Use of fluorescence imaging and indocyanine green for sentinel node mapping during gastric cancer surgery: Results of an intercontinental Delphi survey.

BACKGROUND: Understanding the extent of tumor spread to local lymph nodes is critical to managing early-stage gastric cancer. Recently, fluorescence imaging with indocyanine green has been used to identify and characterize sentinel lymph nodes during gastric cancer surgery, but no published guidelines exist. We sought to identify areas of consensus among international experts in the use of fluorescence imaging with indocyanine green for mapping sentinel lymph nodes during gastric-cancer surgery. METHODS: In this 2-round, online Delphi survey, 27 international experts voted on 79 statements pertaining to patient preparation and contraindications to fluorescence imaging with indocyanine green during gastric cancer surgery; indications; technical aspects; advantages/disadvantages and limitations; and training and research. Methodological steps were adopted during survey design to minimize bias. RESULTS: Consensus was reached on 61 of 79 statements, including giving single injections of indocyanine green into each of the 4 quadrants peritumorally, administering indocyanine green on the same day as surgery, injecting a total of 1 to 5 mL of 5 mg/mL indocyanine green, injecting endoscopically into submucosa, and repeating indocyanine green injections a second time if sentinel lymph node visualization remains inadequate. Consensus also was reached that fluorescence imaging with indocyanine green is an acceptable single-agent modality for sentinel lymph node identification and that the sentinel lymph node basin method is preferred. However, sentinel lymph node dissection should be limited to T1 gastric cancer and tumors ≤4 cm in diameter, and further research is necessary to optimize the technique and render fluorescence-guided sentinel lymph nodes dissection acceptable for routine clinical use. CONCLUSION: Although considerable consensus was achieved, further research is necessary before this technology should be used in routine practice.

Fluorescence-guided surgery of the esophagus.

The use of indocyanine green (ICG) fluorescence near-infrared (NIR) imaging during gastrointestinal surgery has surged in recent years. Its use in esophageal surgery is actively being studied both in the clinical setting and in the lab. NIR imaging has several important applications in esophageal surgery including assessing perfusion of the gastrointestinal-esophageal anastomosis, lymphatic drainage and tracheal blood flow after mediastinal dissection. This is a review of the modern literature summarizing the current knowledge on fluorescence-guided surgery of the esophagus.

The Use of Fluorescence Imaging in Colon Interposition for Esophageal Replacement: A Technical Note.

Every field of surgery has seen an explosion of new technologies aimed at improving surgical technique and reducing complications. The use of near-infrared (NIR) fluorescence to assess perfusion has been described in several surgical disciplines. NIR provides the surgeon with real-time perfusion assessment of a target organ or anastomosis and can be invaluable in aiding decision-making during the index operation. In the following article we discuss the use of fluorescence-guided perfusion assessment during colonic interposition for esophageal replacement. To our knowledge this is the first description of the use of fluorescence-guided perfusion assessment during colonic interposition.

Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study.

BACKGROUND: Our primary objective was to demonstrate the utility and feasibility of the intraoperative assessment of colon and rectal perfusion using fluorescence angiography (FA) during left-sided colectomy and anterior resection. Anastomotic leak (AL) after colorectal resection increases morbidity, mortality, and, in cancer cases, recurrence rates. Inadequate perfusion may contribute to AL. The PINPOINT Endoscopic Fluorescence Imaging System allows for intraoperative assessment of anastomotic perfusion. STUDY DESIGN: This is a prospective, multicenter, open-label, clinical trial that assessed the feasibility and utility of FA for intraoperative perfusion assessment during left-sided colectomy and anterior resection at 11 centers in the United States. RESULTS: A total of 147 patients were enrolled, of whom 139 were eligible for analysis. Diverticulitis (44%), rectal cancer (25%), and colon cancer (21%) were the most prevalent indications for surgery. The mean level of anastomosis was 10 ± 4 cm from the anal verge. Splenic-flexure mobilization was performed in 81% and high ligation of the inferior mesenteric artery in 61.9% of patients. There was a 99% success rate for FA, and FA changed surgical plans in 11 (8%) patients, with the majority of changes occurring at the time of transection of the proximal margin (7%). Overall morbidity rates were 17%. The anastomotic leak rate was 1.4% (n = 2). There were no anastomotic leaks in the 11 patients who had a change in surgical plan based on intraoperative perfusion assessment with FA. CONCLUSIONS: PINPOINT is a safe and feasible tool for intraoperative assessment of tissue perfusion during colorectal resection. There were no anastomotic leaks in patients in whom the anastomosis was revised based on inadequate perfusion with FA.

