of acquired superior triangle lumbar hernia in a morbidly obese woman, which, for the first time, was repaired through the laparoscopic approach. Lumbar hernia in this case was first suspected on physical examination, but its exact location was found, during laparoscopy, to protrude through the superior lumbar triangle. In the absence of a history of trauma, infection, or previous operation, we assume that it was a primary acquired hernia [3, 5, 6, 8, 9]. The superior lumbar triangle (GrynfeltLesgaft), together with the inferior (Petit) triangle, are the two most recognized among the possible areas of anatomic weakness that are contained in the lumbar region [1, 5]. The superior lumbar triangle is bounded by the inferior margin of the 12th rib, along with the lower border of the serratus posterior inferior muscle, by the posterior free border of the internal oblique muscle and by the quadratus lumborum and the erector spinae muscles. The floor is formed by the transversalis fascia and the lumbosacral fascia, and the roof by the latissimus dorsi. The laparoscopic approach for lumbar hernia has significant advantages, especially when the patient is obese. It enables exact location of the anatomic defect, avoiding the need for wide exploration and dissection of the lumbar region through large incision. It provides an excellent anatomic view, thus avoiding injury to structures in proximity to the hernia (ureter, nerves etc.) during repair. It possesses all the well-known advantages of the laparoscopic approach (less postoperative pain, hospital stay, and wound infection). In summary, the laparoscopic repair using a prosthetic mesh is simple and logical, and seems to be effective for small and medium-size defects.

Case report
A 60-year-old morbidly obese woman (110 kg) was admitted because of chronic left lumbar pain and a sensation of a growing mass. Physical examination revealed a sense of a left flank protruding mass and of impulse during coughing. Lumbar hernia was suspected. Abdominal CT revealed a defect of the aponeurosis of the transverse abdominis muscle (lumbodorsal fascia) with protrusion of preperitoneal fat (Fig. 1). Under general anesthesia the patient was placed on her right side. Insufflation with CO2 and introduction of a 30 laparoscope were done about 8 cm to the left of the umbilicus, at its level. The peritoneal cavity was extremely fatty, with adhesions, but no peritoneal defect was seen. A second sleeve (5 mm) was introduced 6 cm below the first. The third sleeve (5 mm) was introduced 67 cm above the umbilicus level, at the anterior axillary line. The adhesions were divided and the retroperitoneal space was

Correspondence to: A. Bickel

1130

Fig. 2. Intraoperative photograph showing the lumbar retroperitoneal abdominal wall defect: thick arrowthe hernia defect; long arrowthe left ureter following dissection and isolation; curved arrowthe psoas muscle. Fig. 1. Abdominal CT demonstrating retroperitoneal fat protruding through left lumbar abdominal wall defect. 5. Geis WP, Hodakowsky GT (1995) Lumbar hernia. In: Nyhus LM, Condon RE (eds) Hernia. J B Lippincott, Philadelphia, pp 412424 6. Pul M, Pul N, Gurses N (1991) Congenital lumbar (Grynfelt-Lesgaft) hernia. Eur J Pediatr Surg 1: 115117 7. Shiki S, Kuwata Y, Kashihara E, Ueda U, Fuchimoto S, Orita K (1991) A case of superior lumbar hernia. Jpn J Surg 21: 696699 8. Stevens KJ, Banuls M (1994) Iliolumbar hernia following bone grafting. Eur Spine J 3: 118119 9. Sutherland RS, Gerow RR (1995) Hernia after dorsal incision into lumbar region; a case report and review of the pathogenesis and treatment. J Urol 153: 382384

References
1. Abramson J (1990) Hernias. In: Schwartz SI, Ellis H (eds) Maingots abdominal operations. Prentice-Hall, pp 271272 2. Bolkier M, Moskovitz B, Ginesin Y, Levin DR (1991) An operation for incisional lumbar hernia. Eur Urol 20: 5253 3. Esposito TJ, Fedorak I (1994) Traumatic lumbar hernia: case report and literature review. J Trauma 37: 123126 4. Fakhry SM, Azizkhan RG (1991) Observation and current operative management of congenital hernias during infancy. Surg Gynecol Obstet 172: 475479

Original articles
Surg Endosc (1997) 11: 10651067

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy
L. de Cannie ` re,1 L. Michel,1 E. Hamoir,2 G. Hubens,2 M. Meurisse,2 J. P. Squifflet,2 P. Urbain,2 L. Vereecken2
1 2

Surgical Services, Mont-Godinne University Hospital (UCL), Yvoir B-5530, Belgium Belgian Group For Endoscopic Surgery, rue St Georges 13, 7181 Feluy, Belgium

Received: 25 March 1997/Accepted: 16 May 1997

Abstract Background: Adrenalectomy is not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. Methods: Some 54 videoendoscopic adrenalectomies performed on 52 patients by five surgical teams between October 1993 and December 1996 were prospectively evaluated. Results: Indications for endoscopic adrenalectomy were pheochromocytoma (n 17), primary hyperaldosteronism (n 15), Cushings adenoma or disease (n 7), nonsecreting adenoma (n 7), single metastasis from adenocarcinoma (n 2), adenoma with dehydroepiandrostenedione (DHEAS) hypersecretion (n 3), and ACTH-secreting metastases from a thymoma (n 1). Of the 54 adrenalectomies performed, 31 were of the left gland, 19 of the right and two bilateral. Laparoscopic adrenalectomy was successful in 50 patients (96%). Median tumor size was 4 cm (range 1.512), median operation duration was 80 min (range 59 360), and median postoperative stay was 4 days (range 2 13). One patient required blood transfusion. Conclusions: Endoscopic adrenalectomy can safely be performedeven sporadicallyby surgeons well versed in adrenalectomy techniques for endocrine disorders and trained in endoscopic surgery. Key words: Laparoscopy Adrenalectomy Pheochromocytoma Endocrine disorders Retroperitoneum

not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. Since experience with endoscopic adrenalectomy is limited and long-term results are not yet available [3, 6, 7, 9, 12, 14], we conducted, within the framework of the Belgian Group for Endoscopic Surgery (BGES), a prospective multicentric study in order to assess the benefits and drawbacks of endoscopic adrenalectomy. The surgeons involved in this study were experienced in laparoscopic techniques and also familiar with the rules and potential drawbacks of open adrenal surgery for endocrine disorders. Materials and methods Source of data
A checklist was sent to members of the BGES in order to collect data about videoendoscopic adrenalectomy performed by surgeons already experienced with laparoscopic surgical techniques and open adrenalectomy for endocrine disorders. The report form includes information on the patients age, sex, and clinical features (preoperative risk factors, American Society of Anesthesiology clinical status classification, previous abdominal surgery, preoperative diagnosis of adrenal disease, blood pressure data, preoperative imaging techniques, patients coexisting conditions, and preoperative pharmacological preparation). Data were also obtained concerning the elected surgical technique (i.e., laparoscopic, retroperitoneoscopic, or both), operation duration, transfusion requirement, morbidity, anesthesiology considerations, pathological results, hospital stay, and follow-up.

Validation Almost all abdominal procedures have been attempted laparoscopically. Despite their retroperitoneal location, kidneys and adrenals have also been reached by the blitz of endoscopic surgery since 1992 [6]. However, adrenalectomy is
Correspondence to: L. Michel Data were acquired from five surgical teams. All cases were operated on between October 1993 and December 1996. The database was managed by project coordinators designated by the board of the BGES.

Results There were 34 women and 18 men with a median age of 44 years (range 1274). Of the 54 adrenalectomies performed,

1066 Table 1. Indications for endoscopic adrenalectomy Indication Pheochromocytoma Hyperaldosteronism Cushings adenoma Cushings disease (bilateral) DHEAS and cortisol hypersecretion Metastasis Nonfunctional adenoma ACTH-secreting metastases of thymoma (bilateral) Total No. of patients 17 15 5 2 3 2 7 1 52

31 were of the left gland, 19 of the right, and two bilateral. Table 1 gives the indications for videoendoscopic adrenalectomy. Twenty-five (48%) patients had undergone previous abdominal operation, and five patients with multiple endocrine neoplasia syndrome (four pheochromocytoma and one Cushings disease) had previous contralateral adrenal surgery. Thirteen patients (25%) demonstrated a body mass index (weight in kilograms divided by height in meters squared) higher than 30, which means that they were regarded as being severely overweight [15]. The 52 patients presented a total of 94 coexisting clinical risk factors. Preoperative assignment risk according to the American Society of Anesthesiologists (ASA) physical status classification was as follows: ASA I (15 cases), ASA II (28 cases), ASA III (nine cases). All 52 patients had their abdomen explored preoperatively by computed tomography (CT). Patients suspected of having pheochromocytoma also had metaiodobenzylguanidine (MIBG) scintigraphy. The initial endoscopic approach of the adrenal was transperitoneal in 49 patients (48 supracolonic access and one transmesocolic access to the left adrenal) and retroperitoneal in three patients. Forty-nine patients were operated in the lateral decubitus position and three in the intermediate position. Endoscopic adrenalectomy was successful in 50 patients (96%). The two unsuccessful procedures involved bilateral procedures in one case for Cushings disease and ACTH-secreting metastases from a malignant thymoma in another. Conversion was justified by bleeding in the first case and difficult endoscopic dissection in the second case. Two patients were initially operated on by a retroperitoneoscopic approach (one for primary hyperaldosteronism in the right adrenal ten years after right nephropexy and one for nonfunctional adenoma in the left adrenal) [13, 8, 10]. The upper pole of their kidney was entangled by adhesions. During dissection of these adhesions the peritoneal layer was slightly torn, allowing CO2 to escape from the retroperitoneal space to the peritoneal cavity with the peritoneal layer falling on the endoscope. In fact, in these two cases the operation was easy to complete by the laparoscopic route because the retropneumoperitoneum had already created a large retroperitoneal working space, rendering further exposure of the adrenal simple and rapid. A third patient was completely operated by the retroperitoneoscopic route. Median tumor size was 4 cm (range 1.512). Median duration of procedure was 80 min (range 60360). Median postoperative stay was 4 days (range 213). Postoperative complications were two pleural effusions and one basilaris artery thrombosis 2 weeks after surgery. One patient oper-

ated for a left pheochromocytoma and a 12-cm-diameter upper pole renal cyst had to be reoperated 12 h later for bleeding in the retroperitoneal space. Blood oozing was found and controlled laparoscopically. This patient was the only one who required blood transfusion. Median length of follow-up was 9 months (238 months). One patient had a radical left nephrectomy because of lymph node recurrence in the hilum of the kidney from an adenocarcinoma of the lung. (Adrenalectomy had been performed 4 months before for a unique left adrenal metastasis from lung adenocarcinoma.) Another patient operated for a unilateral pheochromocytoma is demonstrating persistence of elevated blood pressure and abnormal catecholamine level, related to a contralateral adrenal hyperplasia, that was not demonstrated despite appropriate preoperative imaging techniques (i.e., CT scan and MIBG scintigraphy).

Discussion The actual results of the BGES multicentric study show that videoscopic surgery of the adrenal glands can safely be performed (success rate 96%). However, such procedures should be performed by surgeons who are already trained in videoendoscopic surgery and preferably well versed also in the techniques of open adrenalectomy for endocrine disorders. The actual results compared also favorably with a preliminary report on the first 16 patients from the BGES (success rate was 88%) [4]. Performance of endoscopic or open adrenalectomy for endocrine disorders, especially pheochromocytoma, requires a complete preoperative endocrine and hemodynamic workup. It also supposes close collaboration with the anesthesiology and endocrinology teams, as well as preparation of the patients, if indicated, with antihypertensive medications until the day of operation. Modern imaging techniques, particularly CT scan, are reliable to precisely localize and define the adrenal lesions (i.e., unilateral or bilateral, lesion diameter, and extraadrenal pheochromocytoma). In this BGES experience all patients had a CT scan performed preoperatively. MIBG scintigraphy was also performed for patients suspected of having pheochromocytoma [13]. In fact, modern imaging instruments probably explore the adrenal and extraadrenal lesions more completely than the eyes and/or hands of the surgeon. Consequently, in many cases, the surgical approach can be direct and unilateral instead of what was the past practicecomplete surgical exploration of the abdominal cavity, including visualization of both adrenal glands and surgical search for potential extraadrenal localization. A more selective approach elected on the basis of preoperative imaging techniques reduces the incidence of morbidity related to wide transperitoneal, retroperitoneal, or thoracoabdominal approaches. It is therefore reasonable to wonder whether the videoscopic approach could even further reduce the morbidity of adrenal surgery while increasing the comfort for the patients. So far our results demonstrate that videoendoscopic adrenal surgery performedeven sporadicallyby surgeons experienced in laparoscopic surgery is as safe as the open approach, provided those surgeons are also familiar with the rules and potential drawbacks of adrenal surgery.

1067

The fact that only one patient required transfusion is an objective testimonial that the videoendoscopic approach meets several requisites for safety. The value of removal of metastatic lesions within the adrenal gland is controversial. Despite the fact that in our early experience such metastatic lesions were removed, we think that this indication cannot be justified. The same restriction can be made for removal, whether endoscopically or by open surgery, of adrenal incidentalomas. In a recent study [11], criteria have been recommended for removal of adrenal incidentalomas at high risk for malignancy: (1) diameter larger than 4 cm or increase in size at any reevaluation; (2) CT-scan picture of intratumoral necrosis, hemorrhage, or irregular margins; and (3) high DHEAS levels. Adhering to these criteria allowed us to obtain a high incidence of clear-cut endocrine indications for adrenalectomyi.e., pheochromocytoma, Conn and Cushing syndromes, and elevated DHEAS represent 81% of the caseload. The remaining 19% of rather debatable indications in the current series is low compared with other series [5]. Further studies are compulsory before any definite conclusion can be drawn concerning long-term results of videoendoscopic adrenalectomy and complete cure of endocrine disorders by this mini-invasive surgical approach. More comparative data are also required to conclude that endoscopic adrenalectomy allows decreased postoperative stay and/or reduced postoperative analgesic requirement. In this series, five patients presenting multiple endocrine neoplasia syndrome had sustained in the past a contralateral adrenalectomy by open surgery. Concerning postoperative pain, they acted as their own control and unanimously declared that the endoscopic approach was far more comfortable. On the other hand, postoperative stay longer than 1 week in these patients was related to the initiation of hormonal substitution treatment after bilateral adrenalectomy. In conclusion, minimal access adrenalectomy does not mean minimization of surgical or anesthesiological risks. It may only portend better postoperative comfort for the patient if the videoendoscopic surgeon is competent and skillful enough to successfully complete the operation in a reasonable length of operative time.

8. 9. 10. 11.

12. 13. 14. 15.

P, Kuchel O, Querin S, Pomp A (1993) Early experience with laparoscopic approach for adrenalectomy. Surgery 114: 11201124 Gaur DD, Agarwal DK, Purohit KC (1993) Retroperitoneal laparoscopic nephrectomy: initial case report. J Urol 150: 1255 Heintz A, Junginger T, Bo ttger T (1995) Retroperitoneal endoscopic adrenalectomy. Br J Surg 82: 215 Kerbl K, Figenshau RS, Clayman RV, Chandhoke PS, Kavoussi LR, Albala DM, Stone AM (1993) Retroperitoneal laparoscopic nephrectomy: laboratory and clinical experience. J Endourol 7: 2326 Osella G, Terzolo M, Borretta G, Magro G, Ali A, Piovesan A, Pacotti P, Angeli A (1994) Endocrine evaluation of incidentally discovered adrenal masses (Incidentalomas) J Clin Endocrinol Metab 79: 1532 1539 Pertsemlidis D (1995) Minimal-access versus open adrenalectomy. Surg Endosc 9: 384386 Proye CA, Huart JY, Cuvillier XD, Assez NM, Gambardella B, Carnaille BM (1993) Safety of the posterior approach in adrenal surgery: experience in 105 cases. Surgery 114: 11261131 Stoker ME, Patwardhan N, Maini BS (1995) Laparoscopic adrenal surgery. Surg Endosc 9: 387391 Vanitallie TB, Woteki CE (1987) Who gets fat? In: Bender AE, Brooks LJ (eds) Body weight control. Churchill Livingstone, Edinburgh, pp 3952

Discussion Dr. Roll: Which endoscopic approach do you think is easierthe transabdominal or retroperitoneal? Dr. Michel: Well, actually the three first cases were done retroperitoneally, and I dont recommend that approach. The retroperitoneal approach doesnt improve the post operative recovery, but it does present more difficulties for the surgeon, at least I think so. Out of 52 cases 49 were done transperitoneally. Dr. Siperstein: Weve actually published a comparative series where we utilized both the lateral and retroperitoneal laparoscopic approach for dealing with tumors. Our current philosophy is that for small tumors, less than 4 cm, it is probably easier and faster to remove these via the retroperitoneal approach, given that youve had experience doing these procedures transabdominally before that. Dr. Michel: I agree. The three cases we did retroperitoneally were for small lesions. However, when you have to deal with a big pheochromocytoma, I think you are better off using the transperitoneal approach. Anyway, if you start retroperitoneally and if you have any trouble, because, for instance, you tear the peritoneum, its very easy to convert to a transperitoneal approach. You dont lose time. You dont have to change the position of the patient. All the work that has been done retroperitoneally will help you when you convert to a transperitoneal approach. For these three cases we established retropneumoperitoneum by direct puncture without any control. Did you use ultrasonography to place the Veress needle in the retroperitoneal space? Dr. Siperstein: Our technique for entering the retroperitoneal space, with the patient in the prone jackknife position is, to ultrasound through the back, to outline the kidneys position so we know the relationship of the Gerotas space to the twelfth rib, and then we use a direct viewing trocar, the so called Opti-View trocar, to enter Gerotas space under direct vision, and then with balloon dissection create that space. We found that to be a very safe and reproducible technique. I would not advocate entering that space with anything sharp.

