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 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.

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.

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

Anterior thoracic corpectomy for spinal cord decompression performed endoscopically.

A prospective study was undertaken during the past 3 years to investigate the effectiveness of thoracoscopic corpectomy--endoscopic removal of the vertebral body in 15 cases (8 for pathologic fractures for tumors, 5 for traumatic fractures and 2 for infections). The average age of the patients was 53.2 years (range 28-85 years). The vertebral levels of corpectomy ranged from T3 to L1. The mean operating time was 211 min (range 83-450 min) and the mean estimated blood loss was 890 ml (range 150-2,800 ml). The postoperative morbidity appeared to be more favorable than with open thoracotomy [Alband OW, Corkill G. Thoracic disk herniation: treatment and prognosis. Spine 1979; 4:41-6; Landreneau RJ, Hazelrigg SR, Mack NJ. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg (in press); McAfee PC. Complications of anterior approaches to the thoracolumbar spine: emphasis on Kaneda instrumentation. Clin Orthop 1994;306:110-9; McAfee PC, Bohlman HH, Yuan HA. Anterior decompression of traumatic thoracolumbar fractures with incomplete neurological deficit using a retroperitoneal approach. J Bone Joint Surg [Am] 1985;67: 89-104; Regan JJ, Mack MJ, Picetti GD, Guyer RD, Hochschuler SH, Rashbaum RF. A comparison of video-assisted thoracoscopic surgery (VATS) with open thoracotomy in thoracic spinal surgery. Today's Ther Trends 1994;11: 203-18.] because the mean chest tube duration was 1.22 days (range 1-3 days), the mean length of time in the intensive care unit was 2 days (range 1-4 days), and the mean length of total hospitalization was 6.5 days (range 2-12 days). Overall, the ability to visualize the anterior surface of the dura during corpectomy was better endoscopically than with open thoracotomy techniques--improved magnification, the ability of the operative assistant to see and therefore suction more efficiently, and the perspective of visualization was improved. It was possible to place the 30 degrees angled endoscope within the defect left by the resected vertebral body and look directly posteriorly at the dura, visualizing the epidural vessels and dural pulsations at close range. The limiting factor in wide application of the technique is the absence of a commercially available internal fixation system that can be applied endoscopically.

The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases.

STUDY DESIGN: A prospective multicenter study on 100 consecutive surgical procedures. OBJECTIVES: A prospective multicenter study was performed to evaluate the early perioperative complications in 100 endoscopic spinal procedures--78 video-assisted thoracic surgical procedures and 22 laparoscopic lumbar instrumentation and fusion procedures. SUMMARY OF BACKGROUND DATA: Endoscopic procedures have been widely applied in general surgery for appendectomy, cholecystectomy, liver resection, Nissen fundoplication, colon resection, and hernia repairs. Video-assisted thoracic surgery is widely used for pleural biopsy, lung resection, and sympathectomy. This is the first large series to date investigating the safety and potential complications using endoscopic surgery for anterior decompression or fusion of the thoracolumbar spine. METHODS: Video-assisted thoracic surgical procedures included multilevel anterior thoracic releases for deformity, 27 patients; anterior thoracic discectomies with spinal canal decompression, 41 patients; pyogenic vertebral osteomyelitis decompression, 2 patients; and vertebral corpectomy for neurologic decompression, 8 patients. Mean operative time was 2 hours, 34 minutes (range, 45 minutes to 6 hours), and mean length of stay was 4.97 days (range, 2-21 days). Anterior laparoscopic interbody stabilization and fusion at L4-5 or L5-S1 was performed in 22 patients. The mean operative time was 4 hours, 17 minutes (range, 2 hours, 40 minutes to 9 hours), and the mean length of stay was 5.6 days (range, 1-23 days). RESULTS: The most common video-assisted thoracic surgical complications were transient intercostal neuralgia (six patients) and atelectasis (five patients). The most common laparoscopic complication was bone graft donor site infection (two patients). There were two endoscopic cases that were converted to open procedures, one for extensive pleural adhesions and one for a common iliac vein laceration. CONCLUSIONS: The endoscopic spinal approaches proved to be safe operative procedures in 100 consecutive cases. There were no permanent iatrogenic neurologic injuries and no deep spinal infections.

Laparoscopic-assisted colectomy learning curve.

PURPOSE: The purpose of this paper is to establish the number of cases necessary to master laparoscopic removal of the left or right colon. METHODS: Data were obtained by chart review and by individually completed questionnaires. RESULTS: A total of 144 laparoscopic-assisted or intracorporeal right or left hemicolectomies were completed by four surgeons at separate institutions. Questionnaires were completed by each surgeon for each sequential hemicolectomy, and data concerning the type of surgery and total operating time were recorded. Times were plotted to diagram individual learning curves for each surgeon, and data grouping methods were used to determine the curve for each surgeon as well as for the combined data base. Learning was said to have been completed when the surgeon's operative time reached a low point and subsequently did not vary by more than 30 minutes. A total of 78 right colectomies and 66 left colectomies were completed by the group. Respectively, each surgeon appeared to learn the procedure after 16, 21, 11, and 6 cases. When the entire database was analyzed as a whole, it was shown that between 11 and 15 completed colectomies were needed for learning, after which operative times remained relatively stable. CONCLUSIONS: This analysis, using total operative time as an indication of learning, shows that approximately 11 to 15 completed laparoscopic colectomies are needed to comfortably learn this procedure.

Use of laparoscopy in the diagnosis and treatment of patients with surgical abdominal sepsis.

