surgical endoscopy nov1997

Erratum

‘‘The sensitivity of new color systems in blood-flow diagnosis: the maximum entropy method and angiocolor comparativein vitro flow measurements to determine sensitivity,’’ by C. Sohn and H.P. Weskott (Surg Endosc 11: 1040–1044)

In this article that appeared in the October issue ofSurgical Endoscopy,three figures that should have appeared in colorappeared in black and white. The figures are reprinted here in color. The publisher apologizes for any inconvenience.

Fig. 2. A Color Doppler imaging: time and velocity of bloodflow at one spatial point.B Spatial distribution of mean velocitiesdepending from the time.Fig. 3. Autocorrelation.

Fig. 1. Comparison of principle of power Doppler and conventional colorDoppler imaging.

SurgicalEndoscopy

© Springer-Verlag New York Inc. 1997Surg Endosc (1997) 11: 1141

Minimally invasive management of low-grade and benigngastric tumors

J. Buyske,1 M. McDonald,2 C. Fernandez,2 J. L. Munson,2 L. E. Sanders,2 J. Tsao,2 D. H. Birkett 2

1 Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA2 Department of General Surgery, Lahey Hitchcock Clinic, 41 Mall Road, Burlington, MA 01805, USA

Received: 17 March 1997/Accepted: 28 May 1997

AbstractBackground:Benign gastric tumors and tumors of low-grade malignancy can be safely removed laparoscopically.Methods: Seven patients were considered candidates forlaparoscopic resection of gastric tumors. Inclusion criteriaincluded small tumor size (less than 6 cm), exophytic orendophytic tumor morphology, and benign characteristics.Indications for surgical intervention included bleeding,weight loss, and need for tissue diagnosis. Patients ranged inage from 38 to 70. There were five female and two malepatients. All patients underwent preoperative upper GI en-doscopy. The procedures were performed using a four- orfive-port technique. An Endo-GIA (US Surgical Company,Norwalk, Connecticut) was used to amputate those tumorslocated on the serosal surface of the stomach. Tumors on themucosal surface were exposed via a gastrotomy, then like-wise amputated using an Endo-GIA. The gastrotomy clo-sure was then either hand sewn or stapled. Operating timeranged from 95 to 225 min.Results:Final pathologic diagnoses included lipoma, lym-phoma, leiomyoma, and leiomyosarcoma. There was a 28%conversion rate. There were no complications. Length ofpostoperative stay ranged from 4 to 7 days. There have beenno tumor recurrences in 6–38-month follow-up.Conclusions:Minimally invasive management of benignand low-grade gastric tumors can be performed safely withexcellent short- and long-term results.

Key word: Gastric tumor — Gastric resection — Laparos-copy — Minimally invasive surgery

Minimally invasive techniques have been applied to variousdisorders of the stomach and gastroesophageal junction, in-cluding laparoscopic myotomy for achalasia [3, 5, 16, 21],laparoscopic fundoplication for the treatment of reflux [4,10, 11, 19], highly selective vagotomy for the treatment ofpeptic ulcer disease [2, 12], and formal gastric resectionwith reconstruction for both ulcer disease and tumor [9].Patients requiring diagnostic or therapeutic excision of tu-mors of the stomach have traditionally required laparotomy.Such tumors are often adequately treated with wedge resec-tion [20]. Several authors have presented case reports andsmall series of laparoscopic resection of such tumors [1,6–8, 13–15, 17, 18, 22–24]. We here present our experiencewith a safe and simple approach to minimally invasive man-agement of low-suspicion tumors of the stomach.

Methodology

From January of 1993 to October of 1995 seven patients were identified ascandidates for laparoscopic wedge resection of gastric tumors. Patientsranged in age from 38 to 70 years. Five were female and two were male.Three patients presented with gastrointestinal (GI) bleeding, two with earlysatiety, one with epigastric pain, and one had a lesion discovered inciden-tally during a workup for bacterial endocarditis. A summary of this infor-mation is presented in Table 1.

All patients underwent preoperative upper GI endoscopy. In two casesupper GI fluoroscopy was also performed, and abdominal computerizedtomography (CT) for additional diagnostic information was used in fourcases (Fig. 1).

All patients underwent diagnostic laparoscopy; the plan was to performa minimally invasive wedge resection of the tumor. The camera port wasplaced in the infraumbilical location. Two additional ports were placed inthe upper abdomen to aid in identifying the location of the tumor bypalpation with a closed grasping instrument. After identification of thetumor, one or two more ports were placed to allow for manipulation of thestomach and tumor with Babcock clamps.

For access to the posterior wall of the stomach, and to allow for easiermobilization of the tumor, the stomach was divided from the greater omen-tum using either clips or the Harmonic Scalpel (Ethicon Endo-Surgery,Cincinnati, Ohio). Tumors located on the anterior wall of the stomach wereresected by grasping and elevating the mass with a Babcock clamp andsimultaneously stapling and dividing the base using and Endo-GIA. Tu-mors located on the posterior wall of the stomach were first exposed by

Presented at the annual meeting of the Society of American Gastrointes-tinal Endoscopic Surgeons (SAGES), San Diego, California, USA 19–22March 1997

Correspondence to:J. Buyske

Surg Endosc (1997) 11: 1084–1087

SurgicalEndoscopy

© Springer-Verlag New York Inc. 1997

performing an anterior gastrotomy. An incision was made in the stomachimmediately overlying the tumor using the electrocautery. The gastrotomywas then enlarged with the stapling device (Fig. 2). Stay sutures wereplaced to retract the edges of the stomach wall. The mass on the posteriorwall was then grasped and elevated anteriorly through the gastrotomy (Fig.3). At this point a stapler was fired across the tented-up posterior gastricwall, removing the tumor and simultaneously sealing the defect in theposterior wall (Fig. 4). The gastrotomy on the anterior wall was then closedusing the stapler (Fig. 5). Integrity of the staple line was tested by sub-merging the stomach in irrigation fluid and then insufflating air via thenasogastric tube. In some cases methylene blue was also administered via

the nasogastric tube, and the staple lines were observed for any leak. In onecase although there was no apparent leak, the stomach was felt to have aninsecure closure. The staple line was exteriorized and oversewn through a4-cm extension of a trocar site.

The specimens were removed in a bag via one of the port sites. Marginsas well as histology were evaluated with frozen section. Pathologic diag-noses included one lipoma, three leiomyomas, and two lymphomas. In onecase the tumor was found to be a leiomyosarcoma, and the patient under-went conversion to laparotomy for further exploration, wide excision, andreconstruction.

All patients were placed on nasogastric suction postoperatively. Naso-gastric tubes were removed and feedings were initiated when clinical signsof peristalsis returned.

Table 1. Laparoscopic gastric resections

Age SexPresentingsymptoms Diagnosis

Sizetumor

Operativetime

Daysnasogastrictube

In-hospitaldays

1 61 M Early satiety Leiomyoma 3 cm 95 3 62a 49 F Bleeding Lymphoma 0.7 × 0.5 cm 135 1 53 38 F Incidental finding Leiomyoma 4.2 × 3.4 cm 115 2 74 62 F Epigastric pain Lymphoma 5 × 3 cm 110 3 75 70 F Bleeding Lipoma 5.5 × 2.0 cm 110 3 46 66 F Bleeding Leiomyoma 4.5 × 4.0 cm 225 3 6

a Laparoscopically-assisted.

Fig. 1. CT scans showing(a) an endophytic lesion and(b) an exophyticlesion that were removed by laparoscopic wedge resection.

Fig. 2. An anterior gastrotomy is made using the electocautery and stapler.

Fig. 3. A posterior mass is elevated through the gastrotomy.

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Results

Laparoscopic wedge resection of the tumor was completedin all cases. Tumors ranged in size from 0.7 cm to 5.5 cm indiameter. Two cases were converted to open or lap-assistedprocedures, one to allow for wider excision in the case of aleiomyosarcoma and one to better secure the gastric stapleline. This represents a conversion rate of 28%.

There were no complications of bleeding, leakage of thesuture line, obstruction, or infection. In 6–38-month follow-up there has been no evidence of tumor recurrence.

The duration of nasogastric tube drainage ranged from 1to 3 days. Time from surgery to discharge ranged from 4 to7 days.

These results are summarized in Table 1.

Discussion

A minimally invasive approach to benign and low-gradetumors of the stomach has allowed us to avoid unnecessarylaparotomy in selected patients. In no case did we have anydifficulty locating the tumor. In most cases the tumor wasimmediately visible by virtue of distorting the overlyingcollapsed stomach. Where this was not the case, we wereable to palpate the tumor by running a closed instrumentover the stomach. Intraoperative endoscopy was made

available for all cases in the event that we had difficulty inlocating the tumor, but we did not need to use this additionalmodality. Other authors have reported this to be useful [6,18, 22].

The ability to obtain negative margins without compro-mising the lumen of the bowel was of preoperative concern.Intraoperative pathology consultation was used to assurenegative margins, and in short-term follow-up there has notbeen any evidence of either tumor recurrence or gastricobstruction.

One technical challenge that had not been anticipatedwas that it was frequently difficult to grasp and elevate thesesolid masses. Smaller instruments tended to slip off, andsharp graspers run the risk of violating the tumor. Althoughwe were always successful in obtaining control of the tumorusing simple grasping and retracting instruments, other au-thors have described the use of sutures through the stomachwall as well as T-fasteners to aid in elevating the involvedarea [17].

The technique of anterior gastrotomy for tumors locatedon the posterior wall has been recently described [8]. Weindependently arrived at this technique, and we agree that itprovides excellent access to posterior tumors. All tumorsresected in this manner were completely excised with nega-tive margins.

Conclusion

A minimally invasive approach to benign tumors of thestomach appears to offer a safe and effective alternative tolaparotomy. A high degree of suspicion for the presence ofmalignancy must be maintained. Should preoperative as-sessment or intraoperative pathology consultation revealmalignancy, then appropriate oncologic principles shouldbe followed, including conversion to an open procedurewhere indicated. In the presence of benign disease a simplelaparoscopic wedge resection is a viable option that is avail-able to all laparoscopic surgeons.

References

1. Abercrombie JF, McAnena OJ, Rogers J, Williams NS (1993) Lapa-roscopic resection of a bleeding gastric tumor. Br J Surg 80: 373

2. Cardiere GB, Himpens J, Bruyns J (1994) Laparoscopic proximalgastric vagotomy. Endosc Surg Allied Technol 2: 105–108

3. Cuschieri A (1993) Endoscopic oesophageal myotomy for specificmotility disorders and non-cardiac chest pain. Endosc Surg AlliedTechnol 1: 280–287

4. Cuschieri A, Hunter J, Wolfe L, Swanstrom LL, Hutson W (1993)Multicenter prospective evaluation of laparoscopic antireflux surgery.Surg Endosc 7: 505–510

5. Delgado F, Bolufer JM, Martinez-Abad M, Martin J, Blanes F, CastroC, Moreno-Osset E, Mora F, Benages A (1996) Laparoscopic treat-ment of esophageal achalasia. Surgical Laparosc Endosc 6: 83–90

6. DiLorenzo N, Sica GS, Gaspari AL (1996) Laparoscopic resection ofgastric leiomyoblastoma. Surg Endosc 10: 662–665

7. Fowler DL, White SA (1991) Laparoscopic resection of a submucosalgastric lipoma: a case report. J Laparoendosc Surg 1: 303–306

8. Geis WP, Baxt R, Kim HC (1996) Benign gastric tumors. Minimallyinvasive approach. Surg Endosc 10: 407–410

9. Goh P (1995) Laparoscopic gastric resection. Bildgebung 62(Suppl 1):43

10. Hinder R, Filipi C, Wetscher G, Neary P, DeMeester T, Perdikis G

Fig. 4. A stapler is fired across the tented-up posterior gastric wall.

Fig. 5. The gastrotomy is closed using a stapler.

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(1994) Laparoscopic Nissen fundoplication is an effective treatmentfor gastroesophageal reflux disease. Ann Surg 220: 472–483

11. Jamieson G, Watson D, Jones-Britten R, Mitchell P, Anvari M (1994)Laparoscopic Nissen fundoplication. Advances in surgical techniques.Ann Surg 220: 137–145

12. Kathouda N, Heimbucher J, Mouiel J (1994) Laparoscopic posteriorvagotomy and anterior seromyotomy. Endosc Surg Allied Technol 2:95–99

13. Lacy AM, Tabet J, Grande L, Garcia-Valdecasas JC, Fuster J, DelgadoS, Visa J (1995) Laparoscopic-assisted resection of a gastric lipoma.Surg Endosc 9: 995–997

14. Llorente J (1994) Laparoscopic gastric resection for gastric leiomyo-ma. Surg Endosc 8: 887–889

15. Lukaszczyk JJ, Preletz RJ Jr (1992) Laparoscopic resection of benignstromal tumor of the stomach. J Laparoendosc Surg 2: 331–334

16. Oddsdottir M (1996) Laparoscopic management of achalasia. SurgClinic North Am 76: 451–458

17. Ohgami M, Otani Y, Kumai K, Kuboat T, Kitajima M (1996) Lapa-roscopic surgery for early gastric cancer. Nippon Geka Gakka Zasshi.J Japan Surg Soc 97: 279–285

18. Payne WG, Murphy CG, Grossbard LJ (1991) Combined Laparoscop-ic and Endoscopic approach to resection of gastric leiomyoma. J Lapa-roendosc Surg 5: 119–122

19. Peters J, Heimbucher J, Kauer W, Incarbone R, Bremner C, DemeesterT (1995) Clinical and physiologic comparison of laparoscopic andopen Nissen fundoplication. J Am Coll Surg 180: 385–393

20. Sebastian MW (1997) Benign tumors of the stomach. In Sabiston, DC(Ed) Textbook of Surgery. 15th ed. WB Saunders, Philadelphia, PA.pp 871–872

21. Swanstrom LL, Pennings J (1995) Laparoscopic esophagomyotomy.Surg Endosc 9: 286–290, discussion 290–292

22. Trias M, Targarona EM, Balague C, Bordas JM, Cirera I (1996) En-doscopically-assisted laparoscopic partial gastric resection for treat-ment of a large benign gastric adenoma. Surg Endosc 10: 344–346

23. Watson DI, Game PA, Devitt PG (1996) Laparoscopic resection ofbenign tumors of the posterior gastric wall. Surg Endosc 10: 540–541

24. Yamashita Y, Bekki F, Kakegawa T, Umetani H, Yatsuka K (1995)Two laparoscopic techniques for resection of leiomyoma in the stom-ach. Surg Laparosc Endosc 5: 38–42

Discussion

Dr. Hunter: Is there any way that you can tell preoperativelyabout the risk of leiomyosarcoma in your specimen. I wouldimagine that you’re not going to want to take those on ifthere are features that might predict malignancy.

Dr. Buyske:Most of the tumors underwent endoscopic bi-opsy. Two of the ones that were bleeding were not actuallybiopsied ahead of time. The leiomyosarcoma was biopsied,and retrieved only normal gastric mucosa as a submucosallesion. I think both MRI and endoscopic ultrasound mighthelp in distinguishing between benign and malignant le-sions. That particular tumor was actually small, and had nofeatures of malignancy. In all cases our margins were nega-tive, including that case. In 6-38 month follow-up none ofthe tumors have recurred.