References
1. Brunt LM, Molmenti EP, Kerbl K, Soper NJ, Stone AM, Clayman RV (1993) Retroperitoneal endoscopic adrenalectomy: an experimental study. Surg Laparosc Endosc 3: 300306 2. Clayman RV, Kavoussi LR, Mc Dougall EM, Soper NJ, Figenshau RS, Chandhoke PS, Albala DM (1992) Laparoscopic nephrectomy: a review of 16 cases. Surg Laparosc Endosc 2: 2934 3. de Cannie ` re L, Lorge F, Rosie ` re A, Joucken K, Michel L (1995) From laparoscopic training on an animal model to retroperitoneoscopic or coelioscopic adrenal and renal surgery in human. Surg Endosc 9: 679 701 4. de Canniere L, Michel LA, Hamoir E, Hubens G, Meurisse M, Squifflet JP, Urban P, Vereecken L (1996) Videoscopic adrenalectomy: multicentric study from the Belgian Group for Endoscopic Surgery. Int Surg 81: 68 5. Gagner M (1996) Laparoscopic adrenalectomy. Surg Clin North Am 76: 523537 6. Gagner M, Lacroix A, Bolte E (1992) Laparoscopic adrenalectomy in Cushings syndrome and pheochromocytoma. N Engl J Med 327: 1033 7. Gagner M, Lacroix A, Prinz RA, Bolte E, Albala D, Potvin C, Hamet

Surg Endosc (1997) 11: 10951098

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Final score in laparoscopic cholecystectomy


Cholangiogram 1207, no cholangiogram 116
T. M. Khalili,1 E. H. Phillips,1 G. Berci,1 B. J. Carroll,1 J. Gabbay,1 J. R. Hiatt1,2
1

Division of General Surgery, Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA 2 Department of Surgery, UCLA School of Medicine, Los Angeles, CA, USA Received: 3 April 1997/Accepted: 10 June 1997

Abstract Background: The role of intraoperative fluorocholangiography (IOC) in laparoscopic cholecystectomy (LC) is controversial. We evaluated the use of IOC at an institution where the study is performed routinely. Methods: Records of all patients undergoing LC during a 3-year period ending January 1, 1996 were reviewed. Results: A total of 1207 patients received IOC, whereas 116 patients did not. IOC findings were categorized as follows: normal, 1016 cases (84%); CBD stone, 149 cases (12.3%); anomalies, 23 cases (1.9%); duodenal diverticula, 10 cases (0.8%); ductal strictures, four cases (0.3%); and CBD diverticula, 5 cases (0.4%). In the 116 patients who did not receive IOC, 35 of the procedures could not be performed, whereas 81 were not attempted. Of the 149 IOC that showed CBD stones, two were false positives. Anomalies included accessory right hepatic ducts (11 cases), cystic ducts joining the right hepatic duct (seven cases), and abnormal cystic duct entries (five cases). Duct injuries occurred in 5 cases (0.4%), three before and two after IOC. Four injuries were minor; IOC prevented CBD transection. Conclusions: Routine IOC is feasible, safe, accurate, and provides critical information of immediate use during LC. By treating ductal stones at operation and identifying patients without CBD stones, IOC minimizes need for postoperative studies, including endoscopic retrograde cholangiography (ERC). Key words: Laparoscopy Laparoscopic cholecystectomy Common bile duct Cholangiography

Over 60 years have passed since Mirizzi [24] first recommended routine intraoperative cholangiography during cholecystectomy. The purported advantages of cholangiography in Mirizzis day included identification of common bile duct (CBD) stones and reductions in negative duct explorations and ductal injuries. Later authors advocated a selective approach, arguing that cholangiography added expense, introduced a risk of iatrogenic injury, and might lead to unnecessary common bile duct explorations; indications for operative cholangiography (or for common bile duct exploration) were diligently memorized by generations of medical students. Laparoscopic cholecystectomy has reignited the debate. The work of Berci et al. [4, 26], showing that intraoperative cholangiography was feasible, safe, and would detect a significant number of common bile duct stones and injuries, led to a de facto institutional policy of attempted cholangiography in all patients. The present study was undertaken to evaluate the use of this routine procedure. Patients and methods
We performed a retrospective review of all patients undergoing laparoscopic cholecystectomy (LC) during the 3-year period ending January 1, 1996. CBD stones were classified as suspected or unsuspected based upon history, liver chemistries, and ultrasonography. The technique of intraoperative fluorocholangiography (IOC) has been described previously [5]. All cholangiograms were interpreted initially by the operating surgeon in consultation with a radiologist, and final IOC readings were performed independently by an attending radiologist. Based on the final reading, IOC were classified as normal (free flow of contrast into duodenum, visualization of right and left hepatic ducts, and absence of filling defects) or as showing CBD stones, ductal anomalies, duodenal diverticula, ductal diverticula, or ductal strictures. Ductal anomalies included accessory ducts or abnormal entry of the cystic duct into the CBD; short cystic duct was not considered an anomaly. The charts of all patients with abnormal IOC interpretations were reviewed. All patients with common bile duct injuries were identified.

Presented at the annual scientific session of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA, 1922 March 1997 Correspondence to: J. R. Hiatt

Results The study group included 1323 patients, of whom 1207 (91%) underwent IOC. Among the 116 (9%) patients who did not receive an IOC, the procedure was not attempted in

1096 Table 1. Characteristics of patients n (%) Cholangiogram Normal Abnormal Common duct stone Anomaly Duodenal diverticulum Ductal stricture Ductal diverticulum No cholangiogram Totals 1207 1016 (84) 191 (16) 149 (12.3) 23 (1.9) 10 (0.8) 4 (0.3) 5 (0.4) 116 1323 Age, (yr) (range) 55 (1199) 54 (1197) 61 (1999) 61 (1999) 49 (2282) 79 (6893) 68 (5092) 61 (4378) 51 (1385) 55 (1199) Gender (% F) 67 67 69 69 74 70 57 60 74 68

81 cases; thus, IOC was completed successfully in 97% of patients in whom it was attempted. In 1016 patients (84%), IOC was interpreted as normal. Characteristics of the patient groups are shown in Table 1. The most common abnormality was the presence of CBD stones, which were seen in 149 of the patients (12.3%) who underwent IOC. These stones were unsuspected in 95 (8%) and suspected in 54, based upon history, abnormal liver chemistries, or preoperative ultrasonography. Two cholangiograms were falsely positive (1.3%). Upon identification of choledocholithiasis, laparoscopic CBD exploration was performed in 101 patients (8%); the remainder of the CBD stones were treated with postoperative endoscopic techniques, open explorations, or expectant management. Ductal anomalies occurred in 23 patients (1.9%). The most common anomaly was an accessory right hepatic duct (11 patients). The cystic duct joined the right hepatic duct in seven patients. Posterior or medial insertion of the cystic duct into the CBD was seen in five patients. Duodenal diverticula were found in 10 patients (0.8%). The diverticulum was located in the periampullary region in nine of the patients and in the second portion of the duodenum in one. CBD diverticula, all in the distal duct, were seen in five patients (0.4%). Strictures of the distal CBD were observed in four patients (0.3%). Common bile duct injuries occurred in five patients (0.4%). All occurred in patients who had undergone IOC; there were no known injuries in patients who did not receive IOC (p 0.48). In two patients, the common bile duct was mistaken for the cystic duct, and a choledochotomy was made to perform the cholangiogram. The error was recognized on the IOC, and CBD transection or excision was avoided. Ductal injury occurred during common bile duct exploration, after IOC, in two patients. All of these patients underwent primary repair of the injury. The final patient had Mirizzis syndrome and required a choledochojejunostomy to reconstruct the bile duct. The cost of an IOC was $300. This figure includes all operative costs and is exclusive of professional fees.

Discussion Collected series are summarized in Table 2. Advocates of routine cholangiography have argued that the procedure defines anatomy, demonstrates suspected and unsuspected CBD stones, decreases the risk of retained stones, prevents

or decreases the magnitude of injury, and diminishes the need for postoperative endoscopic retrograde cholangiography (ERC) for evaluation of pain syndromes. Opponents contend that the low incidence of missed stones, occasional false positives, increased cost, risk of iatrogenic injury, and widespread availability of postoperative ERC and endoscopic sphincterotomy (ES) make the procedure unnecessary. The experience reported here showed that routine IOC was feasible (it was performed successfully in 97% of cases in which it was attempted), and safe (there were neither iatrogenic injuries nor any instances of post-IOC pancreatitis). CBD stones were unsuspected in 64% of patients in whom they were found, allowing treatment during the primary operation using laparoscopic techniques. Ductal injuries, which occurred in five patients, were identified by IOC in two cases, thus limiting their severity. All were treated during the first operation. In two cases where the common duct was mistaken for the cystic duct and cannulated for IOC, the error was recognized on IOC, and CBD transection or excision was avoided. Collected experiences with IOC during LC are compared in Table 3. Detection of unsuspected common bile duct stones is one of the major benefits of routine IOC. Proponents of selective IOC have argued that a detailed history and liver chemistries will accurately predict CBD stones [1, 15]. Our experience and that of others [19] suggest that stones will often be missed if IOC is omitted. Furthermore, 2550% of patients with common bile duct stones will develop symptoms and require treatment [17]. Stones found on IOC may be treated using laparoscopic transcystic common bile duct exploration (LTCBE) at the primary operation [3, 16]; this avoids the expense, morbidity, and uncertain long-term efficacy of ERC/ES. In a recent review of patients undergoing ES, Bergman [6] reported recurrent CBD stones in 13% and CBD stenosis in 9%, demonstrating that ES has significant late complications. Ductal injuries have occurred with increased frequency in the laparoscopic era [10, 25, 31]. The most common injury occurs when the common bile duct is mistaken for the cystic duct. Moossa and others [25, 31] have reported that a majority of patients with CBD injuries did not undergo cholangiography at the primary operation. If a choledochotomy is made to obtain an IOC, the injury is readily identified and repaired primarily [7]; this is in contrast to the injury created when IOC is not obtained, the common bile duct is transected and excised, and the injury is recognized with the development of jaundice, cholangitis, or a similar septic complication [7, 25]. A frequent argument against routine IOC has always been the issue of cost-effectiveness, considering increased operative time and charges for the procedure and its interpretation. The argument is erroneous, since the lifetime cost of treatment for a major CBD injury exceeds $300,000 [28]. This figure dwarfs the charges for routine IOC, even if we were to ignore the value of the abnormal cholangiograms and to assume that the normal ones were unnecessary. The experience reported here is of particular relevance to the routine laparoscopic cholecystectomy, where there is no evidence of CBD stones, acute inflammation, or other complicating factors. The surgeon may reason that ductal stones, if found intraoperatively, require extraction by a

1097 Table 2. Collected series Cholangiogram Cholangiography Routine Selective


a

Approach Open Laparoscopic Open Laparoscopic

No. of series 8 8 5 4

References 18, 19, 26, 27, 30, 33, 34, 35 4, 11, 22, 28, 29, 32, 36 12, 13, 14, 23, 38 2, 9, 21, 37

No. of patients 3040 2378 5255 2015

No. attempted (%)a 2895 (95.5) 2351 (98.9) ND ND

No. successful (%)a 2821 (92.8) 2163 (91.0) 977 (18.6) 387 (19.2)

Percentages exclude series [16, 28] for which numbers of cholangiograms were not given

Table 3. Intraoperative fluorocholangiography in laparoscopic cholecystectomy Author (ref.) Phillips et al. (29) Sackier et al. (32) Flowers et al. (11) Traverso et al. (36) Lezoche et al. (22) Carrol et al. (8) Current study Year 1990 1991 1992 1994 1994 1996 1997 No. of patients 58 516 165 624 500 100 1323 CBD stones % 10.7 7.5 4.4 5.1 6.1 15.0 12.3 LTCBDE % 1.8 4.5 0 1.9 ND 15 8.3 Anomalies % 5.9 7.3 1.1 39 2.3 6.0 1.9 CBD injuries % 1.7 0.2 0.3 0.3 0 0 0.4

CBD, common bile duct; LTCBDE, laparoscopic transcystic common bile duct exploration

technically challenging and often unavailable modality (LTCBDE); if found postoperatively, they are easily treated with ERC/ES by his gastroenterologic colleague. The surgeon thus surrenders his right to treat this portion of the biliary tract despite the inherent superiority and safety of CBD stone treatment during the initial operation and the likelihood of evolving technology that will make LTCBDE easier and more applicable. Once lost, the common duct will not be regained, and 100 years of work by surgeons will have been squandered. In summary, routine IOC during LC is feasible, safe, accurate, and provides critical information of immediate use during laparoscopic cholecystectomy. By treating ductal stones at operation, identifying patients without common bile duct stones, and defining anatomic variations, IOC minimizes the need for postoperative studies, including ERC.

7.

8.

9.

10.

11.

12.

13.

References
1. Barkun AN, Barkun JS, Fried FM, Ghitulescu G, Steinmetz O, Pham C, Meakins JL, Goresky CA (1994) Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. Ann Surg 220: 3239 2. Barkun JS, Fried GM, Barkun AN, Sigman HH, Hinchey EJ, Garzon J, Wexler MJ, Meakins JL (1993) Cholecystectomy without operative cholangiography. Ann Surg 218: 371379 3. Berci G, Morgestern L (1994) Laparoscopic management of common bile duct stones: a multi-institutional SAGES study. Surg Endosc 8: 11681175 4. Berci G, Sackier JM, Paz-Partlow M (1991) Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy. Am J Surg 161: 355360 5. Berci G, Shore JM, Hamlin JA, Morgenstern L (1975) Operative fluoroscopy and cholangiography. Am J Surg 135: 3235 6. Bergman JJGHM, Mey S, Rauws EAJ, Tijssen JGP, Gouma DJ, Tytgat GNJ, Huibregtse K (1996) Long term follow-up after endoscopic

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sphincterotomy for bile duct stones in patients younger than 60 years of age. Gastrointest Endosc 44: 643649 Carrol BJ, Friedman RL, Liberman MA, Phillips EH (1996) Routine cholangiography reduces sequelae of common bile duct injuries. Surg Endosc 10: 11941197 Carrol BJ, Phillips EH, Rosenthal R, Gleischman S, Bray JF (1996) One hundred consecutive laparoscopic cholangiograms: results and conclusion. Surg Endosc 10: 319323 Clair DG, Carr-Locke DL, Becker JM, Brooks DC (1993) Routine cholangiography is not warranted during laparoscopic cholecystectomy. Arch Surg 128: 551555 Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD, Baker ME, Newman GE, Cotton PB, Meyers WC (1992) Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 215: 196202 Flowers JL, Zucker KA, Graham SM, Scovill WA, Imbembo AL, Baily RW (1992) Laparoscopic cholangiography: results and indications. Ann Surg 215: 209216 Ganey JB, Johnson PA, Prillaman PE, McSwain GR (1986) Cholecystectomy: clinical experience with a large series. Am J Surg 151: 352357 Gerber A, Apt MK (1982) The case against routine operative cholangiography. Am J Surg 143: 734736 Gregg RO (1988) The case for selective cholangiography. Am J Surg 155: 540544 Hauer-Jensen M, Karssen R, Nygaard K, Solhein K, Amlie E, Havig O, Viddal KO (1985) Predictive ability of choledocholithiasis indicators. Ann Surg 202: 6468 Hunter JG, Soper NJ (1992) Laparoscopic management of common bile duct stones. Surg Clin North Am 72: 10771097 Johnson A, Hosking S (1987) Appraisal of the management of common bile duct stones. Br J Surg 74: 555560 Kakos GS, Tompkins RK, Turnipseed W, Zollinger RM (1972) Operative cholangiography during routine cholecystectomy. Arch Surg 104: 484488 Kitahama A, Derstein MD, Overby JL, Kappelman MD, Webb WR (1986) Routine intraoperative cholangiogram. Surg Gynecol Obstet 162: 317322 Koo KP, Traverso LW (1996) Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy? Am J Surg 171: 495499 Korman J, Cosgrove J, Furman M, Nathan I, Cohen J (1996) The role

1098 of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era. Ann Surg 223: 212216 Lezoche E, Paganini A, Guerrieri M, Carlei F, Lomanto D, Sottili M, Nardovino M (1994) Technique and results of routine dynamic cholangiography during 528 consecutive laparoscopic cholecystectomies. Surg Endosc 8: 14431447 Mansberger JA, Davis JB, Scarborough C, Bowden TA (1988) Selective intraoperative cholangiography: a case for its use on an anatomic basis. Am Surg 54: 3133 Mirizzi PL (1937) Operative cholangiography. Surg Gynecol Obstet 65: 702710 Moossa AR, Easter DW, Sonnenberg EV, Casola G, DAgostino H (1992) Laparoscopic injuries to the bile duct: a cause for concern. Ann Surg 215: 203208 Morgenstern L, Wong L, Berci G (1992) Twelve hundred open cholecystectomies before the laparoscopic era: a standard for comparison. Arch Surg 127: 400403 Pagana TJ, Stahlgren LH (1980) Indications and accuracy of operative cholangiography. Arch Surg 115: 12141215 Phillips EH (1993) Routine versus selective intraoperative cholangiography. Am J Surg 165: 505507 Phillips EH, Berci G, Carroll B, Daykhovsky L, Sackier J, Paz-Partlow M (1990) The importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 12: 792795 30. Rolfsmeyer ES, Bubrick MP, Kollitz PR, Onstad GR, Hitchcock CR (1982) The value of operative cholangiography. Surg Gynecol Obstet 154: 369371 31. Rossi RL, Schimer WJ, Braasch JW, Sander LB (1992) Laparoscopic bile duct injures: risk factors, recognition, and repair. Arch Surg 127: 596602 32. Sackier JM, Berci G, Phillips E, Carroll B, Shapiro S, Paz-Partlow M (1991) The role of cholangiography in laparoscopic cholecystectomy. Arch Surg 126: 10211026 33. Saltzstein EC, Evani SV, Mann RW (1973) Routine operative cholangiography: analysis of 506 consecutive cholecystectomies. Arch Surg 107: 289291 34. Shively EH, Wierman TJ, Adams AL, Romines RB, Garrison RN (1990) Operative cholangiography. Am J Surg 159: 380384 35. Thurston OG (1974) Nonroutine operative cholangiography. Arch Surg 108: 512513 36. Traverso LW, Hauptmann EH, Lynge DC (1994) Routine intraoperative cholangiography and its contribution to the selective cholangiographer. Am J Surg 167: 464468 37. Voyles CR, Sanders DL, Hogan R (1994) Common bile duct evaluation in the era of laparoscopic cholecystectomy. Ann Surg 219: 744 752 38. Wilson TG, Hall JC, Watts J (1986) Is operative cholangiography always necessary? Br J Surg 73: 637640

22.

23. 24. 25. 26. 27. 28. 29.

