Hand-assisted laparoscopic sigmoid resection for diverticular disease: 100 consecutive cases.

BACKGROUND: Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional laparoscopic and open surgery. As compared with conventional laparoscopic surgery, it offers the advantages of tactile feedback, better exposure, and a shorter learning curve. There is increasing evidence that HALS retains the advantages of minimal-access surgery. The aim of this study was to analyze the feasibility as well as the short- and medium-term outcomes of HALS sigmoid resection for diverticular disease. METHODS: The study included 100 consecutive patients between July 1999 and August 2004. Data were prospectively recorded. Follow-up evaluation was performed by standardized telephone interview after a mean postoperative period of 19 months (range, 2-55 months). RESULTS: Two major intraoperative complications occurred: splenic laceration requiring splenectomy and ureteral injury requiring suture. There were only three conversions: one case of pararectal incision and two cases of extended lower Pfannestiel incision. There was no single case of conversion to midline laparotomy. One patient died postoperatively of myocardial infarction. The postoperative complications included intraabdominal hematoma (2%), anastomotic leakage (3%), wound infection (11%) and bladder dysfunction (1%). The reoperation rate was 5%. The median hospital stay was 8 days. In terms of satisfaction with the results, 97% of patients would choose HALS again. CONCLUSIONS: When used for diverticular disease, HALS sigmoid resection has a low intra- and postoperative complication rate. The satisfaction rate among patients is high. Even in technically difficult cases, conversion to midline laparotomy can be avoided.

[Polytrauma with tension pneumothorax with inserted chest tube]. / Polytrauma mit Spannungspneumothorax bei liegender Thoraxdrainage.

The authors report a case of a 25-year-old woman with a polytrauma, caused by a free fall of 12 metres in suicidal intention. Following endotracheal intubation and mechanical ventilation by an emergency physician at the scene, the patient was delivered to the emergency room of an university hospital. An ultrasonic check of the abdomen revealed free fluid in the abdominal cavity, and a rupture of liver and spleen was suspected. Since breath sounds over the right lung were diminished, a chest tube was inserted immediately in the fifth intercostal space in the anterior axillary line. About 300 millilitres of blood were drained by the tube. Shortly thereafter, a laparotomy was performed, where spleen and liver rupture were confirmed and treated. After 60 minutes, the patient developed severe hypotension coupled with ventricular tachycardia and fibrillation, and resuscitation measures had to be initiated. Since breath sounds over the right lung were missing, a tension pneumothorax was suspected and a thoracotomy performed immediately. While huge amounts of air and blood were emerging from the thoracic cavity, a rupture of the right mainstem bronchus as well as of the right pulmonary artery and vena subclavia was identified. The chest tube was found dislocated into the subcutaneous tissue. Despite of open heart compression, application of adrenaline and noradrenaline and substitution of packed red blood cells and of crystalloid and colloid solutions, all resuscitation measures failed so that the patient died shortly after on the operation table. This case illustrates first the difficulties of an adequate thoracic trauma management, particularly, when clinical symptoms are discrete, second the problems of the insertion and control of a chest tube, and third risks associated with wrong position or secondary dislocation which may include - as in our case - "masking" of severe injury patterns and delay of life-saving measures such as an immediate thoracotomy. In order to improve prognosis of patients with poly-/thoracic trauma, establishment of spiral-CT in emergency centres, routine bronchoscopy and safe handling of chest tubes may be helpful.

Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair.

BACKGROUND: Almost half the patients who undergo hernia repair with mesh report a feeling of stiffness and a foreign body in the groin. This study evaluated whether patients noticed any difference between lightweight and standard polypropylene mesh for the repair of inguinal hernia. METHODS: Patients scheduled for elective repair of unilateral or bilateral, primary or recurrent inguinal hernia by the Lichtenstein technique were randomized to receive either a conventional densely woven polypropylene mesh (100-110 g/m(2)) or a lightweight composite multifilament mesh (polypropylene 27-30 g/m(2)). Quality of life was assessed using Short Form 36 before operation and 6 months after surgery. Pain was assessed by means of a visual analogue scale 2 days and 6 months after surgery. The primary outcome measure was the feeling of a foreign body in the groin at 6 months. RESULTS: Some 122 hernias were randomized; 117 were included in the analysis of perioperative data, and 106 were re-examined after 6 months. There were no differences between the treatment groups with respect to early and late surgical complications. Use of lightweight mesh was associated with significantly less pain on exercise after 6 months (P = 0.042). In addition, fewer patients reported the feeling of a foreign body after repair with lightweight mesh (17.2 versus 43.8 per cent with conventional mesh; P = 0.003). Quality of life was improved significantly at 6 months compared with the preoperative assessment, and there were no differences between the treatment groups. CONCLUSION: Lightweight polypropylene mesh may be preferable for Lichtenstein repair of inguinal hernia. Larger cohorts with longer follow-up are needed before it can be recommended for routine use.