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Production and systemic absorption of toxic byproducts of tissuecombustion during laparoscopic surgery

J. S. Wu, D. R. Luttmann, T. A. Meininger, N. J. Soper

Department of Surgery, Washington University School of Medicine, Box 8109, Suite 6108, One Barnes Hospital Plaza, St. Louis, MO 63110, USA

Received: 3 April 1997/Accepted: 22 May 1997

AbstractBackground:Among the potential hazards of laparoscopicsurgery using electrocautery is the intraperitoneal releaseand subsequent absorption of byproducts of tissue combus-tion. In a porcine model of laparoscopic surgery with smokeproduction, our aims were to assess (1) the relationshipbetween levels of intraperitoneal carbon monoxide (CO)and systemic carboxyhemoglobin (COHb) and methemo-globin (MetHb), and (2) intraperitoneal concentrations ofother noxious gases, including hydrogen cyanide (HCN),acrylonitrile (Acr), and benzene (Bzn).Methods:Seven pigs underwent laparoscopic resection ofthree hepatic wedges using monopolar electrocautery in aCO2 pneumoperitoneum. Sequential arterial samples weredrawn to measure [COHb] and [MetHb] perioperatively,while gaseous intraabdominal [CO], [HCN], [Acr], and[Bzn] were assayed intraoperatively.Results:The mean ± SEM duration of operation was 90 ± 2min, and electrocautery was used for 68 ± 4 min. Intraab-dominal [CO] rose from 0 to 814 ± 200 ppm (p < 0.01)while [COHb] increased from 2.9 ± 0.1% to 3.5 ± 0.1% (p< 0.001). Systemic [MetHb] remained unchanged intra- andpostoperatively, ranging from 0.3 to 0.7%. Intraperitoneal[HCN] rose from 0 to 5.7 ± 0.7 ppm (p < 0.001). [Acr],however, did not change significantly from preoperativevalues, ranging from 0 to 1.6 ± 1.0 ppm, and [Bzn] wasundetectable.Conclusions:Laparoscopic tissue combustion increases in-traabdominal [CO] to ‘‘hazardous’’ levels leading to mini-mal, yet significant, elevations of [COHb]. Systemic[MetHb] and intraabdominal [HCN], [Acr], and [Bzn] arenot elevated to toxic levels. Production of intraperitonealsmoke during laparoscopic electrosurgery therefore may notpose a significant threat to the patient.

Key words: Carbon monoxide — Pneumoperitoneum —Carboxyhemoglobin — Methemoglobin — Laparoscopicsurgery — Smoke

Since its introduction in the United States in 1988, laparo-scopic cholecystectomy has rapidly become the new ‘‘goldstandard’’ therapy for uncomplicated cholelithiasis, replac-ing the traditional open operation in most patients. Otherlaparoscopic abdominal operations are also increasing inpopularity due to their advantages for patients in terms ofminimal abdominal wall trauma, decreased postoperativepain, shorter hospital stay, and earlier return to normalphysical activities compared to their open counterparts [17].However, among the disadvantages of laparoscopic surgeryare the detrimental effects from the ‘‘closed abdomen’’ andCO2 pneumoperitoneum [6, 10, 19].

One theoretical disadvantage that has not been thor-oughly investigated is that of smoke generated by electro-cautery in the CO2 pneumoperitoneum. The gaseous prod-ucts of tissue combustion in this setting could be dangerousto the patient as a result of transperitoneal absorption intothe systemic circulation or dangerous to the operating roompersonnel as a result of smoke evacuated through trocarvalves. Three studies have documented elevated intraperi-toneal [CO] in patients undergoing laparoscopic operationsusing electrocautery. Two of those studies also found el-evated systemic carboxyhemoglobin (COHb) levels due totransperitoneal absorption of CO [9, Ott personal commu-nication] while one study did not [5]. In addition, Ott re-ported elevated systemic methemoglobin (MetHb) levelsand detected 26 additional toxic chemical by-products re-sulting from pyrolysis of protein and lipids in the pneumo-peritoneum during laparoscopic surgery [15]. The concen-trations of these compounds were not measured and thesignificance of these findings and their risks are yet un-known.

These phenomena were investigated using an animalpreparation in which large amounts of smoke were pro-duced in a CO2 pneumoperitoneum. In this porcine model,

Presented at the annual scientific session of the Society of American Gas-trointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA,19–22 March 1997

Correspondence to:N. J. Soper

Surg Endosc (1997) 11: 1075–1079

SurgicalEndoscopy


segments of liver were excised using monopolar electrocau-tery. The goals of this study were (1) to ascertain the rela-tionship between intraperitoneal concentration of CO andblood levels of COHb and MetHb in pigs undergoing lap-aroscopic hepatic wedge resections and (2) to assess thepresence and concentrations of three other potentially harm-ful gases that may be byproducts of incomplete tissue com-bustion—hydrogen cyanide (HCN), acrylonitrile (Acr), andbenzene (Bzn)—in the pneumoperitoneum of these animals.

Materials and methods

Seven domestic pigs, each weighing 30–35 kg, underwent laparoscopichepatic wedge resection using monopolar electrocautery for transection ofthe hepatic parenchyma. Since total uptake of CO is dependent on itsconcentration and the duration of exposure as well as FiO2 and ventilatoryrate, the duration of the operation and the cumulative time of electrocauteryuse were recorded while maintaining FiO2 and end-tidal CO2 constant.Experimental procedures, animal care, and maintenance were approved bythe Animal Studies Committee at Washington University School of Medi-cine in accordance with the Animal Welfare Act and the NIHGuide for theCare and Use of Laboratory Animals.

Animal preparation

The animals were fasted and bowel prepped with magnesium citrate andGo-lytely (Braintree Lab, Inc., Braintree, MA) 10 h before surgery. Thepigs were premedicated with ketamine 20 mg/kg, acepromazine 0.1 mg/kg,and atropine 0.04 mg/kg IM. After induction of anesthesia with pentobar-bital 20 to 30 mg/kg IV, anesthesia was maintained with isoflurane. Anendotracheal tube was inserted and connected to a ventilator with a tidalvolume of 15–20 ml/kg at a rate of 12–16 breaths/min. Ventilatory rate wascontrolled to maintain end-tidal CO2 at 40 mmHg while FiO2 was main-tained at 40%. Pulse oximetry was monitored throughout the study. Anarterial line was placed via a cutdown in the femoral artery for frequentarterial blood samplings. Duration of cautery use was recorded by start-stop cumulative arithmetic compilation.

Operative technique: hepatic wedge resection of the rightmedial lobe

The pig was placed in the supine position and the abdomen was preppedwith Betadine and draped sterilely. A 14-gauge Veress needle was insertedinfraumbilically, and the abdomen was insufflated with CO2 to create apneumoperitoneum at a pressure of 15 mmHg. Four 10/12-mm trocarswere used for access: an infraumbilical trocar for the video laparoscope,one trocar in the right flank for grasping forceps, and two lateral trocars—right upper quadrant in the midclavicular line for electrocautery scissorsand left upper quadrant in the midclavicular line for liver retraction.

An electrocautery probe was used to incise Glisson’s capsule of thehepatic right medial lobe and then to divide the parenchyma. Three hepaticwedges, approximately 2 × 2 × 1 cmeach, were resected. As the instrumentprogressively dissected deeper into the hepatic parenchyma, grasping for-ceps were used to hold the tissue and to separate the edges of the liver.Irrigation and aspiration of the operative field were used sparingly; enoughto allow laparoscopic visualization while minimizing the loss of smoke tobe tested. If the amount of smoke in the pneumoperitoneum obscured thesurgeon’s view, smoke was vented until the field was visible. The numberof times this was performed during each experiment was recorded.

At the end of each operation, intraabdominal gas was evacuatedthrough the ports. The total volume of CO2 insufflated and the cumulativeduration of electrocautery during the procedure were also recorded, as wasthe mass of the resected liver. The animals remained anesthetized for 3 hpostoperatively to facilitate blood drawings and were then euthanized.

Blood and gas sampling

For each animal, two arterial blood samples (3 ml each) were drawn in icedheparinized syringes 5 min prior to insufflation, during the surgical pro-

cedure at 1 min after insufflation (prior to electrocautery use), at 8 min, at15 min, and every 15 min after initiating electrocautery intraoperatively,and then hourly postoperatively for 3 h. The blood samples were analyzedimmediately for pO2 and SaO2 by Stat Profile 4 (Nova Biomedical,Waltham, MA). Total hemoglobin, oxyhemoglobin, MetHb, and COHbwere analyzed immediately by the OSM3 Hemoximeter (Radiometer Co-penhagen, Copenhagen, Denmark). The manufacturer lists the accuracy ofthis instrument as ±1%.

Intraperitoneal and exhaled [CO] were determined by Sensidyne-Gastec detector tubes (Sensidyne, Inc., Clearwater, FL) by sampling 100ml of gas from the side port of one of the laparoscopic trocars and from theendotracheal tube during exhalation with a Sensidyne-Gastec multistrokegas sampling pump. Analyses were performed intraoperatively simulta-neous to the blood samples. Sensidyne-Gastec detector tubes use a color-imetric reaction with potassium polladosulfite so that the length of tubingstained corresponds to the concentration of CO in the sample. They detectCO concentrations between 1 and 4,000 parts per million (ppm) at anaccuracy of ±25% [4].

The intraperitoneal smoke was also analyzed for the concentrations ofhydrogen cyanide, acrylonitrile, and benzene. For each gas, the techniquewas the same as that described above except that the detector tubes werespecific for the type of gas analyzed. The lowest detectable concentrationsfor hydrogen cyanide, acrylonitrile, and benzene using this technique are0.36, 0.125, and 0.125 ppm, respectively [4]. Determinations of intraper-itoneal concentrations of these substances were performed intraoperativelysimultaneous to the blood sampling.

Statistical analyses

The InStat statistical computer software package (GraphPad Software, Inc.,San Diego, CA) was used for data analysis. Statistical comparisons amongthe groups with respect to continuous variables were performed with thepaired analysis of variance (ANOVA) test. Specific comparisons weremade using Tukey-Kramer multiple comparisons test. When preoperativevalues were zero, intraoperative and postoperative continuous variableswere analyzed using the two-tailed one-sample Student’st-test. Summaryvalues are expressed as mean ± SEM. Statistically significant differenceswere defined asp < 0.05.

Results

Seven domestic female pigs, weighing 32 ± 0.5 kg, under-went laparoscopic hepatic wedge resections. Duration ofoperation was 90 ± 2 min, during which 99 ± 12 l of CO2(range4 68–140 l) were used for insufflation. Mean cu-mulative electrocautery time was 68 ± 4 min. The smokegenerated was often sufficient to interfere with visualiza-tion; this required a trocar to be opened for a 10-s venting onthe average of six times per procedure (range 4–9). Each 2× 2 × 1 cmhepatic wedge specimen weighed 1.8 ± 0.3 g.

No measurable [CO] could be detected in the animals’exhaled gas. However, intraperitoneal [CO] rose signifi-cantly from 0 ppm prior to hepatic cauterization to 771 ±230 ppm (p < 0.02, range 200–1900 ppm) at 30 min, peakedbetween 60 min (814 ± 201 ppm,p < 0.01, range 500–2,000ppm) and 75 min (814 ± 223 ppm,p < 0.02, range 200–1,600 ppm), and then declined to 557 ± 100 ppm (p < 0.01,range 300–1,000 ppm) at the end of the procedure (Fig. 1).COHb levels rose significantly from a preoperative value of2.9% ± 0.1% to 3.3% 0.1% at 70 min and peaked to 3.5%± 0.1% at the end of the procedure (p < 0.001; Fig. 2).During the first 3 h postoperatively, [COHb] steadily de-clined to baseline levels. MetHb level, however, did notchange (preoperative range4 0.4–0.7%; intraoperative andpostoperative ranges4 0.3–0.7%; Fig. 2).

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Figure 3 reveals intraoperative concentration of hydro-gen cyanide, acrylonitrile, and benzene within the peritonealcavity. Prior to hepatic cauterization, none of these gaseswere detected in the pneumoperitoneum. However, [HCN]rose significantly and peaked to 5.7 ± 0.7 ppm at 15 and 30min (p < 0.001, range 5.0–10.0 ppm) and remained elevatedthroughout the procedure. In contrast, acrylonitrile did notrise significantly from baseline values, with peak concen-tration of only 1.6 ± 1.0 ppm at 15 min (range 0–7.5 ppm)and soon afterward declined to baseline value of zero. Ben-zene was undetectable throughout the procedures.

Discussion

There are conflicting published data regarding the produc-tion and systemic absorption of toxic byproducts of tissuecombustion in the pneumoperitoneum of humans duringlaparoscopic surgery, but no prior animal study has inves-tigated this phenomenon. Since a major criticism of previ-ous clinical studies investigating the production and effectsof CO during laparoscopic surgery was the short duration ofelectrocautery use, we purposely created more smoke thanduring a procedure such as a routine laparoscopic cholecys-

tectomy. This was accomplished successfully since the av-erage electrocautery time of 68 min more than tripled thelongest mean electrocautery time in any previous study [5,9, 15]. The density of smoke often obscured the surgeon’sview to the point that a trocar had to be vented repeatedly.The duration of CO2 pneumoperitoneum during the experi-ments was 90 min, similar to those in the aforementionedstudies [5, 9, 15].

The current study clearly demonstrated that laparoscop-ic electrocautery of the porcine liver increased intraperito-neal concentrations of CO. The levels were slightly higherthan those found in previous human studies. This was ex-pected since the amount of tissue combustion in the animalmodel was much more than that in the clinical series. InOtt’s study of 25 patients undergoing laparoscopic-assistedhysterectomy or laparoscopic vaporization of endometri-osis, with a mean time of tissue combustion of only 2.4 ±1.2 min, intraperitoneal [CO] increased to a mean of 425ppm within 2 min of initiation of cauterization (range 115–2,100 ppm) [OtT personal communication]. Throughout theprocedure, mean intraabdominal [CO] remained in the 500–535-ppm range. Others have reported similar increases ofintraperitoneal [CO] in patients undergoing laparoscopiccholecystectomy [5, 9]. Although there are currently noknown safety limits of intraperitoneal [CO], the Environ-mental Protection Agency’s (EPA) maximum allowable 1-hexposure to ambient CO is 35 ppm with a ceiling concen-tration of 200 ppm [7, 8]. The maximum allowable concen-tration of ambient CO by the Occupational Safety andHealth Administration (OSHA) is 50 ppm for 8 h of expo-sure or 400 ppm/15 min [9, 14].

Given the markedly elevated intraperitoneal [CO],transperitoneal absorption into the bloodstream could leadto toxic effects of end-organ hypoxia due to CO poisoning.If CO were absorbed systemically, one would predict eitherelevated levels of [COHb] or of exhaled [CO]. The basis forthe generation of COHb is hemoglobin’s marked affinity forCO, approximately 200–250-fold greater than that for O2[11]. For nonsmokers, the normal baseline [COHb] is lessthan 1%, although the EPA has set the goal of maintainingnonsmokers’ [COHb] below 2% [8]. Smokers, however,often exhibit up to 8% hemoglobin saturation with CO.

Fig. 1. Intraperitoneal [CO] during laparoscopic hepatic wedge resections.Significant elevations occurred 8 min after initiation of hepatic electrocau-terization and remained elevated throughout the procedure.

Fig. 2. Intra- and postoperative [COHb] and [MetHb] in the porcine modelof laparoscopic hepatic resection using electrocautery. [COHb] was sig-nificantly elevated at 70 min after initiation of hepatic electrocauterizationand remained elevated throughout the remainder of the procedure and for2 h postoperatively. –j– 4 COHb; –l– 4 MetHb.

Fig. 3. Intraperitoneal concentrations of various toxic byproducts of lap-aroscopic hepatic combustion. Of the three gases, only [HCN] was signifi-cantly elevated intraoperatively from baseline. –d– 4 HCN; –j– 4Acrnt; –m– 4 Bzn.

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Above this level, one may suffer various symptoms (e.g.,headaches, dizziness, nausea, dyspnea, palpitations, and im-pairment of manual coordination or judgement), and signs(e.g., tachycardia, tachypnea, and abnormal mental status)of CO toxicity [18]. A few studies, however, showed that[COHb] of only 2–4% significantly decreased the time ofonset of angina in persons with coronary artery disease [1,12] and decreased behavioral performance [13].