Surg Endosc (1997) 11: 10881090

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic fundoplication to enhance pulmonary function in children with severe reactive airway disease and gastroesopheagal reflux disease
S. S. Rothenberg, D. Bratton, G. Larsen, R. Deterding, H. Milgrom, S. Brugman, M. Boguniewicz, S. Copenhaver, C. White, J. Wagener, L. Fan, J. Chang, T. Stathos
National Jewish Center for Immunology and Respiratory Medicine, The Childrens Hospital, Columbia Presbyterian/St Lukes Medical Center for Children, Denver, CO, 80218 USA Received: 25 March 1997/Accepted: 5 July 1997

Abstract Background: The relationship between severe reactive airway disease (RAD) and gastroesophageal reflux disease (GERD) has been noted but the relationship is poorly understood. This study reports our experience with laparoscopic fundoplication and its effect on the pulmonary status of children with severe steroid-dependent reactive airway disease. Methods: Fifty-six patients with severe steroid-dependent RAD and medically refractory GERD underwent laparoscopic Nissen fundoplications. Mean age was 7 years and mean weight was 20 kg. All patients had the procedure completed successfully laparoscopically with an average operative time of 62 min. Average hospital stay was 1.6 days. Results: Forty-eight of 56 patients noted significant improvement in their respiratory symptoms in the first week. Fifty of 56 patients have been weaned off their oral steroids and four others have had a greater than 50% decrease in their dose. Sixteen patients had a documented increase in their FEV1 in the initial postoperative period (avg. 26%). Conclusion: Patients with steroid-dependent RAD and GERD refractory to medical management show improvement in their respiratory status following fundoplication and the majority can be weaned off of their oral steroids. Laparoscopic techniques allow this procedure to be performed safely even in this high-risk group of patients. Key words: Asthma Gastroesophageal reflux Fundoplication Children Laparoscopic

Previous studies have shown that many children with severe reactive airway disease (RAD) also have clinically significant gastroesophageal reflux disease (GERD) [7, 9, 13, 14]. However, the interrelationship between these two disease processes has not been clearly defined. These patients are often steroid dependent because of their RAD and on high doses of antireflux medications without adequate control of their GERD. This may be in part due to the high intraabdominal pressures generated by obstructive airway disease, a higher incidence of hiatal hernia, and the use of adrenergic drugs or other asthma medications which may inhibit the lower esophageal sphincter [11, 12]. What is less clear is the impact their poorly controlled GERD has on their respiratory symptoms. Previous studies have suggested that GERD affects the respiratory system in two major ways. One is through direct aspiration and irritation of the respiratory mucosa and bronchial smooth muscle [1, 2]. The second is via a vagal reflex which results in bronchospasm when the lower esophagus is irritated by acid [8, 10]. While medical therapy has often proven to be ineffective in controlling reflux in these patients, surgical therapy was rarely recommended because of concern over how these patients with significant respiratory compromise would tolerate a major upper abdominal surgery. This study evaluates the impact of the surgical correction of proven GERD in patients with severe steroid-dependent RAD using laparoscopic techniques. Methods
From August 1993 to January 1997 some 56 patients with severe steroiddependent RAD were evaluated and treated for severe GERD unresponsive to medical management (H2-blockers, cAMP inhibitors, and prokinetic agents). Ages ranged from 1 month to 19 years (mean 7 years). Weight ranged from 3.0 to 100 kg (mean 20 kg). All patients were on oral steroids at the time of evaluation and surgery. Doses were weight and age dependent but were as high as 3 mg/kg/day of prednisone. All patients were on multiple inhaler therapy and 30 patients also received inhaled steroids.

Presented at the annual scientific session of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA, 1922 March 1997 Correspondence to: S. S. Rothenberg, 1601 E 19th Avenue, Suite 5200, Denver, CO 80218, USA

1089 Forty-two of the patients had nocturnal asthma and all had been hospitalized at least once (range 18) for their airway disease in the last year. Reflux was documented by UGI in 42 patients, by bronchial washings in 10 (positive for lipid-laden macrophages), and by 24-h pH probe in 48. DeMeester scores [6] ranged from 10 to 146 with a direct association between reflux episodes and increased respiratory symptoms noted in 34 patients. All patients underwent a laparoscopic Nissen fundoplication. The technique involved the use of five ports in a standard configuration as previously described [16]. Port and instrument size were either 5 mm or 3.4 mm depending on the size of the patient. One 10-mm port was placed in patients over 10 kg to allow for the use of the Harmonic scalpel (Ethicon Endosurgery Inc., Cincinnati, Ohio). Eighteen of the 56 patients had the Rosetti modification of the Nissen fundoplication [15].

Results The average operative time for the fundoplication was 62 min (range 35180 min). Twenty-nine patients underwent additional procedures at the same time including gastrostomy tube placement (n 7), thoracoscopic lung biopsy (n 3), and assorted other procedures (n 9). All patients were extubated at the end of the procedure and there were no episodes of significant respiratory compromise in the initial postoperative period. There were three intraoperative complications (5.4%), including one esophageal and one gastric perforation, both repaired laparoscopically. The third was a left pneumothorax which was treated by needle aspiration prior to extubation in the operating room without further sequelae. No procedures were converted to open laparotomy. There were three postoperative complications (5.4%). These included two gastrostomy site infections and one case of severe dysphagia requiring esophageal dilatation. Hospital stay averaged 1.4 days (range 14 days) and was 1.2 days for patients undergoing a Nissen only. There was one late complication of a wrap failure at 16 months. This was accompanied by a worsening of the patients asthma symptoms. The patients symptoms improved with a laparoscopic repair of her fundoplication. Twenty-eight patients were considered old enough to verbalize their own assessment of their respiratory status postoperatively. The others were assessed based on the evaluation of their primary care giver. Forty-eight of 56 patients noted significant symptomatic improvement in their respiratory status in the 1st postoperative week. Fifty-two of 56 have noted symptomatic improvement at follow-up 241 months postoperatively (avg. 17 months). This was objectively born out by a decrease in the need for rescue bronchodilator treatments in 50 of 56 patients (89%) by greater than 50% in most cases. Forty of 42 patients (95%) have noted a disappearance or significant decrease in their nocturnal asthma symptoms. Fifty of 56 patients (85%) have been weaned off their oral steroids and four of the remaining six have had their dose reduced by greater than 50%. Pre- and postoperative (24 weeks) pulmonary function tests were available for comparison in 16 patients. Of note, there was no significant decrease in pulmonary function immediately following laparoscopic fundoplication and in addition FEV1 improved between 8 and 98% (avg. 26%). Discussion The relationship between GERD and respiratory disease in infants and children has been shown to be present in many

forms [9, 14]. Infants often present with severe episodes of apnea and bradycardia and reflux may play a role in sudden infant death syndrome. Reflux may also present as recurrent bouts of pneumonia or sinus infections and in some children can result in significant failure to thrive. However, the interaction between GERD and patients with steroiddependent RAD remains somewhat unclear. A number of studies have attempted to define the relationship but often the findings have been conflicting. A direct relationship was shown by Larsen et al. in a study of children with severe asthma who had a nocturnal component [5]. They performed intraesophageal infusions of normal saline followed by infusion of 0.1 HCl during two periods of the normal sleep cycle. While the saline infusion had no effect, the acid infusion caused changes in breathing pattern consistent with bronchoconstriction and in some cases caused overt wheezing. Several studies have shown that intensive medical management of GERD often fails to have any impact on the patients respiratory status [17]. Shapiro et al. documented significant GERD in 47% of a group of steroid-dependent asthmatics but failed to show an improvement in their airway disease during a 3-week period of intensive medical therapy for their GER. There are numerous other studies which suggest a correlation between GER and worsening respiratory symptoms in a select group of patients with severe asthma, but the benefits of antireflux therapy remain unclear [11, 13]. Folgia et al. [7] have suggested that in this subset of patients, medical therapy may be inadequate and surgical correction may be more efficacious. They showed that while only 30% of patients with severe asthma or recurrent pneumonia and GERD showed improvement on medical therapy, over 90% of those who failed medical therapy had symptomatic improvement of their respiratory symptoms following fundoplication. This and other similar studies suggest that in this subset of patients medical therapy may be inadequate in interrupting the reflex pathway between esophageal irritation and bronchoconstriction but that surgical correction may act as a more effective barrier. In our study all of the patients had steroid-dependent RAD and had failed medical management of their GERD. Previously these patients might not have been considered candidates for fundoplication because of the high morbidity of a major upper abdominal procedure in patients with already-compromised respiratory function and the unclear benefits of correcting GERD as it relates to RAD. However, the ability to perform the procedure safely laparoscopically as shown in both adult and pediatric trials [3, 4, 16] allowed us to be more aggressive in offering surgical correction in this high-risk group. In this series we have performed 56 fundoplications without a postoperative pulmonary complication, and in fact the vast majority of patients noted a significant symptomatic improvement in their breathing in the initial postoperative period. This has been documented in some patients by an improvement in their FEV1. All the patients have been taken off their antireflux medication and over 90% have been weaned off or had a significant decrease in their steroid dose. There has been a marked decrease in the need for prn bronchodilator treatments and nearly all patients have had a significant improvement in their nocturnal RAD symptoms. Many of the patients also relate that minor asthma attacks which would

1090

often progress into severe episodes requiring hospitalization are now easily controlled with inhaler therapy. While the follow-up period is not long enough to draw definitive conclusions, there does seem to be a decreased incidence of hospitalization. While the exact relationship between GERD and severe RAD is still unclear, this study suggests that in many cases there is a direct interaction in the pathophysiology between the two disease processes and that GERD has a significant adverse affect on the severity of RAD. It also appears clear that in these cases surgical fundoplication is superior to a medical antireflux regime in interrupting this relationship. In addition laparoscopic techniques allow for the procedures to be performed safely even in this high-risk group of patients. While this study pertains primarily to children and young adults, it is likely that similar benefits might also be obtained in older patients. Those patients with a long history of RAD and nocturnal asthma as well as childhood history of failure to thrive or recurrent respiratory infections may well have clinically silent GERD. Further study and followup will be necessary to determine the exact pathways of interaction between reflux and bronchospasm and to define that group of patients who are most likely to benefit from surgical correction. References
1. Barish CF, Wu WC, Castell DO (1985) Respiratory complications of gastroesophageal reflux. Arch Intern Med 145: 18821888 2. Berquest WE, Rachelefsky GS, Kadden M (1981) Gastroesophageal reflux associated with recurrent pneumonia and chronic asthma in children. Pediatrics 68: 2935 3. Collins JB, Georgeson KE, Vincente Y, et al (1995) Comparison of open and laparoscopic gastrostomy and fundoplication in 120 patients. J Pediatr Surg 30: 10651071 4. Cushieri A, Hunter J, Wolfe B, et al (1993) Multicenter prospective evaluation of laparoscopic antireflux surgery. Preliminary report. Surg Endosc 7: 505510 5. Davis RS, Larsen GL, Granstein MM (1983) Respiratory response to intraesophageal acid infusion in asthmatic children during sleep. J All Clin Immunol 72: 393398 6. DeMeester TR, Wang CL, Wernly JA, et al. (1980) Technique, indications, and clinical use of 24-hour pH monitoring. J Thorac Cardiovasc Surg 79: 656670 7. Folgia RP, Fonkalsrud EW, Ament ME, et al. (1980) Gastroesophageal fundoplication for the management of chronic pulmonary disease in children. Am J Surg 140: 7279 8. Gustafson PM, Kjellman NI, Tibbling L (1990) Bronchial asthma and acid reflux into the distal and proximal esophagus. Arch Dis Child 65: 12251228 9. Herbst JJ, Hillman BC (1993) Gastroesophageal reflux and respiratory sequelae. In: Pediatric respiratory disease: diagnosis and treatment. WB Saunders, pp 521532 10. Irwin RS, Curley FJ, French CL (1993) Difficult to control asthma. Contributing factors and systemic management protocols. Chest 103: 16621669 11. Malfroot A, Dab I (1995) Pathophysiology and mechanism of gastroesophageal reflux in childhood asthma. Pediatr Pulmonol Suppl 11: 5556 12. Mansfield LE (1989) Gastroesophageal reflux and repiratory disorders: a review. Ann Allergy 62: 158163 13. Martin ME, Grunstein MM, Larsen GL (1982) The relationship of gastroesophageal reflux to nocturnal wheezing in children with asthma. Ann Allergy 49: 318322 14. Orenstein SR, Orenstein DM (1988) Gastroesophageal reflux and respiratory disease in children. J Pediatr 112: 847858 15. Rossatti M, Allgower M (1973) Fundoplication for the treatment of hiatal hernia. Prog Surg 12: 627630

16. Rothenberg SS. Experience with two hundred and twenty consecutive Nissen fundoplications in infants and children. J Pediatr Surg (in press) 17. Shapiro GG, Christie DC (1979) Gastroesophageal reflux in steroid dependant asthmatic youths. Pediatrics 63: 207212

Discussion Dr. Hunter: This may not directly pertain to your asthmatics, but one of the things that Ive been very curious about in the pediatric population is that you generally have a large number of neurologically impaired children in this group, many of whom have difficulties with vomiting. One of the things we have seen in the adult population is the paraesophageal herniation that is associated with vomiting. You didnt really show that any of your wraps degraded. If you look at your whole lap-Nissen experience in children, have you had many wraps degrade, especially in the neurologically impaired childrenhave they had any more difficulty with disruption of the fundoplication? Dr. Rothenberg: Yes, the total series now is about 250 patients up to 18 years of age. Theres been about a 2.5% failure rate, and the majority of them are neurologically impaired patients. Three of these patients developed significant paraesophageal hernias and herniated the wrap up into the chest. Dr. Salky: What is bronchopulmonary dysplasia in relation to adult disease, as most of us are adult surgeons? Dr. Rothenberg: I think bronchopulmonary dysplasia is something that develops often in premature infants as a result of their immature lungs and hyaline membrane disease. They often have an O2 requirement early in life, and basically have what we call twitchy lungs. I think many patients who have bronchopulmonary disease are the ones who go on later in life to be classified as having asthma. The reason I put these patients together is because many of them, as infants, are treated with steroids to help wean them off their oxygen. It appears that a fundoplication in these patients who have reflux, documented reflux, tends to help these patients, as well, get off their steroids and decrease their O2 requirement. Dr. Peters: I understand that theres an epidemiologic explosion in childhood asthma. There was a three page dissertation on it in the Los Angeles Times not too long ago. Does reflux disease have anything to do with what were seeing in adults in Barretts esophagus, as well, and has anybody entertained the possibility that that could be reflux disease? Dr. Rothenberg: Well, weve gotten more and more aggressive at looking at these kids. I see a unique population. A lot of patients are referred into a center in Denver called National Jewish Hospital, which is a nationally known asthma center, and they, for years, have known that these kids all had reflux, but never really thought there was much of a correlation, and part of it was that, no matter how they treated them medically, it never got rid of their reflux, and it didnt seem to make any difference with their asthma. I think theres really a difference in how these kids respond to medical management or surgical management, and I think they respond much better to a surgical fundoplication. Any patient with significant asthma I think warrants a work-up to see if they do have reflux.

Case reports
Surg Endosc (1997) 11: 11181122

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopically assisted radical sacrococcygectomy


A new operative approach to large sacrococcygeal chordomas
K. C. Conlon,1 P. J. Boland2
1 2

Gastric and Mixed Tumor Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA Orthopedic Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA

Abstract. Laparoscopic rectal mobilization and hypogastric arterial isolation were combined with a posterior sacrococcygectomy for the resection of a large sacrococcygeal chordoma in two patients. The laparoscopic procedure as described was uneventful in both cases. There was no postoperative morbidity associated with the laparoscopic procedure. The combination of laparoscopic pelvic dissection and radical posterior sacrococcygectomy is safe, effective, oncologically sound, and should be considered for all patients with a large proximal sacrococcygeal chordoma. Key words: Laparoscopy Chordoma Sacrum Coccyx

Chordomas are uncommon malignant tumors derived from remnants of notochordal tissue. They account for approximately 34% of all primary bone tumors. Scandinavian studies have estimated an annual incidence of 0.5 per million [11, 23]. The sacrococcygeal region is the predominant site, accounting for 50% of cases [17, 22, 31]. Approximately 35% are situated at the sphenooccipital region; the remaining 15% are distributed along the mobile spine [5, 8, 22]. Sacrococcygeal chordomas are twice as common in males as in females, presenting principally in the sixth and seventh decades of life [2, 14, 17, 24, 26, 31]. They are considered to be slow growing, locally invasive tumors, which, particularly in the sacrococcygeal area, can reach a significant size before becoming clinically evident [13, 26]. Surgery is the mainstay of therapy [1, 4, 1215, 19, 26, 28, 30, 31, 33, 34]. For sacrococcygeal chordomas, complete excision with negative surgical margins appears to offer the best chance of cure [2, 12, 16, 22]. However, this is often difficult to achieve due to the tumor size, local infiltration, and the surgeons desire to preserve neurological function and pelvic stability. The role of adjuCorrespondence to: K. C. Conlon

vant chemotherapy and radiotherapy remains controversial [2, 12, 15, 17, 24, 29]. Currently, three basic surgical approaches exist: sequential anterior laparotomy and posterior sacrectomy [30, 31], a synchronous abdominosacral approach [13, 19, 21, 28], or a posterior sacrococcygectomy alone [14, 26]. Both abdominal approaches allow assessment of intraabdominal tumor extension, plus creation of a colostomy, mobilization of the ureter, and control of the iliac vessels. However, the resultant incision and postoperative ileus add to the morbidity of the procedure. These are avoided by using a posterior approach alone, particularly for small tumors not extending above S-3. For larger lesions extending above S-3, or with an anterior extension into the presacral space, a posterior approach alone may compromise tumor clearance and risk uncontrollable hemorrhage from inadvertent damage to the iliac or median sacral vessels [6]. An alternative method of pelvic dissection has recently been developed [25]. Techniques for the laparoscopic mobilization of the rectum in benign and malignant disease have been reported [9, 10, 18]. These minimal-access surgical techniques offer the surgeon the ability to replicate open surgical dissection with potential reduction in postoperative morbidity. We were anxious to apply this approach to the treatment of large sacral tumors. This paper details the technique developed, and the results obtained, in the first two patients treated with a laparoscopically assisted radical sacrococcygectomy for malignant chordoma. Patients and methods Patient 1
The patient, a 66-year-old male Caucasian, presented to our institution with a 6-month history of lower back pain and a buttock mass. There were no gastrointestinal, genitourinary, or neurological symptoms apart from the pain. Clinical examination was normal aside from a palpable left buttock mass. A computerized tomographic (CT) scan of the pelvis revealed a 10 10 cm mass with destruction of the sacrum and coccyx. Magnetic resonance imaging (MRI) demonstrated a large multilobulated mass extending

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Fig. 1. Sagittal MRI (T1-weighted image) of patient 2. Demonstrating a large tumor extending to the upper level of S2. Fig. 2. Axial MRI of the same patient (2). Showing anterior, lateral, and posterior extent of the tumor.

anteriorly into the presacral space but not involving the rectum. Posteriorly, it was noted to extend into the subcutaneous fat and to directly invade the left gluteus musculature. Direct involvement of the thecal sac was not present. A tru-cut biopsy was consistent with a malignant chordoma.