A novel adaptor converts a laparoscope into a high-definition rigid sigmoidoscope.

The rigid sigmoidoscope is an important tool in a surgeon's armamentarium, yet it has remained essentially unchanged despite poor imaging and the inability to project or record the images. Herein we report our initial experience with a novel introducer built from readily available operating room supplies and designed to convert any standard laparoscope into a high-definition rigid sigmoidoscope.

Transanal near-infrared imaging of colorectal anastomotic perfusion.

The influence of perfusion on colorectal anastomotic healing and, conversely, the role of ischemia in anastomotic dehiscence have been reported by many investigators, and yet identifying a modality that can evaluate perfusion in real time and thus guide intraoperative management has proven elusive. This study describes our initial experience using transanal near-infrared (NIR) imaging to evaluate anastomotic perfusion after colorectal anastomoses. Patients undergoing colectomy with an anastomosis within 25 cm of the anal verge were included in this study. A transanal NIR system was used to assess mucosal perfusion at the level of the anastomoses. The rectum was easily navigated under direct vision and the anastomotic staple line visualized. High-quality NIR mucosal angiography was obtained in all subjects, confirming that transanal NIR angiography is feasible and simple to perform. Although NIR mucosal angiography is a promising modality, further study is needed to correlate this technique to the clinical outcome.

Identification of anomolous biliary anatomy using near-infrared cholangiography.

BACKGROUND: Intraoperative cholangiography (IOC) is especially helpful for the detection of anomalous biliary anatomy during laparoscopic cholecystectomy. Fluorescent cholangiography using an intravenously injected fluorophore and near-infrared (NIR) imaging provides similar anatomical detail to standard radiographic cholangiography without ionizing radiation, puncture of the biliary system, or additional operative time. This video shows a laparoscopic cholecystectomy performed under NIR cholangiographic guidance and highlights its ability to identify anomalous anatomy. METHODS: The attached video shows a laparoscopic cholecystectomy being performed on a 28-year-old female with a history of biliary colic and ultrasonographic evidence of cholelithiasis. This patient agreed to be part of a larger randomized study looking at near-infrared cholangiography and its ability to prevent common bile duct injuries (approved by the ethics review board of our institution and registered with clinicaltrials.gov Identifier# NCT01424215). This study uses the Pinpoint system (Novadaq, Ontario, Canada) for NIR imaging (Fig. 1). The Pinpoint mates a high definition white light laparoscopic view to the NIR cholangiography, providing an uninterrupted, augmented view of the anatomy. 1 cm(3) of indocyanine green was injected intravenously prior to the procedure. RESULTS: As shown in the video, an anomalous duct was identified during dissection and development of the critical view of safety. Because of the possibility that this represented an aberrant right hepatic duct, the cystic duct was controlled and divided distal to the anomalous duct and the gall bladder excised from the fossa in the usual manner. The patient did well without sequelae at 1 week and 1 month follow-up. CONCLUSION: Anomolous ductal anatomy of the biliary tree has been reported in up to 23 % of cases.1,2 The ability of IOC to elucidate biliary anatomy and thus prevent bile duct injury has led many to espouse routine cholangiography for all laparoscopic cholecystectomies.3,4 Near-infrared cholangiography (NIRC) is easy to perform, does not add steps to the operative procedure, and produces a similar anatomic roadmap of the hepatocystic triangle to that of standard IOC. Although the clinical significance of the anomalous duct identified in this video is unknown, this video highlights the excellent detail provided by NIRC. Recommendations regarding the routine use of this new technology await the results of an ongoing randomized control study.

Laparoscopic distal pancreatectomy.

