Single-access laparoscopic primary and incisional prosthetic hernia repair: first 50 patients.

BACKGROUND: Primary and incisional hernia can be repaired by multitrocar laparoscopy. Single-access laparoscopy (SAL) recently gained interest to decrease the invasiveness and to reduce the abdominal trauma, besides improved cosmetic results. The authors report first 50 patients who consulted for primary and incisional hernia and treated by SAL prosthetic repair. PATIENTS AND METHODS: Between December 2009 and March 2012, 50 patients (24 females, 26 males) were submitted to SAL for primary (23) and incisional hernia (27). Mean age was 49.1 ± 15.1 years (17-75), and mean body mass index 29.7 ± 5.7 kg/m(2) (19-44.1). A total of 26 primary and 30 incisional hernias were treated. The technique consisted in implied the use of an 11-mm trocar for 10-mm scope, curved reusable instruments without trocars, and dualface prosthesis fixed by tacks without transfascial closures. RESULTS: No conversion to open surgery nor addition of one or more trocars was necessary. Mean perioperative hernia sizes were 7.0 ± 5.0 cm (2-24) in length and 6.0 ± 3.4 cm (1-16) in width, for a surface of 55.0 ± 64.6 cm(2) (2.8-268.2). Mean prosthesis size used was 188.1 ± 113.4 cm(2) (56.2-505.6). Mean laparoscopic time was 60.2 ± 32.8 min (26-153), and mean final scar length was 21.2 ± 4.5 mm (13-35). Mean hospital stay was 2.2 ± 1.2 days (1-8). Perioperative complications were registered in 4 patients and minor early complications in 13 patients of each group. After a mean follow-up of 16.1 ± 8.8 months (4-34), 2 late complications were observed in one patient of each group. CONCLUSION: Primary and incisional hernia can safely be treated by SAL prosthetic repair, but a learning curve is unavoidable. Thanks to this approach, in patients with primary hernia, only a small scar is finally visible, and in patients who proved to be prone to develop incisional hernia, the number of fascial incisions can be reduced.

A laparoscopic approach to left diaphragmatic rupture after blunt trauma.

Diaphragmatic rupture after blunt trauma is rare, but indicates a powerful external impact. Associated lesions are often life-threatening and require a rapid diagnosis and management. We report a case of a 24-year-old man, admitted to the emergency department after a serious car accident. He complained of a left sided thoraco-abdominal pain with breathing difficulties. Chest X-ray showed a left diaphragmatic elevation. Computed tomography demonstrated a left haemo-pneumothorax, herniation of the stomach in the chest and a haemoperitonium. Laparoscopically, herniated organs were re-integrated in the abdominal cavity ; the diaphragmatic tear was repaired by both direct suture and synthetic prosthesis. Closure of a small bowel perforation found during the laparoscopic exploration was also performed. We consider this therapeutic modality to be an excellent approach in the management of acute left side diaphragmatic rupture in haemodynamically stable patients. Firstly, it permits an inspection of the thoracic cavity through the diaphragmatic tear and secondly, an easy repair of damaged structures in the abdominal cavity.

Totally laparoscopic transhiatal esophago-gastrectomy without thoracic or cervical access. The least invasive surgery for adenocarcinoma of the cardia?

BACKGROUND: The recent progress of minimally invasive surgery has allowed esophagectomy to be performed by both combined laparoscopic/thoracoscopic and totally laparoscopic transhiatal approaches. All these techniques imply a thoracic and/or cervical access for the creation of the esophagogastric anastomosis. METHODS: Five surgical ports are introduced in the abdomen. The stomach is mobilized, divided, and tubulized, preserving the right arteries. The lymphadenectomy of the celiac trunk and the hepatic pedicle is achieved. The dissection and resection of distal esophagus and a two-fields mediastinal lymphadenectomy are performed by means of harmonic scalpel. The realization of the intrathoracic esophago-gastrostomy is accomplished by means of a circular stapler. RESULTS: Three patients underwent the procedure. Mean operating time and blood loss were 347 min and 360 cc. There were no intraoperative or postoperative complications. Mean postoperative stay was 9 days. CONCLUSION: In selected cases, it is possible to perform a distal esophagectomy entirely by laparoscopy, without the need for any thoracic or cervical access.

Laparoscopic right posterior hepatic bisegmentectomy (Segments VII-VIII).

