Abstract:

Laparoscopic Nissen fundoplication is indicated in patients with documented gastroesophageal reflux disease who are refractory to maximal medical therapy or who develop a complication of reflux. The laparoscopic approach is a technically demanding procedure which requires extensive two handed tissue dissection and advanced suturing and knotting skills. Our experience with over 400 laparoscopic antireflux procedures over the last three years has highlighted several technical aspects which facilitate the procedure.

Authors:

J.K. Champion, M.D., F.A.C.S., Mercer University School of Medicine, Macon, GA; J. Barry McKernan, M.D., Ph.D., F.A.C.S., Emory University School of Medicine, Atlanta, GA

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Abstract:

Studies of the natural history of gastroesophageal reflux disease (GERD) indicate that most patients have limited disease responsive to simple lifestyle, dietary and medical therapy and do not go on to develop complications.1 Thus the majority of patients manifest a relatively benign form of the disease and do not need antireflux surgery. Indeed, expanding the indications for surgery to include patients with lesser forms of the disease will only serve to lessen the overall rate of successful surgery. However, approximately 25% of the patients with GERD will develop recurrent or progressive disease.1 It is this population of patients that is best suited to surgical therapy. Although at present there is no reliable method to identify which patients will develop progressive disease, there are several factors that predispose patients to complications and failure of medical therapy. These factors should be identified early in the course of therapy and taken into account when considering therapeutic alternatives.

Authors:

Jeffery H. Peters, M.D., F.A.C.S., University of Southern California School of Medicine, USC University Hospital, Los Angeles, CA; Tom R. DeMeester, M.D., F.A.C.S., University of Southern California School of Medicine, Los Angeles, CA

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Abstract:

Endoscopic mucosal resection (EMR) is now in clinical use for the management of small, early-stage gastric carcinomas, although some patients are treated via laparotomy when the lesions are not suitable for EMR due to their size, depth, and location. In many cases of invasive mucosal carcinoma with submucosal involvement, the regional lymph nodes along with the distal portion of the stomach must also be resected. In order to remove the whole resected specimen, a mini-laparotomy of appropriate length (5 cm) is performed which can be located at the optical port site after removing the laparoscope. By applying an abdominal wall elevator through the mini-laparotomy, direct vision is possible which facilitates resection of the regional lymph nodes and intestinal anastomosis. We describe our technique for laparoscopically assisted distal gastrectomy and present our early clinical results.

Authors:

Seigo Kitano, M.D., F.I.C.S., Seigo Maeo, M.D., Norio Shiraishi, M.D., Katsuhiro Shimoda, M.D., Masaki Miyahara, M.D., Toshio Bandoh, M.D., Kouichiro Shuto, M.D., Takanori Yoshida, M.D., Oita Medical University, Oita, Japan

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Abstract:

Laparoscopic treatment of intractable duodenal ulcers is intended for the treatment of patients who do not heal after a trial of intensive regimen of medication such as H2 blockers and/or therapy aimed at eradication of Helicobacter pylori. Patients in a category who are Helicobacter-negative can be offered a laparoscopic treatment of their ulcer by vagotomy. Patients who have early relapses on stopping medical treatment are also candidates for vagotomy. Complications of the disease, such as bleeding or pyloric outlet obstruction, represent valid indications in 1995 for performing surgery in patients with duodenal ulcer disease.

Authors:

Namir Katkhouda, M.D., Ph.D., Ross Bremner, M.D., Adrian Ortega, M.D., Ron Verham, M.D., Patrick Nguyen, M.D., University of Southern California School of Medicine, Los Angeles, CA; Jean Mouiel, M.D., University of Nice School of Medicine, Nice, France

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Abstract:

Although surgery within the lumen of the gut has been performed for many years, this has traditionally involved a laparotomy and enterotomy. With the advances in flexible endoscopy, surgeons and gastroenterologists have been able to perform therapeutic procedures with instruments introduced through the working channel of flexible endoscopes. These procedures, however, have been mainly limited to technically minor ones, such as injection and cautery of bleeding ulcers and resection of polyps and small mucosal lesion. More recently, laparoscopic surgeons have been able to isolate the lumen of hollow organs as a separate working space and develop instrumentation and technique specifically for “intraluminal surgery.” This paper provides an overview of our approach, which includes development of a new device for intraluminal access and operations within the lumen of the stomach. Future application of this approach will also be discussed.