Previous studies of patients undergoing laparoscopic op-erations have shown variable COHb levels. In Ott’s series,all 25 patients showed elevated [COHb] after 10 min ofcauterization, with a mean level of 10.5% (range 2.8–18.5%). The patients with the highest [COHb] were noted tosuffer postoperative symptoms of dizziness, nausea, head-ache, and weakness [Ott personal communication]. Esper etal., however, found only a minimal but statistically signifi-cant increase in [COHb], from 0.7 ± 0.6% to 1.2 ± 0.7% (p< 0.01), in their study of 15 patients undergoing laparoscop-ic cholecystectomy [9]. In contrast, Beebe et al. demon-strated no significant elevation of [COHb] despite elevatedintraperitoneal [CO] during laparoscopic cholecystectomyin nine patients [5].

This porcine study, with prolonged electrocautery timeand constant bathing of the peritoneal cavity with smoke,showed statistically significant elevation of COHb to 3.5%.Since porcine hemoglobin may have different binding ca-pability to CO than human hemoglobin, this absolute valueis uninterpretable. However, comparing this peak concen-tration to the animal’s baseline of 2.9%, COHb only rose0.6% (20%), which would probably be insignificant clini-cally. One possible explanation for the minimal elevation of[COHb] was that the animal was exhaling CO. However,CO was undetectable in the animals’ exhaled gas.

The possibility of the development of methemoglobine-mia during laparoscopic electrocautery was also exploredafter reports by Ott suggested elevation of [MetHb] to 2–3%from a baseline of <1% [15, 16]. Theoretically, elevationsof MetHb (>2%) could produce the same symptoms andsigns as COHb poisoning. However, MetHb was not el-evated in the current study.

Since many other compounds may be liberated duringtissue combustion, levels of other potentially toxic gaseswere also assessed. Approximately 90% of the total weightof the smoke formed from combustion of tissue is in thegaseous phase, most of which is composed of nitrogen, O2,and CO2. The remaining gases and particulate matter aresubstances of potential toxicologic importance; these sub-stances are physiologically active and may remain intraper-itoneal or be absorbed. Ott identified 27 chemical byprod-ucts of human tissue combustion resulting from laparoscop-ic electrocautery of the uterus and fallopian tubes [15]. Hewas, however, unable to quantify these substances. The cur-rent study assessed for the presence and quantity of onlythree of those substances due to technical limitations.

HCN is a toxic, colorless gas that is easily absorbedthrough the lungs, gastrointestinal tract, and skin. The short-term ambient concentration exposure limit according to theU.S. Department of Health and Human Services is 10 ppm[3]. Cyanide exerts its toxic effects by combining with ferriciron in cytochrome oxidase, inhibiting cellular oxygen uti-lization. Smoke-inhalation victims have experienced addi-tive or synergistic effects from CO and cyanide, and only

recently has attention been focused on the potential for com-bined poisoning in victims of enclosed-space fires. In ourstudy, [HCN] peaked to a mean of 5.7 ppm. However, inone animal, the [HCN] did reach 10 ppm, which is theshort-term ambient exposure limit before toxic effects oc-cur. Further studies are warranted to determine if intraper-itoneal [HCN] poses a threat to human patients.

Acrylonitrile is a colorless, volatile liquid that is easilyabsorbed through the skin and lungs and exerts its toxicityby liberating cyanide [2]. The upper limit of ambient expo-sure set by OSHA is 2 ppm [4]. Although our study foundinsignificant elevations of [HCN], the mean level at 15 min(1.6 ± 1.0 ppm) was dangerously close to the OSHA limit.The significance of this finding, too, is unclear. The thirdpotentially toxic gas that was assessed in the current studywas benzene, which was not detected in the pneumoperito-neum of any of the experimental animals.

In summary, the current study was designed to assess forthe intraperitoneal presence and systemic absorption oftoxic byproducts of tissue combustion in a porcine model oflaparoscopic surgery using prolonged application of elec-trocautery. Whether the peritoneum of the pig has identicalgas absorption characteristics to those of the human perito-neum is unknown, rendering translation to the clinical situ-ation imprecise. In this model, intraperitoneal [CO] didreach levels above those established as safe for inhalationby the EPA and OSHA. There was also a statistically sig-nificant elevation of [COHb], but its magnitude does notseem to pose a clinical threat. Intraperitoneal gaseous hy-drogen cyanide just reached the upper safety limit estab-lished for ambient concentrations, and small but potentiallyhazardous concentrations of acrylonitrile levels were de-tected. Intraperitoneal benzene and systemic methemoglo-bin were not elevated. Further investigation is required todetermine the clinical relevance of hydrogen cyanide andacrylonitrile and to quantify the concentration of other po-tentially toxic chemical byproducts of laparoscopic tissuecombustion.

Acknowledgment.The authors gratefully acknowledge the support from theWashington University Institute for Minimally Invasive Surgery as fundedby a grant from Ethicon-Endosurgery, Inc. We also thank Alberto Rojalesfor his assistance in the care of the animals.

References

1. Allred EN, Bleecker ER, Chaitman BR, Dahms TE, Gottlieb SO,Hackney JD, Pagano M, Selvester RH, Walden SM, Warren J (1989)Short-term effects of carbon monoxide exposure on the exercise per-formance in subjects with coronary artery disease. N Engl J Med 321:1426–1432

2. Anonymous (1984) Acrylonitrile. Lancet 1 (8338): 12213. Anonymous (1993) Cyanide toxicity. Agency for toxic substances and

disease registry. Am Fam Physician 8(1): 107–1144. Anonymous (1987) Sensidyne gastec precision gas detector system

manual. Sensidyne, Clearwater, FL5. Beebe DS, Swica H, Carlson N, Palahniuk RJ, Goodale RL (1993)

High levels of carbon monoxide are produced by electro-cautery oftissue during laparoscopic cholecystectomy. Anesth Analg 77: 338–341

6. Callery MP, Soper NJ (1993) Physiology of the pneumoperitoneum.Baillieres Clin Gastroenterol 7(4): 757–777

7. Code of Federal Regulations, Title 40, Part 50 (40CFR50) (1994)

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National primary and secondary ambient air quality standards. USEnvironmental Protection Agency

8. Environmental Protection Agency: Environmental Assessment andCriteria Office (1979) Air quality criteria for carbon monoxide. EPA,Washington, DC

9. Esper E, Russell TE, Coy B, Duke BE 3rd, Max MH, Coil JA (1994)Transperitoneal absorption of thermocautery-induced carbon monox-ide formation during laparoscopic cholecystectomy. Surg LaparoscEndosc 4(5): 333–335

10. Hashikura Y, Kawasaki S, Munakata S, Hashimoto S, Hayashi K,Makuuchi M (1994) Effects of peritoneal insufflation on hepatic andrenal blood flow. Surg Endosc 8: 759–761

11. Kales S (1993) Carbon monoxide intoxication. Am Fam Physician48(6): 1100–1104

12. Kleinman MT, Davidson DM, Vandagriff RB, Caiozzo VJ, Whitten-berger JL (1989) Effects of short-term exposure to carbon monoxide insubjects with coronary artery disease. Arch Environ Health 44: 361–369

13. Masters RL (1971) Air pollution—human health effects. In: McCor-mac BM (ed) Introduction to the scientific study of atmospheric pol-lution. Reidel, Dordrech, Holland, pp 97–130

14. National Institute for Occupational Safety and Health (1972) Occupa-tional exposure to carbon monoxide. DHEW, US Government PrintingOffice, Washington, DC

15. Ott DE (1993) Smoke production and smoke reduction in endoscopicsurgery: preliminary report. End Surg 1: 230–232

16. Ott DE (1994) Laser smoke and hemoglobin oxidation at laparoscopy(abstract). Laser Surg Med 6: 17

17. Soper NJ, Brunt LM, Kerbl K (1994) Laparoscopic general surgery. NEng J Med 330(6): 409–419

18. Thom SR, Keim LW (1989) Carbon monoxide poisoning: a review.Epidemiology, pathophysiology, clinical findings, and treatment op-tions including hyperbaric oxygen therapy. J Toxicol Clin Toxicol 27:141–156

19. Williams MD, Murr PC (1993) Laparoscopic insufflation of the ab-domen depresses cardiopulmonary function. Surg Endosc 7: 12–16

1079

Endoscopic thyroid and parathyroid surgery

Having succeeded in doing hemithyroidectomies and alsoparathyroidectomies through an endoscopic approach, weare fully convinced that endoscopic neck surgery is set toopen up new horizons in the ever-expanding field of mini-mally invasive surgery. Not only was the postoperative dis-comfort greatly reduced, but the cosmetic results, a primaryconcern in neck surgery, have been very satisfactory.

Two technical points are conducive to smooth executionof endoscopic neck surgery. First, the operation is per-formed with the neck slightly flexed and the table tilted tothe reverse Trendelenburg position (Fig. 1). An 11-mm in-cision is made just above the suprasternal notch. With theskin edges elevated, a plane is developed underneath theplatysma muscle between the anterior border of the sterno-mastoid muscles. An 11-mm Endo-path trocar sleeve (Ethi-con Endosurgery, Cincinnati) is fitted into the incision. Thistransparent cannula affords a wider field of vision. A purse-string suture picking up the platysma is tied around thecannula to achieve an air-tight seal. An end-viewing tele-scope is passed down the sleeve after the space is inflatedwith CO2 at 8 mmHg. A 5-mm trocar is introduced near thelower end of the anterior border of the sternamastoid muscleon the side opposite to the lesion. To ensure unimpededmovement of adjacent trocars, less bulky trocars—for in-stance, Hunt/Reich Secondary Trocars (Apple Medical Cor-poration Massachusetts), are preferred. The trocar sheathcan be maintained in position by screwing the cannula in aclockwise direction or by anchoring the stopcock with askin stitch. These plastic cannulas have the added advantageof not interfering with cautery should they come into con-tact with the metallic part of the instruments during activa-tion of the diathermy. A pair of endoscopic scissors insertedthrough this cannula is used to develop a plane between thesternomastoid and the strap muscles. Dissection should bekept in the right plane, care being taken not to wander ontothe anterior surface of the sternomastoid, which would in-vite unnecessary bleeding and the belly of the sternomastoidwould sag down. Another 5-mm trocar is then inserted 2–3cm lateral to the midline incision, piercing through thelower sternomastoid belly on its way. Exposure of the ca-rotid artery readily leads to the posterolateral border of thethyroid gland. Further dissection will mimic that in the opensurgery. A third trocar of smaller size might be requiredhigher up on the same side.

Second, a clear field in the depths of the working spaceis essential. Oozing from small blood vessels can be trouble-some and obscures the view. The usual laparoscopic tech-nique of suction and irrigation is not too desirable for thefollowing reasons: (1) Suction readily collapses the smallspace; (2) irrigation dilutes the blood and delays clotting;

(3) suction is frequently accompanied by fogging of thelens; (4) it is not possible to suck clear all the fluid stainingthe local tissues. By contrast, the proper use of gauze swabscan provide a dry and clear field. When blood is blockingthe view, the telescope is withdrawn. A piece of Nu-gauze(Johnson & Johnson Medical Incorporation, Arlington,Texas) 2 cm × 2 cm insize is grasped by an endo-forcepsand is passed all the way down the central cannula. With thecamera in position again, the gauze swab is used to mop upthe operative field. The gauze partially soaked with blood istucked away from the operative site, ready to be used again.If required, compression by several pieces of Nu-gauze ef-fects hemostasis. The fully soaked gauze swab can be easilyremoved by a grasping forceps while the flapper valve iskept open by depressing the desufflation lever.

Despite encouraging early experience, the establishmentof endoscopic thyroidectomy and parathyroidectomy as ac-ceptable, if not better, alternatives to standard surgical treat-ment mandates a large prospective study comparing thistechnique with the classical open operation in a scientificmanner.

H. C. YeungW. T. NgC. K. Kong

Minimal Invasive Surgery UnitDepartment of SurgeryYan Chai Hospital7-11, Yan Chai Street, Tsuen WanHong Kong (SAR), China

Fig. 1. An operative photograph showing the setup for endoscopic explo-ration of a parathyroid adenoma. Two working ports have been establishedon either side of the central camera port, which is also used for insertion ofthe Nu-gauze.

Surg Endosc (1997) 11: 1135

SurgicalEndoscopy


Editorial

Minimal access and open surgery

Competition or integration?

Minimal access surgery, with all its novelty, challenge, sat-isfaction, and seduction is now running the risk of beingregarded as an entirely new technological field of medicine,competing with (some would say ‘‘replacing’’) traditionalopen surgery.

This mad dash to extol a new surgical tool or techniqueas the great salvation is not new. The evolution of cautery insurgery may well be a paradigm for us. In the Edwin SmithPapyrus the ‘‘fire stick’’ was used for the destruction ofbreast tumors. Hippocrates used cautery to open liver ab-scesses. For centuries ‘‘cautery’’ was regarded as an opera-tion unto itself. Did not Albucassis suggest that ‘‘cauteryhas universal application?’’ Even then specialization devel-oped to the extent that gold cautery was recommended forthroat disorders and bronze for breast tumors. Celsus, Pau-lus Aeginetta, Avicenna—all lauded cautery. It was not un-til the time of Ambroise Pare´ that it was recognized thatunbridled heat application to tissue might often do moreharm than good. Indeed Pare´’s influence at that time shouldgive us food for thought. He not only tried to tame theoverzealous use of cautery but also reintroduced into sur-gery an older but persistently useful technique—that of li-gating blood vessels. In the early days of laparoscopic cho-lecystectomy we almost fell into the same trap as surgeonsdid before Pare´. Some early laparoscopic surgeons, recog-nizing that the laser was certainly a more refined and precisetool than the Egyptian ‘‘fire stick’’ or even Bovie’s laterelectrified loop, began to tout it as a preferred method ofperforming laparoscopic cholecystectomy. The term ‘‘laserlaparoscopic cholecystectomy’’ was widely published [10].And while the new stimulated appropriate questioning ofthe old, there were enough scholars among us to pick up thechallenge and restudy the question. So it was that when KarlSemm raised some concerns about the use of electro-cauteryduring laparoscopic procedures there followed many studiesattesting to the safety of high frequency currents as used inperitoneoscopy. One of the points I am trying to make withthe curious title I have chosen, is that this same tide ofeducated change in how we utilize heat on tissue may berepeated many times over as minimal access surgeryevolves. Even the concepts of access and exposure are inevolution and we have to acknowledge the current limita-tions of minimal access surgery, recognizing that many willbe overcome in the near future.

For the safe performance of most, if not all operations,access, exposure, technique and judgement have long beenregarded as important elements [7]. The development ofchanges and even improvement in access does not neces-sarily mandate changes in technique and judgement. It isdifficult to understand the reluctance of many to combinewhat is feasible and superior about minimal access surgerywith what is known and has worked well in traditional opensurgery. Those who have not learned the lessons of the pastare certainly doomed to repeat them.

One of the stumbling blocks to the integration of mini-mal access surgery and open surgery is the concept of ‘‘con-version’’—an unfortunate term, since it suggests abandon-ment of one method for another. Another is the reluctance tocontinue handling tissues. Just as the lithotomists of a pre-vious generation learned to put the well-lubricated (al-though, at that time, ungloved) finger of the left hand in therectum to bring the bladder stone down to the perineumwhere the incision was made to deliver the stone, so also itis clear that some contemporary laparoscopic surgeons stillfind the surgeon’s hand useful in facilitating specific por-tions of an operation [2, 6, 14].

I submit that if one subscribes to the concept of inte-gration rather than competition with respect to the place ofminimal access surgery, various combinations, skills andstrategies become available [1, 4, 11, 12]. For example, it isclear that there may be at times alternatives to blind trocarinsertion. The Hasson technique still has a place. Even forpneumoperitoneum, recognizing the disadvantages of bothcarbon dioxide and nitrogen, other and ‘‘friendlier’’ gasesare being evaluated [13].

