Video. Chopstick surgery: a novel technique enables use of the Da Vinci Robot to perform single-incision laparoscopic surgery.

INTRODUCTION: Single-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with "wristed" instruments could overcome this limitation but the "arms" collide when working coaxially. This video demonstrates a new technique of "chopstick surgery," which enables use of the robotic arms through a single incision without collision. METHODS: Experiments were conducted utilizing the da Vinci S® robot (Sunnyvale, CA) in a porcine model with three laparoscopic ports (12 mm, 2-5 mm) introduced through a single "incision." Pilot work conducted while performing Fundamentals of Laparoscopic Surgery (FLS) tasks determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, an experienced robotic surgeon performed a cholecystectomy and nephrectomy in a porcine model utilizing the "chopstick" technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This arrangement prevents collision of the external robotic arms. To correct for the change in handedness, the robotic console is instructed to drive the "left" instrument with the right hand effector and the "right" instrument with the left. RESULTS: Both procedures were satisfactorily completed with no external collision of the robotic arms, in acceptable times and with no technical complications. This is consistent with results obtained in the box trainer where the chopstick configuration enabled significantly improved times in all tasks and decreased number of errors and eliminated instrument collisions. CONCLUSION: Chopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery.

Laparoscopic resection of splenic artery aneurysms.

BACKGROUND: Laparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently. METHODS: A laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients. RESULTS: One patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 +/- 12.6 ml, the mean operative time was 187.6 +/- 79.2 min, and the mean postoperative length of hospital stay was 1.8 +/- 1.3 days. The mean time to a clear liquid diet was 5.3 +/- 0.5 h, and the mean time to a regular diet was 1 +/- 0 day. The mean duration of narcotic analgesic use was 5.4 +/- 1.5 days, and the mean time to resumption of regular activities was 12.7 +/- 1.6 days. CONCLUSIONS: These cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.

Minilaparoscopic appendectomy.

The purpose of this study was to evaluate the feasibility of using 2-mm laparoscopic instruments in the treatment of appendicitis and to identify risk factors that may limit their use. Minilaparoscopic appendectomy was performed through a 2-mm port in the umbilicus for a videoendoscope, a 2-mm working port in the right upper quadrant, and a 5/12-mm suprapubic port for an endoscopic stapler. Minilaparoscopic appendectomy was attempted in 26 consecutive patients with appendicitis. Thirty-two consecutive patients undergoing conventional laparoscopic appendectomy with 5- and 10-mm instruments and videoendoscopes before the availability of 2-mm instrumentation were analyzed for comparison. Statistical comparisons were made by the Student t test and Fisher exact test. Differences were considered statistically significant at a P value less than 0.05. There were no conversions to an open appendectomy in the minilaparoscopic appendectomy or conventional laparoscopic appendectomy group. The mean operative time was 69.5 minutes for the minilaparoscopic appendectomy group and 85.5 minutes for the conventional laparoscopic appendectomy group (P = 0.02). The mean postoperative length of stay was 1.7 days for the minilaparoscopic appendectomy group and 2.5 days for the conventional laparoscopic appendectomy group (P = 0.08). There was no significant difference in the complication rates (P = 0.31). Minilaparoscopic appendectomy was completed in 13 (50.0%) patients. Independent risk factors (P = 0.05) for conversion to 5- or 10-mm ports were a retrocecal appendix and increasing patient age. There were no differences in the mean postoperative length of stay (P = 0.12) or complication rate (P = 0.39) between the two groups, but mean operative time was longer (P = 0.05) in the converted group. Perioperative outcomes for minilaparoscopic appendectomy are comparable to those of conventional laparoscopic appendectomy. The use of 2-mm instrumentation in the management of appendicitis is limited in patients with retrocecal appendicitis. Increasing patient age and a history of abdominal surgery may influence the need to convert 2-mm ports to 5- or 10-mm ports.

Geometry and reproducibility in 360 degrees fundoplication.

BACKGROUND: In this study, we set out to precisely define two symmetrical points-a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or "floppy") 360 degrees fundoplication (FP). METHODS: For the terms of this study, circumference = c; diameter = d; c/d = pi; pi = 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n = 5) and intraoperatively (n = 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c. RESULTS: The smallest measured value for c was 7.5 cm (d = 2.39 cm); the largest value for c was 10.0 cm (d = 3.18 cm). The mean value was 8.35 cm (d = 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d = 2.66 cm. This technique creates a correctly oriented, symmetrical, "floppy," true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible. CONCLUSIONS: Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a "floppy" 360 degrees fundoplication.

Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation.

BACKGROUND: Laparoscopy has potential benefit in the placement of ventriculoperitoneal shunts. In patients who have undergone multiple shunt revisions or other abdominal operations, laparoscopy may be particularly beneficial when finding of a suitable area in which to place the shunt is a concern. The purpose of this study was to evaluate the safety and effectiveness of laparoscopically assisted ventriculoperitoneal shunt placement, with an emphasis on using 2-mm instrumentation. METHODS: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation was performed in eight adult hydrocephalus patients from August 1996 to September 1998. All eight patients had undergone 1 to 18 prior shunt revisions. The procedures were performed with two 2-mm trocars. The instrumentation consisted of a 2-mm laparoscope, a 2-mm grasper, and 2-mm scissors. All shunts were placed in an area free of adhesions and checked for flow under direct vision. Four of the patients required a lysis of adhesions to create a space adequate for catheter placement. RESULTS: All of the procedures were successful, with no operative complications. The operative times ranged from 29 to 99 min, (mean, 63 min). The blood loss in all of the procedures was minimal. At this writing, none of the patients have required subsequent distal shunt revisions. No conversions to larger instruments or an open procedure were required. CONCLUSIONS: Laparoscopically assisted ventriculoperitoneal shunt placement using 2-mm instrumentation is safe and effective, offering several advantages over the open procedure. This procedure is ideal for the use of 2-mm instruments.

Left thoracoscopic sympathectomy and stellate ganglionectomy for treatment of the long QT syndrome.

The long QT syndrome (LQTS) is a rare inherited cardiac disorder that may induce fatal cardiac arrhythmias. Patients diagnosed with this disorder generally have several treatment options, including beta-blockade, cardiac pacing, an implantable automatic defibrillator, or a high thoracic left sympathectomy. We report the case of a 6-year-old girl with the LQTS treated by left thoracoscopic sympathectomy and stellate ganglionectomy. The procedure was performed after an initial thorascopic attempt at another institution failed due to inadequate resection of the sympathetic chain. Operative time was 85 min and blood loss was minimal. There were no intraoperative or postoperative complications. The girl's QT interval decreased and she was discharged on the 4th postoperative day. After 9 months of follow-up, she remains asymptomatic. We conclude that the LQTS patients who fail medical treatment can be treated successfully with left thoracoscopic cervicothoracic sympathectomy. We recommend that the extent of sympathectomy for treating the LQTS be T1-T4 and either the entire stellate ganglion or at least the inferior one-third.

Transjugular intrahepatic portosystemic shunt for recurrent hepatic hydrothorax.

For many years, pleural effusions have been recognized as a complication of cirrhosis, occurring in approximately 5.5% of patients. Recent studies have confirmed that small defects in the diaphragm allow for passage of ascitic fluid into the pleural space. Successful management of these patients is challenging, as many of the treatment options can be associated with increased morbidity. The initial treatment should focus on eliminating and preventing the recurrence of ascites with diuretics and water and salt restriction. For those patients who do not respond medically, more invasive techniques have been used including serial thoracentesis, chest tube placement, chemical pleurodesis, and peritoneovenous shunts. We present a patient with recurrent pleural effusions secondary to hepatic cirrhosis who was unsuccessfully treated medically, and subsequently treated with thoracentesis, chest tube drainage and pleurodesis, with ultimate resolution after transjugular intrahepatic portosystemic shunt placement.

Laparoscopic Nissen fundoplication: a technique for the easy and precise manufacture of a true fundoplication.

Passing the stomach behind the esophagus during laparoscopic Nissen fundoplication is a common source of frustration for the laparoscopic surgeon. It often leads to an incorrect formation of the fundoplication, resulting in a wrapping or twisting of the fundus around the distal esophagus. The correct technique should result in the distal esophagus being enveloped inside the fundus without distorting the orientation of the greater curve. We have developed an easy, precise, and reproducible technique to perform this maneuver. The steps for performance of this maneuver are described.

Esophagectomy after pneumonectomy: a surgical challenge.

Esophagectomy after pneumonectomy has been reported rarely, and the surgical approach presents a challenge. We report a case of a transthoracic esophagectomy in a 54-year-old man who had undergone right pneumonectomy for non-small cell lung cancer 16 years previously.