The role of laparoscopy in liver surgery is still a subject of debate. Up to now, isolated hepatic lesions requiring a segmental (or bisegmental) resection have been considered to be an indication for laparoscopic surgery only when they are located in the left lobe or in the right lower lobe, whereas an open approach by laparotomy or thoracotomy is still preferred for lesions of the upper right lobe. Here we report a case of a right posterior hepatic bisegmentectomy (segments VII-VIII) performed for a hepatic hemangioma that was carried out entirely laparoscopically. In our opinion, there is not an a priori contraindication to the laparoscopic resection of any hepatic benign lesion, wherever it is located in the liver parenchyma. Nevertheless, major hepatic resections still have to be performed by expert surgeons in specialized centers.

Evaluation of telesurgical (robotic) NISSEN fundoplication.

BACKGROUND: The laparoscopic surgical approach has proven its benefit for the patient. There are however several shortcomings, which have triggered considerable research for improvement. One improvement may be the introduction of telesurgery by the interposition of a computer interface between surgeon and patient. MATERIAL AND METHODS: A prospective randomized study was conducted in an advanced laparoscopic procedure, Nissen fundoplication. The control group underwent the conventional laparoscopic approach, while the investigational group underwent the telesurgical approach. RESULTS: Feasibility was 100%. The procedure was more time consuming in the Telesurgical group, at all stages of the operation. Mortality was nil and morbidity was comparable in both groups. CONCLUSION: The telesurgical approach is feasible in advanced laparoscopic procedures like Nissen fundoplication. At the present time there is however no obvious added benefit from this new technique.

Feasibility of robotic laparoscopic surgery: 146 cases.

Theoretically, in laparoscopic surgery, a computer interface in command of a mechanical system (robot) allows the surgeon: (1) to recover a number a number of lost degrees of freedom, thanks to intraabdominal articulations; (2) to obtain better visual control of instrument manipulation, thanks to three-dimensional vision; (3) to modulate the amplitude of surgical motions by downscaling and stabilization; (4) to work at a distance from the patient. These advances improve the quality of surgical tasks in a perfect ergonomic position. The purpose of this paper is to evaluate the feasibility of utilizing a robot in laparoscopic surgery. The first robot-assisted procedure in humans was performed in March 1997 by our team. One hundred forty-six patients underwent robot-assisted laparoscopic surgery. Between March 1997 and February 2001 a nonconsecutive series was performed of 39 antireflux procedures, 48 cholecystectomies, 28 tubal reanastomoses, 10 gastroplasties for obesity, 3 inguinal hernias, 3 intrarectal procedures, 2 hysterectomies, 2 cardiac procedures, 2 prostactectomies, 2 arteriovenous fistulas, 1 lumbar sympathectomy, 1 appendectomy, 1 laryngeal exploration, 1 varicocele ligation, 1 endometriosis cure, 1 neosalpingostomy, 1 deferent canal. The robot (Da Vinci system, Intuitive Surgical, Mountain View, CA), consists of a console and a cart with three articulated robot arms. The surgeon sits in front of the console, manipulating joysticklike handles while observing the operative field through binoculars that provide a three-dimensional picture. This computer is capable of modulating these data by eliminating physiologic tremor and by downscaling the amplitude of motions by a factor 5 or 3 to one. This study has demonstrated the feasibility of several laparoscopic robotic procedures. There is no morbidity related to the system. Operating time and the hospital stay were within acceptable limits. The system seems most beneficial in intra-abdominal microsurgery or for manipulations in a very small space. Optimized ergonomics and increased mobility of the instrument tips are beneficial in many steps of abdominal surgical procedures.

Laparoscopic highly selective vagotomy.

BACKGROUND/AIMS: Ten percent of our population has had a gastroduodenal ulcer. Medical treatment heals ulcers in 90% of the cases but they recur in 50-70% of the patients. We present a proposal of surgical treatment for patients with recurrent ulcer after a long-term medical treatment or whose ulcer reappears as soon as medical treatment ceases. METHODOLOGY: Thirty-three patients underwent highly selective vagotomy (HSV) laparoscopic between April 1992 and March 1993. There were 26 male patients and 7 female patients aged 19-65 years (mean age: 38 years). Twenty-six patients were operated electively and preliminary medical treatment lasted an average 5.4 years (range: 0.5-26 years) and the disease had lasted 1-30 years (mean duration: 8.4 years). For patients with a chronic peptic ulcer disease, pre-operative assessment involved a recent gastroscopy, isotopic gastric study and a selection test. RESULTS: HSV proved feasible in 100% of the cases in spite of a history of previous surgery and peritonitis in patients with a perforated ulcer. There were neither conversions nor intra-operative complications. There was no mortality or morbidity. The mean hospital stay was 2 days (range: 1-5 days) for selectively operated patients and 7 days (range: 6-10 days) for patients operated for a perforated ulcer. Twenty-two patients were rated Visick I and II and 3 with Visick III after re-examining. The BAO had decreased by 61% to 89% and the MAO by 60% to 80%. CONCLUSIONS: The treatment of choice for gastro-duodenal ulcer is highly selective vagotomy. The laparoscopic approach shortens the hospital stay and improves patient's comfort.

