Abstract:

The objective of this study was to achieve an ideal cosmetic result and minimize the access trauma to the abdominal wall. The authors developed a technique to perform cholecystectomies and appendectomies with only one incision in the umbilicus. With the upcoming idea of Natural Orifice Transluminal Endoscopic Surgery (NOTES) in the recent years and noticing the lack of feasibility of the technique for the daily routine beside the technique described by these authors, another development was raising the interest of the surgeons around the world. The single-access surgery through the umbilicus is a technique, that can be used in the daily routine and provides the best cosmetic results. Furthermore, injury of the abdominal wall is located at only one site, which might reduce the rate of trocar hernias and abdominal wall infections. Two 5.5-mm trocars were inserted through an incision at the upper edge of the umbilicus. After perforation of the abdominal wall with a stylet of a 5.5-mm trocar, a curved grasper was inserted, without the use of a trocar, into the abdominal cavity. The use of curved instruments facilitates better triangulation and instrument handling. No gas leakage was observed due to the nonexistence of a trocar. Dissection of the Calot´s triangle or appendix vessels can be done with standard instruments. The curved grasper allows retraction of the gallbladder or appendix. The specimen can be removed through the umbilical incision. The authors present a single-access surgery technique for cholecystectomies and appendectomies using curved instruments. The single-access surgery with parallel inserted curved instruments is feasible. No additional complications are related to this modification other than those known to be associated with laparoscopic surgery. This method offers an almost scarless surgery. Whether other advantages such as less trocar hernias, wound infections, and/or a faster recovery can be achieved, it has not yet to be proven.

Authors:

Hamid Mofid, M.D., Surgical Consultant, Department of Surgery, Carsten Zornig, M.D., Head, Department of Surgery, Israelitisches Krankenhaus in Hamburg, Hamburg, Germany

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Abstract:

We present a series of patients who have undergone laparo-endoscopic single-site (LESS) surgery for placement of an adjustable gastric band. From December 2007 to December 2008, LESS surgery to place an adjustable gastric band was performed via a trans-umbilical incision. Essentially, multiple ports were placed through a single incision in the umbilicus to allow for liver retraction, visualization, and working instruments. All critical steps using a standard pars flaccida technique were not altered. Twenty-two patients were carefully selected, including 20 women and 2 men ranging in age from 18 to 67 with a mean age of 42. All patients were discharged home within the 23-hour admission window, and there were no perioperative complications noted. In addition, there were no wound-related complications. LESS surgery for adjustable gastric band shows this technique to be both feasible and safe in selected patients to date. Although technical limitations exist that will undoubtedly be improved upon, further studies must be performed to compare LESS surgery for placement of an adjustable gastric band to traditional laparoscopic techniques.

Authors:

Julio Teixeira M.D., F.A.C.S., Chief Division of Minimally Invasive Surgery, St. Luke's-Roosevelt Hospital Center, Associate Clinical Professor of Surgery, Columbia University College of Physicians & Surgeons, New York, NY

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Abstract:

Electrocautery remains the main energy form used for dissection in laparoscopic cholecystectomy. However, due to its many risks the search continues for safer and more efficient forms of energy. This chapter assesses the outcomes of dissection using ultrasonic energy as compared to monopolar electrocautery during laparoscopic cholecystectomy. Studies included are trials of prospectively randomized adult patients with symptomatic gallstone disease subject either ultrasonic or monopolar electrocautery dissection during laparoscopic cholecystectomy. Seven trials were included in this review, with a total patient number of 695 randomized to two dissection methods: 340 in the electrocautery group and 355 in the ultrasonic group. Ultrasonic dissection is shown to be superior to monopolar electrocautery in laparoscopic cholecystectomy. Disadvantages include a difficult maneuvering technique and overall cost. Appropriate training programs may be implemented to overcome the first disadvantage, and it might be argued that given the combined cost of factors associated with standard clip and cautery technique, cost issues may be outweighed by the benefits of ultrasonic dissection. However, this necessitates further cost-benefit analysis.