Surgical experience with nonfunctioning neuroendocrine tumors of the pancreas.

Nonfunctioning neuroendocrine tumors of the pancreas are rare slow-growing tumors with a more indolent natural history compared with pancreatic adenocarcinoma. This retrospective report reviews the surgical experience with nonfunctioning neuroendocrine tumors in an academic referral center. Statistical analysis was performed using Student's t test and Kaplan-Meier method compared with log-rank tests. Thirty-eight patients (24 males and 14 females) underwent surgery for a neuroendocrine tumor of the pancreas from 1984 through 1999. Twenty-eight patients with a mean age of 59.9 years had nonfunctioning islet cell tumors and 10 patients with a mean age of 59.1 years had functioning islet cell tumors (four gastrinomas, three glucagonomas, two insulinomas, and one vipoma). The nonfunctioning islet cell tumors were located in the head, neck, or uncinate process in 14 patients (50%), the body in seven (25%), and the tail in seven (25%). Operative procedures for the nonfunctioning islet cell tumors included nine pancreaticoduodenectomies, 12 distal pancreatectomies, three palliative bypasses, and four exploratory laparotomies without a resection or bypass. Mean survival for the four patients explored and not resected or bypassed was 7 months. Median survival for node-negative patients was 124 months, for node-positive patients 75 months, and for patients with metastasis to the liver 9 months. Estimated 2-year actuarial survival for the node-negative patients was 77.8 per cent, for node-positive patients 71.4 per cent, and for patients with metastasis to the liver 36.4 per cent. Six patients (60%) with node-negative disease, three (43%) with node-positive disease, and one (9%) with metastasis to the liver are alive at a mean follow-up of 41.8 months (range 1-167). Significant differences in median survival and 2-year survival were demonstrated between the node-positive/node-negative patients and those with metastasis to the liver (P = 0.003). Patients with localized nonmetastatic disease should be considered for pancreatic resection as estimated median survival is 75 months or greater. Hepatic metastasis is a major predictor of survival.

Outpatient endoscopic thoracic sympathectomy using 2-mm instruments.

BACKGROUND: For a long time it has been known that sympathectomy is an effective treatment for hyperhidrosis and other conditions. The surgical options available until recently usually have required thoracotomy or large posterior incisions, and physicians generally have been reluctant to recommend surgery for most patients with "benign" disorders. Recently, thoracoscopic techniques have allowed surgeons to offer these patients a permanent solution with minimal surgical trauma. METHODS: In 20 patients, 30 endoscopic thoracic sympathectomies (ETS) were performed for several indications. Nine patients had bilateral sympathectomies. The procedures were performed on the day of admission, with the patient under general anesthesia using double lumen endotracheal intubation and hand temperature monitoring. Each lung was reinflated on completion of the sympathectomy, and residual pneumothorax aspirated before closure of the incisions. No placement of chest tubes was performed in the operating room. RESULTS: All sympathectomies were completed thoracoscopically. There were no major complications, and 90% of the patients were discharged within 24 hours of admission. The average operative time was 69 min. CONCLUSIONS: Findings from this study show that ETS is a safe and effective procedure that can be performed routinely on an outpatient basis. The use of miniendoscopic (2-mm) instrumentation is safe and effective in most patients and a helpful adjunct in providing these patients with minimally traumatic surgery. Long-term results should be evaluated on the basis of specific indications for sympathectomy.

Mini-laparoscopic cholecystectomy: validating a new approach.

Advances in instrumentation have led to the development of 2-mm laparoscopic equipment. The purpose of our investigation was to validate the safety and efficacy of laparoscopic cholecystectomy (LC) using one 10-mm and three 2-mm ports (mini-LC). Mini-LC was performed using a 2-mm fiberoptic videolaparoscope inserted via a midepigastric port, 2-mm graspers inserted via right upper quadrant ports, and standard dissection, clipping, and cautery instruments inserted via the umbilical port. Data from 100 sequential patients were acquired between July 1996 and August 1997 and compared with those of 100 sequential patients who had undergone conventional LC (C-LC). The operative time ranged from 30 to 256 minutes for the mini-LC group and 25 to 255 minutes for the C-LC group, with means of 89 and 82 minutes, respectively (P > 0.05). Postoperative length of stay ranged from 0 to 18 days for the mini-LC group and 0 to 21 days for the C-LC group, with means of 1.5 and 1.9 days, respectively (P > 0.05). There were no conversions to open cholecystectomy. These data suggest that a more minimalist approach to laparoscopic cholecystectomy can be accomplished safely and effectively.