[Nissen fundoplication done by remotely controlled robotic technique]. / Fundoplicature selon Nissen réalisée à distance du patient par robotique.

Two Nissen fundoplications were performed by a minimally invasive robotic technique on May 19, 1998. The Mona robot, was placed to the left of the patient. It held and activated surgical tools. The surgeon was placed some 3 meters from the patient and was seated at a console. He was not scrubbed. He commanded the 3 robotic arms by manipulating two handles, while observing a 3 dimensional picture recreated by a binocular system. Manipulations of the handles were translated into digital information by a computer. This information was modified by the computer with downscaling of the amplitude of motion by a factor 1 to 3 or 1 to 5. Physiologic tremor was eliminated. The computer delivered an impulse in command of the articulated robot arms via a 5 m long cable. Operating time was 4.30 hours, and 1.30 hours respectively. Blood loss was estimated at 20 and 30 ml. The two patients were discharged on the first postoperative day after a gastrograffin swallow had been performed in order to check the position of the wrap and its patency. Our experience with the Mona device may suggest that surgical robotics could have an increasingly important role in tomorrow's operating theatres. It should allow for more precise procedures, performed under better circumstances.

Laparoscopic rectopexy according to Wells.

BACKGROUND: The laparoscopic approach usually reduces the morbidity of procedures performed by laparotomy. The aim of this study was to demonstrate the usefulness of laparoscopic rectopexy. METHODS: A total of 37 patients were included in this prospective study. The indication was true rectal prolapse in all patients. Incontinence was seen in 33% of the patients. A slightly modified Wells procedure was performed laparoscopically. Postoperatively, the patients were evaluated for resolution of the prolapse and incontinence. They were also questioned about their satisfaction with the procedure. RESULTS: Laparoscopy was successful in all but one case. Follow-up is available in 32 of 37 patients. Prolapse was cured in all patients, and the incontinence resolved in 11 of 12. In addition, 38% of the patients experienced significant constipation preoperatively versus 5% postoperatively.

Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases.

BACKGROUND: Kuzmak's gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study was to analyze the complications of this approach. METHODS: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique. A minimally invasive procedure using five trocars was performed. RESULTS: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications: There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis. One fatality on the 45th day in a patient with a Prader-Willi syndrome. CONCLUSION: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure.

Laparoscopic Nissen fundoplication: laparoscopic dissection technique and results.

BACKGROUND/AIMS: Proton Pump inhibitors and laparoscopic techniques have had a dramatic impact on the therapy of gastroesophageal reflux disease. These techniques have introduced new complications associated with the treatment. This study compares the results of a laparoscopic Nissen fundoplication with life-long proton pump inhibitor treatment. MATERIALS AND METHODS: Between May 1991 and February 1996, 274 patients were treated by laparoscopic Nissen fundoplication (LNF). Two hundred twenty-four patients were included in this prospective study. Thirteen patients presented stage V esophagitis (Barrett); 4 had esophagitis stage IV; 16 had stage III, 181 had stage II and 11 had stage I. Five trocars were needed for the operation. After mobilization of the greater curvature, a fundic wrap of 5 cm was created and fixed on the esophagus. RESULTS: Median operating time was 60 min (39-300). There were 5 perioperative complications (a gastric perforation, three pleural perforations, and one liver laceration treated by coagulation). Three conversions to laparotomy were necessary. There were 4 early complications: two pulmonary infections and two re-operations; one case of wrap necrosis with peritonitis, and one case of small bowel perforation. Gastroscopy was performed in 133 cases. The esophagus was normal in 121 cases, an esophagitis stage I was present in 9, esophagitis stage II in 2, esophagitis stage III in one. Median lower esophageal sphincter pressure was 10 mmHg (2.9-30) preoperatively and 19 mmHg (9-40) post-operatively. Median reflux time was 10% (0-65) preoperatively and 1% (0-38) post-operatively. One hundred fifty-four patients were interviewed with a median follow up of 30 months (1-58). One hundred thirty patients were Visick I, 11 Visick II, 8 Visick III and 5 patients needed re-operation; three reoperations because of dysphagia, 1 because of epigastric pain and 1 for heartburn recurrence. CONCLUSIONS: From these results, we conclude that LNF seems to be an attractive alternative to long term medical treatment.