Patient 2
An 80-year-old female presented with a 3-year history of constipation and low back pain. Three months prior to presentation, she developed perianal numbness and noticed a right buttock mass. Systems review apart from the presenting symptoms was negative. In particular, she denied any bowel or bladder incontinence. Karnosky performance status was >90%. Physical examination revealed a 15 15 cm right buttock mass which was fixed and nontender. On rectal examination a large mass was palpable posteriorly. Aside from diminished perianal sensation, the neurological examination was normal. Plain radiographs showed extensive bony destruction of the sacrum. MRI scan demonstrated a 20 15 cm sacral tumor extending up to and including the S-2 segment with a large posterior soft-tissue component invading the gluteus maximus bilaterally and extending into the subcutaneous tissue on the right (Figs. 1 and 2). There was also a large anterior intrapelvic component, displacing the rectum anteriorly. An open biopsy had been performed, which confirmed the diagnosis of malignant chordoma.

Operative technique
Laparoscopy was performed under general anesthesia. The patient was placed supine on the operating table, with a small pelvic lift. A warming blanket was utilized to maintain a normal body temperature. An open surgical technique for carbon dioxide insufflation was used. A 1-cm subumbilical incision was made exposing the abdominal wall fascia. The peritoneum was opened under direct vision, and a 10/11-mm Hasson-type trocar was inserted (Endopath, Ethicon Endo-Surgery, Cincinnati, OH). This was attached to a high-flow carbon dioxide insufflator (Karl Storz Endoscopy-America, Inc., Culver City, CA) and the intraabdominal pressure was noted. Initial pressure was less than 3 mmHg. Carbon dioxide (CO2) insufflation was commenced through this trocar to an intraabdominal pressure of 14 mmHg. A 30 angled telescope was then inserted and a laparoscopic examination of the peritoneal cavity was performed. A multiport technique was used. Figure 3 illustrates the placement of the operative ports. The surgeon stood on the patients right, with monitors placed at the level of the pelvis. The patient was then placed in a deep Trendelenburg position, rotated slightly to the left. The small bowel was excluded from the pelvis. The sigmoid colon was mobilized in a standard

fashion (Fig. 4). The ureter and iliac vessels were identified. The dissection was carried along the lateral pelvic side wall until the hypogastric artery was exposed. When this was completed a red rubber catheter was brought through the mesentery of the rectum to aid traction. This maneuver freed a port site for other dissecting instruments. The patient was then rotated toward the left-hand side. The rectum was retracted anteriorly and to the left by gentle traction on the red rubber catheter. The peritoneum along the right pelvic side wall was incised in an analogous manner to the left. The iliac vessels and ureter were exposed. The peritoneal dissection was continued cranially to the bifurcation of the aorta, exposing the sacral promontory and the concavity of the sacrum (Fig. 5). A retractor inserted suprapubically aided the retraction of the mesorectum from the sacrum, displaying the presacral space. The avascular, areolar plane between the presacral fascia and the mesorectal fascia was identified, and sharp dissection was performed. Meticulous hemostasis is essential for this portion of the dissection and was easily achieved with electrocautery. The median sacral vessels were clipped and divided at this point. Sharp dissection continued in a plane anterior to the tumor (Fig. 6). Magnification and the use of the 30 laparoscope greatly facilitated this maneuver. Posteriorly, the dissection continued until the tumor was separated from the rectum. To complete mobilization of the rectum, dissection was continued along both lateral pelvic side walls. The lateral suspensory ligaments were divided. At this stage the rectum was completely separated from the sacrum. The ureters were mobilized laterally for protection. Vessel loops were placed around the common iliac arteries bilaterally for emergency vascular control following sacral transection. In the second patient, the hypogastric arteries were ligated in continuity, with nonabsorbable silk sutures. The laparoscopic procedure was completed by the placement of 4 4 gauze packs (inserted through a 10-mm port) into the presacral space which protected the rectum during sacral transection (Fig. 7). Carbon dioxide insufflation was discontinued, and the operative ports were removed under direct vision. The fascia of the 10-mm ports were closed using absorbable suture. Subcuticular sutures were used for all the port sites and dry dressings were applied. The patient was then turned into the prone position. A longitudinal skin incision was made, extending from the spinous process of L-4 to the tip of the coccyx. Lateral cutaneous flaps were raised. The gluteal muscles were divided lateral to the tumor. The superior and inferior gluteal vessels were divided and ligated. The paraspinal muscles were divided at the level of S-1 and were dissected subperiosteally to expose the lower lumber and upper sacral laminae. The sciatic notch was identified laterally, and following identification of the sciatic nerve, the piriformis muscles were transected. The anococcygeal ligament was divided. The anal canal and lower rectal mobilization was performed by finger dissection, completing the anterior dissection. The sacrotuberous and sacrospinous ligaments were divided. A wide upper sacral laminectomy was performed. The S-1 nerve roots were identified and a foraminotomy was performed bilaterally. The distal dural

1120 < Fig. 3. Laparoscopic port placement. A 30 telescope is used with the surgeon standing on the patients right-hand side. Fig. 4. Sigmoid mobilization. The sigmoid colon is retracted to the right and sharp dissection is commenced along the left lateral abdominal wall. The ureter and iliac vessels are identified. Fig. 5. Sacral promontory. Dissection is started at the bifurcation of the iliac artery on the right. The sacral promontory is identified and the presacral space is entered.

sac was mobilized, doubly ligated, and divided. Using an osteotome the sacrum was amputated between S-1 and S-2. The osteotome was guided anteriorly with a finger placed anteriorly and superiorly through the sciatic notch. The S-1 nerve roots were preserved bilaterally. The remaining softtissue connections including the levator-ani muscles were divided and the specimen was excised. Following removal of the specimen, the laparoscopically inserted packs and vessel loops were removed. A Mersilene mesh was placed in the resultant defect to prevent rectal herniation. The wound was closed primarily.

Results The laparoscopic procedure was uneventful in both cases. Blood loss was minimal during the pelvic dissection (est. 25 ml/case). Overall estimated blood loss was less than 1,000 ml in case 1 and approximately 7,000 ml in the second case. In this latter case, the tumor was enormous and bleeding was encountered mainly from the bone and epidural vessels rather than during the soft-tissue dissection. There were no postoperative complications related to

the laparoscopic procedure. The first patient made an uneventful recovery; diet commenced on the 2nd postoperative day. The second patient developed a small intracerebral hemorrhage postoperatively, resulting in intermittent confusion and aphasia which has completely resolved. Enteral feeding was commenced on the 4th postoperative day. Pathology of the resected specimens revealed malignant chordoma in both cases. Soft-tissue margins were negative for tumor; however, in the first case the right ileal bony margin was found to be microscopically positive for tumor. This patient received postoperative radiotherapy. Both patients are ambulatory and free of disease at 18 months follow-up.

Discussion It is accepted by most authors that in the absence of metastatic disease, wide local extirpation of the tumor with nega-

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Fig. 6. Pelvic dissection. A Babcock forceps is used to retract the rectum, allowing dissection in the presacral space. The tumor is separated from the mesorectum by sharp dissection. Fig. 7. Placement of gauze packs. Gauze packs are placed upon completion of the anterior dissection to protect the rectum during sacral transection.

tive surgical margins offers the best chance for long-term, disease-free survival [1, 4, 1215, 19, 26, 28, 30, 31, 33, 34]. This is performed while maintaining pelvic stability and preserving as many of the sacral nerve roots as possible so as to minimize the resultant neurological disability [30]. Traditionally, an anterior celiotomy was combined in a two-phase procedure with a radical sacrococcygealectomy for proximal sacral lesions. This approach enabled the surgeon to assess the intraabdominal extent of the tumor, mobilize and protect the rectum, gain pelvic vascular control, and if required perform either an end- or defunctioning colostomy prior to the sacral resection. This technique, while effective, required repositioning the patient intraoperatively, was associated with longer operative time, and increased postoperative morbidity [30, 31]. A synchronous abdominal and transacral surgical approach was described by Localio and co-workers [19]. Simultaneous pelvic dissection to obtain rectal mobilization with vascular control and posterior dissection for sacral mobilization allowed the tumor to be removed en bloc with a wide margin of resection. They reported their experience with five patients with chordoma, three of whom had their tumor completely excised. Simpson and colleagues [28] recently reported a combined extended ilioinguinal and posterior approach in six patients with proximal chordoma. A wide margin of resection was achieved in five patients, all of whom remain disease free at a median follow-up of 30 months. An additional six patients with other malignant tumors also underwent this procedure. Overall operative mortality was low (8%), but major wound complications occurred in seven patients (58%). A posterior approach alone would avoid the morbidity of an anterior or extended incision. MacCarty et al. [20] first described such an approach for the treatment of sacrococcygeal chordomas. More recently, this approach has gained in popularity. Samson and associates [26] reported 21 cases

treated at the Massachusetts General Hospital between 1972 and 1992. All patients underwent a posterior sacrococcygectomy, 11 of whom had a resection involving either S1 or S2. Five patients (24%) had a separate exploratory laparotomy and colostomy formation. Sixteen patients (76%) received adjuvant radiation therapy. A wide excision was achieved in ten patients, a wide contaminated excision in one case, a marginal excision in three patients, and an intralesional margin obtained in the remaining seven patients. Wound complications were seen in 33% of patients. An actuarial 5-year disease-free survival of 77% was reported. Gennari and colleagues [12] described eight cases in which a posterior approach alone was utilized to perform resection through S2. There were no serious intraoperative complications recorded; however, five patients (63%) had local recurrences at a median follow-up of 41 months. While avoiding the morbidity of the anterior celiotomy, both these studies illustrate the difficulty in obtaining gross tumor clearance by using a posterior approach alone. The laparoscopic technique described in this report combines the advantages of the anterior celiotomy while avoiding the morbidity of the abdominal incision. Since the introduction of laparoscopic cholecystectomy in the late 1980s, many endosurgical procedures have been demonstrated to have decreased surgical morbidity and to lead to reduced hospital stay, shorter recovery, and an improved quality of life. In oncological practice, laparoscopic techniques have been proposed for the diagnosis, staging, palliation, and treatment of various malignancies [3, 7, 27]. Using a multiport technique, a full examination of the abdomen and pelvis is possible. The pelvic viscera can be dissected away from the tumor sharply, under direct vision. In both our cases, the magnification obtained with the laparoscope facilitated mobilization of the rectum from the tumor, allowing us to obtain negative soft-tissue pathological margins. If rectal involvement is suspected, division of the

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bowel and colostomy formation can easily be performed using laparoscopic techniques. The ureters can be identified and mobilized laterally, this is particularly important in large tumors with a substantial anterior component such as our second case. Vascular control can also be achieved. In both our cases, medial sacral vessels were divided, and the internal iliac vessels were controlled with vessel loops. In our second case, we ligated the internal iliac vessels as advocated by Sung and colleagues [32]. This resulted in minimal hemorrhage during the anterior or soft-tissue dissection, with most of the blood loss occurring from osteoporotic bone and epidural vessels. Not all patients are suitable for the approach described in this article. Those who are obese or have a history of prior open-pelvic or gynecologic surgery should be considered for an open procedure. In addition, previous pelvic irradiation is a relative contraindication due to the obliteration of tissue-planes and to the presence of visceral adhesions, which commonly occur. In summary, this paper details a novel way to approach large sacral chordomas, combining minimal-access surgical techniques to mobilize the rectum and obtain pelvic vascular control with a radical posterior sacrococcygectomy. We believe that this combination is safe, effective, oncologically sound, and should be considered for all patients with large proximal sacrococcygeal chordomas.
Acknowledgment. The authors wish to thank Ms. Christine A. Schaar for the illustrations in this manuscript. This work was partially supported by the Milton Ludmar Memorial Fund, the Lillian Wells Foundation, the Bernice and Milton Stern Foundation.

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

References
1. Anson KM, Byrne PO, Robertson ID, Gullan RW, Montgomery AC (1984) Radical excision of sacrococcygeal tumours. Br J Surg 81: 460461 2. Azzarelli A, Quagliuolo V, Cerasoli S, Zucali R, Bignami P, Mazzaferro V, Dossena G, Gennari L (1988) Chordoma: natural history and treatment results in 33 cases. J Surg Oncol 37: 185191 3. Barlett DL, Conlon KCP, Gerdes H, Karpeh MS (1995) Laparoscopic ultrasonography: the best pretreatment staging modality in gastric adenocarcinoma? Case report. Surgery 118: 562564 4. Bethke KP, Neifeld JP, Lawrence W (1991) Diagnosis and management of sacrococcygeal chordoma. J Surg Oncol 48: 232238 5. Bjornsson J, Wold LE, Ebersold MJ, Laws ER (1993) Chordoma of the mobile spine: a clinicopathologic analysis of 40 patients. Cancer 71: 735740 6. Bowers RF (1949) Giant cell tumor of the sacrum: a case report. Ann Surg 128: 11641171 7. Conlon KC, Dougherty E, Klimstra DS, Coit DG, Turnbull AS, Brennan MF (1996) The value of minimal access surgery in the staging of patients with potentially resectable peri-pancreatic malignancy. Ann Surg 223: 134140 8. Dahlin DC, MacCarty CS (1952) Chordoma. Cancer 5: 11701178 9. Darzi A, Lewis C, Guillou PJ, Monson JRT (1995) Comparison of

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laparoscopic abdomino-perineal vs. open abdomino-perineal resection of the rectum. Surg Endosc 9: 414417 Darzi A, Menzie-Gow N, Henry MM, Guillou PJ, Monson JRT (1995) Laparoscopic rectopexy for complete rectal prolapse. Surg Endosc 9: 301303 Erikson B, Gutenberg B, Kindbolm L (1952) Chordoma a clinicopathological and prognostic study of a Swedish national series. Acta Orthop Scand 52: 4958 Gennari L, Azzarelli A, Quagliuolo V (1987) A posterior approach for the excision of sacral chordoma. J Bone Joint Surg Br 69: 565568 Gray SW, Singhabhandhu B, Smith RA, Skandalakis JE (1975) Sacrococcygeal chordoma: report of a case and review of the literature. Surgery 78: 573582. Healy JH, Lane JM (1989) Chordoma: a critical review of diagnosis and treatment. Orthop Clin North Am 20: 417426 Huth JF, Dawson EG, Eilber FR (1984) Abdominosacral resection for malignant tumors of the sacrum. Am J Surg 148: 157161 Kaiser TE, Pritchard DJ, Unni KK (1984) Clinicopathologic study of sacral chordoma. Cancer 54: 25742578 Keisch ME, Garcia DM, Shibuya RB (1991) Retrospective long-term follow-up analysis in 21 patients with chordomas of various sites treated at a single institution. J Neurosurg 75: 374377 Koeckerling F (1994) Laparoscopic abdominoperineal excision with high transection of the inferior mesenteric artery. Surg Oncol Clin North Am 4: 731743 Localio SA, Eng K, Ranson JH (1980) Abdominosacral approach for retrorectal tumors. Ann Surg 191: 555560 MacCarty CS, Waugh JM, Mayo CW, Coventry MB (1952) The surgical treatment of presacral tumors: a combined problem. Proc Mayo Clin 27: 7384 Michel LA, De Cloedt P (1989) Synchronous abdominal and transsacral approach for excision of sacrococcygeal chordoma. Acta Chir Belg 89: 316319 ONeill P, Bell BA, Miller JD, Jacobson I, Guthrie W (1985) Fifty years of experience with chordomas in southeast Scotland. Neurosurgery 16: 166170 Paavolainen P, Teppo L (1976) Chordoma in Finland. Acta Orthop Scand 47: 4651 Rich TA, Schiller A, Suit HD, Mankin HJ (1985) Clinical and pathological review of 48 cases of chordoma. Cancer 56: 182187 Sackier JM, Berci G, Hiatt JR, Hartunian S (1992) Laparoscopic abdominoperineal resection of the rectum. Br J Surg 79: 12071208 Samson IR, Springfield DS, Suit HD, Mankin HJ (1993) Operative treatment of sacrococcygeal chordoma: a review of twenty-one cases. J Bone Joint Surg Am 75: 14761484 Shimi S, Banting S, Cuschieri A (1992) Laparoscopy in the management of pancreatic cancer: endoscopic cholecystojejunostomy for advanced disease. Br J Surg 79: 317319 Simpson AHRW, Porter A, Davis A, Griffin A, McLeod RS, Bell RS (1995) Cephalad sacral resection with a combined ilioinguinal and posterior approach. J Bone Joint Surg 77: 405411 Spratt JS, Martin AE, McKeown J (1981) Sacral chordoma: a case study and review. J Surg Oncol 18: 101103 Stener B, Gunterberg B (1978) High amputation of the sacrum for extirpation of tumors: principles and technique. Spine 3: 351366 Sundaresan N, Huvos AG, Krol G, Lane JM, Brennan M (1987) Surgical treatment of spinal chordomas Arch Surg 122: 14791482 Sung HW, Shu WP, Wang HM, Yuai SY, Tsai YB (1987) Surgical treatment of primary tumors of the sacrum. Clin Orthop 215: 9198 Touran T, Frost DB, OConnell TX (1990) Sacral resection: operative technique and outcome. Arch Surg 125: 911913 Xu WP, Song XW, Yue SY, Cai YB, Wu J (1990) Primary sacral tumors and their surgical treatment: a report of 87 cases. Chin Med J 103: 879884

Surg Endosc (1997) 11: 11111114

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic colposuspension using mesh reinforcement


R. A. Birken, P. L. Leggett
Houston Northwest Medical Center, 710 FM 1960 West, and Tops Surgical Specialty Hospital, 17080 Red Oak, Houston, TX 77090, USA Received: 27 January 1997/Accepted 4 June 1997

