Metastatic Adenocarcinoma of Unknown Origin Presenting as Small Bowel Perforation: A Case Report and Literature Review.

Metastatic malignant tumors that originate from occult primaries are defined as "cancers of unknown origin." We herein present the case of a 59-year-old man who presented with small bowel perforation secondary to metastatic adenocarcinoma of an unknown primary site. Imaging exhibited two pulmonary nodules, neither of which was dominant, along with mediastinal and retroperitoneal lymphadenopathy. Immunohistochemical profiling of the small bowel biopsy specimens revealed the tumor was most likely pulmonary in origin.

Laparoscopic-assisted primary repair of a complicated ventral incisional hernia.

Postoperative wound dehiscence is a difficult problem for the general surgeon. Often, patients are too sick, or the wound environment is too hostile, to undergo primary repair. When an eventual repair is performed, a variety of methods are available, but most are associated with unacceptably high morbidity rates, specifically high incidences of recurrences and poor cosmetic outcome. We present here a case of postoperative wound dehiscence following a colostomy takedown repaired in a previously undescribed way--a laparoscopically assisted ventral incisional hernia repair. The method of repair is described, and the current literature regarding alternatives is reviewed.

Application of Doppler technology as an aid in identifying vascular structures during laparoscopy.

BACKGROUND: Intraoperative ultrasound has been used extensively during open surgery to assess bowel viability, to identify vascular structures, and to assess for congenital abnormalities. The extension of this technology in laparoscopic procedures has been hampered by the size of the equipment and the significant learning curve that accompanies its use. METHODS: Using a readily available Parks Inst. Co. Doppler Probe (8.1 MHz) and a 15-inch section of thick-walled, 9.5-mm OD Stainless Steel tubing, a Laparoscopic Doppler Probe was constructed. The parts were separately gas-sterilized, and a small segment of Penrose drain was used to create an airtight seal. The probe was passed through a 10-mm port, allowing assessment of vascular structures. RESULTS: Two Laparoscopic Doppler Probes were available for evaluation during a 1-month period at our hospital. Surgeons were then surveyed at the end of the 1-month period as to the utility of the devices. CONCLUSIONS: The Laparoscopic Doppler probe was used to identify the cystic artery during gallbladder dissection, to assess mesenteric blood vessels during laparoscopic colectomy, and to identify femoral vessels during laparoscopic preperitoneal hernia repair. It was found to be quick to construct, easy to use, and provided useful information to the operating surgeon.

Laparoscopic bilateral adrenalectomy with the use of a single midline hand-assist port.

Indications for bilateral adrenalectomy are rarely present in patients with Cushing's syndrome. The laparoscopic approach to adrenalectomy provides a postoperative course that compares favorably with that of open adrenalectomy, and the hand-assisted technique may provide an additional alternative to the open approach in performing bilateral adrenalectomy.

Major thoracic surgery in octogenarians: the video-assisted thoracic surgery (VATS) approach.

BACKGROUND: Thoracic surgery is associated with a high morbidity and mortality rate in the elderly patient population. Appropriate management of thoracic diseases is often avoided because of the inherent risks associated with the access thoracotomy. The purpose of this study was to evaluate the perioperative outcomes of octogenarians who underwent video-assisted thoracic surgery (VATS) for a variety of thoracic conditions. METHODS: A retrospective chart review was done on all patients who were between 80 and 90 years of age and underwent elective VATS between January 1995 and August 2001. RESULTS: A total of 162 consecutive VATS procedures were performed in 157 patients. Comorbid conditions consistent with their advanced age included chronic obstructive pulmonary disease, hypertension, coronary artery disease, and diabetes. The procedures included 96 lung resections (53 lobectomies, 42 wedge/segment resections), 46 pleurectomies, 8 decortications, 8 mediastinal biopsies, 3 pericardial windows, and 1 drainage of hemothorax. The pathology included 76 primary lung cancers, 35 metastatic diseases, 37 benign conditions, 9 nesotheliomas, and 3 carcinoid tumors. The average operative time and length of hospital stay after surgery were 51 min and 2.6 days, respectively. There were 3 (1.9%) mortalities, 2 from cardiac complications and 1 from pneumonia. Two (1.2%) patients required reexploration for bleeding. Four (2.5%) cases were converted to open thoracotomy thirteen (8.0%) cases had an air leak, of which 11 were managed on an outpatient basis with a Heimlich valve. They were discharged from the hospital an average of 3.3 days postoperatively. CONCLUSION: With VATS, surgical therapy can be offered to octogenarians with a low morbidity and mortality rate, as well as a short hospital stay.

Laparoscopic incisional and ventral hernia repair (LIVH): an evolving outpatient technique.