Methods of separating viscera and maintaining exposureas alternatives to pneumoperitoneum are also being devel-oped. The use of preformed balloons to maintain extraperi-toneal spaces is an area in point. The reluctance to ‘‘con-vert’’ or the shame in having one’s procedure regarded as‘‘laparoscopicallyassisted’’ can be illustrated in the area ofsplenectomy for the large pathologic spleen [2]. Who candeny the superior ability to visualize and, with adequatetraining and experience to separate the pathologic spleenfrom surrounding viscera with minimal access techniques?However, have we proven that going to great effort, timeand exposure to pulverize the specimen in order to avoid anincision larger than a trocar site is superior to an incision at

SurgicalEndoscopy

© Springer-Verlag New York Inc. 1997Surg Endosc (1997) 11: 1063–1064

that point in the procedure for safe, pure, total removal andadequate subsequent pathologic examination? The samemay be true for other solid viscera [8].

Rather than deny the problem of lesion localization atminimal access surgery, those anxious to solve the problemof the inability to palpate it have been utilizing some othernovel techniques such as ultrasound and, like Pare´ havefound a previously described but incompletely utilized tech-nique, namely, intraoperative flexible endoscopy to be ofincreasing value [3]. That these techniques may be joinedwith other modalities such as magnetic resonance imagingin the conduct of the operative procedure is one of the mostsatisfying developments.

These, then, are but a few examples of the reasons wethink ‘‘integration’’ superior to ‘‘competition’’ when we tryto compare and contrast minimal access and open surgery.But what shall we do aboutconversion? It should be seen interms of good judgement rather than failure. Making thischoice will be helped immeasurably by incorporating basicsurgical principles and techniques, with appropriate modernmodifications, into the training of all surgeons. In fact, weneed to do it for all would-be interventionists.

References

1. Angelini L, Lirici MM, Papaspyropoulos V, Sossi FL (1997) Combi-nation of subcutaneous abdominal wall retraction and optical trocar tominimize pneumoperitoneum retraction—related effects and needleand trocar injuries in laparoscopic surgery. Surg Endosc 11: 1006–1009

2. Ballaux KG, Himpens SM, Leman G, Van den Bossche MRP (1997)Hand-assisted laparoscopic splenectomy for hydatid cyst. Surg Endosc11: 942–943

3. Kim SH, Milsom JW, Church JM, Ludwig KA, Garcia-Ruiz A, Okuda

J, Fazio VW (1997) Perioperative tumor localization for laparoscopicsurgery. Surg Endosc 11: 1013–1016

4. Larson GM (1997) Combining minimal access procedures expands thepotential of laparoscopic surgery (Editorial). Surg Endosc 11: 225

5. Melzer A, Schmidt A, Kipfmu¨ller, Gronemeyer D, Seibel R (1997)Technology and principles of tomographic image-guided interventionsand surgery. Surg Endosc 11: 946–956

6. Naitoh T, Gagner M (1997) Laparoscopically assisted gastric surgeryusing Dexterity Pneumo Sleeve. Surg Endosc 11: 830–833

7. Paolucci V, Schaett B, Gutt CN (1997) Exposure of the operative fieldin laparoscopic surgery. Surg Endosc 11: 856–864

8. Poulin C, Labbe´ (1997) Fully thoracoscopic pulmonary lobectomy andspecimen extraction through rib resection: preliminary report. SurgEndosc 11: 354–358

9. Read C, de La Torre RA, Scott JS (1997) Balloon dissection of thespace of Bogros via the femoral canal for total extraperitoneal lapa-roscopic herniorrhaphy. Surg Endosc 11: 687–692

10. Reddick ES, Olsen D, Alexander W, Bailey A, Baird D, Price N, PruittR (1990) Laparoscopic laser cholecystectomy and cholelithiasis. SurgEndosc 4: 133–135

11. Simedh K, Skullman S, Kald A, Anderberg B, Nystrom P-O (1997)Laparoscopic bowel mobilization combined with intraoperative colo-noscopic polypectomy in patients with an inaccessible polyp of thecolon. Surg Endosc 11: 643–644

12. Spivak H, Hunter JG (1997) Endoluminal surgery. Surg Endosc 11:321–325

13. Tsoi EKM, Organ CH (1996) Abdominal Access in open and laparo-scopic surgery. Wiley-Liss, New York

14. Watson DJ, Gaure PA (1997) Hand-assisted laparoscopic verticalbanded gastroplasty: initial report. Surg Endosc (in press)

K. A. Forde

Department of SurgeryColumbia University161 Fort Washington AvenueNew York, NY 10032USA

1064

News and notices

New Address for the European Association forEndoscopic Surgery (E.A.E.S.)

Effective January 1, 1997, the new correspondence, telephone, and faxnumbers of the E.A.E.S. office are:

E.A.E.S. Office, c/o Mrs. Ria Palmen

Luchthavenweg 81Unit 1.425657 EA EindhovenThe Netherlandsor: P.O. Box 3355500 AH VeldhovenThe NetherlandsTel: +31 40 2525288Fax: +31 40 2523102

Volunteer Surgeons NeededNorthwestern Nicaragua LaparoscopicSurgery Teaching Program,Leon, Nicaragua

Volunteer surgeons are needed to tutor laparoscopic cholecystectomy forthis non-profit collaboration between the Nicaraguan Ministry of Health,the National Autonomous University of Nicaragua, and Medical TrainingWorldwide. The program consists of tutoring general surgeons who havealready undergone a basic laparoscopic cholecystectomy course. MedicalTraining Worldwide will provide donated equipment and supplies whenneeded.

For further information, please contact:

Medical Training WorldwideRamon Berguer, MD, ChairmanTel: 707-423-5192Fax: 707-423-7578e-mail: [email protected]

Fellowship in Minimally Invasive SurgeryGeorge Washington Medical CenterWashington, DC USA

A one-year fellowship is being offered at the George Washington Univer-sity Medical Center. Interested candidates will be exposed to a broad rangeof endosurgical Education and Research Center. Active participation inclinical and basic science research projects is also encouraged.


Debbie Moser202-994-8425

or, send curriculum vitae to:

Dr. Jonathan M. SackierDirector, Washington Institute of Surgical EndoscopyGeorge Washington University Medical CenterDepartment of Surgery2150 Pennsylvania Avenue, N.W.6B-417Washington, DC 20037, USA

Essentials of Laparoscopic SurgerySurgical Skills UnitUniversity of DundeeScotland, UK

Under the direction of Professor A. Cuschieri the Surgical Skills Unit isoffering a three-day practical course designed for surgeons who wish toundertake the procedures such as laparoscopic cholecystectomy. This in-tensely practical program develops the necessary operating skills, empha-sizes safe practice, and highlights the common pitfalls and difficultiesencountered when starting out. Each workshop has a maximum of 18participants who will learn both camera and instrument-manipulation skillsin a purpose-built skills laboratory. During the course there is a live dem-onstration of a laparoscopic cholecystectomy. The unit has a large libraryof operative videos edited by Professor Cuschieri, and the latest books onendoscopic surgery are on display in our Resource area. Course fee in-cluding lunch and course materials is $860.

For further details and a brochure please contact:

Julie Struthers, Unit Co-ordinatorSurgical Skills UnitNinewells Hospital and Medical SchoolDundee DD1 9SYTel: +44 382 645857Fax: +44 382 646042

Advanced Endoscopic SkillsSurgical Skills UnitUniversity of DundeeScotland, UK

Each month Professor Cuschieri Surgical Skills Unit offers a 41⁄2 daycourse in Advanced Endoscopic Skills. The course is intensely practicalwith ‘‘hands on’’ experience on a range of simulated models. The programis designed for experienced endoscopic surgeons and covers advanceddissection techniques, extracorporeal knotting techniques, needle control,suturing, internal tying technique, stapling, and anastomotic technique.Individual workstations and a maximum course number of 10 participantsallows for personal tuition. The unit offers an extensive collection of sur-gical videos and the latest books and publications on endoscopic surgery.In addition, participating surgeons will have the opportunity to see liveadvanced laparoscopic and/or thoracoscopic procedures conducted by Pro-fessor Cuschieri and his team. The course is endorsed by SAGES. Coursefee including lunch and course materials is $1850.



The Practical Aspects of Laparoscopic FundoplicationSurgical Skills UnitUniversity of DundeeScotland, UK

A three-day course, led by Professor Cuschieri, designed for experiencedlaparoscopists wishing to include fundoplication in their practice. The

SurgicalEndoscopy


course covers the technical details of total and partial fundoplication usingsmall group format and personal tuition on detailed simulated models.There will be an opportunity to observe one of these procedures live duringthe course. Maximum course number is six. Course fee including lunch is$1850.



Courses at the Royal Adelaide Centre forEndoscopic Surgery

Basic and Advanced Laparoscopic Skills Courses are conducted by theRoyal Adelaide Centre for Endoscopic Surgery on a regular basis. Thecourses are limited to six places to maximize skill development and tuition.Basic courses are conducted over two days for trainees and surgeons seek-ing an introduction to laparoscopic cholecystectomy. Animal viscera insimulators is used to develop practical skills. Advanced courses are con-ducted over four days for surgeons already experienced in laparoscopiccholecystectomy who wish to undertake more advanced procedures. Awide range of procedures are included, although practical sessions can betailored to one or two procedures at the participants request. Practical skillsare developed using training simulators and anaesthetised pigs.

Course fees: $A300 ($US225) for the basic course and $A1,600($US1,200) for the advanced course.

For further details and brochure, please contact:

Dr. D. I. Watson or Professor G. G. JamiesonThe Royal Adelaide Centre for Endoscopic SurgeryDepartment of SurgeryRoyal Adelaide HospitalAdelaide SA 5000 AustraliaTel: +61 8 224 5516Fax: +61 8 232 3471

Advanced Laparoscopic Suturing and SurgicalSkills Courses

MOET InstituteSan Francisco, CA, USA

Courses are offered year-round by individual arrangement. The MOETInstitute is accredited by the Accreditation Council for Continuing MedicalEducation (ACCME) to provide continuing medical education for physi-cians and designates these CME activities for 20–40 credit hours in Cat-egory 1 of the Physician’s Recognition Award of the American MedicalAssociation. These programs are also endorsed by the Society of Gastro-intestinal Endoscopic Surgeons (SAGES).


Wanda Toy, Program AdministratorMicrosurgery & Operative Endoscopy Training (MOET) Institute153 States StreetSan Francisco, CA 94114, USATel: (415) 626-3400Fax: (415) 626-3444

Courses at WISEWashington Institute for Surgical EndoscopyWashington, DC, USA

The Washington Institute of Surgical Endoscopy is pleased to offer thefollowing courses:

Laparoscopic antireflux and hiatal hernia surgery (July 14–15, 1997); Lap-aroscopic management of the common bile duct and difficult cholecystec-

tomy (May 15–16, August 11–12, November 10–11, 1997); Laparoscopiccolon and rectal surgery (June 20–21, September 15–16, December 4–5,1997). Also, courses for operating room nurses and technicians will be runon a monthly basis and personal instruction and preceptorship is available.

For further information, please call:

Debbie MoserWashington Institute of Surgical Endoscopy2150 Pennsylvania Avenue, N.W.Washington, DC 20037Tel: 202-994-9425

Call for AbstractsSociety of American Gastrointestinal Endoscopic Surgeons(SAGES) 1998 Annual MeetingApril 1–4, 1998Seattle, WA, USA

Abstract deadlines: Oral and Poster abstracts: September 12, 1997Video Submissions: September 18, 1997

For further information, or to obtain an abstract form, please contact:

SAGES Program CommitteeSociety of American Gastrointestinal Endoscopic SurgeonsSuite #30002716 Ocean Park BoulevardLos Angeles, CA 90405Tel: (310) 314-2404Fax: (310) 314-2585e-mail: [email protected]

Eighteenth Annual Turnbull SymposiumImportant Issues in Colorectal SurgeryNovember 21 and 22, 1997Cleveland, OH, USA

Pre-symposium courses on laparoscopic colorectal surgery, office investi-gations in colorectal surgery, pelvic anatomy and live demonstrations ofrectal surgery are offered to limited number of applicants.

Postgraduate Courses in Colorectal SurgeryNovember 19, 20, 22, 1997Cleveland, OH, USA

Laparoscopic intestinal surgery; techniques for investigation of the largebowel; endoscopy, intrarectal, and endoanal ultrasound, live surgery dem-onstrations, inherited colorectal cancer. Space for these courses is limited.

For further information regarding the Turnbull Symposium or the Post-graduate Courses, please contact:

J.M. Church, MDDepartment of Colon and Rectal SugeryCleveland Clinic Foundation9500 Euclid Avenue, A111Cleveland, OH 44195Tel: (216) 444-9052Fax: (216) 445-8627email: [email protected]

1139

European Course on Laparoscopic Surgery(English language) November 18–21, 1997Brussels, Belgium

Course director: G.B. Cadiere


Administrative SecretariatConference Services s.a.Avenue de l’Observatoire, 3 bte 17B-1180 Bruxelles

Tel: (32 2) 375 16 48Fax: (32 2) 375 32 99

Second Asian Pacific Symposium and Workshop onMinimally Invasive Thoracic and Cardiac Surgery

December 9–11, 1997Taipei, Taiwan

The main themes are updates and live operative demonstrations of thora-coscopy and video-assisted thoracic surgery, minimally invasive cardiacsurgery, and thoracoscopic spine surgery.


Hui-Ping Liu, MDDivision of Thoracic and Cardiovascular SurgeryChang Gung Memorial Hospital199 Tun-Hwa N Rd.Taipai, Taiwan 10591Tel: 866-3-3281200Fax: 866-3-3285818

Colorectal Disease in 1998February 19–21, 1998Fort Lauderdale, FL, USA

Symposium Director: Steven D. Wexner, MD

Cleveland Clinic Florida presents its ninth annual postgraduate course.Provides an intensive, in-depth, analytical review of all aspects of colo-rectal disease, including laparoscopy; colorectal carcinoma screening andgenetics, inflammatory bowel disease; and pouch surgery. There will be areview of both basic and advanced principles of diagnosis and managementof disease. Video techniques will be shown as well. The faculty is inter-

nationally represented and includes leading experts in the field. Simulta-neous Spanish and Italian translation is available.

For more information, please contact:

Cleveland Clinic FloridaDepartment of Education2950 West Cypress Creek RoadFort Lauderdale, FL 33309-1743Tel: 800-359-6101, ext. 6066Fax: 954-978-5539

6th World Congress of Endoscopy Surgery ‘‘Roma 98’’6th International Congress of European Associationfor Endoscopic Surgery

June 3–6, 1998Rome, Italy

The program will include: the latest, original high quality research; sym-posia; plenary lectures; abstract presentations (video, oral, and posters);EAES and SAGES postgraduate courses, OMED postgraduate course ontherapeutic endoscopy; working team reports; educational center and learn-ing corner; meeting of the International Society of Nurses and Associates;original and non original scientific reports; and a world expo of newtechnology in surgery.


Congress Secretariat: Studio EGAViale Tiziano, 1900196 Rome, ItalyTel: +39 6 322-1806Fax: +39 6 324-0143

Tenth International Conference of the Society for Mini-mally Invasive TherapySeptember 3–5, 1998London, England

Host Chairman: Mr. J. Wickham


The Society for Minimally Invasive Therapy2nd Floor, New Guy’s HouseGuy’s HospitalSt. Thomas StreetLondon, SE1 9RT, EnglandTel: +44 (0)171 955 4478Fax: +44 (0)171 955 4477email: [email protected]

1140

Bedside percutaneous endoscopic gastrostomy

A safe alternative for early nutritional support in critically ill trauma patients

E. H. Carrillo, 1 B. T. Heniford,2 D. L. Osborne,1 D. A. Spain,1 F. B. Miller, 1 J. D. Richardson1

1 Department of Surgery, University of Louisville School of Medicine, and the Trauma Program in Surgery, University of Louisville Hospital, 530South Jackson Street, Ambulatory Care Building, Louisville, KY 40292, USA2 Department of General Surgery, Laparoscopic Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA


AbstractBackground:Percutaneous endoscopic gastrostomy (PEG)is a good alternative that provides long-term nutritional sup-port and is associated with minimal morbidity.Methods:During a 24-month period, we studied 54 criti-cally injured patients who underwent early PEG to provideenteral nutritional support. Patients were selected due to theinability to tolerate intake by mouth secondary to multipleassociated injuries, especially to the central nervous system.Results:All patients sustained multiple injuries with an av-erage Injury Severity Score of 27. The mean Glasgow ComaScale at the time of admission was 7 and at the time of thePEG was 10. Eleven patients (20%) had an intracranialpressure (ICP) device, and there was no significant increasein the mean ICP before, during, or after the procedure. In63% of patients, tube feedings were interrupted for a varietyof problems in the 72 h preceding the PEG, and in 70% ofpatients an average of five radiographs were obtained todocument tube position. In 95% of patients, the nutritionalgoal was achieved within 48 h of PEG placement. Therewere one immediate and two delayed complications afterPEG placement. There were two deaths, neither related tothe PEG placement.Conclusions:Early PEG in critically injured patients is asafe and effective method of providing access to the GI tractfor nutritional support. In patients with significant braininjuries, adequate sedation and the presence of an ICP moni-tor help to minimize secondary insults to the brain.

