Laparoscopic sutured anastomosis of the bowel.

BACKGROUND: Even though the safety and efficacy of sutured anastomosis have been proved in open surgery, laparoscopic sutured anastomosis is rarely performed because it is difficult and time-consuming. We aim at description of a standardized technique for laparoscopic sutured anastomosis of the bowel and definition of its learning curve. METHODS: Fifty-six laparoscopic sutured anastomoses of cow small intestine were performed in a laparoscopic simulator. In a survival animal trial, 10 end-to-end, 2 gastrojejunostomy, 2 cholecystojejunostomy, 2 colocolic, and one side-to-side anastomoses were performed, using the same technique. RESULTS: In the survival cases, we had no leaks or obstruction, minimal adhesions, and only one stenotic gastrojejunostomy. The mean end-to-end anastomotic time was 50 min. The technique was suitable for most sites in the GIT. The learning phase required 40 anastomoses in the simulator. CONCLUSIONS: The described technique seems relatively fast, safe, and universal, and it needs about 40 anastomoses to be mastered.

The Tübingen balloon. A new method for adjusting the tension of the fundic wrap during laparoscopic Nissen fundoplication.

An adequate fundic wrap is fundamental to the success of conventional and laparoscopic Nissen fundoplications. Nevertheless, up to now there has been no standardized method for the surgeon to determine intraoperatively the width and tension of the fundic wrap according to objective criteria. With the support of Rüsch (Kernen, Germany), we developed a measurement balloon for use in laparoscopic Nissen fundoplication. The balloon allows the surgeon to define the width of the wrap and predetermine its length, as well as to measure its tension. Depending on the measured balloon pressure, the surgeon can perform fundic sutures more or less tightly. On the basis of 41 fundoplication model tests, we found that a fundic wrap typically described as "loose and floppy" produced a balloon pressure of 50-60 mmHg. In 10 laparoscopic Nissen fundoplications on domestic pigs, we were able to adjust the fundic wrap intraoperatively to a balloon pressure in this range (mean; 53.5; SD; 2.25). After the optimal intraoperative balloon pressure in humans has been investigated in a prospective study that is in progress, the Tübingen balloon is expected to serve as an instrument for quality assurance in reflux surgery.

Indications and results of local treatment of rectal cancer.

BACKGROUND: Local therapy of early rectal carcinoma has become an alternative to the classical radical operation which has a higher morbidity and mortality rate. METHODS: Rectal carcinoma was treated by transanal endoscopic microsurgery (TEM) in 113 patients. The indications for the procedure were pT1 low-risk tumour, advanced tumour in high-risk patients, and patients who refused more radical surgery based on oncological guidelines. RESULTS: Sixty-four patients had pT1, 33 pT2 and 16 pT3 tumours. No patient died as a result of TEM. The rate of complications which needed operative intervention was 7 per cent. So far, two of the patients treated by local resection of pT1 low-risk tumours have had a recurrence. In both cases, a secondary procedure was possible with curative intent. CONCLUSION: Patients with pT1 rectal tumours represent a suitable group for local treatment because of the acceptability of the procedure and the low recurrence rate.

[Value of training courses in minimally invasive surgery]. / Die Wertigkeit von Trainingskursen in der Minimal-Invasiven Chirurgie.

The actual situation regarding the education für MIS requires the optimisation and standardisation of the training system. This paper presents the results of an inquiry about the evaluation of the course of operative laparoscopy. 80-90% of those interviewed made the comments "very good" and "good", with regard to the imparting of the theoretic foundation of the technique of endoscopic operations, for sufficient possibility of manual training and for the realistic setting of the animal organ model compared with the clinical operation. Because of our experience, we recommend attending such training courses before starting laparoscopic operations.

Local therapy of rectal tumors.

PURPOSE: The aim of the study is to outline the rising importance of local treatment of rectal tumors and a changing strategy in therapy of early rectal cancer. METHODS: As the surgical procedure, transanal endoscopic microsurgery was used. Indications for the local procedure were pT1 low-risk tumors and tumors of higher stages in patients with severe risk factors and of those who refused the operation according to oncologic guidelines. RESULTS: A total of 236 rectal adenomas and 98 carcinomas were locally excised using the transanal endoscopic microsurgery technique. Mortality rate was 0.3 percent, and rate of complications requiring surgical reintervention was 5.5 percent in adenomas and 8 percent in carcinomas. Final histology of removed carcinomas revealed 56 pT1, 27 pT2, and 15 pT3 stages. After an average follow-up time of 24 months, two recurrences were observed in the group of patients with pT1 low-risk carcinomas who only underwent local therapy. In both cases, a second intervention for cure was undertaken but for tumors in a late stage. CONCLUSIONS: In selected cases, local therapy of rectal carcinoma avoids high morbidity and mortality of the classical operation. Quality of life will be improved, especially if an artificial anus can be avoided. In case of recurrence, the chance of a secondary procedure for cure is not to be underestimated.

