How to maintain the quality of laparoscopic surgery in the era of lack of hands?

Lack of personnel in the operating rooms is not a future problem, it is today's reality in many hospitals throughout the OECD countries. As studies anticipate that this situation will not change overnight (1), the issue of the quality of surgery within this new environment needs to be addressed on short notice. The problem is even more critical for laparoscopic surgeons, who have enjoyed proportionally more assistance since the emergence of minimally invasive surgery. After analyzing the tasks performed by OR assistants and nurses, we have looked at available techniques and tools (2) that could help laparoscopic surgeons, using the following criteria to assess their benefits : capability to address the shortage of assistance, impact on quality of surgery, economic affordability within the existing Belgian healthcare system.

Totally preperitoneal endoscopic inguinal hernia repair.

BACKGROUND: Recurrence rate after conventional inguinal hernia repair is high. However, the Stoppa technique has provided the best results. The totally preperitoneal endoscopic inguinal hernia repair is developed in order to combine the results of the Stoppa technique with the advantages of minimally invasive surgery. METHODS: Between October 1992 and August 1994, 403 patients with a total of 632 inguinal hernias, including 82 recurrences, were treated by totally preperitoneal endoscopic inguinal hernia repair with mesh placement of at least 10 x 15 cm. RESULTS: Mean(s.e.m.) operating time was 42(1.2) min for unilateral and 58(1.0) min for bilateral hernia repair. Mean(s.e.m.) postoperative hospital stay was 2(0.04) days. Complication rates during and after operation were 0.3 and 3.3 per cent respectively. The morbidity rate at 1 month after operation was 3.5 per cent. The recurrence rate was 0.3 per cent at 1-year follow-up. CONCLUSION: Totally preperitoneal endoscopic inguinal hernia repair is safe and reproducible for any type of primary or recurrent inguinal hernia, even in patients with previous subumbilical surgery or severe systemic disease. Careful follow-up is mandatory to assess the late recurrence rate.

[Complete pre-peritoneal endoscopic closure of inguinal hernias]. / Vollständig präperitonealer endoskopischer Leistenhernienverschluss.

BACKGROUND: Considering the high recurrence rate after conventional inguinal hernia repair, the totally preperitoneal endoscopic inguinal hernia repair has been used. METHODS: The present experience of the authors embraces 1085 patients with a total of 1717 inguinal hernias, including 200 recurrences. The operative technique is described with emphasis on pitfalls and tricks. RESULTS: Analysis of the data concerning the first 403 patients with 1 year complete follow-up reveals a mean (SEM) operating time of 42 (1.2) min for unilateral and 58 (1.0) min for bilateral hernia repair. Mean (SEM) postoperative hospital stay was 2 (0.04) days. Complication rates during and after operation were 0.3% and 3.3% respectively. The morbidity rate at 1 month after operation was 3.5%. The recurrence rate was 0.3% at 1-year follow-up. CONCLUSION: Totally preperitoneal endoscopic inguinal hernia repair is safe and reproducible for any type of primary or recurrent inguinal hernia, even in patients with previous subumbilical surgery or severe systemic disease. Careful follow-up is mandatory to assess the late recurrence rate.

[Endoscopic extraperitoneal colposuspension]. / Colposuspension par voie endoscopique extra-péritonéale.

The authors point out the advantages and the inconveniences of the different surgical procedures (conventional surgery, transperitoneal celioscopy and extraperitoneal endoscopy) performed in order to treat urinary stress incontinence. An original extraperitoneal endoscopic procedure, using a non resorbable mesh (polypropylene), is proposed. The technique is based on the principle of the open approach described by Burch. The short branches of an Y shaped mesh are sutured at the antero-lateral walls of the vagina. The basis of the Y is pulled out of the extraperitoneal space by using a grasper introduced through a short incision of the skin and the subcutaneous tissues, and perforating the aponeurosis of the rectus muscle. This technique provides the surgeon with an effective and strong tension on the mesh under endoscopic view control. The basis of the mesh is then fixed at the insertion of the rectus muscle on the pubic bone.

Is laparoscopic splenectomy a justified approach in hematologic disorders? Preliminary results of a prospective multicenter study. Belgian Group for Endoscopic Surgery.