BACKGROUND: Laparoscopic management of distal pancreatic malignancies has been slow to gain a foothold in all but high-volume tertiary referral centers. The aim of this study was to assess the safety and outcomes of laparoscopic distal pancreatectomy (LDP) performed in a low-volume community hospital by a diverse group of surgeons, none of whom have a specialized laparoscopic background. METHODS: We conducted a retrospective review of all patients who underwent open distal pancreatectomies (ODPs) and LDPs between August 2001 and June 2008. Data included type of surgery, open versus laparoscopy, demographics, operative time, blood loss, length of hospital stay, histopathologic diagnosis, postoperative complications, American Society of Anesthesiologists score, and mortality. RESULTS: Twenty-seven patients with pancreatic masses underwent distal pancreatic resection during the study period. Fifty-nine percent (n = 16) underwent LDP, and 41% (n = 11) underwent ODP. Mean patient age was 66 y (range, 40 to 86) for the LDP group and 62 (range, 40 to 84) for the ODP group. Mean operative time was 231 min (range, 195 to 305) for LDP and 240 (range, 150 to 210) for the ODP technique. Mean length of stay for LDP and ODP was 8 (range, 3 to 22) and 12 d (range, 5 to 2), respectively. Morbidity was 25% (n = 4) in the LDP group and 36% (n = 4) in the ODP group. None of the differences between the LDP and ODP groups were statistically significant. No mortalities occurred in either group. CONCLUSION: This study supports the idea that LDP can be safely and effectively performed by any surgeon comfortable with basic laparoscopy and may not require specialized training or a specialized center. Further data are required to make more definitive conclusions.

A novel retraction instrument improves the safety of single-incision laparoscopic cholecystectomy in an animal model.

INTRODUCTION: Single-incision laparoscopic cholecystectomy (SILC) promises improved cosmesis and may further minimize the invasiveness of intraabdominal interventions but cannot come at the expense of patient safety. This study describes the evaluation of a novel 5-mm instrument designed for SILC that maintains an equivalent critical view to that obtained with standard multiport laparoscopic cholecystectomy (MLC). MATERIALS AND METHODS: Sixteen animals were randomly assigned to one of four study arms. Four techniques for laparoscopic cholecystectomy were used: standard four-port MLC, three-instrument SILC (SILC-A), three-instrument SILC using a suture for lateral retraction (SILC-B), and three-instrument SILC using the novel instrument for retraction (SILC-C). Each case was timed and video-recorded. The video was cropped to obscure the method of retraction and evaluated by five experienced laparoscopic surgeons blinded to the technique used. Each case was rated subjectively on a safety and visualization scale of 1-4. RESULTS: SILC-A and SILC-B cases were significantly longer in duration than both SILC-C and MLC cases. The safety and visualization scale results were lower for the SILC-A technique but were equivalent for the MLC, SILC-B, and SILC-C techniques. CONCLUSION: This study introduces a novel instrument for gallbladder retraction. In this initial evaluation, the new instrument showed encouraging results in its ability to generate good visualization, support the safe critical view technique, and reduce the length of the procedure.

Natural orifice translumenal endoscopic surgery inguinal hernia repair: a survival canine model.

INTRODUCTION: With over 20 million repairs performed worldwide annually, inguinal hernias represent a significant source of disability and loss of productivity. Natural orifice translumenal endoscopic surgery (NOTES™), as a potentially less invasive form of surgery may reduce postoperative disability and accelerate return to work. The objective of this study was to assess the safety and short-term effectiveness of transgastric inguinal herniorrhaphy using a biologic mesh in a survival canine model. MATERIALS AND METHODS: Under general anesthesia with the animal in Trendelenburg position, a gastrostomy was created. A 4 × 6 cm acellular dermal implant was deployed endoscopically across the myopectineal orifice, draped over the cord structures, and secured with Bioglue. Following completion of bilateral repairs the animals were survived for 14 days. At the end of the study period, the animals were euthanized and a necropsy performed. Cultures of a random site within the peritoneal cavity and at the site of implant deployment were obtained. In addition, a visual inspection of the peritoneal cavity was performed. RESULTS: All animals thrived postoperatively and did not manifest signs of peritonitis or sepsis at any point. At necropsy accurate placement and adequate myopectineal coverage was confirmed in all subjects. Cultures of a random site within the peritoneal cavity and at the site of implant deployment had no growth. DISCUSSION: This study confirms that NOTES-inguinal herniorrhaphy using a biologic implant can be performed safely. In addition, the transgastric technique provided good short-term myopectineal coverage without infectious sequelae.

Transitioning to single-incision laparoscopic inguinal herniorrhaphy.