Key words: Percutaneous endoscopic gastrostomy (PEG)— Nutrition — Trauma

Adequate nutritional support is a mainstay in the care ofcritically injured patients. Most patients receive nutritionalsupport by either nasoenteric feedings or parenteral nutri-tion. Surgical gastrostomy is, in general, unacceptable inthese patients as it typically requires general anesthesia anda laparotomy for placement, with their associated compli-cations. Over the last two decades, the use of percutaneousendoscopic gastrostomy (PEG) has evolved as an excellentalternative to access the gastrointestinal (GI) tract for long-term nutritional support [5] with a very low morbidity andmortality [4, 10, 11]. Some clinicians propose the use ofparenteral nutrition as the easiest way to achieve nutritionalgoals and minimize complications in the critically injuredtrauma patient; however, enteral feeding remains the pri-mary choice for nutritional support when the GI tract isfunctional. Borzotta and associates have shown improvedcognitive results in patients with head injuries when fedenterally compared to those receiving total parenteral nutri-tion (TPN) [2]. Recent studies have also shown that enter-ally delivered nutrients are better utilized and provide cy-toprotection for the intestinal mucosa. Enterally fed patientsexperience fewer septic complications, presumably becauseof enhanced immunocompetence [9].

Historically, nasogastric (NG) tubes have been utilizedto access the GI tract to provide nutritional support. Thesetubes are quite useful short term, but they are associatedwith complications such as esophagitis, aspiration pneumo-nia, sinusitis, pneumonia due to aspiration or otherwise, anderosion into and deformation of nasal cartilage [10].Smaller, softer, and longer nasoenteric feeding tubes (NET)which can be advanced into the proximal jejunum have beenproposed as an alternative to NG tubes to limit these adverseeffects. Unfortunately, frequent dislodgements, obstructionof the lumen, and the cumbersome and time-consumingmaneuvers to correctly place these tubes limit their clinicalusefulness.

Surgical gastrostomy is a time-tested and well-acceptedtechnique to provide long-term access to the GI tract and


Correspondence to:E. H. Carrillo

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PEG has become a popular minimally invasive alternative.The main advantages of this technique are that it is techni-cally easier to perform, can be done under local anesthesia,involves little systemic stress, and is more cost effective[10]. The purpose of this study was to review our experiencewith PEG as a bedside technique in critically ill traumapatients and determine its safety and feasibility in a high-risk population.


Patients

Over a 28-month period ending in July 1996, 54 consecutive criticallyinjured patients admitted to the Trauma Service at the University of Lou-isville Hospital, underwent bedside PEG placement in the Surgical Inten-sive Care Unit (SICU). The procedure was completed in 53 patients (98%).Demographic information (age, gender, mechanism of injury, GlasgowComa Scale [GCS], Injury Severity Score [ISS]) [1], procedure-relatedinformation (technical problems, monitoring abnormalities), and postop-erative hospital outcome variables (nutritional goal achieved, pulmonary orother complicated wound problems, and mortality) were collected fromeach case and analyzed. During the review period, another 67 PEG place-ments were performed in the operating room or endoscopy suite.

Anesthesia

In all patients, 1% Xylocaine (lidocaine hydrochloride, Astra USA, Inc.Westboro, MA) was used as a local anesthetic. Intravenous sedation wasprovided with Versed (midazolam HCl, Roche Laboratories, Nutley, NJ).We considered it important to emphasize that proper sedation and localpain control should be obtained to minimize secondary trauma to patientswith severe head injuries. Diprivan (propofol, Stuart Pharmaceuticals, Wil-mington, DE) was also used as a rapidly acting intravenous anestheticagent in severe closed-head-injury patients in order to avoid sudden in-creases in the intracranial pressure (ICP).

Surgical technique

All procedures were performed bedside in the SICU by a general surgeryresident (postgraduate year [PGY]-2) or the trauma chief resident (PGY-5)under continuous supervision by the trauma attending staff. All patientswere kept NPO for at least 6 h before the procedure. Universal precautionsand sterile conditions were maintained. Blood pressure, pulse oximetry,end-tidal CO2, and cardiac activity were routinely monitored during all

procedures. Optics included a flexible gastroscope (Olympus GIF V-10)attached to a high-resolution monitor. After a complete esophagogastro-duodenoscopy (EGD), insufflation of the stomach and transillumination ofthe gastric and abdominal wall were performed as previously described[10, 11]. The lights in the room dimmed to facilitate location of the inser-tion site, which ideally should be 3 cm below the costal margin at thejunction of a line drawn between the umbilicus and midclavicular line. Inall cases, a MIC Removable OTW PEG Kit (Ballard Medical Products,Draper, UT) was utilized. The proper selection of the insertion site iscritical for the success of this procedure. The chosen site of insertion,facilitated by the point of maximum transillumination in the abdominalwall, is depressed with a finger while the anterior gastric wall is observedwith the endoscope. If the site depressed with a finger is a good location onthe gastric wall, the skin is infiltrated with 1% lidocaine and a 1-cm skinincision is made. The site should be free of major vessels, viscera, and scartissue. A needle is then placed through the incision, transabdominally intothe stomach. An endoscopic snare is used to secure the needle, the stylet isremoved, and a guidewire is passed through the needle (Fig. 1). Once thewire has been secured with the endoscopic snare, it is pulled against the endof the scope and then withdrawn as a unit. Tension is maintained at bothends of the guidewire and the gastrostomy tube is then loaded onto theguidewire with the tapered end first. The gastrostomy tube is pushed downthe esophagus, into the stomach, exiting the abdominal wall at the site ofneedle insertion (Fig. 2). The PEG tube is then pulled through the abdomi-nal wall until the button or bumper on the distal end of the tube appears to‘‘snugly’’ approximate the stomach to the anterior abdominal wall. Arepeat gastric endoscopy is performed to document position, the tube issecured with the external bolster under endoscopic control to avoid unnec-essary tension, and finally a picture is obtained to document placement. Weroutinely leave the PEG to gravity drainage for 12 to 24 h before enteralfeedings are started.

Results

Fifty-four multiple trauma patients aged 18–95 years (av-erage 42 years) underwent PEG placement. There were 38men and 16 women. The mechanism of injury was blunttrauma in 43 (motor vehicle accident in 32, fall in 11),gunshot wounds in four, and various other injuries in seven.Most procedures (56%) were carried out for low GCS orpersistent vegetative state (PVS). Sixteen patients (30%)with predominantly orthopedic injuries underwent PEG asan adjunct to nutritional support. In four patients, aspirationand severe maxillofacial trauma were the indication forPEG.

The mean ISS was 27 (range 8–42). Glasgow Coma

Fig. 1. The ‘‘push’’ technique under endoscopic guidance. The needle iswithdrawn; the flexible wire is secured and then pulled with a snare. Fig. 2. The tube is passed over a guidewire in a retrograde fashion. It is

pushed into the stomach, exiting the abdominal wall until the tapered endof the PEG dilates the stoma tract through the abdominal wall.

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Scale score upon admission was 3 to 15 (mean 7) and on theday of the PEG was 3 to 15 (mean 10). Associated surgicalprocedures were performed in all patients with an averageof 2.3 per patient (range 1–4); the most common operationswere orthopedic and neurosurgical, which occurred in 32patients, followed by maxillofacial in 20, vascular and tho-racic in eight, and abdominal procedures in seven patients.

In the 72 h prior to placement, 34 patients (63%) re-quired interruption of their tube feeds for a variety of tech-nical problems. In 38 patients, an average of five radio-graphs were obtained (range 1–16) to document the locationof the feeding tube. Concomitant full EGD at the time ofPEG placement revealed an unsuspected pathology in 30patients (55%) requiring specific treatment in 12 patients(Table 1).

The interval between admission and PEG averaged 7days (range 2–12). At the time of the PEG placement, 40patients (74%) were endotracheally intubated and requiredmechanical ventilation. In the last year of our experience,simultaneous percutaneous dilational tracheostomy (PDT)was performed in 14 patients with no complications. In 11patients (20%) an ICP monitor was in place at the time ofthe PEG with no significant changes in ICP before or duringthe PEG (14 vs 16 cm H2O).

Full enteral nutritional support was achieved within 48 hof PEG placement in 95% of patients.

There were no significant complications related to theEGD, although three patients developed transient arterialoxygen desaturation which corrected after suctioning andrepositioning the endotracheal tube. The procedure wasconverted, in one patient, to an open gastrostomy afterbleeding at the entrance site in the stomach was noted, afterthe initial PEG placement. Two delayed complications wereobserved; one patient developed aspiration pneumonia, andin the second, the patient inadvertently pulled the tube, re-quiring surgical replacement. Two patients died in this se-ries. Neither death was related to the PEG placement; eachwas the result of underlying associated injuries.

Discussion

Adequate nutrition is an important part of the overall care ofcritically ill trauma patients. Unfortunately, it is too oftenneglected or relegated to a secondary role. PEG has beenstrongly advocated as a safe, reliable, and acceptable tech-

nique to provide adequate enteral nutrition [4, 8–10]. Ingeneral, our series confirms this; however, some points areimportant to emphasize.

Monitoring the ICP is important during this procedure inpatients with severe head injuries to minimize secondaryinsults to the brain. In our series, an ICP monitor was inplace in 11 patients (20%) with minimal changes in the ICP.Adequate local anesthesia, IV sedation, and occasionallybrief paralyzation are extremely important to avoid suddenelevation of the ICP.

Despite concerns of endoscopic surgery in critically illpatients, PEG has been shown to be safe, reliable, and useful[4, 5, 9, 11]. Its use should be considered carefully forpatients in whom it may not be possible because of (1)hemodynamic instability, (2) recent esophageal or gastricsurgery, or (3) coagulopathy. Prior abdominal surgery hasbeen mentioned as a relative contraindication. We per-formed PEG in six patients with prior abdominal surgeryand agree that by following the technical steps carefully itcan be performed without added risk to the patient [13, 15].

In this experience, we have shown that bedside PEG incritically ill trauma patients is a safe, reliable, and expedi-tious technique. In the two patients where an open G-tubehad to be performed, better patient restraint and a conser-vative approach to the gastric bleeding possibly could haveavoided the open procedure. The presence of a PEG tube iswell tolerated by the patient; some in this series remained inplace for over a year with no documented complications.Desired nutritional goals were achieved in 48 h in 95% ofpatients with minimal or no side effects. The delivery offeedings through a PEG is simple and easily implemented inthe rehabilitation or home setting. This technique also fa-cilitates transfers and discharges to and from long-term fa-cilities. It is an effective method with which to maintainhydration and nutrition in the multiple trauma patient, andwe believe it is the alternative of choice for long-term ac-cess to the GI tract. Physicians caring for these patients areencouraged to become familiar with this technique, whichwe believe is slightly more invasive than placing an NGtube.

As part of the protocol of PEG placement, all patientsare routinely fed in the 30° upright position, and trachealsecretions are routinely checked for the presence of dye orglucose. One potential advantage of PEG catheters is thatsince they do not cross the gastroesophageal junction andthen stent it open, the incidence of reflux and aspiration istheoretically less that with NG tubes. The overall incidenceof aspiration in patients with PEG tubes, however, rangesfrom 11 to 14% [9, 14]. The risk of aspiration is not de-creased by placement of more distal tubes, as shown in thisand other institutions [7, 12, 14].

This series of critically injured patients demonstratesthat bedside PEG placement can be safely performed withminimal morbidity in the ICU by surgical residents withappropriate staff supervision. These patients, in general, donot tolerate general anesthetics and intrahospital transportwell [6]. Currently, we routinely perform the ‘‘push’’ tech-nique as described by Gauderer and Ponsky in 1980 [5](Figs. 1 and 2). A potential complication of PEG tubes isextrusion of the tube out of the stomach. The literaturesuggests that it occurs secondary to pressure necrosis of thegastric wall when the fastener of the tube is positioned

Table 1. Endoscopic findings during PEG

Diagnosis Number of Patients

Normal 24Gastritis 17

Severe (5)a

Mild (12)Reflux esophagitis 6b

Gastric ulcer 4c

Duodenal ulcer 3d

Specific treatment after PEG placement:a Four patients.b Three patients.c Three patients.d Two patients.

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under excessive tension [3]. To avoid this complication, weposition the external fastener ring of the PEG under endo-scopic visualization of the bumper of the tube in the stom-ach to ensure that it is not left under undue traction. We donot routinely use prophylactic antibiotics with this proce-dure and wound infection was not a problem in any of thesepatients.

In general, therefore, we believe that early bedside PEGshould be considered in critically ill trauma patients for thefollowing indications:

● Patients with severe neurological injuries or PVS who arelikely to need long-term enteral feedings

● Patients with multiple associated injuries who cannot tol-erate adequate nutritional intake through the oral route

● Those patients with multiple and severe facial injurieswho may be intolerant or have a contraindication to a NGtube

References

1. Baker SP, O’Neill B, Haddon W Jr, Long WB (1974) The injuryseverity score: a method for describing patients with multiple injuriesand evaluating emergency care. J Trauma 14: 187–196

2. Borzotta AP, Osborne A, Bledsoe F, Paxton J, Mardesic S (1993)Enteral nutritional support enhances cognitive recovery after severeclosed head injury. Surg Forum 44: 29

3. Chung RS, Schertzer M (1990) Pathogenesis of complications follow-ing percutaneous endoscopic gastrostomies (PEG). Am Surg 56: 134–137

4. D’Amelio LF, Hammond JS, Spain DA, Satyak JP (1994) Tracheos-

tomy and percutaneous endoscopic gastrostomy in the management ofthe head-injured trauma patient. Am Surg 60: 180–185

5. Gauderer MWL, Ponsky JL, Izant RJ Jr (1980) Gastrostomy withoutlaparotomy: a percutaneous endoscopic technique. J Pediatr Surg 15:872–875

6. Indeck M, Peterson S, Smith J, Brotman S (1988) Risk, cost, andbenefit of transporting ICU patients for special studies. J Trauma 28:1020–1025

7. Kadakia SC, Sullivan HO, Starnes E (1992) Percutaneous endoscopicgastrostomy or jejunostomy and the incidence of aspiration in 79 pa-tients. Am J Surg 164: 114–118

8. Kelly KM, Lewis B, Gentili DR, Benjamin E, Waye JD, Iberti TJ(1988) Use of percutaneous gastrostomy in the intensive care patient.Crit Care Med 16: 62–63

9. Moore FA, Haenel JB, Moore EE, Read RA (1992) Percutaneoustracheostomy/gastrostomy in brain-injured patients—a minimally in-vasive alternative. J Trauma 33: 435–439

10. Ponsky JL, Gauderer MWL (1989) Percutaneous endoscopic gastros-tomy: indications, limitations, techniques and results. World J Surg 13:165–170

11. Ponsky JL, Gauderer MW, Stellato TA, Aszodi A (1985) Percutaneousapproaches to external alimentation. Am J Surg 149: 102–105

12. Spain DA, DeWeese RC, Reynolds MA, Richardson JD (1995) Trans-pyloric passage of feeding tubes in patients with head injury does notdecrease complications. J Trauma 39: 1100–1102

13. Stellato TA, Gauderer MWL, Ponsky JL (1987) Percutaneous endo-scopic gastrostomy following previous abdominal surgery. Ann Surg200: 46–50

14. Strong RM, Condon SC, Solinger MR, Namihas BN, Ito-Wong LA,Leuty JE (1992) Equal aspiration rates from postpylorus and intragas-tric-placed small-bore nasoenteric feeding tubes: a randomized pro-spective study. JPEN J Parenter Enteral Nutr 16: 59–63

15. Townsend MC, Flancbaum L, Cloutier CT, Arnold MW (1992) Earlypostlaparotomy percutaneous endoscopic gastrostomy. Surg GynecolObstet 174: 46–48

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Laparoscopy in the critically ill

R. Orlando, III, K. L. Crowell

Department of Surgery, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102-5037, USA, and University of Connecticut School of Medicine,Farmington, CT 06034, USA

Received: 3 April 1997/Accepted: 19 May 1997

AbstractBackground:Laparoscopy was evaluated in critically ill pa-tients with suspected acute cholecystitis, mesenteric isch-emia, or gastrointestinal perforation. We studied laparosco-py to assess its utility, accuracy, and effect on cardiopul-monary stability.Methods:Twenty-six surgical ICU patients with possibleabdominal sepsis underwent laparoscopy. Nineteen werepost cardiac surgery; the remainder had other diagnoses.Video laparoscopy was performed with hemodynamicmonitoring and inotropic support as needed. Eight patientshad bedside laparoscopy.Results:Fifteen patients had suspected acute cholecystitis.Laparoscopy was positive in 10; four had open cholecys-tectomy, four laparoscopic cholecystectomy, and two tubecholecystostomy. Nine patients had suspected mesentericischemia; laparoscopy was positive in five, revealing cir-rhosis in two and ischemic bowel in three. Two patients hadsuspected perforated viscus with colonic perforation in oneand one false negative. There were no adverse hemody-namic events.Conclusions:Laparoscopy can be performed safely in criti-cally ill patients. It is useful in patients with acute chole-cystitis and in patients who are post cardiac surgery withrefractory lactic acidosis in whom a diagnosis of mesentericischemia is considered.