Laparoscopic fundoplication.

BACKGROUND: The effectiveness of laparoscopic Nissen fundoplication (LNF) was assessed in patients with chronic gastroesophageal reflux disease (GERD) using pH study and different quality-of-life indexes. We correlated both types of data and hypothesised that improvement in quality of life following LNF does not necessarily correlate with improvement in pH values. METHODS: Seventy patients presenting with typical symptoms of GERD (14 with Barrett's esophagus) underwent LNF between May 1997 and December 2000. All patients were evaluated both prior to and 3 months after surgery using 24-h pH study, endoscopy, and a validated quality-of-life questionnaire. RESULTS: Following LNF, reflux was reduced to normal in all but six patients. Howevers despite persistent reflux, the Gastrointestinal Quality of Life Index (GQLI), of these six patients improved postoperatively from 79.5 +/- 12.2 to 111.7 +/- 8.3. These results correlate with those of patients who had normal postoperative pH studies-namely, 88.5 +/- 19.3 to 112 +/- 16.7. There was no difference in quality-of-life improvement between patients with Barrett's esophagus and those without it. CONCLUSION: There is only a weak correlation between quality-of-life assessment and pH study. Because the patient's quality of life is likely to improve following LNF, an objective means parameter of assessing the effectiveness of antireflux surgery, such as pH study or endoscopy, is recommended.

[Problem of recurrent incisional hernia after mesh repair of the abdominal wall]. / Zur Problematik des Narbenhernienrezidivs nach Netzplastik der Bauchwand.

INTRODUCTION: Depending on the surgical technique, mesh material and follow-up, the figures for recurrences of incisional hernia vary from 0 to 31%. What are the reasons for recurrences, and which options exist for more successful therapy? METHODS: Fourteen operations for recurrences after mesh repair of incisional hernias were analyzed retrospectively and correlated with a literature review of the years 1990-2000. RESULTS: An inadequate surgical technique is the main reason for recurrences after the use of polypropylene or polyester, but with PTFE, it is instead the properties of the material. In our patients we found central mesh recurrences. The first results with laparoscopic technique are very promising. CONCLUSIONS: Open incisional hernia mesh repair should be performed with the sublay technique, preferably with polypropylene; the use of polyester can be recommended only with reservations and the use of PTFE ought to be limited to very few indications. The entire incision should always be prepared with safe fixation of the mesh and wide overlap of the hernia. Recurrences after polypropylene implantation can be treated with additional mesh; concerning PTFE, a different material is recommended. A final evaluation of laparoscopic mesh repair cannot be assessed yet.

[Standardized sublay technique in polypropylene mesh repair of incisional hernia. A prospective clinical study]. / Standardisierte Polypropylennetzplastik der Narbenhernie in Sublay-Technik. Eine prospektive klinische Studie.

INTRODUCTION: With the introduction of meshes to support hernia repairs the recurrence rates were reduced from 50% to less than 10%. Special complications such as scar plates with restriction of the mobility of the abdominal wall, pain and fistula formation are described. METHODS: In a prospective study trial 38 patients with incisional hernia were treated with Marlex mesh repair in the standard sublay technique. RESULTS: Within a mean follow-up period of 3 years most of the patients were free from pain and very satisfied. Two recurrences (5.2%) occurred and 2 hematomas (5.2%) had to be removed surgically. CONCLUSIONS: Using a standard operation technique with the mesh in sublay position, even with heavy-weight Marlex mesh, good clinical results can be achieved compared to published findings. To our surprise we found two central recurrences through the mesh.