[Local therapy of rectum carcinoma. A prospective follow-up study]. / Die lokale Therapie des Rektumcarcinoms. Eine prospektive Beobachtungsstudie.

Local therapy of rectal carcinoma with the method of TEM was performed in 98 patients during the period from August 1, 1989 to January 31, 1994. 56 of the patients had pT1, 27 pT2, and 15 pT3 tumours. There was no lethality. The rate of complications, which required operative intervention, was 8%. No lymph node metastases were found in the specimens of the patients with pT1 tumours, who were re-resected, because the margin of the primary specimen were judged to be not free of tumour. In the specimens of the re-resected patients with pT2 carcinomas, lymph node involvement was more common than remnants of the primary tumour. Two of the patients with local therapy of pT1 low-risk carcinomas developed a recurrence so far. A secondary procedure for cure according to oncologic criteria could be performed in both cases. In selected cases the local therapy of rectal carcinoma avoids the high morbidity and mortality of the classical operation. Live quality will be improved, especially if an artificial anus can be avoided. In case of a recurrence the chance of a secondary procedure for cure is not to be underestimated.

[Local therapy of early rectal carcinoma with curative intent: implications for a change in oncologic strategy]. / Die lokale Therapie des Rektumfrühkarzinomes in kurativer Absicht: Implikationen für eine Anderung der onkologischen Strategie.

Patients with pT1 low-risk rectal carcinomas seem to be overtreated by a classical radical operation. A total of 170 patients with rectal carcinomas were locally treated with the transanal endoscopic microsurgery (TEM) technique. Four of the group with pT1 low-risk tumours with local therapy developed a recurrence, three of whom underwent a curative secondary procedure, bringing the failure rate to one out of 81. Two recurrences were diagnosed among the 22 patients who were re-resected after local treatment in stage pT1 low risk. Both patients died of the tumour disease, another due to dehiscence of the suture, bringing the failure rate in the re-resected group to three of 22.

TEM results of the Tuebingen group.

From August 1st 1989 to May 1st 1993, 190 rectal adenomas and 75 carcinomas were locally excised with the TEM technique. The mortality was 0.4%, the rate of complications which required surgical re-intervention was 3% in adenomas and 8% in carcinomas. The final histology of the removed carcinomas revealed 44 pT1, 23 pT2 and eight pT3 stages. In two of the eight re-resected patients with pT1 low-risk tumours, residual primary tumour but no lymph node metastases were found. In contrast to this, three of the eleven re-resected patients with pT2 low-risk tumours had already developed lymph node metastases. After an average follow-up time of 14 months, two recurrences were observed in the group of the only locally treated patients with pT1 low-risk carcinomas. Both underwent a secondary procedure for cure but in late tumour stages. No recurrence was diagnosed so far among the re-resected patients.

Indications and technique for TEM (transanal endoscopic microsurgery).

Transanal Endoscopic Microsurgery (TEM) was introduced into clinical practice by the Buess group in 1983. Since then vast experience has been gained in removing tumours of the rectum by the operative rectoscope. Though the indication in benign lesions for TEM as a local resection therapy is undisputed, the indication for resection of T1 or advanced carcinomas has to be evaluated. By using a 40 mm operating rectoscope sealed with a gastight working insert to prevent pressure loss after creation of a pneumorectum and a stereoscopic optic with sixfold magnification, exact visualisation of a rectal tumour can be achieved. The insertion of endoscopic surgical instruments like the high frequency knife, forceps, scissors, and suction device allows precise excision of the lesion as well as suture closure of the wound. Recently a bipolar multifunctional combination instrument has been developed for more precise dissection, less blood loss and shorter operation times.

[Minimally invasive surgery of the colon and rectum]. / Minimal invasive Chirurgie des Kolon und Rektum.

In the period from 1.8.89 to 1.7.92 140 adenomas and 63 carcinomas were locally resected from the rectosigmoid area with the instruments of TEM. The mortality was 0.5%, the rate of dehiscence of the suture 9.8%. 75% of these were treated conservatively. One of the 29 patients with locally resected pTl-low risk-carcinoma developed a recurrence so far. The rate of recurrent adenomas was 1.4%. From 7.1.1992 to 24.5.1993 21 procedures in colorectal surgery were performed laparoscopically or in a combined laparoscopic transanal operation. The mortality was zero. 1 case of suture dehiscence, 2 cases of crural phlebothrombosis and 1 lesion of the left ureter were observed. The use of TEM in the combined procedure means an extension of the range of minimally invasive colorectal surgery to the lower rectum.

In vitro fragmentation of gallstones with lithotriptors for use in laparoscopic cholecystotomy.