Authors:

Toshiyuki Mori, M.D., Ph.D., Yutaka Atomi, M.D., Ph.D., Kyorin University, Tokyo, Japan; Sunil Bhoyrul, M.D., Lawrence W. Way, M.D., University of California, San Francisco, CA

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Abstract:

With the introduction of laparoscopic cholecystectomy, the general surgery community was thrust into the new world of minimally invasive surgery. The marked benefits of laparoscopic cholecystectomy became apparent in a short period of time, driving the procedure to widespread use long before any clinical trials or studies were available to document the procedure’s safety. Although there was early concern over the potential dangers of the laparoscopic approach, it took several years before there was enough data to verify this concern.2 The most significant of these potential dangers is injury to the bile ducts.

Authors:

Douglas O. Olsen, M.D., F.A.C.S., Vanderbilt University, Nashville, TN

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Abstract:

The surgical management of biliary stone disease has long since included ERCP and endoscopic sphincterotomy (ES) for the diagnosis and treatment of common bile duct (CBD) stones. Indications to ERCP/ES have progressively expanded from the diagnosis and treatment of retained CBD stones after cholecystectomy to the management of severe cholangitis and acute pancreatitis in high-risk patients to the treatment of all patients with gallstones and CBD stones as part of an integrated endosurgical sequential approach.

Authors:

Alessandro M. Pagnini, M.D., Ph.D., F.A.C.S., Emanuele Lezoche, M.D., F.A.C.S., University of Ancona, Ancona, Italy

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Abstract:

Laparoscopic surgical treatment of calculous disease of the gallbladder and biliary system has largely replaced the open surgical approach because of its well known and obvious advantages. This approach has also changed the traditional management of biliary duct stones. Formally, biliary calculous disease was managed by the surgeon in one setting usually by laparotomy with choledochotomy and common duct exploration. Referral for postoperative Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Sphincterotomy (ES) was most commonly done for retained stones.

Authors:

Paul. S. Strange, M.D., Frank Troiano, M.D., St. Francis Hospital, Beech Grove, IN

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Abstract:

Several indications for laparoscopic splenectomy are represented mainly by hematological disorders such as Idiopatic Thrombopenic Purpura (ITP) or hereditary spherocytosis. Patients with ITP who do not respond, have relapses of the disease under steroid treatment, or need a gradually increased dose of steroids, represent an excellent indication for laparoscopic splenectomy, as the spleen is not enlarged. Patients are usually small, thin, young females, making the procedure much easier. The size of the spleen in hereditary spherocytosis varies, sometimes making the procedure a little more difficult, especially as those patients have pigmented gallbladder stones necessitating a concurrent laparoscopic cholecystectomy. Other indications are represented by staging of Hodgkin’s disease, lymphoma of the spleen, and splenic infarcts without abscesses. Some patients with autoimmune hemolytic anemia might benefit from laparoscopic splenectomy, but hypersplenism due to cirrhosis is strongly contraindicated, as the risk of intraoperative hemorrhage is great and not usually managed easily laparoscopically.

Authors:

Namir Katkhouda, M.D., Adrian Ortega, M.D., Ross Bremner, M.D., Patrick Nguyen, M.D., Ron Verham, M.D., University of Southern California School of Medicine, Los Angeles, CA; Jean Mouiel, M.D., University of Nice School of Medicine, Nice, France

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Abstract:

The optimal management of inguinal hernia continues to excite lively debate and, despite centuries of research, the ideal approach has yet to be established. The traditional repairs of McVay, Bassini, and Shouldice involve suturing together tissues that are not normally in apposition. This approximation of tissues under tension may account for the reported recurrence rates of up to 21% for primary repairs and also explain the lengthy, painful recovery periods. Laparoscopic hernia repair has demonstrated good short-term results but is technically demanding, requires violation of the peritoneal cavity, and has unknown long-term results. Between October 1993 and April 1995, we performed 103 hernia repairs using a novel approach, the mini-hernia repair (endoscopically guided surface repair of inguinal hernia). This technique allows the benefits of an open surgical approach such as hands-on manipulation, three-dimensional vision, a familiar anatomical approach, and the use of conventional instruments, to be combined with the advantages derived from the use of laparoscopic instrumentation, namely, minimized tissue trauma and improved cosmesis.

Authors:

Charles C. Nduka, B.A., M.B., B.S., Ara Darzi, M.D., F.R.C.S., F.R.C.S.(I.), St. Mary's Hospital, London, England

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Abstract:

In 1870 Reincke reported two cases in which tumors developed at the sites of paracentesis for ascites due to peritoneal carcinomatosis. History was repeated in a different context when two cases of port-site metastasis were reported in 1993. In the last 200 years tumor spread has remained a difficult phenomenon to understand, and minimal access surgery has added several more questions. Port-site metastasis has gained the attention of not only minimally invasive surgeons but also the media. Performing an operation for a benign condition is quite different from performing one for a malignant condition. Patients suffering from the latter may not value the advantages of minimal access surgery if there is an increased risk of tumor spread and less of a likelihood for cure.