[Hand-assisted, laparoscopic nephrectomy for live donor organ harvesting. Initial results]. / Handassistierte, laparoskopische Nephrektomie zur Lebendnierenspende. Erste Ergebnisse.

We report technique and preliminary results with a new, laparoscopic hand-assisted, technique for live donor nephrectomy. A special device (Pneumo-Sleeve, Handport) in a short (7.5-8 cm) Pfannenstiel incision allows the surgeon to insert his or her hand into the insufflated abdominal cavity and to use it as a "multifunctional instrument" while pneumoperitoneum is preserved. This technique offers significant advantages over the pure laparoscopic approach in terms of maintained tactile feedback, facilitated exposure and dissection, decreased operation time and easy retrieval of specimen with minimized allograft warm ischemia time.

Central mesh recurrence after incisional hernia repair with Marlex--are the meshes strong enough?

The use of biomaterial meshes in the repair of incisional abdominal wall hernias is now widely accepted internationally. The introduction of synthetic meshes to achieve tension-free repair has led to a satisfactory reduction in the recurrence rate to less than 10%. However, the use of such biomaterials can result in the occurrence of undesirable complications such as increased risk of infection, seromas, restriction of the abdominal wall and failure caused by mesh shrinkage. Additionally, at the time of writing there is much discussion concerning the potential risk of a persistent foreign body reaction directly associated with the meshes with regard to possible malignant transformation. As such, the trend seems to be toward the use of lighter meshes utilizing less non-absorbable material. One particular novel mesh theoretically capable of guaranteeing the necessary mechanical stability uses 70% less biomaterial. Against this background, we report a central mesh recurrence through the mesh following incisional hernia repair with a Marlex mesh. To our knowledge, this is the first description of a central mesh recurrence, and we discuss a possible mechanism with particular emphasis on the required abdominal wall forces both physiologically and after incisional hernia repair.

Carbon dioxide absorption during extraperitoneal and transperitoneal endoscopic hernioplasty.

UNLABELLED: Transabdominal preperitoneal (TAPP) or total extraperitoneal (TEP) hernioplasty are probably associated with differing degrees of CO(2) absorption which can influence anesthetic management and perioperative morbidity. We studied 20 patients with either TAPP or TEP for perioperative CO(2) absorption (calculated from CO(2) elimination and metabolic CO(2) production) and ventilatory changes required to maintain normocapnia (blood gas analyses). CO(2) absorption reached plateau values in the TAPP group, but increased over time in the TEP group. Median CO(2) absorption during insufflation was 61 mL/min (range 43-78) for TAPP and 114 mL/min (range 75-178) for TEP, with a maximum of 114 mL/min (range 75-178) for TAPP and 258 mL/min (range 112-585) for TEP. Median minute ventilation (V(E)) required for maintaining normocapnia was 9. 5 L/min (range 7.7-11.5) for TAPP and 12.9 L/min (range 9.0-22.6) for TEP (P: < 0.01). Seven patients in the TEP group required over 18 L/min V(E), although no patient in the TAPP group required more than 14 L/min V(E). All patients in the TEP group had significant subcutaneous emphysema resulting in one case of delayed tracheal extubation. We conclude that CO(2) absorption is consistently less with TAPP. IMPLICATIONS: The greater magnitude of carbon dioxide absorption during total extraperitoneal hernioplasty puts an additional load on the lungs and could pose a risk for patients with chronic lung disease who might be unable to eliminate excess carbon dioxide.

[Laparoscopy in small bowel ileus]. / Laparoskopie bei Dünndarmileus.