Totally preperitoneal laparoscopic approach combined with minianterior dissection in the treatment of indirect inguinal hernias.

Totally preperitoneal laparoscopic hernioplasty has become more popular recently and will possibly replace the transabdominal preperitoneal procedure. This procedure, however, is more demanding for the surgeon, especially in large indirect hernias. We describe an alternative technique derived from Darzi's anterior endoscopic approach. To date, it has been used in 15 patients, all with good success. The technique results in a shorter operative time and is easier for the surgeon.

How to avoid esophageal perforation while performing laparoscopic dissection of the hiatus.

An increasing number of surgeons attempt advanced laparoscopic procedures, involving the distal esophagus such as Nissen fundoplication, truncal vagotomy, and Heller's myotomy. At this time, there are probably as many techniques as there are surgeons. The authors have tried to provide a "ready to use" universal strategy that details how to approach the distal esophagus while avoiding the dangerous pitfalls of surgery in that area.

Isolated perforations of the small bowel from blunt abdominal trauma. Report of two cases and review of the literature.

On account of two recent cases, the authors present a review of the literature of small bowel isolated perforations following blunt abdominal trauma. Although these injuries are quite rare and their management relatively easy, the diagnostic approach is often hazardous and may lengthen the operative delay, worsening morbidity and mortality. The authors review the various physiopathological mechanisms (deceleration, crushing and rupture phenomena) responsible for small bowel perforations, as well as the predisposing factors. They emphasize the multiple pitfalls of the diagnosis and try, through a study of the literature, to establish systematic guidelines. The advantages and deficiencies of the various complementary investigations are discussed. The authors conclude with indications of conservative treatments and segmentary enterectomies respectively.

[Nissen's fundoplication by celiovideoscopy]. / Fundoplicature selon Nissen par coelio-vidéoscopie.

One hundred and sixty two laparoscopic fundoplications were performed between may 1991 and december 1993 by the first author. No perioperative death was observed. There were 4 intraoperative complications (3%): 1 gastric perforation, 2 pleural perforations and 1 liver laceration. There were 3 conversions to laparotomy: 2 for left liver hypertrophy and 1 for needle holder defect. The duration of the operation ranged from 40 minutes to 5 hours (median 120 minutes). The median postoperative stay was 2 days. Five postoperative complications occurred: 2 cases of pneumonia and 3 cases necessitating second-look laparatomy (1 necrosis of the valve, 1 small bowel perforation and 1 obstruction due to migration of the entire stomach into the chest). The follow-up ranges from 4 to 897 days (median 10 months). Long-term complications were: one recurrence of heartburn reoperated laparoscopically and two cases of long-term postoperative dysphagia.

Operative strategy in laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy was attempted in 17 consecutive patients and was successful in 15. STUDY DESIGN: This study is a critical analysis of the operative strategy in laparoscopic splenectomy, as reviewed in the operative video recordings and operative summaries of the 17 patients discussed. RESULTS: The 15 successful laparoscopic splenectomies were all conducted according to the same strategy: mobilization of both the upper and lower pole of the spleen, division of the short gastric vessels close to the spleen, and dissection and separate ligation of the main trunk of the splenic artery and vein. An erroneous strategy that diverged from the one proposed, resulted in parenchymatous hemorrhage and open conversion in two patients. CONCLUSIONS: In this series of 15 successful laparoscopic splenectomies, the most important technical aspect seems to be full mobilization of the spleen before the hilum is dissected.

Laparoscopic proximal gastric vagotomy.

Proximal gastric vagotomy, considered the conventional surgical treatment of choice for peptic ulcer disease, is now performed laparoscopically. Thirty-three patients underwent the procedure. Seven patients were treated on an emergency basis for perforated peptic ulcer. Morbidity and mortality of the procedure were zero. Patient acceptance (Visick staging) was good to excellent in 22 of 25 patients in follow-up. Laparoscopic proximal gastric vagotomy appears to be a good treatment in chronic peptic ulcer disease even when complicated by an acute perforation.