Patients often present to the surgeon with abdominal pain, tenderness, and fever. Many exhibit progressive sepsis due to abdominal pathology. Delay in diagnosis and treatment often occurs due to the use of multiple, time-consuming, expensive diagnostic studies. We delineate the use of diagnostic laparoscopy in subsets of patients in whom confusion exists as to the cause of abdominal sepsis--i.e., females in child-bearing years, elderly patients, obese patients, immunosuppressed patients, and patients with suppression of physical findings. The methodical assessment of the entire abdominal cavity is performed utilizing manipulation of the patient's position (Trendelenburg, supine, reverse Trendelenburg, left side up, right side up) and meticulous inspection of the entire small bowel. Diagnoses included acute appendicitis, gangrenous appendicitis, perforated appendicitis with peritonitis or abscess, gangrenous cholecystitis, ischemic bowel disease, perforating carcinoma of the colon, perforating diverticulitis with abscess or peritonitis, tubo-ovarian abscess, closed-loop small-bowel obstruction, megacolon, and perforation of the colon. Laparoscopic treatment of 96% of the patients was performed successfully and a laparoscopic-assisted approach was used in the remainder. There was one mortality (cardiac) and no major morbidity. The development of a Formal Diagnostic Exploratory Laparoscopic (FDEL) approach has aided in the assessment of each of the diagnoses of sepsis in the abdominal cavity. The diagnostic and therapeutic approach laparoscopically avoids extensive preoperative studies, avoids delay in operative intervention, and appears to minimize morbidity and shorten the postoperative recovery interval.

Laparoscopic bilateral inguinal herniorrhaphies: use of a single giant preperitoneal mesh patch.

Recent reports support excellent results following laparoscopic inguinal herniorrhaphy. Similarly, nonlaparoscopic preperitoneal bilateral inguinal herniorrhaphy has been performed with a giant anterior abdominal mesh with excellent results. In order to maximize patient benefit, we have used the laparoscopic approach to repair bilateral inguinal hernias using a large single patch of mesh in the preperitoneal space for the past 12 months. Twenty-nine patients with an age range of 26 to 83 have undergone this procedure. Technical details included creation of preperitoneal flaps to cover the preperitoneal retropubic space and inguinal and femoral canals bilaterally; use of "keyhole" technique to surround cord structures with mesh (transfixing mesh to important anatomic landmarks); and closure of peritoneum. Ninety-four per cent of patients were discharged on the operative day with minimal pain. One-third required pain medication; patients returned to work five to nine days post-operatively. There have been no recurrences, no morbidity requiring hospitalization, and no complications related to mesh or the laparoscopic approach. This procedure combines the benefits of two successful approaches to bilateral inguinal herniorrhaphy, is associated with excellent short-term results, and should be considered as a potential "best option" in patients with bilateral inguinal hernias.

Sequential psychomotor skills development in laparoscopic colon surgery.

OBJECTIVES: To quantify the complexity of each of three skills used in laparoscopic colon surgery and to quantify the relative complexity of seven laparoscopic colon procedures on a graduated complexity scale. DESIGN: Five surgeons used a scale of 1 through 6 to measure the relative complexity of three laparoscopic skills (intracorporeal mobilization, intracorporeal devascularization, and intracorporeal anastomosis) to assess the relative difficulty of seven laparoscopic procedures (right colon resection, sigmoid colon resection, low anterior resection, Hartmann's procedure, left colon resection, abdominoperineal resection, and transverse colon resection) using detailed evaluation of their first 100 laparoscopic colon resections. SETTING: Three private community hospitals. MAIN OUTCOME MEASURES: The complexities of intracorporeal mobilization, intracorporeal devascularization, and intracoporeal anastomosis were recorded for seven laparoscopic colon procedures. RESULTS: The least complex procedure was right colon resection, followed in increasing complexity by sigmoid colon, Hartmann's procedure, low anterior resection, abdominoperineal resection, left colon resection, and transverse colon resection. The addition of each laparoscopic skill increased the complexity during each procedure. All three skills were not required for every procedure. CONCLUSIONS: Since all procedures do not require all three skills, skills can be learned sequentially if patients are chosen judiciously. A sequence of laparoscopic procedures performed by surgeons is recommended. The relative complexities for each procedure suggest an outline (map) for surgeons to use during laparoscopic colon surgery.

Laparoscopic herniorrhaphy: results and technical aspects in 450 consecutive procedures.

BACKGROUND: The effectiveness of laparoscopic herniorrhaphy, the patient outcome, and technical aspects have been controversial. We have performed 450 consecutive laparoscopic inguinal herniorrhaphies and have reviewed the rationale, technical aspects, and the outcomes. METHODS: Four hundred and fifty consecutive laparoscopic herniorrhaphies were performed using synthetic mesh for tensionless repair and adhering to surgical principles of preperitoneal herniorrhaphy. Patients were 16 to 83 years of age, 74% men, 26% women. Mesh was transfixed to anatomic landmarks with suture or staples. The peritoneum was closed, separating mesh from abdominal contents. RESULTS: Ninety percent of patients were discharged from perioperative care; 10% were in the hospital 23 hours as a result of urinary retention, cardiac disease, etc. No adhesive or mesh complications occurred. Three hernias recurred at 2 to 4 months after operation. Two were repaired laparoscopically. CONCLUSIONS: Laparoscopic inguinal herniorrhaphy is a safe and effective procedure. It compares favorably with other classic methods of hernia repair (especially use of a tensionless repair with mesh). Patients exhibit minimum morbidity and ambulate soon with minimal discomfort. This repair should be considered preferential in many subsets of patients.