Today laparoscopic procedures are routinely performed in patients with intestinal adhesions from previous abdominal surgery. Does laparoscopy have a potential benefit in acute small-bowel obstruction? Theoretically, a lower rate of wound complications and incisional hernias, as well as less subsequent adhesions with a lower incidence of recurrent intestinal obstruction, can be expected. However, laparoscopy is successful in only 50-70% of selected patients, thereby representing the highest rate of conversion in minimally invasive surgery. Laparoscopic management of severe abdominal distension with massively dilated and fragile small-bowel or dense adhesions is extremely difficult even when performed by experienced surgeons. Significantly prolonged operating time, the high risk of bowel injury (> 6-10%) and an increased frequency of early reoperations jeopardize the patient's safe outcome. However, in strictly selected patients the laparoscopic approach may be promising. In acute intestinal obstruction without a history of previous abdominal surgery, laparoscopy is--in the absence of adhesions--an excellent diagnostic tool and may also be a successful therapeutic modality in a variety of bowel-obstruction etiologies. Furthermore, the laparoscopic option should be considered in patients who previously had undergone small laparotomies (e.g., appendectomy) or laparoscopic surgery. We recommend "postlaparoscopic" intestinal obstruction as the ideal case for laparoscopic reexploration. Incarcerated hernias at the site of trocar insertion or adhesions due to peritoneal tears are easily identified as the cause of obstruction and successfully cured with the laparoscope. In conclusion, we advocate the laparoscopic approach in acute small-bowel obstruction exclusively for selected patients. Clinical studies are required to define appropriate surgical indications objectively.

Neurotensin-related regulation of the postprandial lower-oesophageal-sphincter pressure.

BACKGROUND: Ingestion of food has been shown to modulate the lower-oesophageal-sphincter pressure (LESP). Fat is especially effective in decreasing the postprandial LESP. As there is good evidence that neurotensin (NT) is able to decrease the LESP, we conducted the present trial to determine whether NT could possibly be a mediator of the fat-induced decrease of the LESP. METHODS: Six half-breed dogs were fitted for cervical side-to-side oesophagostomy to allow repeated oesophageal intubation; plasma NT immunoactivity was recorded during infusion of NT and after intragastric instillation of 200 ml of a fat solution. Experiments were repeated, with the specific NT antibody GN25 administered intravenously. RESULTS: The optimal dose of NT required to simulate a postprandial situation was 50 pmol/kg/h. Infusion of this NT dose led to a statistically significant decrease of the LESP. Simultaneous administration of the NT antibody (immunoneutralisation) significantly inhibited this effect. Intragastric fat decreased the LESP and increased plasma NT. Immunoneutralisation of endogenously released NT led to an earlier restoration of baseline LESP, but this effect was not statistically significant. CONCLUSIONS: NT and intragastric fat modulate the LESP. NT appears to mediate the postprandial, fat-induced decrease of the LESP. Research with specific NT-receptor antagonists is necessary to determine the exact role of NT and other regulatory peptides in this context.

[Laparoscopic stoma technique]. / Laparoskopische Stomaanlage.

Laparoscopic stoma creation may be performed as an independent intervention, in combination with local anorectal procedures or as a part of complex laparoscopic intestinal operations. With the exception of specialized methods to preserve continence, every type of stoma formation can be performed laparoscopically. Indications for laparoscopic fecal diversion do not differ from open surgery. Apparent advantages are the limitation of the laparotomy to the location of the stoma, rapid return of bowel function and less postoperative discomfort and morbidity, especially when intestinal diversion is required as an independent procedure. Previous surgery is not a contraindication for the laparoscopic procedure. However, dense adhesions may compromise the ability to identify the bowel segment to be exteriorized and require adhesiolysis. Therefore, the risk of intra- and postoperative complications and the frequency of conversions (reported between 4.1 and 15.7%) is increased in patients with previous surgery. The overall rate of complications reviewed in the literature, including stoma-related problems, seems to be similar or superior to conventional laparotomy. Still, laparoscopic enterostomies are not routinely performed in most institutions. Presently available data are limited and randomized trials have not been performed. We recommend the use of laparoscopic techniques for fecal diversion in patients with intestinal obstruction requiring palliative treatment and in patients with high probability for future abdominal surgery, e.g. in Crohn's disease.

[Effect of ultrasonic diagnosis and incidence of appendectomy and laparoscopy]. / Einfluss der Sonographie auf Appendektomie und Laparoskopiefrequenz.

A total of 330 of 409 patients with suspected acute appendicitis were examined by ultrasound, and an appendectomy was performed in 146 patients. The negative appendectomy rate was 7% with preoperative ultrasound (n = 72) compared with 31% without (n = 74). Laparoscopy did not reduce the negative appendectomy rate, but was useful in patients with opposing clinical and sonographical findings.