BACKGROUND AND OBJECTIVES: The contemporary results of open incisional and ventral hernia repair are unsatisfactory because of high recurrence rates and morbidity levels. Laparoscopic repair of ventral and incisional hernias (LIVH) can be accomplished in a simple, reproducible manner while dramatically lowering recurrence rates and morbidity. METHODS: One hundred consecutive patents underwent laparoscopic repair of their ventral and incisional hernias over a 27-month period. Composix mesh and Composix E/X mesh (Davol Inc., Cranston, RI) were utilized for the repairs. Transfixion sutures were not used. RESULTS: All repairs were completed laparoscopically. No conversions to open techniques were necessary. No postoperative infections have been observed. One recurrent hernia was identified and subsequently repaired with the same technique. CONCLUSIONS: LIVH can be accomplished with a dramatic reduction in recurrence rates and morbidity. The technique for this repair is still in a state of evolution. The construction and handling characteristics of this particular type of mesh have allowed us to eliminate transfixion sutures and to simplify the repair technique while maintaining a very low recurrence rate.

Laparoscopic pyloroplasty in idiopathic hypertrophic pyloric stenosis in an adult.

BACKGROUND AND OBJECTIVES: Idiopathic hypertrophic pyloric stenosis, in adults, is a rare disease. Partial gastrectomy, gastroenterostomy, pyloromyotomy, pyloroplasty and endoscopic dilatation have all been recommended with variable results. A 54-year-old white female is presented with the onset of symptoms of idiopathic hypertrophic pyloric stenosis one year prior to operation. Two endoscopic pyloric sphincter balloon dilatations provided only temporary relief. METHOD: A laparoscopic pyloroplasty was performed. RESULT: The patient tolerated a solid diet on postoperative day three. The patient was symptom-free at a 13 month follow-up. CONCLUSIONS: Idiopathic hypertrophic pyloric stenosis in adults can be treated with laparoscopic pyloroplasty, offering a minimally invasive alternative to open repair.

Sesqui- and diterpenes from the liverwort Gackstroemia decipiens.

Six rosanes, 5 beta,11 beta-dihydroxy-ros-15-ene, 5 beta,12 beta-dihydroxy-ros-15-ene, 11 beta-hydroxy-7-oxo-rosa-5,15-diene, 1 alpha,5 beta,11 beta-trihydroxy-7-oxo-ros-15-ene, 5 beta,20-epoxy-20-hydroxy-ros-15-ene and 5 beta,20-epoxy-20-methoxy-ros-15-ene along with the enantiomer of the already reported 11 beta-hydroxy-rosa-5,15-diene and the known 5 beta-hydroxy-ros-15-ene have been isolated from the liverwort Gackstroemia decipiens. Furthermore, the sesquiterpenes 3-acetoxy-7,11-dihydroxy-farnesa-1,5,9-triene and 1 beta,10 beta-epoxy-nardosin-7,11-diene were identified. Their structures were elucidated by NMR spectroscopy.

Visual clues in minimally invasive surgery: use of 2-D versus 6-D enhanced performance of complex minimally invasive complex skills.

UNLABELLED: In the recent past, we used two 2-D videoscopes to obtain both a close detailed view and simultaneously a panoramic view to improve the efficient and safe access for instruments into the microscopic working field by way of the benefits of the panoramic view. This bi-modal visual set of clues allows for (1) insertion of suture, (2) cutting of suture with scissors (3) retraction of tissue, and (4) removal of suture and needle. During these experiences, we observed the benefits accrued to the surgeon by allowing the focusing of his/her attention on the work (technical skills) without diffusing energy to other activities. Similarly, when training surgeons to perform micro-anastomoses, and while working to improve performance in micro-anastomoses, we hypothesize that two or more videoscopic views of the 3-dimensional working space would provided added visual information to the surgeon during the microscopic work. To examine this hypothesis, we have used a non-animate model, in the performance of complex skills in videoscopic surgery. METHODS: Inanimate videoscopic models for suturing and tying (24 studies) were used in this study. The technical skill studied was the sophisticated skill of suturing. The speed and accuracy of Free-Handed suturing and tying was determined in these studies. They were compared using a single 2-D system verses three videoscopic views reconstructing a 3-D effect. RESULTS: In each of these models, the delineation of multiple views allowed greater detailed 3-dimensional information for the surgeon. The sutures were placed faster, more accurately, and with fewer false motions. These data allow us to conclude the use of multiple high-resolution 2-D views will improve accuracy and efficiency in the performance of delicate and precise skills in videoscopic surgery.

11-oxygenated cytotoxic 8,9-secokauranes from a New Zealand liverwort, Lepidolaena taylorii.