BACKGROUND: Laparoendoscopic single-site surgery (LESS) offers cosmetic benefits and may represent further progress towards reducing the invasiveness of surgical interventions. We report our initial experience with LESS totally extraperitoneal (TEP) inguinal herniorrhaphy. MATERIALS AND METHODS: Beginning March 2009, we transitioned from a multiport laparoscopic TEP (MLH) technique to a single-incision TEP (SITE) technique. The first 52 consecutive patients who underwent SITE at our institution were compared with the preceding 52 MLH repairs. RESULTS: Of the first 52 patients undergoing SITE, there were no conversions to either open or multiport surgery. The mean operative time for the SITE cases did not differ significantly from that of MLH. Complications were equivalent between the 2 groups and included postoperative seroma and urinary retention. CONCLUSIONS: Transitioning from MLH to SITE was readily accomplished without significantly altering operative time or morbidity.

Evaluation of a modified circular stapler for use as a viscerotomy formation and closure device in natural orifice surgery.

BACKGROUND: The most challenging of the many hurdles surgeons must overcome to perform natural orifice translumenal endoscopic surgery (NOTES) safely is viscerotomy closure. The perfect device must be easy to deploy, suitable for use on any viscera, and able to create a rapid, reliable, and durable closure. The authors developed a novel device based on an existing circular stapler platform to create and then subsequently close a viscerotomy. The device was tested initially on an ex vivo porcine stomach model, then used on a survival canine model to confirm adequacy of gastric closure and rapidity of deployment. METHODS: Three study arms, each containing five stomachs, were used. For the experimental arm, a Surgassist (PMI, Langhorne, PA, USA) powered circular stapler (EEA) modified with an auger tip and premounted endoloops was used. This novel device was compared with two gold standard closure techniques: hand-sewn two-layer closure and linear stapled closure. Each stomach then was inflated slowly with dye, and the pressure at which each closure leaked was recorded. For evaluation of the closure's durability and ease of use, five mongrel dogs undergoing transgastric intraabdominal surgery had their gastrotomy formed and closed using the modified Surgassist stapler. Each animal was survived 14 days, then killed, after which a necropsy was performed. RESULTS: In the ex vivo model, the modified PMI EEA consistently achieved burst pressures exceeding 260 mmHg, which was statistically significant compared with either the hand-sewn closure or the linear stapled closure. In the survival group, all the animals survived for the 2-week study period without signs of sepsis. At necropsy, the closures were found to be intact. CONCLUSION: The prototype transvisceral purse-string device consistently produced a tight, safe, and reliable closure. It can be deployed and cinch-closed rapidly. This study suggests that this new device may be a promising option for use in NOTES.

Experimental in vivo canine model for gastric prolapse of laparoscopic adjustable gastric band system.

BACKGROUND: The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse. METHODS: The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm(3) was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus. RESULTS: Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve. CONCLUSION: The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.

Feasibility study of natural orifice transluminal endoscopic surgery inguinal hernia repair.

BACKGROUND: A potentially less-invasive technique, transluminal surgery, may reduce or eliminate pain and decrease time to full return of activities after abdominal operations. Inguinal hernia repair is perfectly suited to the transgastric endoscopic approach and has not been previously reported. OBJECTIVE: Our purpose was to evaluate the feasibility of transgastric bilateral inguinal herniorrhaphy (BIH). DESIGN: Feasibility study with a nonsurvival canine model. INTERVENTIONS: Under general anesthesia, male mongrel dogs weighing 20 to 30 kg had a dual-channel endoscope introduced into the peritoneal cavity over a percutaneously placed guidewire. An overtube with an insufflation channel was used. Peritoneoscopy was performed, and bilateral deep and superficial inguinal rings were identified. The endoscope was removed, premounted with a 4 x 6 cm acellular human dermal implant and then readvanced intraperitoneally through the overtube. The implant was then deployed across the entire myopectineal orifice and draped over the cord structures. Bioglue was then applied endoscopically, and the implant was attached to the peritoneum. After completion of bilateral repairs, the animals were killed and necropsy performed. RESULTS: Five dogs underwent pure natural orifice transluminal endoscopic surgery (NOTES) intraperitoneal onlay mesh (IPOM) BIH. Accurate placement and adequate myopectineal coverage was accomplished in all subjects. At necropsy no injuries to the major structures were noted but Bioglue misapplication with contamination of unintended sites did occur. LIMITATIONS: Our study involved only a small number of subjects in nonsurvival experiments, and no gastric closure was used. CONCLUSIONS: Many of the characteristics of inguinal hernia repair are especially well suited to the transgastric approach. The repair is in line with the transgastric endoscope vector, bilateral defects are adjacent, and the IPOM technique does not require significant manipulation or novel instrumentation.