Abstract Background: For patients with stress urinary incontinence, surgical reestablishment of the bladder neck has proved amenable to a laparoscopic approach, which shortens hospitalization and reduces tissue trauma. The use of mesh reinforcement to improve the durability of colposuspension can refine this proven procedure even further. Methods: We performed laparoscopic Burch colposuspension on 54 patients with stress urinary incontinence and compared our results with those of other investigators. Results: All patients reported resolution of incontinence postoperatively: 83.3% received no supplementary medication while 16.7% took antispasmodic-anticholinergic medications. Two cases required conversion to an open procedure. Hospital stay declined from 2.7 days (first quartile) to 1.9 days (last quartile) (average, 2.3 days). Complications were rare, and in a 28-month follow-up, no reoperations were required. Conclusion: Laparoscopic Burch colposuspension using mesh reinforcement provides durable resolution of stress incontinence with low risk of conversion, short hospitalization, and few complications. Key words: Burch colposuspensionColposcopy Laparoscopic surgeryStress urinary incontinence Urethropexy

Stress urinary incontinence is a common problem that affects 10 million middle-aged women nationwide and costs $10.3 billion annually to manage [10]. Stress incontinencethe involuntary discharge of urine when intraabdominal pressure increasesoccurs when the pressure of laughing, coughing, or straining pulls on the bladder orifice and opens it, even though the sphincteric mechanism is intact. Lack of anatomic support displaces the bladder neck, making it hypermobile and susceptible to these pressures, as well as to irritative bladder symptomatology. Correction of
Correspondence to: R. A. Birken, 17070 Red Oak Dr., Suite 201-A, Houston, TX 77090, USA

this condition requires reestablishing the bladder neck anatomically, ensuring reliable fixation without outlet obstruction. The surgical approaches include anterior colporrhaphy, sling procedures, colposuspensions and transvaginal needle suspension procedures [2, 9, 12, 16, 18]. Electrical stimulation of the muscles of the pelvic floor has also been employed to improve or cure stress incontinence [15]. In fact, it has been estimated that more than 100 surgical approaches have been described [3]. Of these, the Burch colposuspension has been called the gold standard for bladder neck suspension. It is one of the most popular and most successful operative procedures for the surgical resolution of stress urinary incontinence [11]. Not unlike the variations evidenced in the broad spectrum of laparoscopic and open surgical approaches to urinary incontinence resolution, there are variations in the performance of the laparoscopic application of the Burch procedure itself. Approaches may be intraperitoneal or extraperitoneal, and modifications have included a laparoscopic approach and the use of mesh for urethrovesical reinforcement [9, 17, 20]. Applying laparoscopic technique to the surgical solutions for stress urinary incontinence has, as with its other applications, reduced tissue trauma, helped eliminate the pain related to wound healing, and decreased the time required for hospitalization and recovery [6, 7]. To evaluate the clinical effect of laparoscopic Burch colposuspension, we report here our experience with 54 patients with stress urinary incontinence who were treated with the laparoscopic Burch procedure and the use of mesh reinforcement. We also compared our experience with that of other investigators using this approach. Materials and methods
All patients suffered from involuntary discharge of urine because of an anatomic displacement of the bladder. A diagnosis of genuine stress urinary incontinence was based on physical examination, review of clinical history, and urodynamic studies. After standard preoperative studies were completed and reviewed, each patient was scheduled for surgery. At surgery, patients were placed in a modified lithotomy position at a steep Trendelenburg angle with plantar surfaces of the feet apposed. Genitourinary operative sites were swabbed with Betadine solutions, dried, and draped.

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Fig. 1. The retropubic space is exposed by dissection.

Fig. 2. The mesh, stapled to Coopers ligament, reinforces suspension of the bladder neck.

With the patient under general anesthesia, we place a 10- or 15-ml Foley catheter in the bladder to drain it during surgery. On the midline, 1 to 2 cm below the umbilicus, we insert a Veress needle and insufflate the peritoneum to 15 mm Hg. After making three incisions for trocars, we place 2-0 Vicryl pursestring sutures in each before inserting the trocars. These are left untied, yet ready for closure. Then we placed the three trocars through small incisions: a 10-mm trocar at the subumbilical site and two 12-mm trocars, one on the umbilical plane 10 cm left of the umbilicus and another in the lower left quadrant. Using the subumbilical port for the laparoscope, we identify the bladder and the obliterated umbilical ligaments. We make bilateral transverse incisions in the peritoneum, about 2 cm above the bladder, between the round ligaments and the umbilical ligaments. To access the retropubic space and expose Coopers ligament, we dissect the tissue, dividing the layers and exposing the retropubic space (Fig. 1). With the ligament exposed, we perform the procedure. Electrocautery controls bleeding, ensuring good visualization. With the neck of the bladder and the endopelvic fascia in view, the surgeon inserts a finger within the vaginal vault to assess the defect tactually and to maneuver the bladder neck into proper position. Depending on the degree of displacement, we will use one or two 1 3cm strips of Prolene mesh (of the type typically employed in hernia repair) to suspend the neck from Coopers ligament. Typically, two strips are placed, each one lengthwise on each side of the neck, extending in spokelike fashion from the paravaginal fascia 2 cm away from the base of the neck outward to the ligament. Five to eight titanium staples fired from an EMS Disposable Endostapler hold the mesh in place. Pushing up against the bladder neck with a finger through the top of the vaginal vault relieves the tension of the defect, properly positions the bladder neck for placement, and assists in controlling stapling. Sides are completed one at a time (Figs. 2 and 3). The mesh and endostapler are products of Ethicon (Sommerville, NJ, U.S.A.). To ensure an intact bladder free of injury, we fill it with methylene blue solution. This evaluation concludes the suspension procedure. We then perform culdoplasty, if necessary, with the use of 2-0 Ethibond suture (Fig. 4). The peritoneum is closed with a pursestring suture of 2-0 Vicryl on each side. The sutures placed early in the operative procedure are tied when the trocars are removed, providing good fascial closure and excellent control of hemostasis. We then give indigo carmine dye intravenously and perform cystoscopy to evaluate ureteral function.

Fig. 3. The suspension is completed on the left side.

Results Fifty-four women, 32 to 77 years of age, underwent laparoscopic Burch colposuspension between June 1994 and May 1996. All patients reported resolution of their incontinence in follow-up visits 26 weeks after surgery; 45 (83.3%) received no supplementary medication and nine (16.7%) took antispasmodic-anticholinergic medication, such as hyoscyamine sulfate (e.g., Levsinex or Levbid). Follow-up extended

Fig. 4. In culdoplasty, after the ligaments are approximated and the sutures are tied extracorporeally, the second ligature is placed to complete the procedure.

from 5 to 28 months (average, 14 months), and no patient has required reoperation. In addition to colposuspension, 41 patients (75.9%) underwent culdoplasty, 15 (27.8%) vaginal hysterectomy, 13 (24.1%) bilateral salpingo-oophorectomy, and five (9.3%) colporrhaphy. There were two conversions to a traditional

1113

open procedure because of extensive pelvic adhesions that prevented adequate exposure endoscopically. Overall, average hospital stay was 2.3 days (range, 15 days). Dividing the patients in quartiles showed that the average hospital stay declined over time 30%, from 2.7 days in the first quartile to 1.9 days in the fourth. The percentage of patients requiring medication for complete resolution also declined from 30.8% in the first quartile to 14.2% in the fourth after dropping to a low of 7.7% in the third quartile. Postoperative complications were few: one patient experienced postoperative bladder retention, but it quickly resolved, and postoperative urinary tract infections were rare. None of our patients developed significant detrusor instability postoperatively.

Discussion Stress incontinence in women, though not a physically limiting disability, has been shown to affect lifestyle dramatically and affect psychological health adversely, especially self-esteem [8]. Although medical management is the frontline therapy and proves successful in the majority of patients, some cases require surgical intervention. In other instances, coexistent gynecological pathology requiring surgery creates the opportunity to correct borderline cases. In a comparison of methods, Black and Downs [1] found in a review of 34 studies that colposuspension was more effective than needle suspension in curing or improving stress incontinence. They concluded that, in general, 85% of patients undergoing colposuspension can expect to be continent 1 year after surgery, whereas only 5070% of those undergoing needle suspension can anticipate continence at 1 year. In general, colposuspension cure rates range from 100% to 71%, while those for needle suspension and the sling procedure drop from a high of 100% to as low as 40% [1]. Furthermore, in a study of five reports comparing colposuspension methods (the Burch procedure versus the Marshall-Marchetti-Kranz procedure), the Burch procedure was deemed superior, but the difference failed to be statistically significant. When the review of the comparison of colposuspension methods was enlarged to include eight studies in all, still no one method emerged as statistically significantly different. All were small studies. These findings indicate the importance of designing large prospective studies that incorporate long-term follow-up. In our series, all 54 patients undergoing laparoscopic Burch colposuspension with reinforcing mesh reported resolution of their symptoms; only nine (16.7%) of them required medication to ensure complete continence. Other reports on patients undergoing this procedure do not provide the number of those who relied on medication postoperatively. Of the three published reports of patients who underwent the Burch adaptation incorporating mesh, one, including 59 patients, reported no failures [20]; another, including 40 patients, reported resolution or improvement of symptoms in all patients [11]; and a third, with 30 patients, reported success in 29 cases, based on a physical examination and a patient questionnaire [17]. These expressions of outcome, because of their lack of specificity as well as the absence of an objective measure (a fault from which our

own study suffers) make comparison difficult. However, from patient reports, it is clear that the procedure brings symptomatic resolution in almost all women undergoing treatment. The durability of that response, because of the newness of the procedure, is difficult to assess. In our own study, we have followed patients for 28 months (average, 14 months), and no reoperations have been required. Other investigators who employed mesh likewise report no failures or reoperations; however, follow-up has been brief. Minor postoperative complications were self-limiting. We can hope for additional reports on these patients in order to better assess the durability of the success of the procedure. In our series, two patients required conversion to an open procedure (3.7%), a rate lower than that reported by others, both with larger and smaller series. Though in 1996 Radomski and Herschorn [14] reported a conversion rate of 26.1% in 46 patients, Frankel, writing in response to their experience, reported a conversion rate of 6% in 166 patients [4]. At issue was whether previous pelvic surgery was a contraindication to laparoscopic urethropexy. Cooper et al. [3] reported a conversion rate of 11.5% in 113 patients, further noting that most of these conversions occurred within the first quartile of patients. Our conversions also occurred earlywithin the first 40%and were cases in which pelvic adhesions prevented clear viewing. Though ours is not a comparative study, other investigators have found patients undergoing laparoscopic urethropexy to require less postoperative analgesia and a shorter hospital stay, and to enjoy a quicker return to normal activity than those undergoing open urethropexy [13]. Hospitalization, which dropped over time, was much briefer than the 510 days required for the open procedure [5, 19], and it would remain briefer today, even though stays today would no doubt be shorter than ones from 1979 and 1989. (One of our patients undergoing the open procedure stayed only four days.) Overall, the Burch procedure has proved a reliable method of urethropexy, posing little untoward risk to the patient and providing effective relief of symptoms that, according to our follow-up, is lasting. The laparoscopic approach extends to the patient the benefits of a shorter hospital stay, smaller wounds, and low risk of conversion. For the physician, the laparoscopic approach makes identification of anatomical landmarks and control of bleeding easier. The adaptation of employing mesh provides a broader surface of attachment, better support, and is believed to be responsible for the consistently good results reported by those using this method.
Acknowledgment: We acknowledge with grateful appreciation the contribution our nurses, Rebecca Churchill-Winn, R.N., CNOR, CRNFA, and Judith Gherdovich, LVN, make to successful surgical and clinical patient care.

References
1. Black NA, Downs SH (1996) The effectiveness of surgery for stress incontinence in women: a systematic review. Br J Urol 78: 497510 2. Burch JC (1968) Coopers ligament urethrovesical suspension for stress incontinence. Am J Obstet Gynecol 100: 764772 3. Cooper MJW, Cario G, Lam A, Carlton M (1996) A review of results

1114 in a series of 113 laparoscopic colposuspensions. Aust NZ J Obstet Gynaecol 36: 4448 Frankel G (1996) Re: Laparoscopic Burch bladder neck suspension: early experience [letter]. J Urol 155: 1447 Korda A, Ferry J, Hunter P (1989) Colposuspension for the treatment of female urinary incontinence. Aust NZ J Obstet Gynaecol 29: 146 149 Lam AM, Jenkins GJ, Hyslop RS (1995) Laparoscopic Burch colposuspension for stress incontinence: preliminary results. Med J Australia 162: 1821 Langebrekke A, Dahlstrom B, Eraker R, Urnes A (1995) The laparoscopic Burch procedure: a preliminary report. 74: 153155 Lagro-Janssen T, Smits A, Van Weel C (1992) Urinary incontinence in women and the effects on their lives. Scand J Prim Health Care 10: 211216 Marshall VF, Marchetti AA, Krantz KE (1949) THe correction of stress incontinence by simple vesico-urethral suspension. Surg Gynecol Obstet 88: 509518 McDougall EM, Klutke CG, Cornell T (1995) Comparison of transvaginal versus laparoscopic bladder neck suspension for stress urinary incontinence. Urology 45: 641646 Ou CS, Presthus J, Beadle E (1993) Laparoscopic bladder neck suspension using hernia mesh and surgical staples. J Laparoendosc Surg 3: 563566 12. Pereyra AJ (1959) A simplified surgical procedure for the correction of stress incontinence in women. West J Surg Obstet Gynecol 67: 223 226 13. Polascik TJ, Moore RG, Rosenberg MT, Kavoussi LR (1995) Comparison of laparoscopic and open retropubic urethropexy for treatment of stress urinary incontinence. Urology 45: 647652 14. Radomski SB, Herschorn S (1996) Laparoscopic Burch bladder neck suspension: early results. J Urol 155: 515518 15. Ramahi A (1995) Electrical stimulation of pelvic floor muscles for the treatment of urinary incontinence. American Urogynecologic Society Quarterly Report 13: 13 16. Raz S (1981) Modified bladder neck suspension for female stress incontinence. Urology 17: 82 17. Shanberg AM, Gweon P, Chamberlin D (1996) Laparoscopic Prolene mesh suspension of the bladder neck in patients with types I and II urinary stress incontinence [abstract]. J Urol (Suppl) 155: 490A 18. Stamey TA (1973) Endoscopic suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet 136: 547556 19. Stanton SL, Cardozo LD (1979) Results of the colposuspension operation for incontinence and prolapse. Br J Obstet Gynaecol 86: 693 697 20. von Theobald P, Barjot P, Liegeois P, Herlicoviez M, Levy G (1994) La colposuspension selon la technique de Burch par coelioscopie [abstract]. Presse Med 23: 13011303

4. 5. 6. 7. 8. 9. 10. 11.

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Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Splenic rupture from colonoscopy


We read with interest the paper by Espinal and associates [2] where two new cases of splenic injury during colonoscopy were added to a review of 15 patients previously reported in the English language literature. In addition to partial capsular avulsion as the main mechanism of injury, endoscopic techniques such as slide-by and hooking were cited as contributing factors. Speaking of splenic rupture during colonoscopy in the absence of bowel perforation, a further potentially dangerous maneuver is the exertion by the endoscopist of outer pressure on the left hypochondrium to straighten the splenic flexure. A 70-year-old woman underwent emergency splenectomy 6 h after an apparently easy surveillance colonoscopy without biopsy. Two fractures (4 cm long 2 cm deep, and 2 cm long 1 cm deep) were observed on the upper and lower pole of the convex surface of the spleen, respectively. Her recovery was uneventful and histology showed normal parenchyma [1]. A note of caution must be expressed about the risks of this maneuver, which should be enumerated among the possible mechanisms of spleen injury during colonoscopy. References
1. Arnaud JP, Bergamaschi R, Casa C, Boyer J (1993) Splenic rupture: unusual complication of colonoscopy. Colo-proctology 6: 356357 2. Espinal EA, Hoak T, Porter JA, Slezak FA (1997) Splenic rupture from colonoscopy. A report of two cases and review of the literature. Surg Endosc 11: 7173

R. Bergamaschi1 J. P. Arnaud2
1

National Center for Advanced Laparoscopic Surgery Trondheim University Hospital 7006 Trondheim, Norway 2 Department of Visceral Surgery Angers University Hospital 49033 Angers, France

Surg Endosc (1997) 11: 1134

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

New endoscopic methods for the detection of early colorectal cancer


What are we doing?
The advent of new endoscopic techniques has contributed to the increase in the detection of early colorectal cancers [1]. Using a similar approach to one already used for early gastric cancers, endoscopic mucosal resection or strip biopsy has been used to treat early colorectal cancer. Kudo and colleagues [1] from Japan have developed a number of endoscopic techniques and concepts that have allowed the detection of what they term early colorectal cancer and cancer de novo. One such method uses chromoscopic techniques with indigo-carmine, which has made possible the detection of early, diminutive, flat carcinomas that could be missed by conventional colonoscopy. Studying these early, flat, and depressed colorectal lesions, Kudo and his colleagues developed a classification system and proposed the use of magnification and stereomicroscopy to improve the detection of these lesions. The detailed method and technique were well described in their recent publication [2]. To date, there have been no prospective randomized trials comparing the endoscopic vs surgical resection of early colorectal cancers. However, it is easy to understand the benefits of avoiding surgical resection in any patient who can be cured by endoscopic means. As colorectal surgery is a specialty involving clinical, surgical, and endoscopic management of patients, it is our belief that those performing colonoscopy should be well informed of new endoscopic techniques to improve the detection of these early colorectal lesions. As the scope of technology widens, the aim of modern medicine is to focus on the prevention of any potential disease by earlier detection, with no added cost to the patient and reduced morbidity and mortality. All endoscopists must be made aware of any new technology which can contribute to the decrease in the great number of colorectal cancers, which still account for an enormous number of deaths worldwide.