Authors:

Raghu S. Savalgi, M.B.B.S., L.R.C.P., M.R.C.S., F.R.C.S., Ph.D., Yale University School of Medicine, New Haven, CT; David R. Rosin, M.S., F.R.C.S., F.R.C.S.(Edin), St. Mary's Hospital, London, England

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Abstract:

Over the last few years, laparoscopic surgery has gained widespread acceptance in surgical practice. The indications range has expanded extraordinarily in that time. Some of the practiced procedures are already considered the gold standard, while others are still on the way there. The fascinating technique and results notwithstanding, a number of risks, mistakes, and complications are possible in both the initial and the advanced states. We present our experience from 2118 laparoscopic operations performed between February 1991 to March 1995, focusing on the intraoperative complications.

Authors:

Dr. med. Henning Niebuhr, Dr. med. Ulf Nahrstedt, Dr. med. Silke Hollman, Prof. Dr. med. Klaus Rückert, Ochsenzoll General Hospital, Hamburg, Germany

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Abstract:

The existing occlusive clamps used in endoscopic surgery are modifications of the basic conventional “scissors clamp” design used in open surgery. All the current clamps, including “atraumatic” ones, cause tissue damage. The scissors design is intrinsically unsound because the occlusive force is not uniformly distributed and is much greater near the pivot end than between the free ends of the jaws. The ideal occlusive clamp should be based on “parallel occluding jaws,” as this mechanism ensures a uniform occlusion without undue crushing of the bowel. During the last two years we have been involved in the development of a detachable endoscopic atraumatic clamp. This has necessitated considerable biological experimentation, mechanical engineering design work, and clinical evaluation. The biological studies were concerned with the measurement of the forces (compression and friction) necessary to occlude and seal bowel at different intraluminal pressures without causing surface damage. The mechanical engineering and design development of the parallel jaw action clamp incorporating pseudoelastic nickel-titanium (Ni-Ti) spring was based on the data obtained from the biological studies. Once the basic design was established, miniaturization allowed the production and clinical evaluation of an endoscopic detachable parallel action clamp (DPAC) that can be introduced through 5.0-mm ports.

Authors:

Alfred Cuschieri, M.D., Ch.M., F.R.C.S., Tim Frank, B.A., M.Sc., Ph.D., Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland

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Abstract:

During the past decade, several investigators reported effective application of intraoperative ultrasonography as a new diagnostic modality in surgery. Intraoperative ultrasonography has been successfully applied in the screening of the biliary tract and in the examination of the liver, pancreas, urinary tract, and endocrine organs. It has also been used successfully during vascular surgery. With the advent of minimal access surgery, the application of expensive preoperative diagnostic tests has visibly increased, particularly the use of ERCP procedures in patients with cholecystolithiasis. The loss of tactile feedback during laparoscopic surgery for gastrointestinal malignancy stimulated the increasing use of CT and MRI imaging. With our prior experience in intraoperative ultrasonography and in the advent of minimal access surgery, we were stimulated to introduce laparoscopic intraoperative ultrasonography (LIOU) in 1990 for screening the biliary tract for laparoscopic cholecystectomy. More reports on the use of laparoscopic intraoperative ultrasonography followed.

Authors:

J.F. Smulders, M.D., J.J. Jakimowicz, M.D., Ph.D., F.R.C.S.(Ed), Catharina Hospital, Eindhoven, The Netherlands

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Abstract:

Complications in laparoscopic surgery are becoming more prevalent as more open procedures convert to laparoscopic procedures. This article will address incisional herniation of trocar wound sites and management of inferior epigastric bleeds. A trocar wound closure device allows for avoidance and rapid management of both the aforementioned complications. Clinical reports on the incidence of incisional hernias vary widely. However, the largest current clinical study (Kadar, Reich, Liu, et al.) regarding the incidence at .17% (3.1% in 12-mm extraumbilical sites and 0.23% at 10-mm extraumbilical sites). Some physicians feel that closure of the fascia is adequate for reducing the chance of incisional hernias. However, of the hernias reported in the Kadar study, one-half of the hernias occurred despite attempts to close the fascia. Another clinical paper reports two of the three hernias presented occurred in the preperitoneal space. In the past, if the fascia could easily be closed using conventional techniques, it was done; but if obesity made it difficult, only the skin was closed. This can no longer be considered good surgical technique.

Authors:

Gary F. Willen, M.D., F.A.C.O.G., University of California at Davis, Barton Memorial Hospital, South Lake Tahoe, CA

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