Completely laparoscopic resection of a rare pyloric tumor with laparoscopically sutured gastroduodenostomy.

We report the case of a 31-year-old woman who presented with epigastric pain and weight loss. Esophagogastroduodenoscopy revealed a submucosal mass in the distal antrum and pylorus. Endoscopic biopsy of the mass was nondiagnostic. A CT scan confirmed a 3.0-cm mass in the posterior wall of the distal antrum. She underwent laparoscopic resection of the distal antrum and pylorus with end-to-end gastroduodenostomy. Pathologic examination showed an adenomyoma of the antrum and pylorus. Her postoperative course was uncomplicated, and she continues to do well 38 months postoperatively. Gastric adenomyoma is a rare, benign intramural tumor of the antrum and pylorus. Fewer than 40 cases have been described in the literature. The lesions are generally within 4 cm of the pylorus. Histologically, they are characterized by ductal structures lined by cuboidal to columnar epithelium surrounded by smooth muscle bundles and, occasionally, Brunner's-type glands and heterotopic pancreas. Treatment is by resection, and recurrence has not been reported. Laparoscopic resection of portions of the stomach has been reported. Side-to-side gastrojejunostomies (Billroth II) performed laparoscopically have been reported. This is the first report in the English-language literature of a completely laparoscopically performed sutured gastroduodenostomy. Technical details of the procedure and adenomyomas are discussed.

Thoracoscopic repair of a recurrent diaphragmatic hernia four years after initial trauma, laparotomy, and repair.

Traumatic diaphragmatic hernia is not an uncommon problem and has been noted after either penetrating or blunt trauma. A high index of suspicion must be maintained in order to identify patients with this injury, as delay in identification may result in significant morbidity and death. It is essential that a thorough evaluation be performed, and if a diaphragmatic hernia is found, surgical repair is necessary. We present a case of thoracoscopic repair of an incarcerated recurrent diaphragmatic hernia appearing several years after successful open (via laparotomy) repair of an acute blunt traumatic hernia. A brief review of the surgical literature is also presented. With the broadening use of minimally invasive surgical techniques, we feel that their application to the repair of chronic diaphragmatic hernia is safe and effective, reduces morbidity, and results in a faster recovery.

Thoracoscopic approach to posterior mediastinal neurogenic tumors in the adult.

Although neurogenic tumors are the most frequent posterior mediastinal tumors, few reports exist on thoracoscopic resection, and methods are not yet standardized. Two cases of thoracoscopic resection of benign posterior mediastinal schwannomas are presented. We believe that in carefully selected patients, thoracoscopic resection can be performed easily and with minimal morbidity.

Feasibility of laparoscopic cholecystectomy with miniaturized instrumentation in 50 consecutive cases.

A new technique utilizing miniaturized (2 mm) instrumentation to perform laparoscopic cholecystectomy (LC) is introduced. The safety and efficacy of this mini-LC were assessed. Fifty consecutive mini-LCs were performed using one 10-mm port and three 2-mm ports (cumulative port size 16 mm). A 2-mm fiberoptic video-laparoscope was placed in the mid-epigastrium through a 2-mm port. A 10-mm umbilical port was then placed under direct visualization, allowing access for standard laparoscopic instruments. Two additional 2-mm ports were placed in the right upper quadrant allowing insertion of grasping instruments. Parameters reviewed included total operative time (OT), postoperative length of stay (LOS), anatomic pathology, complications, and rate of conversion to conventional LC and open cholecystectomy. Results were compared to those of 50 consecutive conventional LCs using two 10-mm and two 5-mm ports (cumulative port size 30 mm). The OT for the mini-LC and conventional LC were 88 +/- 5.9 and 78 +/- 5 minutes (mean +/- SD), respectively, (p = NS), and postoperative LOS for the mini-LC and conventional LC were 1.5 +/- 0. 2 and 1.8 +/- 0.4 days (mean +/- SD), respectively, (p = NS). Of the 50 mini-LC cases, 5 required conversion to conventional LC. One cystic duct leak was detected and successfully treated conservatively; no common bile duct injuries occurred; and no patients required conversion to open cholecystectomy. This study demonstrates the safety and efficacy of minilaparoscopic instruments for the performance of cholecystectomy. The data reveal that this new technique is comparable to conventional LC.