References
1. Kudo S, et al (1995) Depressed type of colorectal cancer. Endoscopy 27: 54 2. Kudo S (ed) (1996) Early colorectal cancer. Detection of depressed types of colorectal carcinoma. Igaku-Shoin, New York

L. Oliveira1 S. D. Wexner2
1

Department of Colorectal Surgery, Mario Kroeff Hospital, Rio de Janeiro, Brasil Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, FL, USA

Surg Endosc (1997) 11: 10991101

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Utility of transesophageal echocardiography and pulmonary artery catheterization during laparoscopic assisted abdominal aortic aneurysm repair
A. J. DAngelo, R. G. Kline, M. H. M. Chen, V. J. Halpern, J. R. Cohen
Department of Surgery, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040, USA Received: 27 March 1997/Accepted: 5 July 1997

Abstract Background: Advanced laparoscopic procedures are more commonly performed in elderly patients with cardiac disease. There has been limited data on the use of pulmonary artery catheters (PAC) and transesophageal echocardiography (TEE) to monitor hemodynamic changes. Methods: We prospectively studied eight patients undergoing laparoscopic assisted abdominal aortic aneurysm repair. All patients had a PAC and all but one had an intraoperative TEE. Data included heart rate (HR), temperature (temp), pulmonary artery systolic (PAS) and diastolic (PAD) pressures, mean arterial pressure (MAP), central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), mixed venous oxygen saturation (MVO2), and oxygen extraction ratio (O2Ex) and was obtained prior to induction, during insufflation, after desufflation, during aortic cross-clamp, and at the end of the procedure. End diastolic area (EDA), a reflection of volume status, was measured on TEE. ANOVA was used for data analysis. Results: No changes were noted in HR, temp, PAS, PCWP, CI, MVO2, and O2Ex. PAD and CVP were greater during insufflation compared with baseline and aortic cross-clamp without associated changes in EDA. MAP was higher at baseline compared with all other times during the procedure. Conclusions: Insufflation increased PAD and CVP. However, volume status as suggested by EDA and PCWP did not change. These data question the reliability of hemodynamic measurements obtained from the PAC during pneumoperitoneum and suggest that TEE may be sufficient for evaluation of volume status along with the added benefit of timely detection of ventricular wall motion abnormalities. Key words: Laparoscopy Vascular Abdominal aortic aneurysm

Advances in laparoscopy have resulted in complex procedures being performed on more elderly patients with coexisting cardiac disease. The growing experience with the multiple laparoscopic approaches has introduced an expanded awareness of the physiologic implications of pneumoperitoneum. Although peritoneal insufflation is well tolerated in a young and healthy population, recent studies have shown significant alterations in cardiac performance during laparoscopy [3, 5, 7]. There has been limited and conflicting data comparing the available intraoperative means of monitoring, especially in patients with significant coexisting cardiopulmonary disease [5, 8]. For the laparoscopically assisted abdominal aortic aneurysm (L-AAA) repairs at our institution, we have recently developed a policy of monitoring these patients intraoperatively with both transesophageal echocardiography (TEE) and pulmonary artery catheterization (PAC). This study presents the preliminary findings in the first eight patients studied with this protocol.

Materials and methods


We are currently performing L-AAA repair under institutional review board approval. In November 1995 we adopted a policy of monitoring all patients with both TEE and PAC. In the subsequent 12 months eight patients underwent L-AAA. The patient selection criteria and operative technique have been previously described [1]. Selection criteria included patients undergoing elective infrarenal AAA repair with a tube graft. Patients were excluded if they had a contraindication to laparoscopy or refused to participate in the study. We have recently modified some of the operative techniques. Briefly, lower extremity pneumatic compression devices were applied and patients were placed in Trendelenburg position with the legs straight and abducted. The operating surgeon was positioned between the legs while the camera holder (first assistant) and the third assistant stood to the left of the patient. The bowel retractor (second assistant) stood on the right. A 1-cm supraumbilical midline cutdown was performed and under direct vision the peritoneal cavity was entered. A modified Glassman viscera retainer fish (Adept-Med) was then inserted directly into the peritoneal cavity. A Hasson cannula was introduced and a pneumoperitoneum was obtained to 15 mmHg. Under direct visualization five 10-mm trocars

Correspondence to: J. R. Cohen

1100 ANOVA analysis was used to determine statistical significance which was accepted for p < 0.05.

Results Eight patients underwent attempted L-AAA during the study period. Seven were completed successfully. One patient was converted to an open AAA repair secondary to adhesions which had formed from a previous hysterectomy. That patients data was still used for analysis since we were able to obtain hemodynamic parameters during pneumoperitoneum. One patient did not have a TEE during the procedure because of technical problems with the equipment. There were no mortalities in this series. Mean operative time was 3.77 1.0 h. The mean aneurysm size was 5.5 cm and the average age was 70.6 years. No changes were noted in HR, temp, PAS, PCWP, CI, MVO2, and O2Ex. There were also no changes in ESA, EDA, and %EFa (Table 1). However, both PAD and CVP were greater during insufflation than during baseline (Fig. 2). MAP was significantly greater at baseline compared to all other times during the procedure (Table 1).
Fig. 1. Placement of trocars for aortic dissection and location of the minilaparoromy. A, camera; B, dissector; C, dissector; D, bowel retractor; E, bowel retractor; F, suction. were inserted (Fig. 1). A 30 laparoscope was inserted into port A. The operating surgeon used ports B and C for dissection. Using ports D and E, the small bowel was retracted to the right and cephalad with the fish, thus exposing the aneurysm. Port F was used for suction or additional retraction as needed. The retroperitoneum at the level of the deuodenum was opened with a combination of electrocautery and blunt dissection. The site of aortic cross-clamping at the neck of the aneurysm just inferior to the left renal vein was identified and the anterior, medial, and lateral surfaces down to the vertebral bodies were laparoscopically dissected. Upon completion of the neck dissection, the right and left common iliac vessels were dissected. At the end of the laparoscopic dissection, the trocars were removed and an 811-cm incision was made at the level of the umbilicus. Through this incision, a Creech endoaneurysmorrhaphy was performed using standard open instruments [2]. After 5,000 U of heparin was given, the iliac vessels were occluded with straight Fogarty clamps introduced through incisions B and C and the neck was controlled with an aortic cross clamp introduced through incision E. The aneurysm was opened and the ostia of the inferior mesenteric and lumbar vessels were oversewn. A polytetrafluoroethylene (PTFE) tube graft was sewn into place. The aortic wall was closed over the graft and the retroperitoneum was closed over the aneurysm sac. All port sites were closed with 0 polyglactin sutures with an Endoclose (U.S. Surgical, Norwalk, CT) and the abdominal wound was closed with #1 polydioxanone. Postoperatively, all patients were brought to the ICU. All patients were admitted on the day of surgery. An arterial line and PAC were inserted prior to the induction of anesthesia. Data obtained included heart rate (HR), temperature (temp), pulmonary artery systolic (PAS) and diastolic (PAD) pressures, mean arterial pressure (MAP), central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), mixed venous oxygen saturation (MVO2), and oxygen extraction ratio (O2Ex). After laryngoscopy and tracheal intubation, a TEE transducer probe was inserted. Following initial examination of the heart and great vessels, the probe was positioned to monitor a transgastric, transverse-plane, short-axis view of the midpapillary level of the left ventricle. End diastolic area (EDA) and end systolic area (ESA) were measured off-line with manual planimetry. The percent ejection fraction area (%EFa) was determined from the formula %EFa [ EDA ESA)/EDA] * 100. These PAC and TEE data were subsequently obtained during insufflation, after desufflation but prior to infrarenal aortic cross-clamping, during aortic cross-clamping, and then at the end of the procedure when hemostasis had been achieved.

Discussion The use of laparoscopy has increased exponentially in recent years, especially for older and more debilitated patients. Understanding the hemodynamic effects of pneumoperitoneum has become of paramount importance. Intraoperative monitoring of such patients has traditionally included intraarterial and pulmonary artery catheters. However, the accuracy of the hemodynamic parameters obtained from these devices during pneumoperitoneum has been questioned in the recent literature [5]. The addition of TEE has expanded the wealth of available intraoperative information, allowing for timely management of any adverse events. The use of intraoperative TEE has increased in recent years. It has a very high sensitivity for myocardial ischemia which manifests as wall motion abnormalities. In addition, it has been shown to be a valuable adjunct for volume resuscitation in patients undergoing infrarenal AAA repair [4]. As we completed the first ten patients to undergo LAAA, it came to our attention that the pulmonary artery pressures always appeared to increase during insufflation and decrease with desufflation. If this were so, then the hemodynamic variables measured during pneumoperitoneum would not reflect the true volume and pressure status. This prompted the current study to add TEE and compare the data with those obtained from PAC. No changes were noted in HR, temp, PAS, PCWP, CI, MVO2, and O2Ex. Of importance is that temperature did not change during the procedure. Open AAA repair is associated with postoperative hypothermia, which can be associated with hemodynamic compromise and coagulopathy [6]. The conditions under which L-AAA is performed allow for minimal heat loss. The laparoscopic portion is done with a warming insufflator. The minilaparotomy used to sew in the graft does not result in significant heat loss. The normother-

1101 Table 1. Results of attempted L-AAA Baseline HR Temp PAS (mmHg) MAP (mmHg) PCWP (mmHg) CI (l/min/m2) MVO2 (pO2) O2Ex (%) ESA (cm2) EDA (cm2) %EFaa
a

Insufflation 64.0 8.9 35.5 0.4 34.6 5.6 92.5 9.0 19.9 3.9 2.6 0.6 44.0 5.0 21 5 7.0 6.9 12.4 7.9 49.8 24.5

Desufflation 64.4 9.2 35.0 0.6 31.8 4.4 84.6 9.8 17.0 4.5 2.9 0.5 48.8 7.9 17 5 7.4 6.1 14.4 7.7 52.3 19.4

Cross clamp 63.9 11.2 35.1 0.7 29.3 5.6 83.4 12.1 15.6 7.6 2.7 0.5 43.6 7.0 19 6 7.7 5.8 13.5 8.5 45.9 17.5

Closure 64.1 9.3 34.9 0.7 36.4 6.4 87.5 7.4 18.8 2.7 3.2 0.9 48.0 6.9 19 6 7.7 6.8 14.6 9.5 52.3 16.9

71.6 11.1 36.3 0.5 31.6 12.5 104.4 15.0* 14.9 10.4 2.8 0.5 43.6 5.1 19 6 6.7 5.9 13.0 7.9 53.1 20.0

* p < 0.05 compared to all other values of MAP %EF is the estimated ejection fraction area determined by the formula: [(EDA ESA)/EDA] *100

Fig. 2. *p < 0.05 compared to baseline in both groups.

mia results in a smoother postoperative course and fewer bleeding complications. The MAP was significantly greater at baseline than at any other time during the procedure. The baseline measurements were taken prior to induction of anesthesia. Patient anxiety can produce an artificially elevated blood pressure. Inhalational anesthetics produce peripheral vasodilation as well as cardiac depression. The combination of these two factors is the likely cause for the difference seen. We have since changed the timing of baseline measurements to just after the induction of anesthesia but prior to skin incision for a more accurate comparison to the measurements obtained during the procedure. The PAD and CVP increased significantly when compared to baseline. However, the PCWP and more importantly the EDA on TEE did not change. The PAC measures pressures in the pulmonary arterial tree. While volume status is the primary determinant of PAD, other factors influence the parameters measured. Positive pressure ventilation will artificially increase the measured pressures. Pneumoperitoneum causes the diaphragm to be elevated, which increases the pressure in the thoracic cavity, which in turn is reflected in the variables obtained with a PAC. TEE is a monitoring device which is independent of intrathoracic pressure. Ventricular function and filling can be monitored on a continuous basis. Any adverse effect that pneumoperitoneum will have on preload or ventricular contractility is quickly and readily seen.

Our data showed that there was no significant increase in preload during any part of the procedure as measured by the EDA on TEE. The EF%a was also unchanged. The EDA obtained during TEE has been shown to be a reliable method of determining intravascular volume status [9]. In addition, the ability to detect ventricular contractility and myocardial ischemia as manifested by wall motion abnormalities may prove TEE to be a superior method of monitoring these patients intraoperatively. Given the changes seen with PAD and CVP, which are probably inaccurate due to artificial elevation from pneumoperitoneum, TEE may be a better alternative to monitor cardiac status and should be considered in patients with coexisting cardiac disease undergoing laparoscopic procedures. References
1. Chen MHM, DAngelo AJ, Murphy EA, Cohen JR (1996) Laparoscopically assisted abdominal aortic aneurysm repair: a report of 10 cases. Surg Endosc 10: 11361139 2. Creech O (1966) Endoaneurysmorrhaphy and treatment of aortic aneurysms. Ann Surg 164: 935946 3. Dorsay DA, Greene FL, Baysinger CL (1995) Hemodynamic changes during laparoscopic cholecystectomy monitored with transesophageal echocardiography. Surg Endosc 9: 128134 4. Gillespie DL, Connelly GP, Arkoff HM, Dempsey AL (1994) Left ventricular dysfunction during infrarenal abdominal aortic aneurysm repair. Am J Surg 168(2): 144147 5. Harris SN, Ballantyne GH, Luther MS, Perrino AC Jr (1996) Alterations in cardiovascular performance during laparoscopic colectomy: a combined hemodynamic and echocardiographic analysis. Anesth Analg 83: 482487 6. Kahn H, Faust G, Richard R, Doscher W, Cohen JR (1994) Hypothermia and bleeding during abdominal aortic aneurysm repair. Ann Vasc Surg 8(1): 69 7. McLaughlin JG, Scheeres DE, Dean RJ, Bonnell BW (1995) The adverse hemodynamic effects of laparoscopic cholecystectomy. Surg Endosc 9: 121124 8. Portera CA, Compton RP, Walters DN, Browder IW (1995) Benefits of pulmonary artery catheters and transesophageal echocardiographic monitoring in laparoscopic cholecystectomy patients with cardiac disease. Am J Surg 169(2): 202206 9. Swenson JD, Harkin C, Pace NL, Astle K, Bailey P (1996) Transesophageal echocardiography: an objective tool in defining maximum ventricular response to intravenous fluid therapy. Anesth Analg 83: 11491153

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Intraoperative ultrasound assessment in management of complex pancreatic pseudocysts


M. R. Back,1 M. Sadra,1 M. E. Dempsey,2 R. Sinow,2 S. R. Klein1
1 2

Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA Department of Radiology, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA

Received: 19 June 1996/Accepted: 27 October 1996

Abstract. Preoperative imaging studies and operative inspection may provide insufficient information to appropriately manage certain complex pancreatic pseudocysts. Intraoperative ultrasound accurately identifies and localizes peripancreatic fluid collections, cyst wall thickness, parenchymal and ductal anatomy, and relationships to adjacent visceral and vascular structures. Adjunctive use of intraoperative ultrasonography altered the surgical management in the clinical case described herein and is advocated for assessment of problematic pancreatic pseudocysts. Key words: Intraoperative ultrasound Pancreatic pseudocyst Internal drainage Roux-en-Y cystojejunostomy

relative paucity of descriptions by American surgeons [5, 6]. Herein, we report a case requiring adjunctive use of intraoperative ultrasound to fully define and localize a complex pancreatic pseudocyst and facilitate appropriate internal drainage via a Roux-en-Y cystojejunostomy.

Case report
A 40-year-old Latino male presented to Harbor-UCLA Medical Center with his second episode of acute alcohol-induced pancreatitis. He required endotracheal intubation in the Emergency Department secondary to respiratory distress and early pulmonary artery catheter monitoring during resuscitation. He manifested six of Ransons criteria in addition to hyperamylasemia in the first 48 h of hospitalization. Initial abdominal CT scan revealed an extensive pancreatic inflammatory process without necrosis extending down the left paracolic gutter. The patient developed a polymicrobial pneumonia believed due to an early aspiration episode requiring multiple antibiotics and 3 weeks of mechanical ventilation. Repeat abdominal CT scan 3 weeks after admission showed evolving liquefaction of the peripancreatic inflammation. The patients 4 weeks of intensive care management were complicated by candidal and staphyloccocal epidermidis line infections. After several weeks of bowel rest, enteral feeds were resumed with subsequent intermittent hyperamylasemia requiring continued hyperalimentation. Despite overall improvement in the patients condition and resolution of sepsis, oral feeds after 56 weeks of hospitalization were associated with progressive gastroesophageal reflux symptoms and leftsided abdominal pain. A third abdominal-pelvic CT scan demonstrated an inflammatory fluid collection within the gastrosplenic ligament, which had a poorly defined wall (Fig. 1A). Contiguous, but more inferior, a 15 11 14 cm fluid collection with a 5-mm wall was identified. This collection extended from the tail of the pancreas involving the left anterior pararenal space and left paracolic gutter (Fig. 1B). Multiple septations were seen within the pseudocyst as it tracked into the pelvis within the retroperitoneum (Fig. 1C). Based on the patients symptomatology, pseudocyst enlargement, and apparent wall maturation, exploratory laparotomy with intent of internal drainage was performed 7 weeks after admission. At operation, obliteration of the lesser sac was confirmed and the descending colon and supporting mesentery were elevated and densely adherent to the left paracolic inflammation overlying the extensive retroperitoneal pseudocyst. As there was no palpable indentation into the posterior gastric wall even following anterior gastrotomy, intraoperative ultrasound was performed to evaluate the ill-defined retrogastric fluid col-

Refinements in transcutaneous ultrasonography, computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) now provide adequate evaluation of most pancreatic pseudocysts with regard to the necessity for and proposed route of operative drainage. Preoperative planning and intraoperative management may prove difficult with complex pseudocysts possessing multiple fluid collections, ill-defined retroperitoneal locations, unclear anatomic relationships to adjacent visceral and vascular structures, or characteristics suspicious for a cystic pancreatic neoplasm. Further operative delineation of complex pseudocysts has relied upon interpretation of contrast cystography performed after blind needle aspiration through peripancreatic retroperitoneal tissues and cyst walls. Intraoperative ultrasound imaging has been utilized mainly by Japanese [3] and German [4] authors for inflammatory and neoplastic pancreatic, hepatic, and biliary diseases with a
Correspondence to: M. R. Back, Section of Vascular Surgery, Department of Surgery, College of Medicine, University of Florida, PO Box 100286, Gainsville, FL 32610-0286, USA

1127

Fig. 1. Axial post contrast CT images through abdomen and pelvis obtained preoperatively. A Image within upper abdomen demonstrating inflammatory fluid collection within the gastrosplenic ligament. B Pseudocyst extending from region of tail of pancreas into left anterior pararenal space. C Multiple septations within pseudocyst as it is seen to extend into the pelvis within the retroperitoneum.

lection seen on the preoperative CT scan 5 days prior to surgery. The exam was performed using an ATL Ultramark4 (ATL, Bothell, WA) scanner which was placed in a sterile sleeve with methylcellulose gel coupling. The 7.5-MHz sector transducer was inserted into the stomach through the anterior gastrotomy. Imaging directly through the posterior gastric wall, no inflammatory fluid collection could be identified, suggesting interval resolution prior to surgery. Further imaging, however, of the left anterior pararenal space and left paracolic gutter did confirm and better define the multiseptated pseudocyst seen on the previous CT scan (Figs. 2 and 3). Without a significant retrogastric component identified by ultrasonography, an alternative site for internal pseudocyst drainage was selected along the dependent portion of the large left paracolic cystic collection. Because drainage at this site required penetration of the adherent overlying sigmoid mesentery, ultrasonography identified vessels to be avoided. Grain stain of aspirated cloudy pseudocyst fluid revealed no organisms although final cultures grew out staphylococcal epidermidis. Following further fluid decompression through the cyst wall and retrieval of free tissue debris from the large paracolic cavity, a Roux-en-Y cystojejunostomy was constructed with interrupted, single-layer, absorbable suture. Ultrasonography confirmed collapse of all cystic collections after completion of the cystoenterostomy. The patient recovered uneventfully from surgery and resumed oral feeds without adverse sequelae. A final abdominal CT scan 1.5 weeks after operation documented continued collapse of the pseudocyst. The patient remained asymptomatic at follow-up 6 months after surgery.

