Mini-laparoscopic placement of a peritoneal dialysis catheter.

BACKGROUND: The laparoscopic placement of continuous ambulatory peritoneal dialysis (CAPD) catheters is now an accepted technique. We evaluated a new technique for CAPD catheter placement that requires only a single 2-mm port. METHODS: A pilot study was conducted at an academic minimally invasive surgery center. Seven consecutive patients in whom a CAPD catheter was required underwent placement of a 2-mm Veress port and a laparoscope. A carbon dioxide pneumoperitoneum was induced up to 14 mmHg. Under direct visualization with a 2-mm scope, a CAPD catheter was advanced over the right lower quadrant toward the pelvis using a modified Seldinger technique. RESULTS: Seven patients (four women and three men) with end-stage renal disease underwent mini-laparoscopic placement of a CAPD catheter. Mean patient age was 35.3 +/- 11.3 years (range, 17-50). Mean operative time was 20.7 +/- 5.0 min (range, 14-29). Patients were dialyzed in the immediate postoperative period. No leaks were identified, and there were no intraoperative or postoperative complications. CONCLUSION: A mini-laparoscopic technique using a single 2-mm port and a modified Seldinger technique is feasible, safe, and effective for peritoneal dialysis catheter placements.

Robots in laparoscopic surgery.

BACKGROUND: The Da Vinci Robotic System became available at our institution in late August 2000. We decided to utilize this system to perform advanced laparoscopic procedures. METHODS: This is a review of the status of robotics and its application in surgery. We report our experience using the Da Vinci system. RESULTS: We have used the Da Vinci for 34 advanced laparoscopic cases: 7 gastric bypasses for morbid obesity, 9 Heller myotomies for achalasia, 11 donor nephrectomies, 2 gastrojejunostomies, and single cases of bilateral adrenalectomy, Nissen fundoplication, Toupet fundoplication, and cholecystectomy. No robot-related complications were noted. CONCLUSIONS: This early experience suggests that robotic surgery is a safe and effective alternative to conventional laparoscopic surgery. We believe that robotic surgery, with its ability to restore the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, will allow us to perform complex procedures with greater precision and confidence and better results.

Changing patterns of care for occult breast lesions in a community teaching hospital.

We performed a retrospective analysis of 384 consecutive stereotactic breast biopsies (SBBs) from March 1995 through January 1999 and compared it with our historical breast biopsy experience. Two hundred forty-four patients underwent biopsies for microcalcifications and 135 patients for abnormal mammographic densities. Pathology diagnoses included 302 patients with benign disease, 35 patients with atypical ductal hyperplasia, 4 patients with lobular carcinoma in situ, 29 patients with ductal carcinoma in situ, and 9 patients with invasive breast cancer. These diagnostic rates were compared with our prior needle-localized pathology findings. For the study period, the number of mammograms, open biopsies, and needle-localized biopsies remained stable. The number of SBBs, however, increased progressively in every year. Medicare reimbursement for SBB was $921.19, and for breast biopsy after needle localization, $1566.22. Our study strongly suggests that the availability of SBB has significantly lowered the threshold for recommending biopsy of abnormal mammograms. The increased utilization of SBB almost certainly indicates an increase in the overall cost of breast care. This cost must be balanced against substantial potential benefits of this minimally invasive technique: possible earlier diagnosis of atypical and precancerous lesions, patient reassurance in cases of uncertain mammographic interpretation, and a reduced need for follow-up of indeterminate mammograms.