Key words: Laparoscopy — Critical illness — Acute acal-culous cholecystitis — Mesenteric ischemia

During the past several years, laparoscopic techniques havebeen used in increasing numbers of elective surgical proce-dures. Laparoscopic approaches to diagnosis and therapy in

emergent situations and in unstable patients are evolving.Critically ill patients often develop signs and symptoms ofsepsis or the systemic inflammatory response syndrome(SIRS). Nonspecific findings such as fever, leukocytosis,abdominal distention, and metabolic acidosis raise concernsabout possible intraabdominal sepsis. Acute cholecystitis,mesenteric ischemia, and gastrointestinal perforation are of-ten difficult to diagnose with standard approaches such asphysical examination, abdominal sonography, and com-puted tomography. Laparoscopic assessment of possible in-traabdominal sepsis warranted investigation because it isminimally invasive, rapid, can be performed at the bedsidein unstable patients, and had the potential to be highly ac-curate. We examined our experience with laparoscopy toassess its utility, diagnostic accuracy, effect on cardiopul-monary stability, and safety.

Patients and methods

This study entailed a retrospective analysis of patients who had diagnosticor therapeutic laparoscopy while in the Surgical Intensive Care Unit(SICU) at Hartford Hospital, an 800-bed tertiary-care teaching institution.There are 24 SICU beds with approximately 1,700 admissions annually.Between July 1991 and June 1996, 26 SICU patients underwent laparos-copy.

The study group included 17 males and nine females with a mean ageof 69 years (range 54–81). The mean SICU stay prior to laparoscopy was10 days (range 0–33 days). The admitting SICU diagnoses are listed inTable 1. The cardiac, vascular, and two of the general surgery patients wereall evaluated laparoscopically during the postoperative period. Three of thegeneral surgery patients were admitted preoperatively with abdominal painand sepsis. Eleven patients had a history of remote abdominal operations.

Twenty patients (77%) were mechanically ventilated prior to contem-plation of laparoscopy. The remainder were intubated just prior to theprocedure. All patients had arterial lines in place and 21 (81%) had pul-monary artery catheters. Twenty-two patients were receiving vasoactiveinfusions at the time of the laparoscopy, ranging from renal-dose dopamine(seven patients) to high doses of dobutamine, amrinone, milrinone, phen-ylephrine, epinephrine, or norepinephrine (14 patients).

All of the postoperative patients had an unstable course with clinicaland laboratory findings suggestive of an intraabdominal source of sepsis.Twenty-two patients (85%) had abdominal exam findings suggestive ofintraabdominal pathology and six (23%) were febrile. Nine (35%) hadleukocytosis, 12 (46%) had elevated serum lactate levels, and 21 (81%) hadabnormal liver chemistries and/or elevated serum amylase and lipase.Prelaparoscopy ultrasound was performed in 13 patients: It was positive in


Correspondence to:R. Orlando, III

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four, indeterminate in five, and negative in four. Abdominal computedtomography was performed in six patients and demonstrated ascites in twoand portal venous air in one.

These findings, often accompanied by low systemic vascular resis-tance, prompted the decision to perform laparoscopy. Indications for lap-aroscopy were categorized as suspected acute cholecystitis in 15, possiblemesenteric ischemia in nine, and perforated viscus in two patients.

Video laparoscopy was performed using open cannulation of the ab-domen with a carbon dioxide pneumoperitoneum and hemodynamic moni-toring and inotropic support as needed. Abdominal pressures were initiatedat 10–12 mmHg and increased to 15 mmHg if needed for visualization ofthe peritoneal cavity. Eight patients had diagnostic laparoscopy performedat the bedside. Patients treated in the operating room had general anesthesiawith muscle relaxation. Patients undergoing laparoscopy in the SICU re-ceived sedation with intravenous narcotics, benzodiazepines, or propofol inaddition to neuromuscular blockers. Two or three ports were employed fordiagnostic laparoscopy. Peritoneal fluid was usually aspirated and sent formicrobiologic analysis.

Results

Table 2 shows the results of laparoscopy in the three diag-nostic categories which were considered. Among the 26patients in the series, there were 16 positive and 10 negativeexaminations. There were no false positives and one falsenegative. The single false negative occurred in a patientwith a suspected perforated viscus in the setting of perito-nitis and SIRS. Laparoscopy documented patchy fat necro-sis. Subsequent abdominal CT scan revealed severe pancre-atic necrosis.

Among patients diagnosed with acute cholecystitis, fourhad open cholecystectomy, four had laparoscopic cholecys-tectomy, and two had laparoscopic tube cholecystostomy. Inpatients with suspected mesenteric ischemia, the positivefindings included mesenteric ischemia in three and unsus-pected cirrhosis in two. One of the two suspected perforatedviscus patients had a diverticular perforation of the colonand the other was the false negative mentioned above. Inaddition to the open cholecystectomies, conversions to opensurgery were carried out for small-bowel resection in threecases, for Hartmann procedure in one, and for cecostomy inone.

Analysis of preoperative laboratory tests includingwhite blood cell count, liver chemistries, amylase, lipase,arterial blood gases, and serum lactate did not demonstrateany correlation with the presence or absence of intraab-dominal pathology found at laparoscopy. Preoperative ul-trasound was also poorly correlated with operative findingsin the patients with suspected cholecystitis.

All patients tolerated the pneumoperitoneum withoutadverse consequences. Hemodynamic stability was main-tained in all but one case (see below) without the need forany increase in the level of inotropic support. There were noepisodes of oxygen desaturation or ventilatory compromise.There were no complications observed in the patients un-dergoing bedside laparoscopy, who were generally more

unstable. Only one of these patients, who had a colonicperforation, required transfer to the operating room for anopen procedure.

One operative complication occurred, a perforation ofthe small bowel secondary to manipulation of ischemicbowel with grasping forceps. At the time of the perforationand subsequent open small-bowel resection, enteric con-tents were spilled and the patient became hypotensive. Thiswas treated with a single bolus of phenylephrine and rep-resents the only hemodynamic compromise observed in thisseries. One patient developed a postoperative wound infec-tion following open cholecystectomy.

Overall, 11 patients (42%) survived to hospital dis-charge and 15 patients died (58%). None of the deaths weredue to complications or laparoscopy or intraabdominal sep-sis.

Discussion

Critically ill patients may develop acute abdominal condi-tions similar to those of ambulatory patients such as diver-ticulitis or they may develop intraabdominal catastrophescharacteristic of the SICU population including acute acal-culous cholecystitis and mesenteric ischemia. Diagnosis ofthese problems can be quite difficult: Physical findings areoften unreliable due to altered mental status, laboratoryfindings are frequently confounded by coexisting diseaseprocesses, and radiologic studies may be impractical be-cause of logistical and safety considerations in transportingunstable patients.

The diagnosis of acute acalculous cholecystitis can beespecially problematic. Laboratory findings are usuallynonspecific (1). While bedside ultrasonography eliminatesthe need for transport, it is often inconclusive [4, 8, 13, 17].Radionuclide hepatobiliary scans are of limited value inpatients who are not receiving enteral nutrition. Morphineaugmentation during cholescintigraphy was previously re-ported to improve accuracy in critically ill patients [9]; how-ever, this finding has not been confirmed in a subsequentstudy [7]. Brandt et al. [5] and Sleeman et al. [18] havesupported the utility of laparoscopy in trauma ICU patientswith suspected acute cholecystitis. We advocate laparoscop-ic cholecystectomy when feasible but laparoscopic chole-cystostomy is effective in the absence of gangrenous cho-lecystitis. Open cholecystectomy is required for gangrenouscholecystitis in situations not amenable to laparoscopictreatment.

Suspected mesenteric ischemic is a difficult consider-ation in the critically ill because the only nonoperative di-agnostic modality is mesenteric angiography. This requirestransport of an unstable patient to the radiology departmentand involves the use of potentially nephrotoxic contrastagents [14]. Laparoscopy is now emerging as a diagnostic

Table 1. Admitting SICU diagnosis

Type of surgery No. patients

Cardiac 19Vascular 2General surgery 5

Table 2. Results of diagnostic laparoscopy in patient groups

Suspected diagnosis No. patients Positive Negative

Acute cholecystitis 15 10 5Mesenteric ischemia 9 5 4Perforated viscus 2 1 1

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technique because of these uncertainties. One early casereport described the use of laparoscopy to confirm the di-agnosis of small-bowel infarction after abdominal aortic re-construction [11]. Forde and Treat described the use of lap-aroscopy to determine the need for further evaluation withlaparotomy in a series of 10 patients with clinical conditionssimilar to ours [10]. Bender and Talamini [3] and Brandt etal. [4] reported safety and utility of laparoscopy in criticallyill patients.

The single false negative in this experience demon-strates that diagnostic laparoscopy will not adequatelyevaluate the retroperitoneum. This patient had severe pan-creatitis with necrosis and CT scanning remains the defini-tive diagnostic procedure.

Despite known adverse physiologic effects of pneumo-peritoneum, procedures were well tolerated in our patients.Respiratory effects of pneumoperitoneum include hypercar-bia, respiratory acidosis, diaphragmatic elevation, reducedfunctional residual capacity, and ventilation perfusion mis-match. Cardiovascular alterations include elevated centralvenous pressure and pulmonary artery pressures, increasedsystemic vascular resistance and mean arterial pressure, anddecreased stroke volume and cardiac output, especially inpatients with limited cardiac reserve. These phenomena aredependent upon baseline cardiopulmonary function, intra-vascular volume status, and the magnitude of intraperitonealpressure increases [14–16,19]. Safran et al. [16] and Carrollet al. [6] described the safe and successful use of laparos-copy in high-risk patients with severe cardiac dysfunction.Careful physiologic monitoring is necessary to safely per-form laparoscopy in this very ill group of patients.

To minimize the risk of procedural complications, theHasson technique of trocar introduction is advisable. Manyof these patients have distended bowel, and the use of aVeress needle and blind trocar insertion can result in bowelinjury. The inclusion of a Leuken’s trap in the suction tub-ing circuit is helpful for the collection of ascitic fluid forGram’s stain and culture. We also advocate the gentle use ofatraumatic grasping forceps to manipulate the bowel, pre-ferring to grasp the mesentery rather than the often edema-tous, friable, and unforgiving bowel wall itself.

Bedside laparoscopy is readily accomplished with allnecessary equipment on a single rolling cart including cam-era, monitor, light source, and insufflator. The relative in-flexibility of the ICU beds compared to an operating roomtable limits patient positioning and therefore is more suitedto diagnostic rather than therapeutic procedures. This sug-gests that bedside procedures may be most appropriatewhen the clinician’s guess is that the result of laparoscopywill be negative.

Laparoscopic evaluation was clinically useful evenwhen surgically remediable problems were not discovered.We believe that this approach is particularly useful in pa-tients who are hemodynamically unstable following cardiacsurgery. Low cardiac output is seen in conjunction withlactic acidosis, and mesenteric ischemia is difficult to ex-clude as a possible explanation. Diagnostic laparoscopymakes a rapid diagnosis and permits confident applicationof aggressive hemodynamic support when no abnormalitiesare identified in the abdomen. Three patients in this serieswho were evaluated due to a hyperdynamic, septic-

appearing state were discovered to have end-stage cirrhosis,which was completely unrecognized in two. This findingwas influential in the assessment of prognosis and in sub-sequent decisions regarding withdrawal of support. Liverfailure is known to produce a hyperdynamic state with in-creased cardiac output and decreased systemic vascular re-sistance, similar to the hemodynamic picture seen in sepsis[2], as well as predisposing to more severe hemodynamicand metabolic perturbations [12].

Laparoscopy can be performed safely in critically illpatients. It is a useful diagnostic procedure in patients withsuspected acute cholecystitis, which is often difficult to di-agnose in the critically ill. Cardiac surgical patients withrefractory lactic acidosis in whom a diagnosis of mesentericischemia is considered and who are often unstable can alsobe accurately assessed with diagnostic laparoscopy.

References

1. Babb RR (1992) Acute acalculous cholecystitis: a review. J Clin Gas-troenterol 15: 238–241

2. Baumgartner JD, Vaney C, Perret C (1984) An extreme form of thehyperdynamic syndrome in septic shock. Intensive Care Med 10: 245–249

3. Bender JS, Talamini MA (1992) Diagnostic laparoscopy in criticallyill intensive care unit patients. Surg Endosc 6: 302–304

4. Brandt CP, Priebe PP, Eckhauser ML (1993) Diagnostic laparoscopyin the intensive care patient. Avoiding the nontherapeutic laparotomy.Surg Endosc 7: 168–172.