The feasibility and safety of laparoscopic splenectomy were evaluated in a prospective multicenter study of 50 patients operated on for idiopathic thrombocytopenic purpura (ITP) (n = 31), hereditary spherocytosis (n = 6), hemolytic anemia (n = 4), Hodgkin's disease or lymphoma staging (n = 5), benign splenic tumors (n = 3), and wandering spleen (n = 1). Conversion to laparotomy was required in 10%. An accessory spleen was routinely searched for, although the lesser sac was opened during surgery in only 10%; the overall incidence was 14%. Hospital mortality was 2% and postoperative morbidity 22%. Postoperative hospital stay and home rehabilitation were improved when exclusively laparoscopic splenectomy was performed. In ITP patients, at a mean follow-up of 8.2 months, 8 patients (27%) had recurrence of thrombocytopenia, which was transient in 7% and permanent in 20%. Laparoscopic splenectomy is feasible and safe when performed in selected patients by expert laparoscopic surgeons. Adequate selection of patients and routine, careful search for accessory spleen are critical. The recurrence rate (20%) for ITP was high at 8.2 months, and this factor is the major limitation of laparoscopic splenectomy at present.

Endoscopic extraperitoneal lumbar sympathectomy.

From June 24, 1993, until November 9, 1993, eight sympathectomies were performed by extraperitoneal endoscopy for treatment of Sudeck atrophy. Seventy-five percent of the patients were satisfied with the result of the intervention. A follow-up after 4 months shows that four patients are free of pain. Two are satisfied, but some pain remains. In two cases, the intensity of the pain remains unchanged but the character of the pain has changed. This new technique is safe and offers the well-known advantages of minimal invasive surgery. Moreover, this endoscopic approach opens perspectives for the exploration of the entire retroperitoneum.

Retroperitoneal endoscopic lumbar sympathectomy: laboratory and clinical experience.

Retroperitoneal endoscopic lumbar sympathectomy was performed in four pigs in the prone or lateral position to study the feasibility of these new approaches. Positioning, port placement and the dissection technique are described in detail. In nine patients retroperitoneal endoscopic lumbar sympathectomy, using the lateral position technique, was performed. The importance of port placement and dissection techniques for visualisation of the sympathetic chain are emphasised. The endoscopic retroperitoneal approach enables the sympathetic chain to be accurately localised whilst enhanced endoscopic vision aids dissection. Retroperitoneal endoscopic lumbar sympathectomy is a feasible technique offering patients the benefits of the minimally invasive approach.

Experimental retroperitoneal endoscopic surgery.

Techniques for retroperitoneal endoscopic procedures with the patient in prone position were evaluated in experimental studies in the pig. Nephrectomy, para-aortic lymph node dissection, lumbar sympathectomy and assisted aorto-femoral bypass were performed and the experience is reported herein. The prone position contributes to the creation of the retroperitoneal working space and eliminates the need for extensive retraction and thus for additional ports. The modified open Hasson technique was found to be the preferred retroperitoneal access procedure.

Experience with a totally implantable catheter in adult patients: a single institution retrospective study of 114 cases.

One hundred and fourteen consecutive totally implantable catheters were inserted in 114 patients between April 1984 and April 1987. Catheters were inserted under neuroleptanalgesia, through the jugular vein in 101 cases or the internal saphenous vein in 13 cases. No problem was encountered during the insertion procedure. Infection occurred in 5.2% of the patients but removal of the device was required in only 2.6%. Occlusion of the catheter occurred in 6.1% of the patients but never during the first 2 months. This complication rate is lower than the one observed with external tunnelled catheters. The comfort of the patient is substantially improved and nursing care is greatly facilitated.

[The treatment of aorto-enteric fistulas. Remark apropos of 2 case reports]. / Le traitement des fistules aorto-digestives. Note à propos de deux observations.

Aorto-enteric fistulas: about two cases. In this paper, on the occurrence of two new cases records, we resume the current data of the publications about aorto-enteric fistulas. We emphasize the symptomatology inasmuch the diagnostic approaches of primary and secondary aorto-enteric fistulas. The different ways of the operative treatment are discussed. The conclusion is extra-anatomic bypass associated with graft excision is currently the best therapeutic choice in case of secondary fistulas. About primary fistulas, the treatment is still controversial immediately by extra-anatomic bypass or arterial graft in situ and closure of the digestive fistula.

[Geometric representation of the human thorax in electrocardiographic theory]. / Représentation géométrique du thorax humain en théorie électrocardiographique.

An accurate representation of the thoracic surface is required to solve the inverse problem of electrocardiography. For the purpose we have searched the second degree surface which fits 55-88 positions distributed around the trunk. Over a group of 17 young men, we have found that the positions always scattered around an ellipsoid the cephalo-caudal limits of which extended far away from the zero potential gradient levels. This discrepancy is discussed and a proposal is formulated.