[Appendectomy 1997--open or closed?]. / Appendektomie 1997--Offen oder geschlossen?

Unlike laparoscopic cholecystectomy, laparoscopic appendectomy (LAE) has not yet become popular. Are there no significant advantages? Or is the poor acceptance of LAE related to its longer learning curve, longer operative times and the need for additional equipment, which lead to some inconvenience when the procedure is done on an emergency basis? LAE may be performed as safely as open appendectomy (OAE) with fewer wound complications. Superior laparoscopic exploration allows an accurate diagnosis and reduces the rate of negative appendectomies. In contrast, postoperative pain, recovery and the cosmetic result are equal to or at best slightly better than in open surgery. Therefore, in the routine patients, there is no need to replace OAE by LAE. In the case of an uncertain diagnosis, the laparoscopic approach is generally superior, allowing thorough abdominal exploration. This has to be considered in each individual case; however, women with lower abdominal pain and suspected appendicitis will certainly benefit from laparoscopy, as well as older patients with an unclear diagnosis. The lower rate of wound infections is beneficial to obese patients and to patients with gangrenous or perforated appendicitis. Furthermore, the decision for one procedure or the other is influenced by the patient's individual preference and cosmetic aspects. The verifiable benefit of the laparoscopic procedure for certain categories of patients and the potential advantages in the individual case suggest that competent handling of laparoscopic technology will be required in future. Therefore, experienced surgeons should take more active interest in instruction and training--even when surgery has to be performed after hours.

[Manually assisted laparoscopic surgery--realistic evolution of the minimally invasive therapy concept? Initial experiences with the "Endohand"]. / Manuell assistierte laparoskopische Chirurgie--realistische Evolution des minimal-invasiven Therapiekonzepts? Erste Erfahrungen mit der "Endohand".

The essential limitations of laparoscopic procedures--lack of palpation, problematic retrieval of specimen and anastomosis, etc.--are abolished by the hand of the surgeon, which is inserted into the peritoneal cavity through a mini-laparotomy. While holding the pneumoperitoneum, the hand acts as an intelligent instrument performing surgical exploration, exposition of the field of operation, blunt dissection or intracorporal knot-tying. The mini-laparotomy is used to insert conventional instruments and suture material, as well as for specimen retrieval and anastomosis. Our preliminary experience (3x splenectomy, 2x sigmoid colectomy, 1x anterior resection of rectum, 1x proctocolectomy with J-pouch) shows that even extensive laparoscopic operations are accomplished much more simply. The time spent for such procedures is markedly reduced.

[Laparoscopic diagnosis and therapy of closed traumatic diaphragmatic rupture]. / Laparoskopische Diagnostik und Therapie geschlossener traumatischer Zwerchfellrupturen.

Diagnosis of blunt diaphragmatic rupture is still a challenging problem. This injury is generally treated by direct closure of the defect via a laparotomy or a thoracotomy. As it occurs frequently in severely traumatized patients, we wondered whether those patients could benefit from the well-known advantages of minimally invasive surgery. We report the records of two patients who underwent laparoscopy for blunt diaphragmatic hernia. In both patients, the hernia was laparoscopically closed without opening the abdomen. We did not see any intra- or postoperative complications related to minimally invasive surgery; the postoperative recovery was impressively short. Taking into account the fact that diaphragmatic ruptures are frequently misdiagnosed, we recommend laparoscopy as a useful tool in cases where these injuries may be suspected. In selected patients, primary closure of the defect may be achieved within the same laparoscopy so that laparotomy can be avoided.

Laparoscopic resection of pheochromocytoma.

The following case report presents the diagnostic procedures, laparoscopic therapy, and postoperative course of a 48-year-old patient with pheochromocytoma. During the previous 15 years, he had occasionally presented with hypertension, intermittent attacks of severe perspiration, and tachycardia; no diagnostic measures were performed at the time. During an ultrasound examination of the abdomen performed due to gastrointestinal complaints, a 5-cm adrenal tumor was discovered incidentally. Further diagnostic procedures then indicated the presence of a pheochromocytoma which was resected laparoscopically. The anesthesia was tolerated well, although isolated systolic blood pressure peaks to 200 mmHg were observed. The laparoscopic tumor resection presented no problems, although identifying the tumor proved to be difficult and resulted in an extended operation time of 4 h and 20 min. The postoperative course was unremarkable. This case report presents our laparoscopic technique and confirms that techniques proven in the "open" resection of a pheochromocytoma can also be utilized in the laparoscopic approach.