Discussion The imaging advantages afforded intraoperative ultrasound over preoperative transabdominal studies are directly related to the necessary distance traversed by the sound beam. Intraoperative transducers may be placed nearly directly on the tissue to be scanned, thus avoiding beam scattering by the abdominal wall and intervening adipose tissue and bowel gas. Intraoperative ultrasonography of the pancreas requires beam penetration depths of 46 cm typically, which allows use of higher-frequency transducers (57.5 MHz). The improved image resolution with limited beam attenuation at shallower penetration depths provides detailed anatomic inspection of retroperitoneal structures. By allowing direct ultrasonic insonation of the pancreas and surrounding tissues the technique obviates reliance on blind needle aspiration and attempted contrast cystography with the potential risk of inadvertent injury to important adjacent visceral and vascular structures. Radiographic interpretation of cystograms and comparison with pseudocyst findings on preoperative CT scans or ultrasonography may be problematic. Intraoperative ultrasound can be performed directly upon the pancreas after transection of the gastrocolic omentum. If inflammation obliterates the lesser sac, scanning is accomplished through adjacent structures such as gastrohe-

patic and gastrocolic ligaments, transverse mesocolon, duodenum, or posterior gastric wall after gastrotomy. Operative findings in the majority of cases confirm anatomic details provided by preoperative imaging studies and are usually sufficient to determine appropriate drainage for pancreatic pseudocysts. The utility of adjunctive intraoperative ultrasonography is measured in its ability to alter surgical management by providing unique anatomic information not delineated by preoperative imaging. Indications for intraoperative ultrasonography encompass certain subsets of complex pseudocysts seen on preoperative studies where anatomical detail is inadequately defined as well as cases where operative findings do not coincide with preoperative predictions and further assessment is required. Intraoperative ultrasound enables localization or exclusion of peripancreatic fluid collections poorly defined by preoperative studies or not clearly evident by inspection or palpation. The technique assists identification of pseudocyst anatomic relationships to adjacent visceral and vascular structures. Intraoperative ultrasound is particularly valuable in assessing pseudocyst adherence to posterior gastric or duodenal walls to facilitate safe construction of a cystoenteronostomy. Failure of pseudocyst adherence to the posterior gastric wall occurs in approximately one-quarter of cases, according to Bradley [2], despite preoperative imaging suggesting such as a relationship. Lack of pseudocyst adherence as demonstrated by intraoperative ultrasound in our case required an alternative route of drainage. After pseudocyst localization intraoperative ultrasound assists selection of optimal drainage sites by evaluating the adequacy of cyst wall thickness and the presence of vessels within the wall. Presence of color-flow Doppler and duplex scanning capabilities combined with B-mode ultrasound images may aid identification of smaller vascular structures. Assessment of pancreatic parenchyma by intraoperative ultrasound may also reveal dilatations of the pancreatic duct and luminal stone formation that could predict recurrent inflammatory episodes and necessitate later surgical intervention. Multiple septated fluid collections exist within peripancreatic pseudocysts in at least 10% of cases [1]. While the anatomic distribution of the cystic process may be well defined by preoperative ultrasonography or CT scans, communications between fluid collections are infrequently demonstrated. Intraoperative ultrasound may reveal such intracystic communications and septations but more importantly can evaluate residual fluid collections after operative decompression of adjacent pseudocysts and determine the

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Fig. 2. Intraoperative ultrasound of multiseptated retroperitoneal pseudocyst in left paracolic gutter with internal reflections from tissue debris. A Longitudinal section. B Transverse section. Fig. 3. A Transverse ultrasound section of pancreas imaged through posterior gastric wall with no intervening inflammatory fluid collection visible. B Duplex scanning confirms continuous flow signal through splenic vein posterior to the pancreatic body.

need for surgical fenestration of internal septations or separate routes of drainage. If there exists concern for a cystic pancreatic neoplasm when an inflammatory etiology is lacking, intraoperative ultrasound may provide additional anatomic detail to assist differentiation of solid and cystic components of the lesion and identify suspicious sites for safe biopsy. Needle or incisional biopsy and ultrasound findings assist appropriate choice of drainage or resectional therapy. The operator-dependent nature of ultrasonography requires multidisciplinary communication between surgeon and radiologist. Surgeons, however, should be encouraged to familiarize themselves with ultrasound techniques and image interpretation. This operative adjunct is relatively simple to perform and is not time consuming, but it does require availability of ultrasound probe and scanner, sterile plastic sleeves or gas sterilized probes, and gel or saline for acoustic coupling. Intraoperative ultrasonography is a use-

ful addition to the armamentarium of techniques available for management of problematic pancreatic pseudocysts. References
1. Bradley EL (1982) Complications of pancreatiitis. WB Saunders, Philadelphia, PA 2. Bradley EL (1995) Pancreatic pseudocyst. In: Cameron JL (ed) Current surgical therapy. 5th ed. Mosby, St. Louis, MO, pp 428431 3. Miyashita T, Suzuki T, Uchida K (1982) Intraoperative ultrasonography for pancreatic surgery. J Clin Surg 37: 6371 4. Printz H, Klotter H, Nies C, Hasse C, Neurath M, Sitter H, Rothmund M (1992) Intraoperative ultrasonography in surgery for chronic pancreatitis. Int J Pancreatol 12: 233237 5. Sigel B, Coelho JCV, Donahue PE, Nyhus LM, Spigos DG, Baker RJ, Machi J (1982) Ultrasonic assistance during surgery for pancreatic inflammatory disease. Arch Surg 117: 712716 6. Sigel B, Machi J, Kikuchi T, Anderson KW, Horrow M, Zaren HA (1987) The use of ultrasound during surgery for complications of pancreatitis. World J Surg 11: 659663

Surg Endosc (1997) 11: 11231125

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Endoscopic nasobiliary drainage for bile duct injury after laparoscopic cholecystectomy
K. Hanazaki,1 H. Sodeyama,1 Y. Sode,1 M. Miyazawa,1 S. Yokoyama,1 M. Wakabayashi,1 N. Kawamura,1 M. Ohtsuka,1 T. Miyazaki,1 Y. Matsuda2
1 2

Department of Surgery, Nagano Red Cross Hospital, 1512-1 Wakasato, Nagano 380, Japan Department of Internal Medicine, Nagano Red Cross Hospital, 1512-1 Wakasato, Nagano 380, Japan

Received: 29 May 1996/Accepted: 28 September 1996

Abstract Bile duct injuries are a potential complication of laparoscopic cholecystectomy (LC). A patient who underwent successful endoscopic nasobiliary drainage (ENBD) for a bile duct injury sustained during LC is presented. Of particular note, the patient also had Chilaiditis syndrome. A 59-year-old woman was admitted with symptomatic cholecystolithiasis and Chilaiditis syndrome. LC was performed. Postoperatively, the patient complained of abdominal discomfort. Laboratory examination revealed cholestasis. Bilious material began spilling from an intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage. ENBD was performed. Repeat ERCP 10 days later failed to show a bile leak or stenosis of the common bile duct. The patient improved rapidly and had no complaints after the procedure. ENBD is a useful endoscopic technique to prevent peritonitis from bile leakage after LC. Chilaiditis syndrome is not a contraindication for LC. Key words: Bile duct injury Laparoscopic cholecystectomy Endoscopic nasobiliary drainage Chilaiditis syndrome

stent placement [5, 14]. Herein is presented a report of successful endoscopic nasobiliary drainage (ENBD) for a bile duct injury after LC in a patient with Chilaiditis syndrome [3]. There have been no previous reports of the successful treatment of a leak from a bile duct injury using ENBD alone. This is also the first case report of LC for cholecystolithiasis in a patient with Chilaiditis syndrome. Case report
A 59-year-old woman was admitted to our hospital with symptomatic cholecystolithiasis. On physical examination, the patient had slight tenderness in the right upper quadrant of the abdomen. A chest radiograph revealed bowel gas under the right hemidiaphragm (Fig. 1). Abdominal computed tomography (CT) demonstrated interposition of the bowel between the liver and diaphragm (Fig. 2). Abdominal ultrasonography showed gallbladder stones with acoustic shadowing. Helical CT revealed bowel shadows anterior to the gallbladder and no anomalies of the cystic ductcommon bile duct (CBD) junction (Fig. 3). Preoperatively, the diagnosis was cholecystolithiasis with Chilaiditis syndrome. There were no abnormal laboratory findings on admission. LC was performed 8 days after admission. The bowel anterior to the liver and gallbladder characteristic of Chilaiditis syndrome was easy to remove using the laparoscopic instruments. Intraoperative cholangiography (IOC) was not performed because of severe wall thickening of the cystic ductCBD junction. The operation was uneventful, with no evidence of bile duct injury. The histologic findings were consistent with chronic cholecystitis. Postoperatively, the patient complained of abdominal discomfort. Approximately 12 h after LC, she had an excessive amount of bilious drainage from a Penrose drain that had been placed through one of the subcostal trocar sites. Laboratory examination revealed cholestasis 3 days after LC. The serum glutamic oxaloacetic transaminase concentration was 53 IU/l (normal; 8 to 32 IU/l), the serum glutamic pyruvic transaminase concentration was 53 IU/l (normal; 5 to 35 IU/l), and the total bilirubin concentration was 4.3 mg/dl (normal; 0.2 to 1.0 mg/dl). ERCP showed bile leakage from the cystic ductCBD junction (Fig. 4). ENBD was performed and continued for 10 days. ERCP 10 days later did not show any bile leakage from or stenosis of the CBD (Fig. 5). The patient improved rapidly and had no complaints after the procedure.

The incidence of bile duct injury after laparoscopic cholecystectomy (LC) has recently been reported [8, 11, 13] to range between 0.25 and 0.5%. This complication occurs more frequently LC than with open cholecystectomy (OC), in which the incidence is one in 1,000 [13]. Several recent reports [5, 14] have suggested that a significant percentage of patients with a bile duct injury after LC can be treated by interventional endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterectomy (EST) or

Discussion The superiority of LC over OC has been evidenced by the lower complication rate of this new gold-standard opera-

Correspondence to: K. Hanazaki

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Fig. 1. Chest radiograph showing bowel gas under the right hemidiaphragm. Fig. 2. Abdominal computed tomography revealing interposition of the bowel between the liver and the diaphragm.

tion. However, bile duct injury is always a potential complication of cholecystectomy [6]. The treatment of bile leakage after OC by EST or stent placement has been reported to yield acceptable results, especially when the patient is referred early [7]. Several recent reports have suggested that ERCP with sphincterotomy and stenting is an effective treatment for a bile leak after LC [5, 14]. In these studies, success rates as high as 83 to 100% were reported. These results show that the guidelines for decompression of the biliary tree after OC can also be applied after LC. In the case presented here, IOC was not performed because of the severe inflammatory changes in the wall of the cystic ductCBD junction. Therefore, bile leakage was not

Fig. 3. Helical computed tomography revealing bowel shadows anterior to the gallbladder without anomalies of the cystic ductcommon bile duct junction. Fig. 4. Postoperative endoscopic retrograde cholangiopancreatography showing bile leakage from the cystic ductcommon bile duct junction.

detected intraoperatively. Postoperatively, the patient had abdominal symptoms with bilious drainage and cholestasis. The leak was confirmed by ERCP and treated by ENBD. The clinical presentation of postoperative bile duct injury is characterized by cholestasis, jaundice, persistent bile leak-

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syndrome [6]. This condition, which is characterized by interposition of small or large bowel between the liver and diaphragm, is a rare anomaly [10, 12]. The incidence ranges from 0.025 to 0.28% in the general population, and increases with age, occurring in about one of 50,000 adults [10]. There have been no previous reports of LC in patients with cholecystitis and Chilaiditis syndrome. The laparoscopic removal of the bowel from between the liver and the diaphragm was not difficult. There appears to be no absolute contraindication to LC in patients with cholecystitis and Chilaiditis syndrome. It has recently been reported that this syndrome may be associated with abdominal complaints which could require an emergency or elective operation [1, 2, 10, 12]. Consequently, further study is necessary to define the indications for LC in these patients. In conclusion, ERCP is a powerful diagnostic and therapeutic tool in the management of laparoscopic biliary injuries. ENBD following ERCP may be the first choice for emergent decompression to prevent peritonitis from bile leakage.

References
1. Bishop CCR, Whitehead SM, Jackson BT (1987) Misdiagnosis of the Chilaiditis syndrome. Br Med J 295: 1655 2. Brenner M, Penschuck C (1981) Incarcerated Chilaiditi disease. A rare indication for surgery. Chirurg 52: 454456 3. Chilaiditi D (1910) Zur Frage der Hepatoptose und Ptose im allgemeinen im Anschluss an drei Falle von temporarer, partieller Leberverlagerung. Fortschr Gediete Rontgenstr Nuklearmed 16: 173208 4. Collins PG, Goey TF (1984) Iatrogenic biliary stricture: presentation and management. Br J Surg 71: 900902 5. Davids PHP, Ringers J, Rauws EAJ, de Wit LT, Huibregste K, van der Heyde MN, Tytgat GNJ (1993) Bile duct injury after laparoscopic cholecystectomy: the value of endoscopic retrograde cholangiopancreatography. Gut 34: 12501254 6. Jatzko GR, Lisborg PH, Pertl AM, Stettner HM (1995) Multivariate comparison of complications after laparoscopic cholecystectomy and open cholecystectomy. Ann Surg 221: 381386 7. Kozarek RA, Traverso LW (1991) Endoscopic stent placement for cystic duct leak after laparoscopic cholecystectomy. Gastrointest Endosc 37: 7173 8. Larson GM, Vitale GC, Casey J, Evons JS, Gilliam G, Heuser I, McGee G, Kao M, Scherm MJ, Voyles CR (1991) Multipractice analysis of laparoscopic cholecystectomy in 1983 patients. Am J Surg 163: 221226 9. Lin XZ, Chang KK, Shin JS, Lin CY, Lin PW, Yu CY, Chou TC (1993) Emergency endoscopic nasobiliary drainage for acute calculous suppurative cholangitis and its potential use in chemical dissolution. J Gastroenterol Hepatol 8: 3538 10. Risaliti A, De Anna D, Terrosu G, Uzzau A, Carcoforo P, Bresadola F (1993) Chilaiditis syndrome as a surgical and nonsurgical problem. Surg Gynecol Obstet 176: 5558 11. Scott TR, Zucker KA, Bailey RW (1992) Laparoscopic cholecystectomy: a review of 12397 patients. Surg Laparosc Endosc 2: 191197 12. Takagi Y, Abe T, Nakada T, Matsuura H, Yasuda K (1995) A case of Chilaiditis syndrome associated with strangulated volvulus of the sigmoid colon. Am J Gastroenterol 90: 1905 13. The Southern Surgeons Club (1991) A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 324: 10731078 14. Vitale GC, Stephens G, Wieman TJ, Larson GM (1993) Use of endoscopic retrograde cholangiopancreatography in the management of biliary complications after laparoscopic cholecystectomy. Surgery 114: 806814

Fig. 5. Endoscopic retrograde cholangiopancreatography 10 days after endoscopic nasobiliary drainage did not show bile leakage or stenosis of the common bile duct.

age through abdominal drains, and sepsis [4]. More important, however, is the occasional occurrence of an initial symptom-free period, which can be misleading. This symptom-free period can last for several days to weeks, after which the patient develops cholestasis [5]. In our case, a Penrose drain which had been placed through a subcostal trocar site revealed the bile leak at an early stage. Thus, it could be argued that a drain should be placed in the gallbladder bed in the uneventful LC. In the endoscopic treatment of bile leaks after LC, all previously reported patients have been treated by EST and/ or stent placement following ERCP. Lin et al. [9] have reported that ENBD is an effective treatment for acute, calculus, and suppurative cholangitis. Emergency decompression of the CBD is a life-saving procedure for patients with peritonitis due to a bile leak or suppurative cholangitis. We recommend ENBD prior to other forms of decompression. EST and stent placement should be employed only after clinical improvement is seen with ENBD. Interventional endoscopic techniques are technically more difficult and require more time than ENBD. Of particular interest, our patient also had Chilaiditis

Letters to the editor


Surg Endosc (1997) 11: 11311132

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

A simple and useful method for retracting the left liver lobe
The left lobe of the liver needs to be constantly retracted upward while laparoscopic dissection of the esophageal hiatus is being performed in a variety of operations, such as vagotomy, fundoplication, and esophageal myotomy. Many surgeons advocate using the suction and irrigation tube passed through the subxiphoid or the right subcostal trocar for retraction [2, 3, 5]. Different types of liver retractors, either expandable or malleable [1, 2, 4], have been designed. However, these various techniques carry disadvantages of one form or another, including the serious risk of inadvertent liver laceration, the need for an extra pair of hands (or a mechanical arm to maintain it in position), or the requirement of expensive instruments which have to be passed through 10-mm ports. A simple technique using the readily available grasping forceps is described. A self-locking atraumatic grasping forceps is inserted through an epigastric 5-mm trocar about 5 cm from the xiphisternum. With the left lobe of the liver elevated by another forceps inserted through a lateral working port, the grasping forceps is advanced into the hiatal area to grasp the uppermost muscle fibers of the crus of the diaphragm (or above). Liver retraction and exposure of the hiatus could be further enhanced by depressing the handle of the grasper. The locked grasper, once positioned optimally, may be held in place automatically by securing it to the surgical drapes using a towel clip (Fig. 1). This technique has added advantages, such as small port wound, elimination of the risk of instrumental injury to the liver, and unimpeded movement of the working instruments both inside and outside the abdominal cavity. It has been suggested in one surgical text that in the absence of a specially designed liver retractor, it might be necessary to divide the triangular ligament of the left liver lobe [1]. The described technique affords excellent exposure and obviates the need for detaching the diaphragmatic connections of the left lobe of the liver.