Authors:

Walid Sasi, M.B.Ch.B., M.Sc., M.R.C.S.I., Department of Surgery, Our Lady of Lourdes Hospital, Drogheda, Ireland

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Abstract:

In the last three years, investigations on natural orifice translumenal endoscopic surgery (NOTES) have entered the clinical experimental phase. Our aim was to carry out the first cross-sectional survey in Hungary about inpatients and specialists' opinions concerning natural orifice surgery. A total of 155 patients were included in the survey from two hospitals. Patients received a handout that described in detail the various available techniques for cholecystectomy, plus a 10-item questionnaire. Respondents had to choose between undergoing laparoscopic or NOTES cholecystectomy, indicate the acceptable complication rate, provide the reason for their choice, and select an ideal orifice. Specialists attending lectures on NOTES at two Hungarian congresses were given a separate questionnaire that was designed for physicians. We measured their perceptions about the need for the new method and about the unsolved issues it involved, their choice of entry site, their assessment of which type of specialist should perform NOTES operations, and the timeframe that would be needed for the widespread adoption of the method. With complication rates presumed to be equivalent to each other, 53% of inpatients chose a NOTES operation over laparoscopy for a cholecystectomy. Those who had prior endoscopy (p = 0.03), prior open surgery (p = 0.03), or who were male (p = 0.05) were more likely to opt for NOTES. The preferred approach was transvaginal (49%) for women, and transcolonic (66%) for men. Regarding the specialists, 37% would like to use NOTES in their practice and 49% would undergo a NOTES procedure; of these, 43% were unable to indicate the ideal orifice, 22% preferred the vagina, 20% the stomach, and 15% a hybrid approach. A total of 54% of surgeons believed that there is a real demand for NOTES, whereas 37% felt that it is an unnecessary innovation.

Authors:

Dániel Gerö, Medical Student, Semmelweis University, Budapest, Hungary, Péter Lukovich, M.D., Assistant Professor, First Department of Surgery, Semmelweis University, Budapest, Hungary, Bors Hulesch, M.Sc., Sociologist, The MSI Consultancy Ltd., Farnham, UK, Tímea Pálházy, M.D., Resident, First Department of Surgery, Semmelweis University, Budapest, Hungary, Bence Kecskédi, M.D., Resident, First Department of Surgery, Semmelweis University, Budapest, Hungary, Péter Kupcsulik, M.D., Ph.D., F.A.C.S., Chair Professor, First Department of Surgery, Semmelweis University, Budapest, Hungary

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Abstract:

This study was conducted to compare the outcome of total thyroidectomy using novel hemostatic devices and the classic suture ligation technique. This prospective study included 195 consecutive patients undergoing total thyroidectomy between January 2008 and March 2009. The main outcomes measured were operating time, intraoperative blood loss, postoperative drainage, pain score, and postoperative complications. The three groups tested were similar in terms of demographics, thyroid gland weight and pathology, and postoperative complications. According to two-way analysis of variance, the use of hemostatic devices in thyroid volume less than 40 ml was not found to significantly correlate with operating time, intraoperative blood loss or postoperative drainage. Novel hemostatic devices are safe, useful, and time-saving adjuncts for thyroid surgery, and the use of these devices seems to have great advantages in the patients with large goiters.

Authors:

Yesim Erbil, M.D., Professor, Department of General Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey, Aziz Sümer, M.D., Department of General Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey, Serkan Sari, M.D., Department of General Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey, Candas Ercetin, M.D., Department of Public Health, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey, Halim Issever, M.D., Associate Professor, Department of Public Health, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey, Selçuk Özarmagan, M.D., Professor, , Department of General Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey

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Abstract:

The efficacy of prophylactic hemostasis with endoclips after polypectomy is still controversial. The purpose of this study is to evaluate the efficacy of prophylactic hemostasis for postpolypectomy mucosal defects using endoclips under infrared imaging. Patients with colon polyps who were endoscopically treated at Jikei University Aoto Hospital were retrospectively reviewed to compare the delayed bleeding rate in the infrared imaging group with the conventional imaging group. A total of 813 colon polyps in 416 patients were endoscopically treated from July 2003 to November 2006. The overall postpolypectomy bleeding rate in the infrared imaging group was shown to be significantly lower than in the conventional imaging group. The postpolypectomy bleeding from the endoclip site was also significantly lower in the infrared imaging group than in the conventional imaging group. Even the number of applied endoclips was significantly fewer in the infrared group than the conventional group. The prophylactic use of endoclips with infrared imaging effectively reduced the postpolypectomy bleeding with fewer clip applications.

Authors:

Naoto Tamai, M.D., Department of Endoscopy, Koji Matsuda, M.D., Ph.D., Department of Endoscopy, Kazuki Sumiyama, M.D., Ph.D., Department of Endoscopy, Kimio Isshi, M.D., Ph.D., Department of Endoscopy, Norichika Narimiya, M.D., Ph.D., Department of Endoscopy, Hisao Tajiri, M.D., Ph.D., Department of Endoscopy, Department of Gastroenterology and Hepatology, Jikei University School of Medicine, Tokyo, Japan

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