In preliminary in vitro experiments, five different lithotriptors for use in laparoscopic cholecystotomy were tested to determine the fragmentation time and rate of a defined group of gallstones. The Alexandrit laser and the ultrasonic lithotriptor were too ineffective to warrant further investigation. In phantom tests with pig gallbladders, the pulsed dye laser and the electrohydraulic lithotriptor had a fragmentation rate of 100%, but the rate of clearing of the gallbladder was 0% as stone debris always remained in the gallbladder. The clearing rate of the RotoLith mechanical lithotriptor was 84.6%. The RotoLith lithotriptor was the most effective device because the stones were ground into such small particles that they could easily be rinsed out of the gallbladder. As the RotoLith procedure does not need to be monitored optically, the opening of the gallbladder need not exceed 3 mm compared to 10 mm for the other lithotriptors. This makes closure of the gallbladder safer and it would seem feasible to perform the procedure using the RothoLith lithotriptor under local anaesthesia.

LaparoLith. A new instrument for stone fragmentation in laparoscopic cholecystectomy.

Laparoscopic cholecystectomy can be performed with incisions of a maximum diameter of 10 mm. The removal of a stone-filled gallbladder at the end of an operation via the 10-mm port needs often-extensive tissue-consuming manipulations for stone removal or minilaparotomy. Stone fragmentation can be achieved by mechanical crushing and by ultrasound-, electrohydraulic-, and tunable dye laser lithotripsy. The clinical employment of the LaparoLith (Baxter Healthcare Corporation), an instrument which allows mechanical fragmentation of stones inside the gallbladder, is presented here. We have used the LaparoLith in nine patients and have been successful in stone fragmentation in seven of these. The LaparoLith seems to be helpful in laparoscopic cholecystectomy, preventing extension of the subnavel incision.

Technique and results of transanal endoscopic microsurgery in early rectal cancer.

The anatomy of the pelvis makes it difficult to perform local excisions in the rectum when the tumor is some distance from the anal verge. We have, therefore, developed a new minimally invasive technique for tumor resection. A rectoscope with a 40-mm diameter permits tumor resection under stereoscopic control in the gas-dilated rectal cavity. Excisions in full-thickness technique up to segmental resections with end-to-end anastomosis can be performed. In selected cases, local excision of a small rectal cancer can be regarded as appropriate treatment. However, most local resections of carcinomas are performed when removal of an adenoma is planned, and the postoperative histology shows a carcinoma. Since 1983, we have operated on 326 patients, 274 who have been enrolled in a prospective clinical trial. Definitive histologic examination proved that 74 of these tumors were carcinomas. The rate of severe complications in patients with carcinomas was 9%, and the mortality rate was 0%. The advantages of this new technique are: The stereoscopic magnified view in the gas-dilated rectum allows precise surgery in an operative field that is otherwise difficult to reach. During the postoperative period, minimal discomfort and pain result in a short hospitalization.

[Training program for minimally invasive surgery]. / Trainingsprogramm für die Minimal-invasive Chirurgie.

Currently 'Minimally Invasive Surgery' (MIS) is rapidly finding a widening range of applications and increasing numbers of surgical departments start with new MIS techniques. Surgical work under endoscopic control requires an intensive readjustment to operation technique bringing about new problems in training. We believe that intensive training of MIS procedures on suitable training phantoms should be a prerequisite for clinical application of MIS and therefore have established a training center for MIS in Tübingen, FRG, offering weekly hands on training courses for different procedures.

[Laparoscopic cholecystectomy: new evaluation of a surgical method in the light of endoscopic techniques]. / Die laparoskopische Cholezystotomie: Neubewertung einer Operationsmethode im Licht endoskopischer Techniken.

The laparoscopic cholecystotomy was developed to remove calculi while preserving a functioning gallbladder. 120 phantom tests on pig's gallbladders were performed. No major complications were observed in 20 animal experiments with pigs. Compared with competing conservative and interventional methods the laparoscopic cholecystotomy provides immediate removal of stones and a definite closure of the gallbladder by a clip. Calcified stones are no contraindication for the procedure. After introduction into the clinical routine, an outpatient treatment in local anaesthesia seems to be possible. Patients with a high operative risk should be treated by this method. The laparoscopic cholecystotomy represents an alternative to the percutaneous transhepatic litholysis and the ESWL.

Experimental laparoscopic cholecystotomy.

This instrument set for a single puncture technique of laparoscopic cholecystotomy was developed in 100 phantom tests with pig gallbladders and was later evaluated in 12 animal experiments. No complications were observed. After clinical development, treatment on an outpatient basis under local anaesthesia seems possible. For the patient this would mean avoiding general anaesthesia, shorter hospitalization, pain reduction and good cosmetic results, while reducing expenditure for the public health authorities at the same time. To avoid recurrent stones, diet and low-dose drug therapy should be considered. Because the procedure is minimally invasive, repetition of the laparoscopic procedure seems justified if stones recur.