Continuous infusion of intraperitoneal bupivacaine after laparoscopic surgery: a randomized controlled trial.

BACKGROUND: A standard approach for postoperative analgesia in laparoscopic surgery is to infiltrate the incisions with local anesthetic in combination with systemic opioids. The intraperitoneal introduction of local anesthetic in this setting has the potential to provide appropriate analgesia without the side effects of systemic opioids. We performed a randomized clinical trial of the On-Q pump delivery system to determine the safety and efficacy of this device for this novel purpose. METHODS: Thirty patients undergoing laparoscopic adjustable gastric banding were randomly assigned to one of two groups. The treatment group received On-Q pump systems filled with 0.375% bupivacaine, while the control group received pumps filled with 0.9% normal saline. The pump's catheter was introduced intraperitoneally, and bupivacaine or saline was then delivered for the first 48 h after surgery. Patient's subjective pain scores were evaluated at preset intervals. In addition, shoulder pain, morphine requirements, and anti-emetic requirements were tabulated. RESULTS: A statistically significant decrease in patient's subjective reports of pain by visual analog score was noted in the On-Q group 1.8+/-1.93 vs. control 3.5+/-2.4, p<0.046 and remained significant until the end of the study (48 h). No statistical difference was noted in shoulder pain, morphine requirements, or anti-emetic requirements at any time point. CONCLUSION: Our trial was able to provide evidence of significant reduction in postoperative pain as measured by subjective pain scores with the use of continuous intraperitoneal bupivacaine using the On-Q pain pump system. Further investigation is warranted to evaluate the cost effectiveness of this technique.

Thrombosis of the Lap-Band system.

BACKGROUND: The laparoscopic adjustable gastric band (LAGB) has proven itself a procedure with excellent long-term weight loss results and extremely low morbidity and mortality. The LAGB has become an indispensable addition to the armamentarium of most bariatric surgeons. Commonly reported complications associated with the lap band system include gastric prolapse, band erosion, hardware infection, and port/tubing leakage. METHODS: We report a case of a patient suspected of having a Lap-Band leak. He presented with a clinical course of multiple adjustments without restriction and inability to aspirate the expected volume from the band. Following adjustment under fluoroscopy he became severely dysphagic. He underwent urgent operative exploration and was found to have an intact but overinflated band. Under close inspection, a clot in the proximal band was noted, acting as a ball valve allowing the addition of fluid but not aspiration. CONCLUSIONS: This case highlights an unusual explanation for what is thought of as typical signs of band leakage. In addition it raises serious questions about the importance of preventing blood and particulate matter from entering the Lap-Band system both at the initial operation and at subsequent adjustments.

Posterior prolapse: an important entity even in the modern age of the pars flaccida approach to lap-band placement.

BACKGROUND: The most prevalent long-term complications in patients who undergo laparoscopic adjustable gastric band (LAGB) surgery are pouch dilatation and gastric prolapse (slippage). Gastric prolapse can be divided into the anterior and posterior variety. Posterior prolapse is thought to be specific to the perigastric approach due to a lack of posterior band fixation. We report a series of 3 patients out of 1,104 who underwent LAGB placement using the pars flaccida approach and developed a posterior prolapse. METHODS: Between March 2002 and December 2005, 1,104 patients underwent LAGB insertion using the pars flaccida approach at our institution. 3 patients (0.27%) developed posterior prolapse requiring reoperation. RESULTS: All 3 patients presented with similar complaints, including solid food intolerance, gastroesophageal reflux and/or regurgitation. Although identical to those reported with anterior prolapse, diagnosis was definitively made with barium video esophagogram. All patients were treated with reoperation, but band replacement was impossible in 2 of the 3 cases secondary to extensive adhesion formation. CONCLUSION: The finding of 3 patients who experienced posterior prolapse, despite using the pars flaccida approach, highlights the fact that this complication although diminished, has not been eliminated as previously thought. We describe the presentation, work-up, and management of this rare but important entity in the modern era of LAGB.