5. Brandt CP, Priebe PP, Jacobs DG (1994) Value of laparoscopy intrauma ICU patients with suspected acute acalculous cholecystitis.Surg Endosc 8: 361–364

6. Caroll BJ, Chandra M, Phillips EH, Margulies DR (1993) Laparoscop-ic cholecystectomy in critically ill cardiac patients. Am J Surg 59:783–785

7. Fig LM, Wahl RL, Stewart RE, Shapiro B (1990) Morphine aug-mented hepatobiliary cholescintigraphy in the severely ill: caution is inorder. Radiology 175: 467–473

8. Flancbaum L, Majerus TC, Cox EF (1985) Acute posttraumatic acal-culous cholecystitis. Am J Surg 150: 252–256

9. Flancbaum L, Alden SM, Trooskin SZ (1989) Use of cholescintigra-phy with morphine in critically ill patients with suspected cholecysti-tis. Surgery 106: 668–674

10. Forde KA, Treat MR (1992) The role of peritoneoscopy (laparoscopy)in the evaluation of the acute abdomen in critically ill patients. SurgEndosc 6: 219–221

11. Iberti TJ, Salky BA, Onofrey D (1989) Use of bedside laparoscopy toidentify intestinal ischemia in postoperative cases of aortic reconstruc-tion. Surgery 105: 686–689

12. Moreau R, Hadengue A, Soupison T, Kirstetter P, Momzer MF, Jan-jack D, Vauquelin P, Assolis M (1992) Septic shock in patients withcirrhosis: hemodynamic and metabolic characteristics and intensivecare unit outcome. Crit Care Med 20: 746–750

13. Orlando R, Gleason E, Drezner AD (1983) Acute acalculous chole-cystitis in the critically ill patient. Am J Surg 145: 472–476

14. Reines HD (1992) Evaluating the acute abdomen in an ICU patient. In:Civetta JM, Taylor RW, Kirby RR (eds) Critical care. J B Lippincott,Philadelphia

15. Safran D, Orlando R III (1994) Physiologic effects of pneumoperito-neum. Am J Surg 167: 281–286

16. Safran D, Sgambati S, Orlando R III (1993) Laparoscopy in high riskcardiac patients. Surg Gynecol Obstet 176: 548–554

17. Savino JA, Scalea TM, Del Guercio LRM (1985) Factors encouraginglaparotomy in acalculous cholecystitis. Crit Care Med 13: 377–380

18. Sleeman D, Almeida J, Sosa JL, Puente I, McKenney M, Martin L(1995) Acalculous cholecystitis: the use of diagnostic laparoscopy. JLaparoendosc Surg 5: 227–231

19. Wittgen CM, Andrus CH, Fitzgerald SD, Baudendistel LJ, Dahms TE,Kaminski DL (1991) Analysis of the hemodynamic and ventilatoryeffects of laparoscopic cholecystectomy. Arch Surg 126: 997–1001

1074

Mesh configurations in laparoscopic extraperitoneal herniorrhaphy

A comparison of techniques

J. E. Korman, J. R. Hiatt, D. Feldmar, E. H. Phillips

Division of General Surgery, Department of Surgery, Room 8215, Cedars-Sinai Medical Center, 8700 Beverly Boulevard,Los Angeles, CA 90048, USA

Received: 3 April 1997/Accepted: 3 July 1997

AbstractBackground:Laparoscopic total extraperitoneal (TEP) her-nia repair utilizes slit mesh that is placed around the sper-matic cord to secure the prosthesis and prevent recurrence.Because of concern that encircling of the cord might in-crease pain and morbidity, we compared patients with meshrepairs using encircled and nonencircled techniques.Methods:The 191 male patients who underwent bilateralTEP repairs were divided into three groups. In 100 consecu-tive patients (group A), the slit mesh was closed around bothspermatic cords; in 56 patients (group B), the slit mesh wastucked under the spermatic cords but not closed; in 35 con-secutive patients (group C), the slit was closed around onecord and tucked under the other, in a randomized fashion.Results:The groups had similar operative times (A: 83 ± 25min; B: 79 ± 21; C; 77 ± 24), use of pain medication (A: 2.7± 2.5 days; B: 2.4 ± 1.9; C: 3.1 ± 2.4), and recovery beforereturn to work (A: 7.9 ± 7.0 days; B: 8.2 ± 6.1; C: 6.7 ± 4.8).The incidence of indirect hernias was similar in all groups.Complication rate was 20% in A, 20% in B, and 14% in C(p 4 NS). Chronic pain was more frequent in A (A: 6, B:0, p 4 0.06). In group C, fluid collections were more com-mon on the closed side (closed: 3, tucked: 0;p 4 0.08).There were no recurrences in any group.Conclusions:Closing the slit around the spermatic cord inlaparoscopic inguinal hernia repair is not essential for pre-vention of early recurrence. Fluid collections tended to bemore frequent when the mesh was closed around the cord,and chronic pain was more frequent in the group with closedmesh bilaterally.

Key words: Hernia — Laparoscopic total extraperitonealhernioplasty — TEP — Laparoscopy — Mesh

Extraperitoneal approaches to laparoscopic hernia repairhave low recurrence rates and avoid both visceral contactwith the prosthetic material and an incision in the perito-neum [8]. The total extraperitoneal (TEP) repair was devel-oped by Phillips [8] and McKernan [6] to emulate the openpreperitoneal repair of Stoppa [11], which had proven ef-fectiveness. In many TEP repair techniques, a large piece ofmesh is used to cover all of the potential defects, and themesh is slitted and closed around the spermatic cord. Somesurgeons have feared that unless the slit is closed snuglyaround the cord, making a new internal ring, recurrence islikely. Conversely, a too-tight closure could cause circum-ferential scarring, compression of the cord structures, andsubsequent testicular pain, atrophy, and fluid collections.After an extensive experience with mesh closure around thecord structures, the authors adopted a technique in which theslit mesh is tucked under the spermatic cord, with the goalof decreasing postoperative pain. The present study wasundertaken to compare various techniques related to slittingand closure of the mesh.

Methods

This study analyzed the outcomes of 191 male patients who underwentbilateral laparoscopic inguinal hernia repair at Cedars Sinai Medical Centerfrom July 1992 to February 1997. Patients were assigned to three groupschronologically. Group A included the first 100 consecutive patients of thestudy, in whom the slit mesh was closed around both the right and leftspermatic cords (Fig. 1A). Group B included 56 consecutive patients inwhom the slit mesh was tucked under the spermatic cords, but not closedaround them (Fig. 1B). Group C included 35 consecutive patients whoserved as their own controls: The mesh was closed around one cord andtucked under the other (Fig. 2), with the sides chosen by random numberassignment. There was no correlation between the side that the slit wasclosed on and presence of indirect hernias. Patients were allocated chrono-logically first to group A, then group C, and finally group B.

All repairs were performed by the total extraperitoneal (TEP) approachas previously published [3, 4], and all aspects of the hernia repairs, otherthan handling of the slit in the mesh, were identical, including dissection,size of mesh, and stapling techniques. The data gathered included patientage, type of hernia defect (direct vs indirect), and type of repair (slitsecured around cord vs slit tucked under the cord). Outcome measuresincluded operative time (defined as time from Veress needle insertion to


Correspondence to:E. H. Phillips

Surg Endosc (1997) 11: 1102–1105

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closure of wound), the presence of more prominent pain on one side(evaluated without knowledge of technique employed), number of daysthat oral pain medication was taken, number of days until the patientreturned to work, complications (including groin fluid collections and tes-ticular pain, swelling, or atrophy), and recurrence. Seromas, hematomas,and hydroceles of any detectable size were all considered to be fluidcollections. Chronic pain was defined as frequent or daily pain that lastedlonger than 6 weeks postoperatively.

Technique

The preperitoneal space is accessed by blunt dissection as previously pub-lished [3, 4]. Under direct vision, the preperitoneal tissue is dissected from

Cooper’s ligament, the underside of the abdominal wall, the direct andindirect portions of the inguinal region. The spermatic cord, femoral canal,and aponeurotic sling are visualized bilaterally.

If an indirect hernia is present, the sac is reduced and, if large, excisedafter ligation with an endoloop. Cord lipomas (preperitoneal fat herniatedthrough the internal ring), if present, are reduced but not excised. Afterboth inguinal regions are completely dissected, a 12 cm × 12 cm sheet ofmesh is fashioned for the repair. This mesh is prepared either with a3-cm-long slit approximately 4 cm from one end (Fig. 3, top) or a key-likeslit in the lateral third of the mesh (Fig. 3, bottom). The sheet is rolled andsecured with an absorbable suture at each end, leaving unrolled the seg-ment with the slit (Fig. 1A, B).

If the slit is to be closed, the tongue of the mesh is placed under thetesticular vessels and vas deferens from lateral to medial, with the medialsegment of mesh secured onto Cooper’s ligament (Fig. 1A). Then the slitis closed to itself, creating a new internal ring. During this positioning, thesurgeon must be careful not to place medial or lateral tension on the cordstructures. In the tucked slit technique, the lateral segment is tucked underthe testicular vessels, not quite reaching the vas deferens (Fig. 1B). Afterthe contralateral mesh is placed, the stay sutures are cut; both sheets ofmesh are unrolled superiorly and stapled to the anterior abdominal wall,medial to the epigastric vessels, and most important, the two pieces ofmesh are stapled to each other in the midline.

Fig. 1. A Rolled mesh with slit closed around spermatic cord and stapledto Cooper’s ligament (group A).B Rolled mesh with slit draped overspermatic cord. Lateral flap is tucked under cord, and medial segment isstapled to Cooper’s ligament (group B).

Fig. 2. Bilateral repair (group C). Tucked technique on right side, closedon left. Mesh is unrolled, and the two pieces are stapled together in themidline.

Fig. 3. Dimensions of mesh and orientation of slit. Top: closed technique.Bottom: tucked technique.

1103

Results

There were 100 patients in group A, 56 in group B, and 35in group C (Table 1). Patients in group B were younger thanin group A. Frequency of indirect hernias, operative times,use of pain medication, recovery before return to work, andcomplication rates were similar in all groups. There were norecurrences in any group.

Specific complications are shown in Table 2. Groinfluid collections and chronic pain accounted for the majorityof complications.

When complications were compared for groups A and B(Table 3), there was a greater incidence of chronic pain inthe former, which approached statistical significance. Tes-ticular pain and groin fluid collections occurred with similarfrequency.

In group C, the closed and tucked sides were compared(Table 4). There were no differences in the frequency ofindirect hernias, testicular pain, or increased pain on oneside relative to the other. In four patients, pain was greateron one side (two on the closed side and two on the tuckedside;p 4 1). Fluid collections were more common on theclosed side, approaching statistical significance. There wereno recurrences on either side.

Discussion

The extraperitoneal approaches (TAPP or TEP) dependupon the use of a large piece of mesh to cover all potentialhernia sites and to overlap normal abdominal wall. In amulti-institutional review of laparoscopic hernia repair [9]use of mesh that was too small was the most common rea-son for early recurrence. Regarding technical aspects ofTEP, some authors report no need to slit the mesh [12]instead draping it over the spermatic cords, while othersmaintain that securing the mesh around the cord will pre-vent recurrences and migration of the prosthesis [1]. Vari-ous techniques and outcomes are compared in Table 5. Noreports have analyzed results based upon differing configu-rations of the mesh prosthesis.

Our analysis showed that a new internal ring, created byclosing the mesh around the cord (group A), was not neededto prevent recurrence. Although the numbers were relativelysmall, and follow-up was limited, most recurrences after theTEP repair occur within the first 2 years [9]. Though therewas no difference in the duration before return to work oruse of pain medication, groin fluid collections and chronicpain were somewhat more frequent in patients with meshclosed around the cord.

In group C, the two methods were compared in indi-

vidual patients. We found no difference in pain betweenthe two sides, no significant difference in the occurrenceof testicular pain, and no recurrences. However, therewas a difference in the incidence of groin fluid collec-tions on the closed side that approached statistical signifi-cance.

In summary, closure of the slit mesh around the sper-matic cord is not essential to prevention of recurrence in

Table 2. Complications

A(n 4 100)

B(n 4 56)

C(n 4 35)

Chronic pain (6) Seroma (5) Hematoma (2)Hydrocele (5) Urinary retention (3) SeromaHematoma (4) Nausea/vomiting Chronic painPersistent lipoma Hydrocele Retroperitoneal bleedingBradycardia Thigh numbnessUrinary retentionSeromaTesticular pain

Table 3. Complications: groups A and B compared

A B p value

n 100 56Testicular pain,n (%) 1 (1) 0 0.4Fluid collection,n (%) 10 (10) 6 (11) 0.9Chronic pain,n (%) 6 (6) 0 0.06

Table 4. Complications: closed and tucked sides (group C) compared

Closed Tucked p

Indirect hernia, % 46 54 0.5Difference-side of pain,n (%) 2 (6) 2 (6) 1Testicular pain,n (%) 1 (3) 0 0.3Fluid collection,n (%) 3 (9) 0 0.08

Table 5. Comparison of laparoscopic herniorrhaphy techniques

Author Techniquea Use of slit nRecurrence

(%)

Deans [2] TAPP None 150 0Payne [7] TAPP ND 48 1Stoker [10] TAPP ND 75 0Vellasco [14] TAPP Horizontal

slit—closed

25 6

Swanstrom [12] TAPP/TEP

None 158 2

Arregui [PersonalCommunication3/10/97]

TEP None 300 0.7

McKernan [6] TEP Verticalslit—closed

200 0

Liem [5] TEP None 120 8Vanclooster [13] TEP None 195 0Phillips TEP Oblique

slit—closed

172 0

a TAPP4 Transabdominal preperitoneal repair; TEP4 Totally extraperi-toneal repair; ND4 No data

Table 1. Comparison of groups

A B C

n 100 56 35Average age, years 52 ± 12* 41 ± 13* 54 ± 16Mean followup, months 40 15 35Indirect hernia,n (%) 118 (59) 60 (54) 35 (50)Operative time, min. 83 ± 25 79 ± 21 77 ± 24Pain medication, days 2.7 ± 2.5 2.4 ± 1.9 3.1 ± 2.4Return to work, days 7.9 ± 7.0 8.2 ± 6.1 6.7 ± 4.8Complications,n (%) 20 (20) 11 (20) 5 (14)Recurrence 0 0 0

* p 4 0.03 (A vs B)

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TEP laparoscopic herniorrhaphy. Moreover, this additionalmaneuver, which some surgeons find tedious, may be asso-ciated with a greater frequency of fluid collections andchronic pain. These data may not be applicable to unilateralrepairs or to repairs that do not include mesh fixation toCooper’s ligament. It is important to emphasize that ourtechniques employed large pieces of mesh which were fixedto Cooper’s ligament bilaterally and to one another in themidline. Utilizing these technical principles, results havebeen excellent.

References1. Avery C, Foley RJE, Prasad A (1995) Simplifying mesh placement

during laparoscopic hernia repair. Br J Surg 82: 6422. Deans GT, Wilson MS, Royston CMS, Brough WA (1995) Laparo-

scopic ‘bikini mesh’ repair of bilateral inguinal hernia. Br J Surg 82:1383–1385

3. Fallas MF, Phillips EH (1995) Laparoscopic near-total preperitonealhernia repair. In: Phillips EH, Rosenthal RJ (eds) Operative strategiesin laparoscopic surgery. Springer Verlag, Berlin, pp 88–92

4. Friedman RL, Phillips EH Extraperitoneal laparoscopic hernioplasty.In: Maddern G, Hiatt JR, Phillips EH (eds) Hernia repair: open vs.laparoscopic approaches. Churchill-Livingstone, London (in press)

5. Liem MSL, van Steensel CJ, Boelhouwer RU, Weidema WF, CleversGJ, Meijer WS, Vente JP, de Vries LS, van Vroonhoven TJMV (1996)The learning curve for totally extraperitoneal inguinal hernia repair.Am J Surg 171: 281–285

6. McKernan JB, Laws HL (1993) Laparoscopic repair of inguinal her-nias using a totally extraperitoneal prosthetic approach. Surg Endosc 7:26–28

7. Payne JH, Grininger LM, Izawa MT, Podoll EF, Lindahl PJ, BalfourJ (1994) Laparoscopic or open inguinal herniorrhaphy? Arch Surg 129:973–981

8. Phillips EH, Carroll BJ, Fallas MF (1993) Laparoscopic preperitonealinguinal hernia repair without peritoneal incision: technique and earlyresults. Surg Endosc 7: 159–162

9. Phillips EP, Rosenthal R, Fallas MJ, Carroll BJ, Arregui M, Corbitt J,Fitzgibbons R, Seid A, Schultz L, Toy FK, Wadell RL, McKernan B(1995) Reasons for early recurrences following laparoscopic hernio-plasty. Surg Endosc 9: 140–145

10. Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM (1994) Laparo-scopic versus open inguinal hernia repair: randomised prospectivetrial. Lancet 343: 1243–1245

11. Stoppa RE (1995) The preperitoneal approach and prosthetic repair ofgroin hernias. In: Nyhus LM, Condon RE (eds) Hernia. JB Lippincott,Philadelphia, pp 188–210

12. Swanstrom LL (1996) Laparoscopic herniorrhaphy. Surg Clin NorthAm 76(3): 483–491

13. Vanclooster P, Meersman AL, de Gheldere CA, Van de Ven CK(1996) The totally extraperitoneal laparoscopic hernia repair: prelimi-nary results. Surg Endosc 10: 332–335

14. Vellasco JM, Gelman C, Vallina VL (1996) Preperitoneal bilateralinguinal herniorrhaphy: evolution of a technique from conventional tolaparoscopic. Surg Endosc 10: 122–127

Discussion

Dr. Dudai: I’d like to know whether you have any idea, ortried to investigate, about the effects of the fibrosis thatcreate the mesh around the vas deferens, or the motility ofthe sperm in the vas deferens.