[New trends in biliary surgery]. / Neue Tendenzen in der Gallenchirurgie.

On the basis of the experience gained in 893 laparoscopic procedures performed on the gallbladder, and with increasing frequency on the bile-ducts, and on the basis of a comprehensive review of the literature from 1992 and 1993 pertaining to this subject, a critical analysis of laparoscopic gallbladder surgery has been accomplished. As substantiated by recent publications, laparoscopic cholecystectomy has achieved wide acceptance in surgical practice. Over the course of the last two years, discussion has focussed on the avoidance of injury caused by Veress needle and trocar puncture and specific pneumoperitoneum-associated complications, as well as the minimisation of overlooked and/or spilled bile-duct calculi and the avoidance of iatrogenic bile-duct injuries. Procedures to be taken in order to achieve the necessary improvement in laparoscopic cholecystectomy are described.

[Intraoperative cholangiography and anterograde bile duct exploration in laparoscopic cholecystectomy--technique, results, perspectives]. / Intraoperative Cholangiographie und anterograde Gallenwegsexploration bei laparoskopischer Cholezystektomie--Technik, Ergebnisse, Perspektiven.

The avoidance of (unrecognized) bile duct injuries (1) and the management of bile duct stones (pre-, intra- or postoperatively?) (2) are believed to be the main problems in laparoscopic cholecystectomy (LCE) at present. They must be a challenge for surgery to develop and improve the concepts of minimally invasive therapy for treatment of cholelithiasis. Intraoperative cholangiography (IOC) plays a very important role and is the basis of innovative, laparoscopically assisted procedures (3) for single session therapy of gallbladder and bile duct stones. (1) A detailed analysis of the literature proves the value of IOC for avoidance or early recognition of iatrogenic bile duct injuries. IOC is of most importance to compensate fundamental restrictions of the laparoscopic technique (missing possibility for palpation or anterograde preparation). IOC adds additional safety to the laparoscopic procedure and detects unsuspected bile duct stones. (2) At present, surgical management of cholecysto-/choledocholithiasis is split in two independent procedures: LCE and pre- or postoperative endoscopic retrograde cholangiography (ERC) with optional endoscopic papillotomy (EPT). A critical analysis of the literature and of the results of 623 LCE performed between 10/91 and 9/93 in the own institution leads to the following conclusions: Preoperative ERCs are performed unnecessary in about 50% of cases. They could be avoided by routine use of IOC. The combination of two independent procedures (LCE and ERC/PT) for treatment of cholelithiasis increases mortality and morbidity. Thus, the outcome of "therapeutic splitting" is not clearly superior to conventional treatment by open surgery.2+ common bile duct exploration allows final diagnosis and treatment in a single session. Additional risks and costs caused by choledochotomy as well as by pre- or post-operative endoscopic retrograde procedures (ERC, EPT) are avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

[Initial experiences with laparoscopic fundoplication]. / Erste Erfahrungen mit der laparoskopischen Fundoplikatio.

Over the past decade decreasing numbers of anti-reflux surgical procedures have been performed. The two main reasons are improved pharmacotherapeutics and the complication rate associated with anti-reflux surgery. But in patients who are medically refractory or in those requiring long-term medications the Nissen-Rossetti fundoplication still has its place in the therapy of reflux disease. Laparoscopic procedures have begun to replace many conventional operations and have pushed surgeons to use this technique in antireflux surgery. Since April '92 we planned laparoscopic Nissen-Rossetti fundoplications in 22 patients. 21 operations were carried out laparoscopically (1 conversion). There were no intraoperative complications. 1 patient suffered from 10 weeks dysphagia. Oesophagitis was healed in 19 patients and improved (grade IV to I) in 2 after 12 weeks. Our results demonstrate that laparoscopic fundoplication is a proven alternative to open surgery. In the future the possibility of avoiding costs and risks of lifelong drug therapy will help to establish well indicated laparoscopic fundoplication.