Four new cytotoxic 8,9-secokauranes have been identified from the liverwort Lepidolaena taylorii. The 11-oxygenation found in three of these has not been encountered in the 8,9-secokauranes known from higher plants. NMR studies were combined with molecular modelling to determine the preferred conformations. Six structurally related kauren-15-ones were also found, including three new compounds. Some of these compounds showed differential cytotoxic activity against human tumor cell lines. The probable mode of cytotoxic action was supported by Michael addition of a thiol. Two 8,9-secokauranes were the main cytotoxins in another New Zealand liverwort. L. palpebrifolia.

Minimally invasive anterior retroperitoneal approach to the lumbar spine. Emphasis on the lateral BAK.

STUDY DESIGN: Eighteen patients with lumbar instability from fractures, postlaminectomy syndrome, or infection were treated prospectively with minimally invasive retroperitoneal lumbar fusions. OBJECTIVES: To determine if interbody Bagby and Kuslich fusion cages and femoral allograft bone dowels can be inserted in a transverse direction via a lateral endoscopic retroperitoneal approach to achieve spinal stability. SUMMARY OF BACKGROUND DATA: Endoscopic spinal approaches have been used to achieve lower lumbar fusion when instrumentation is placed through a laparoscopic, transperitoneal route. However, complications of using this approach include postoperative intra-abdominal adhesions, retrograde ejaculation, great vessel injury, and implant migration. This study is the first clinical series investigating the use of the lateral retroperitoneal minimally invasive approach for lumbar fusions from L1 to L5. METHODS: Eighteen patients underwent anterior interbody decompression and/or stabilization via endoscopic retroperitoneal approaches. In most cases, three 12-mm portals were used. Two parallel transverse interbody cages restored the neuroforaminal height and the desired amount of lumbar lordosis was achieved by inserting a larger anterior cage, distraction plug, or bone dowel. RESULTS: The overall morbidity of the procedure was lower than that associated with traditional "open" retroperitoneal or laparotomy techniques, with a mean length of hospital stay of 2.9 days (range, outpatient procedure to 5 days). The mean estimated intraoperative blood loss was 205 cc (range, 25-1000 cc). There were no cases of implant migration, significant subsidence, or pseudoarthrosis at mean follow-up examination of 24.3 months (range, 12-40 months) after surgery. CONCLUSIONS: This preliminary study of 18 patients illustrates that endoscopic techniques can be applied effectively through a retroperitoneal approach with the patient in the lateral position. Unlike the patients who had undergone transperitoneal procedures described in previous reports, in these preliminary 18 patients, there were no cases of retrograde ejaculation, injury to the great vessels, or implant migration.

Synergistic benefits of combined technologies in complex, minimally invasive surgical procedures. Clinical experience and educational processes.

The new burden surgical technology must assume demands not only improved efficiency and reduced risk, but also diminished cost and resource utilization. To this end, we have instituted the use of multiple, sequential technologies in complex, minimally invasive procedures: laparoscopic gastric surgery (44 cases), spine procedures (38 cases), and colectomies (96 cases). The technologies include head-mounted display, 3-D optics, robotic arm, harmonic scalpel, and optical access trocars. The combined use of these technologies shortened operative times, diminished use of personnel, and as associated with no technical mishap. Surgeon concentration and control of the operative environment were increased. In an effort to promote combined use of technologies, a structured teaching process was designed and implemented. It required five (average) experiences for efficient, hands-on implementation of combined technologies. We conclude that combined use of sophisticated technologies is safe and efficient; is accomplished by structured, moderately intense educational experience; and diminishes cost and use of human resources.

Head-mounted video monitor for global visual access in mini-invasive surgery. An initial report.

Video-assisted technology for minimally invasive surgery uses the coaxial approach (working field between surgeon and video monitor). Complex procedures and two-team approaches disrupt this relationship causing paradoxic motion. In an effort to obviate these issues, a head-mounted monitor display has been used by the surgeon in 74 of these complex operative procedures. The head-mounted display (HMD) eliminates the negative effects of yaw, roll, and pitch - each of which is detrimental to the performance of complex operative procedures. There has been no visual strain or ocular fatigue observed. In contrast, the HMD allowed increased concentration without subjective muscle strain for as long as 640 mins. The authors conclude that the HMD improves efficiency in complex procedures, increases safety, diminishes cost, and allows optimum visualization of the operative field by the surgeon and assistants in congested operating-room environments.

Benign gastric tumors. Minimally invasive approach.