W.T. Ng H.C. Yeung


Department of Surgery Yan Chai Hospital Tsuen Wan Hong Kong Fig. 1. The left liver lobe is retracted upward by a grasping forceps. Note its tip holds onto the diaphragm while its handle is held in place by being secured to the surgical drapes using a towel clip.

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References
1. Bailey RW, Zucker KA (1993) Laparoscopic management of peptic ulcer disease. In: Zucker KA, Bailey RW, Reddick (eds) Surgical laparoscopy update. Quality Medical, St Louis, MO, pp 241 86 2. Dubois F (1992) Laparoscopic vagotomy. In: Cushieri A, Buess G, Perissat J (eds) Operative manual of endoscopic surgery. SpringerVerlag, Berlin, pp 254262

3. Katkhouda N, Mouiel J (1991) A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. Am J Surg :361364 4. Martin IG, Dexter SPL, Marton J, Gibson J, Asker J, Firullo A, McMahon MJ (1994) Fundus-first laparoscopic cholecystectomy. Surg Endosc 9: 203206 5. Reters J, DeMeester T (1994) Minimally invasive surgery of the foregut (minimally invasive approaches to ulcer therapy). Quality Medical, St. Louis, MO

Surg Endosc (1997) 11: 11061110

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Transcystic biliary decompression after direct laparoscopic exploration of the common bile duct
C. Hensman, G. Crosthwaite, A. Cuschieri
Department of Surgery and Surgical Skills Unit, Ninewells Hospital and Medical School, University of Dundee, Tayside DD1 9SY, Scotland Received: 5 March 1997/Accepted: 15 May 1997

Abstract Background: A purpose-designed transcystic common bile duct (CBD) decompression cannula is described for use as an alternative to T-tube insertion following laparoscopic direct CBD exploration. This permits safe primary closure of the choledochotomy. Methods: Following direct supraduodenal laparoscopic clearance of large common bile duct stones, the biliary decompression cannula is inserted percutaneously inside its peel-away sheet over a guide-wire into the CBD via the cystic duct. When in place, the cannula is secured to the cystic duct by two catgut extracorporeal Roeder knots and the choledochotomy is then closed. The terminal multiperforated S-shaped segment of the Cuschieri biliary decompression cannula prevents postoperative dislodgement. Results: Transcystic decompression of the extrahepatic biliary tract using the Cuschieri cannula has been used in 12 patients who underwent laparoscopic supraduodenal CBD exploration for large or occluding stones. There was no instance of postoperative dislodgement of the cannula and all patients had effective drainage of the common bile duct (average 300 ml bile per 24 h). The procedure was uncomplicated in all but one patient who developed self-limiting leakage from the CBD suture line in the early postoperative period. The median hospital stay after surgery was 4 days, with a range of 3 to 10 days. The cystic duct decompression cannula was capped and sealed under an occlusive dressing at the time of discharge. Removal of the cannula was carried out without any complications as a day case 1116 days after surgery. Conclusions: Transcystic biliary decompression is safe and effective. The experience with is use indicates that compared to T-tube drainage, transcystic decompression may accelerate recovery and reduce the hospital stay in patients following laparoscopic direct exploration of the CBD. Its insertion is less technically demanding than placing a Ttube through the choledochotomy. Transcystic decompres-

sion with complete primary closure of the CBD realizes the full benefits of the single-stage management of common bile duct calculi and permits confirmation of complete stone clearance after surgery. Key words: Common bile duct Transcystic biliary decompression Direct laparoscopic exploration

Correspondence to: A. Cuschieri

Several reported studies have revealed the feasibility, safety, and efficacy of open single-stage laparoscopic treatment of patients with gallstones who also harbor ductal calculi [1, 2, 6, 7, 10, 11, 14, 15]. The preliminary findings of a randomized, controlled clinical trial show documented advantages, i.e., reduced hospital stay and avoidance of unnecessary ERCP with single-stage surgical management compared to the two-staged approach [5]. Whenever possible, the transcystic technique is used to achieve ductal clearance laparoscopically, but when this fails, and in the presence of large occluding calculi, a laparoscopic supraduodenal exploration of common bile duct (CBD) is needed. Following clearance, most laparoscopic surgeons close the choledochotomy around a T-tube as in open surgery. This appears to delay recovery, and in the EAES study, the median hospital stay of patients treated by laparoscopic direct CBD exploration was 10 days as opposed to 5.5 days after transcystic clearance [5]. The use of a T-tube to drain the CBD following laporoscopic exploration is technically demanding and reduces the benefits of the minimal access approach. Primary closure of the CBD without decompression drainage is practiced by some laparoscopic surgeons but this is not considered orthodox practice for two reasons. In the first instance, manipulations inside the lower end of the CBD are followed by temporary obstruction due to periampullary edema in the first few days after surgery [9]. Secondly, primary closure without decompression precludes postoperative cholangiography to confirm complete ductal clearance.

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Fig. 2. The drainage cannula is threaded over the guide-wire into the peritoneal cavity.

a needle, a 0.035-mm floppy guide-wire, a dilator, and a peel-away sheath (Fig. 1A,B).

Technique of insertion and fixation of cannula


Following supraduodenal exploration of the CBD and confirmation of stone clearance by flexible choledochoscopy, the needle and guide-wire are inserted through the parietes in a suitable site in the right flank. The needle is then removed, leaving the guide-wire in situ. The dilator with the peelaway sheath is introduced into the peritoneal cavity over the guide-wire (Fig. 2). The dilator is then replaced by the biliary decompression cannula, which is threaded over the guide-wire and through the peel-away sheath. A length of guide-wire (circa 5.0 cm) is inserted into the cystic duct and thence into the CBD, and the biliary decompression cannula is then railroaded by means of a grasper over it until the perforated S-shaped terminal segment is beyond the cysticcommon duct junction (Fig. 3). The guidewire is then removed and a saline syringe is attached to the luer external fitting of the cannula. The position of the terminal segment of the decompression cannula inside the CBD is checked through the choledochotomy, and if correct, the cannula is fixed to the cystic duct and to the parietes. Fixation of the drainage cannula to the cystic duct is achieved by two Roeder 0-gauge chromic catgut knots (Fig. 4). The first is close to the cystic ductCBD junction [12]. The second Roeder knot is placed a few millimeters further laterally. Saline irrigation through the cannula is maintained during the locking of the Roeder knots by the push rod to prevent overtightening and occlusion of the cannula. A loose loop of cannula is left between the cystic duct fixation point and the parietes before the cannula is secured externally to the skin near the exit hole by two nonabsorbable sutures.

Fig. 1. a Cuschieri transcystic biliary decompression set. b Close-up of the S-shaped terminal segment.

For many years during open biliary surgery, we have practiced decompression of the CBD after direct exploration by inserting a cannula into the CBD followed by primary closure of the duct [3]. This practice has been extended to laparoscopic duct exploration. Initially, we used an infant enteric feeding Portex tube (Fr. 7) for this purpose [16] but encountered problems with dislodgement of the tube postoperatively in some patients. This led to the design of a laparoscopic cystic duct biliary decompression cannula which overcomes this problem and provides more efficient drainage. This paper reports our experience in patients undergoing laparoscopic direct CBD exploration with cystic duct decompression of the biliary tract and primary closure of the supraduodenal choledochotomy.

Closure of the choledochotomy


Saline irrigation is maintained during closure of the choledochotomy, which is carried out with interrupted or continuous 4/0 Polysorb (USSC, Norwalk, CT, USA) mounted on a ski needle using an intracorporeal microsurgical technique [4] (Fig. 5). On completion, the common duct is flushed through the transcystic cannula to check for leaks and a completion cholangiogram is performed. If this confirms ductal clearance, the cystic duct is transected between the lateral catgut ligature and the clipped neck of the gallbladder. A silicon subhepatic drain leads to the closed choledochotomy.

Patients and methods Laparoscopic CBD drainage catheter set


The Cuschieri biliary decompression set (Cook Surgical, Bloomington, U.S.A) consists of a specially designed 1-m-long silicon cannula with a luer lock connection at the proximal end and a distal perforated S-shaped segment with a terminal opening. The S bend prevents postoperative dislodgement of the functional segment of the cannula from the CBD while the multiple perforations ensure efficient bile drainage. The cannula is available in three sizesFr. 5, 7, 8. The biliary decompression cannula was designed for percutaneous insertion and its deployment system consists of

Patients
Twelve patients, two males and three females, aged 5472 years, all with large CBDs, underwent laparoscopic supraduodenal CBD during laparo-

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Fig. 3. Insertion of decompression cannula held in a grasper through the cystic duct over the guide-wire.

Fig. 5. Closure of the choledochotomy.

Fig. 4. Fixation of the biliary decompression cannula to the cystic duct by catgut Roeder knots.

scopic cholecystectomy with primary closure of the choledochotomy and decompression of the biliary tract by means of a cystic duct decompression cannula. All had clinical jaundice with raised alkaline phosphatase at the time of the intervention. Preoperative ultrasound examination confirmed a dilated intrabiliary tree. All patients were ASA category I or II and none had clinical evidence of ascending cholangitis. Two patients had undergone unsuccessful endoscopic stone extraction due to inability to cannulate the bile duct. Preoperative preparation was with intravenous cystalloid hydration, bladder catheterization, and forced diuresis with mannitol. An intramuscular injection of synthetic vitamin K analogue was administered 24 48 h after surgery. All patients received single-dose antibiotic prophylaxis during induction of general anesthesia. The tube cholangiogram was repeated postoperatively in all the patients.

surgeon was confident of the anatomy, the cystic artery was double clipped and divided. Cystic duct fluorocholangiography using a digitized C-arm was performed using a Fr. 4 or 5 ureteric catheter inside a cholangiogasper (Storz, Tuttlingen, Germany) in all patients. The biliary radiological pathology is outlined in Table 1. The technique of CBD stone clearance varied. Only the anterior aspect of the CBD was dissected and stay sutures were not used. The peritoneum and underlying fascial layer over the supraduodenal portion of the CBD was divided and a longitudinal choledochotomy was performed. The size of the opening in the CBD was always smaller by approximately 30% than the largest stone in the individual patient. Because of the high elastin content of the CBD, a choledochotomy can be stretched to allow delivery of a stone. The advantages of a small choledochotomy include less devacularization and reduced suturing time. The ductal calculi were cleared from the CBD by various means. Bimanual compression of the duct from below using two atraumatic graspers with massage of the stones into and then out of the choledochotomy was successful in five; Fogarty balloon dislodgement occurred in six; and one patient required a visually guided Dormia basket extraction using a 5-mm flexible choledochoscope (Storz, Tuttlingen, Germany). Following ductal stone extraction, all patients had completion choledochoscopy, which indicated total clearance in 11 patients. In one patient a missed stone was located near the common hepatic bifurcation and was removed at the same procedure.

Postoperative course The cystic duct cannula was left on free drainage for the first 48 h utilizing a closed drainage system. The average output of bile via the biliary decompression cannula was 300 ml per 24 h period. The subhepatic drain was removed on the 3rd day in all but one patient (day 8). A postoperative cholangiogram was performed in all patients via the cystic duct cannula 48 h post surgery (Fig. 6). The cystic decompression cannula was sealed and cov-

Results Operative outcome The triangle of Calot was dissected in a standard fashion utilizing the four-port Dundee technique [13]. When the

1109 Table 1. Common duct pathology at operation Sex, age (years) F, 54 F, 62a M, 49 F, 68 F, 54 M, 69 F, 46 F, 72a F, 61 F, 52 F, 51 F, 57
a

CBD diameter (mm) 15.0 12.0 10.0 20.0 15.0 18.0 11.0 18.0 12.0 15.0 11.0 16.0

No. of CBD stones 1 4 3 8 3 1 5 6 2 7 4 3

Stone size (mm) 20 815 612 10 511 15 10 615 810 10 8 12

Failed attempts at endoscopic stone extraction

ered with an occlusive dressing in 11 patients as the cholangiogram was normal and there was no bile drainage from the subhepatic drain. The subhepatic drain was removed the next day (3rd day). In one patient the cholangiogram demonstrated leakage from the CBD suture line. This was accompanied by bile drainage from the subhepatic drain. This complication was managed conservatively as ultrasound examination showed no internal collection and the patient was afebrile. The bile leakage dried up within 8 days. Another patient developed patchy atelectasis which progressed to a chest infection requiring antibiotic treatment. The median hospital stay was 4.0 days with a range of 3 to 10 days and 80% of patients were discharged within 5 days post surgery. The patients returned to hospital for removal of the cystic duct drainage cannula 1116 days after surgery and were kept for observation in hospital for a period of 34 h. None developed any symptoms of bile leakage into the peritoneal cavity during this observation period or thereafter.

Discussion This experience with the Cuschieri cystic duct biliary decompression cannula as an alternative to T-tube drainage has demonstrated that the technique is safe and easy to deploy. The provision of an effective decompression of the biliary tract is demonstrated by a low suture-line bile leakage rate of 8% despite the narrow caliber of the system (Fr. 58). The placement of a T-tube after direct supraduodenal CBD exploration is technically demanding and time consuming. It carries a significant morbidity due to dislodgement and infection, which may delay discharge from hospital. Furthermore, T-tube drainage of narrow ducts can contribute to late stricture formation [8]. Although there are no comparative data, T-tube insertion after laparoscopic direct CBD exploration appears to detract from the advantages of the minimal access approach. The median postoperative stay of 10.5 days observed in the EAES trial [5] is indicative of this detrimental effect. Previous debimetric studies have documented a temporary hold-up at the lower end of the CBD due to sludge, fibrin debris, or edema following manipulations to extract ductal calculi [9]. Thus temporary decompression is advis-

Fig. 6. Postoperative cholangiogram.

able in the prevention of postoperative bile leakage from the choledochotomy suture line. In addition, the postoperative tube cholangiogram provides the only reliable means for detecting retained stones. Thus, although some surgeons have practiced primary repair after laparoscopic direct CBD exploration, this cannot be regarded as standard orthodox surgical practice. Decompression of the biliary tract by the transcystic cannula facilitates closure of the choledochotomy, because, contrary to T-tube insertion, there is no long tube in front of the suture line. The closure of the bile duct either by continuous or interrupted suturing is thus quicker and more precise. The cystic duct biliary decompression cannula also serves as a safe access to the CBD for subsequent imaging or intervention. If retained ductal stones are documented in the postoperative period, flushing, fluoroscopic basket ex-

1110

traction by the Burhenne technique, or lithotripsy all constitute viable management options. If endoscopic stone extraction is preferred, the insertion of a guide-wire through the cannula into the bile duct and then the duodenum will serve as an excellent guide for the endoscopic sphincterotomy. The cannula was designed specifically with this in mind. The cystic duct decompression cannula can also be placed in the CBD as a means of safe access in patients when there is doubt about the clearance of stones after transcystic exploration of the CBD. References
1. Berci G, Morgenstein L (1994) Laparoscopic management of common bile duct stones. A multi-institutional SAGES study. Surg Endosc 8: 11681175 2. Carroll BJ, Fallas MJ, Phillips EH (1994) Laparoscopic transcystic choledochoscopy Surg Endosc 8: 310314 3. Cuschieri A (1984) Exploration of the common bile duct. In: Cuschieri A, Berci G (eds) Common bile duct exploration. Martinus Nijhoff, Boston, pp 8188. 4. Cuschieri A, Szabo Z (1995) In tissue approximation in endoscopic surgery. Isis Medical Media: Oxford, pp 113139 5. Cuschieri A, Croce E, Faggioni A, Jakimowicz J, Lacy A, Lezoche E, Morino M, Ribeiro VM, Toouli J, Visa J, Wayand W (1996) EAES ductal stone study: preliminary findings of multi-center prospective

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randomised trial comparing two staged vs single-stage management. Surg Endosc 10: 11301135 Ferzli GS, Massad A, Kiel T, Worth MH (1994) The utility of laparoscopic common bile duct exploration in the treatment of choledocholithiasis. Surg Endosc 8: 296298 Fielding GA, ORouke NA (1993) Laparoscopic common bile duct exploration. Aust NZ J Surg 63: 113115 Gillett DA, May RE, Kennedy R (1985) Complications of T-tube drainage of the common bile duct. Ann R Coll Surg Engl 67: 370371 Holdsworth RJ, Sadek SA, Ambikar S, Cuschieri A (1989) Dynamics of bile flow through the choledochal sphincter following exploration of the common bile duct. World J Surg 13: 300304 Lezoche E, Paganini AM (1995) Single-stage laparoscopic treatment of gallstones and common duct stones in 120 unselected consecutive patients. Surg Endosc 9: 10701075 Lezoche E, Paganini AM, Carlei F, Feliciotti F, Lomanto, Guerrieri M (1996) Laparoscopic treatment of gallbladder and common bile duct stones: a prospective study. World J Surg 20: 535542 Nathanson LK, Easter DW, Cuschieri A (1991) Ligation of the structures of the cystic pedicle during laparoscopic cholecystectomy. Am J Surg 161: 350354 Nathanson LK, Shimi S, Cuschieri A (1991) Laparoscopic cholecystectomy: the Dundee technique. Br J Surg 78: 155159 Petelin JB (1991) Laparoscopic approach to common duct pathology. Surg Laparoendosc 1: 3341 Phillips PH, Carroll BJ, Pearlstein A, Daykhowsky L (1993) Laparoscopic choledochoscopy and extraction of common bile duct stones. World J Surg 17: 2228 Shimi S, Banting S, Cuschieri A (1992) Transcystic drainage after laparoscopic exploration of the common bile duct. Min Invas Ther 1: 273276

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