BACKGROUNDS: Historically, major subsets of benign gastric tumors requiring surgical excision have required open laparotomy. METHODS: We have used laparoscopy to resect lesions in eight such patients. Lesion locations were gastroesophageal junction (one), gastric body (three), and pylorus (four). Four lesions were successfully located by instrument palpation. Six lesions were excised using gastrotomy, eversion of tumor, and resection, followed by stapled gastrotomy closure. The lesion at the posterior GE junction was evaluated through a gastrotomy and resected transgastrically. The two pyloric lesions were removed by laparoscopic distal gastrectomy and gastrojejunostomy. RESULTS: Procedure times were 55-210 min; oral feeding was instituted on postoperative day 1-5; patients were discharged 1-6 days postoperatively. CONCLUSIONS: Benign tumors of the stomach may be approached and resected laparoscopically; a transgastric, intra-organ approach is safe and efficient; laparoscopic distal gastrectomy is safe and technically feasible; patients have a shorter recovery interval and shorter postoperative hospital stay. Cautious progress in this field is recommended.

Minimally invasive surgical techniques to treat spine infections.

Minimally invasive techniques including closed laparoscopy and thoracoscopy as well as video-assisted procedures using limited open incisions provide an excellent alternative for treating vertebral osteomyelitis and tuberculous infections in the thoracic and lumbar spine. The traditional principles of surgical debridement and a stable interbody fusion are unchanged when applying endoscopic techniques. In the future, the spinal endoscopist will have available a larger selection of endoscopic instruments, more sophisticated video technology, and the development of anterior instrumentation systems to allow for rigid internal fixation. These advances, along with the surgeon's endoscopic experience and refined techniques, will further establish minimally invasive surgical techniques in the field of spinal surgery.

Robotic arm enhancement to accommodate improved efficiency and decreased resource utilization in complex minimally invasive surgical procedures.

Resource allocation, including manpower and other expenses, have limited the evolution of minimally invasive surgical procedures to provide humanism and to improve surgical care for patients. Robotic enhancement has been proposed as a mechanism to improve the cost-benefit relationship for patients. To this end, we have used the robotic arm enhancement to minimize resource and personnel utilization during minimally invasive procedures. Phase I of our study has included the use of the robotic arm in 24 laparoscopic hernia repairs, cholecystectomies, and nissen fundoplications with the surgeon as a solo surgeon, i.e., the primary surgeon is the only participant in the operative sterile field. The scrub nurse did not participate in the procedures. During this study, there were no technical mishaps, no complications related to the solo surgeon-robotic arm concept, and the operative times were statistically similar to equivalent procedures utilizing multiple personnel. The hernia repair is least complex and most amenable to solo surgery due to the use of only three access ports; cholecystectomy occasionally requires four access ports increasing its complexity to a measurable degree. Nissen fundoplication, however, requires five access ports and proved to be the most complex of the procedures to adapt successfully to solo surgery utilizing robotic arm enhancement. Phase II of our study has involved the use of a combination of technologically complex and sophisticated technology to improve outcomes in complex laparoscopic procedures. The head-mounted display, the robotic arm, and the harmonic scalpel have been used in 140 complex minimally invasive procedures; the procedures were laparoscopic spine surgery (24 cases), laparoscopic gastric surgery (28 cases), and laparoscopic colon resection (88 cases). The use of these sophisticated technologies added safety, improved versatility, and did not increase the length of the operative procedures. The use of multiple technologies had an additive effect on the benefits. There were no experiences in which the technologies contributed to a technical complication or an adverse result for the patients. However, the successful use of these technologies requires an in depth educational experience for the surgeon and for the operating room team. In a further effort to improve efficiency and control of the visual fields during minimally invasive surgery, we have implemented a prototype voice activation, head-directed control, and instrument tracking by robotic arm enhancement in order to control the visual field through computer programming. Prototype voice activation and deactivation also allows instruments to be used in the visual field for the surgical procedure while not being used for tracking of the visual field. Tracking with the instrument utilizing a color-coded tracking system, and the head-directed control system have both been 100% effective in our hands, have not induced errors in technical performance of procedures, and have shortened the time required for performance of specific procedural tasks. Further, this process improves versatility for the surgeon, increases concentration, reduces fatigue and does not interfere with the position of the surgeon. Areas for improvement which have been observed utilizing these techniques are (1) the use of appropriate and consistent voice activation terminology, (2) the proper positioning of the instrument tracking unit in the most appropriate locations on the video screen and on the instrument within the visual field, and (3) the appropriate use of head-directed control of the robotic arm. We have concluded from these experiences that the robotic technology will continue to reduce costs and minimize risk for patients undergoing minimally invasive surgical procedures; moreover, safety, versatility, and diminished use of resources will accrue utilizing the additive benefit of sequential sophisticated technologies requiring a simultaneous educational