Dr. Korman: That’s a good question. That was also one ofthe main factors in our undertaking this study. We wereconcerned that this fibrosis, encircling the vas, would con-tribute to more testicular pain. We don’t have any answerson the motility of the sperm.

Dr. Dudai: A very important issue, especially in bilateralhernia in young patient.

Dr. MacFadyen: Any other comments? Well, I think

you’ve answered a question that all of us have had, as to theimportance of whether that slit was an important issue ornot, and it appears from your paper that it is not. That willprobably expedite the procedure for some people who havefound that to be complicated. Could you comment on that alittle bit, about the technical aspect of slipping that around?

Dr. Korman: Certainly I think that devoting time to bring-ing the flap all the way around and closing it is cumber-some. With our slit we use it to actually help us. We drapethe slit over the cord. It helps in positioning the mesh in theright spot, so it doesn’t drift too far medially, too far later-ally, and, as it is well placed, we then anchor it to Cooper’sligament. We drape the mesh over the cord while its rolledup, and that was shown in one of our illustrations. That alsohelps in placing the mesh and making the mesh much easierto handle.

Dr. Felix: In our large series we did see hernias actuallythrough the slit. Has your group seen that as a problem?Some of us have covered the slit, and tried to avoid thathernia by covering the slit itself, and I’d be interested to seeif that was a cause of recurrence in your larger series ofhernias that you’ve done.

Dr. Korman: We have no recurrences to date. There aretimes, if we feel that our slit perhaps is too big, we’ll just layanother piece of mesh over it. We certainly don’t rule outputting in other smaller pieces of mesh, even laterally, ifthere are indirect hernias, we’ll put another piece of meshout laterally to basically cover any potential defect that wemight be concerned about.

Dr. Phillips: I did want to add that we have had one recur-rence. What had happened is that the stapling technique hadnot gone through both pieces of mesh—was inadequatelyfixed to itself in the midline, bilateral, and inadequatelyfixed to Cooper’s ligament. But, most importantly, the meshhad blown out bilaterally into both direct hernias, so thelateral parts were absolutely still there, so I was a littlesurprised by the comment about lateral recurrences that hadbeen seen. This recurrence was definitely a failure of themesh being fixed to itself in the midline. We have to look atour report here about the slit, nor not to slit, not to close. Wedid this in bilateral repairs. I’m not 100% sure that we canapply this to unilateral repairs, but in bilateral repairs itseems, because the only place we fixed the mesh was toCooper’s ligament and to the two prostheses to themselvesin the midline, and no staples lateral at all, and we have nothad any lateral recurrences.

Dr. MacFadyen: Certainly it seems that the mesh itselfseems to fixate within a very short period of time. Myimpression is it tends to fix within probably about 7–10days, or do you think it’s even shorter?

Dr. Phillips: Well, certainly in 24 hours I think the plateletaggregation is there, so that’s it’s fixed, but it’s not securelyenough fixed that it, you know, would stay there. I think oneof the reasons that the TEP repair doesn’t have any trocarsite hernias is because the peritoneum is covering the trocarsites and allowing the wound to heal without intrusion ofintra-abdominal organs up into the defect, so I think thesame thing occurs by having the intact peritoneum, allowingthe mesh to stay where it is, and then, in 14 days, I think itprobably has about 75–85% of its strength adherence.

1105

Laparoscopic cryosurgery for hepatic tumors

Experimental observations and a case report

V. R. Tandan,1 D. Litwin, 2 M. Asch,2 M. Margolis,2 S. Gallinger2

1 Department of Surgery, McMaster University, St. Joseph’s Hospital, Room G815, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada2 Department of Surgery, The University of Toronto, Mt. Sinai Hospital, Toronto, Ontario, Canada

AbstractBackground:Hepatic cryosurgery has been shown to be asafe technique that may be well suited to a laparoscopicapproach.Methods:The technical feasibility and safety of laparoscop-ic cryosurgery was explored first in a pig model. Thereafterwe performed the first successful case of laparoscopic he-patic cryosurgery at our institution.Results:In the animal model, we found that it is possible tosafely identify, target, and cryoablate specific lesions in theliver. Temperature in the peritoneal cavity remained above35°C, and pathologic examination of the abdominal wallaround the cryoprobe site revealed no damage. We alsosuccessfully treated a 62-year-old man with a metastaticcolorectal carcinoma deep in the right lobe of the liver withlaparoscopic cryosurgery using a transpleural approach.Conclusion:We conclude that laparoscopic cryosurgery isfeasible for lesions anywhere in the liver. For lesions highon the dome of the liver, a transpleural approach may pro-vide better access.

Key words: Cryosurgery — Laparoscopic ultrasound —Liver tumors — Laparoscopy

Cryosurgery, a treatment in which tumors are frozen andthen left in situ to be reabsorbed, was first applied to theliver by Cooper in 1963 [1]. Cryosurgery has the advantageof being a focal treatment that causes little hepatic paren-chymal loss; thus, lesions in multiple sites in the liver can betreated. In addition, lesions adjacent to large blood vesselscan be frozen without damage to the vessels, since the flow-ing blood acts as a heat sink to protect them [2]. There arealso some animal data to suggest that cryosurgery may pro-vide added benefits over resection as a result of a hypoth-

esized immune response to the frozen tumor [3]. With ad-vances in surgical technique and the use of intraoperativeultrasound, hepatic cryosurgery is being used routinely inmany centers throughout the world for a variety of indica-tions, including primary hepatocellular carcinoma andmetastatic colorectal cancer.

Recent advances in technology for laparoscopic surgeryhave made it technically possible for almost any abdominalsurgical procedure to be performed via the laparoscope.Hepatic cryosurgery is a procedure that lends itself well tothe laparoscopic approach because the cryoprobes can bepassed through incisions ofø12 mm and no specimen isremoved. There are several technical aspects that make lap-aroscopic hepatic cryosurgery challenging. We addressedthese questions first in a pig model, and we can now reportthe first successful case of laparoscopic hepatic cryosurgeryperformed at our institution.


Animal experiments

The first experiment was performed on two pigs to determine the technicalfeasibility and safety of creating a cryosurgical lesion in the liver laparo-scopically. Under general anesthesia, a standard Veress needle techniquewas used to create a pneumoperitoneum using CO2 to a pressure of 15 mmHg. A 10-mm port was created at the umbilicus and a 30° telescopeinserted. A second 10-mm port was created in the left upper quadrant, andthe laparoscopic ultrasound probe (B&K model no. 3535) was introduced(Fig. 1). After performing a laparoscopic ultrasound examination of theliver, we made a 10-mm incision in the right upper quadrant. Under directvision, a Teflon sheath specially designed to accommodate the 5-mm cryo-probe was placed into the abdomen (Fig. 2). An L hook was passed throughthis port with minimal loss of pneumoperitoneum, and the liver capsulewas scored over the mid right lobe using electrocautery. The 5-mm cryo-probe was then passed through the Teflon sheath and introduced into theliver parenchyma. There was no significant loss of pneumoperitoneumfrom this setup. With intermittent ultrasonographic monitoring, a 4-cmfreezeball was created. Intraabdominal temperature was continuouslymonitored during freezing.

The goal of the second experiment was to demonstrate our ability toidentify, target, and accurately freeze a preexisting lesion in two pigs. TheCorrespondence to:V. R. Tandan

Surg Endosc (1997) 11: 1115–1117

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initial anesthesia and port placement was identical to experiment 1. Underthe guidance of the intraoperative ultrasound, a 2-cm lesion was created bypercutaneously injecting saline mixed with India ink into the liver paren-chyma. The right upper quadrant Teflon sheath was then introduced in thesame fashion as experiment 1. The ‘‘lesion’’ was then identified with thelaparoscopic ultrasound by a blinded team. With the help of our interven-tional radiologist, who is an integral part of the cryosurgical team, thecryoprobe was passed into the center of the lesion and the freezeball wascreated. Intraabdominal temperature and pressure were monitored continu-ously during freezing. After a 4-cm iceball had been generated, the probewas warmed and removed. A 5-mm forceps was used to pack the probetract with surgicel before thawing was complete. The animals were thenkilled and the livers harvested and sent for pathologic examination. Theskin and abdominal wall around the Teflon sheath were also excised andsubmitted for pathological examination.

Case report

A 62-year-old man with a histologically proven advanced adenocarcinomaof the rectum was found on helical CT of the abdomen to have a 2-cmmetastasis in the middle of the right lobe of the liver. Because the patientrequired preoperative radiation and attempted pelvic exenteration to treatthe rectal tumor, we concluded that a formal right hepatic lobectomy wasunwarranted and thus opted for cryosurgery. The laparoscopic approachwas taken in order to allow the patient to proceed with his radiotherapy andpelvic surgery as soon as possible.

Under general anesthesia, a pneumoperitoneum was created using thestandard Veress needle technique. Ports were then placed, as shown in Fig.1. The abdomen was inspected for evidence of spread of the rectal cancer.The liver was then carefully examined using the laparoscopic ultrasoundthrough ports A and B to provide both transverse and sagittal images. Theliver was quite coarse and nodular. The original 2-cm lesion was identifiedas well as several other suspicious lesions in both the left and right lobes.

Using a Truecut needle, all suspicious lesions, including the original

one, were percutaneously biopsied twice under the direction of the lapa-roscopic ultrasound. All of the biopsies were done from one skin site in the7th interspace in the anterior axillary line. Frozen-section examination ofall biopsy specimens revealed no evidence of malignancy, except in theoriginal lesion, which was confirmed as malignant.

The Teflon sheath described in the animal experiments was then intro-duced under direct visualization through a 10-mm skin incision at the siteused for the needle biopsies. The liver capsule was scored with electro-cautery, and with the aid of our interventional radiologist, the cryoprobewas passed into the lesion under the guidance of the laparoscopic ultra-sound. Two freeze/thaw cycles of 8 min each were performed, producingfreezeball measuring 38 mm in diameter. Patient core temperature andintraabdominal temperature were continuously monitored during the freez-ing process. After the probe was warmer than −20°C, it was removed andthe tract was packed with surgicel.

Results

Animal experiments

In the first animal experiment, we were able to generate a4-cm iceball with no difficulty. The animals remained he-modynamically stable throughout the procedure, and thetemperature in the peritoneal cavity did not drop below35°C.

Fig. 1. Port positions used for laparoscopic hepatic cryosurgery (right lobelesion).

Fig. 2. Cryoprobe inserted in Teflon sheath used as a laparoscopic port.

1116

In the second animal experiment, we generated 4-cmiceballs in the two pigs. Again, the animals remained stablethroughout and the intraabdominal temperature did not dropbelow 35°C. After 20 min of observation, there was nosignificant bleeding from the probe site. Pathologic exami-nation of the liver revealed that the cryoablation was cen-tered on and encompassed the entire ‘‘lesion’’ in both cases(the lesion was grossly visible to the pathologist as a resultof the India ink). Histologic examination of the abdominalwall, including skin from around the Teflon port, demon-strated no injury.

Clinical case

Intraoperative laparoscopic ultrasound demonstrated clearlythat the original lesion had been encompassed in the iceballwith a minimal 8-mm margin. While waiting for the biopsyresults, we noted that the central venous pressure (CVP) wasincreasing markedly and that air entry on the right side wasabsent (the patient remained stable with no tachycardia,hypotension, or difficulty with oxygenation). A diagnosis ofa pneumothorax was made, and a 20 F chest tube was in-serted in the 5th interspace without incident. The core tem-perature remained above 35°C and the intraabdominal tem-perature did not drop below 35°C. Estimated blood loss was<100 cc.

The patient spent 1 h in the post-anesthetic care unit(PACU) and was returned to the surgical ward. He wasambulatory the following morning and resumed a regulardiet on the 1st postoperative day. The chest tube was re-moved on the 1st postoperative day. The preoperative plate-let count was 179; it fell to a low of 115 on the 1st post-operative day and returned to 137 on the 2nd postoperativeday. Urine was examined for the presence of myoglobin,which has been reported as a possible complication of cryo-surgery, but none was detected [4]. The patient was dis-charged home in excellent condition on the 4th postopera-tive day with plans to proceed with treatment of his rectaltumor in the near future.

Discussion

We have demonstrated the technical feasibility and safety oflocalizing, targeting, and cryoablating tumors in the liverusing a laparoscopic approach. Cooling of the peritonealcavity and damage to the skin from the probe site do notappear to be problems, and the procedure offers the advan-tages of decreased postoperative pain and a shorter hospitalstay than with open cryosurgery. The complication of thepneumothorax is predictable in high right lobe lesions ne-

cessitating a transpleural probe placement. For these cases,a double lumen endotracheal tube to allow collapse of thelung and a prophylactic chest tube may be warranted. Skillin the use of laparoscopic ultrasound techniques is essentialto this procedure. There are few data available to comparelaparoscopic to conventional intraoperative ultrasound, butour experience with this new technology since January 1994in >30 patients booked for liver resection suggests that lap-aroscopic ultrasound is close to but not as sensitive as openintraoperative ultrasound [5]. Whether this result is due tothe learning curve or is a limitation of the current technol-ogy remains to be seen. We have found that our multidis-ciplinary approach, including the employment of an inter-ventional radiologist who is scrubbed as part of the surgicalteam, has been extremely helpful in targeting lesions deep inthe liver.

Although hepatic cryosurgery is used in many centersthroughout the world for various indications, there have notbeen any controlled trials comparing this therapy to resec-tion—or any other treatment, for that matter. Surgical re-section—the current standard therapy for resectable primaryliver cancers, as well as for hepatic metastases from specificprimary tumors such as colorectal, adrenal, and neuroendo-crine tumors—has not been compared with nonsurgicalmanagement in a controlled trial. At the same time, >40years’ experience on thousands of patients has led to theaccumulation of a large body of evidence demonstratingthat resection can provide 5-year survival rates of 25–50%in properly selected patients. We now practice in an era ofevidence-based medicine, so cryosurgery must be comparedto resection in a controlled clinical trial. Until it is, cryo-surgery should be reserved for patients deemed to haveunresectable disease by virtue of the anatomic location ofthe tumor, hepatic functional reserve, or comorbid condi-tions.

References

1. Cooper IS (1963) Cryogenic surgery. N Engl J Med. 268 743–7492. Gage AA, Fazekas G, Riley E (1967) Freezing entry to large blood

vessels in dogs. Surgery 61(5): 748–7543. Jacob G, Li AK, Hobbs KE (1984) A comparison of cryodestruction

with excision or infarction of an implanted tumor in rat liver. Cryobi-ology 21: 148–156

4. Onik G, Rubinsky B, Zemel R, Weaver L, Diamond D, Cobb C, Por-terfield B (1991) Ultrasound-guided hepatic cryosurgery in the treat-ment of metastatic colon carcinoma: preliminary results. Cancer 67:901–907

5. Tandan V, Asch M, Margolis M, Page A, Gallinger S (1997) Laparo-scopic versus open intra-operative ultrasound of the liver: a controlledstudy. J Gastrointest Surg 1: 146–151

1117

Evaluation of laparoscopic Toupet fundoplication as a primary repairfor all patients with medically resistant gastroesophageal reflux

B. A. Jobe,1 J. Wallace,1 P. D. Hansen,1,2 L. L. Swanstrom1,2

1 Department of Surgery, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201, USA2 Minimally Invasive Surgery Department, Legacy Portland Hospitals, 501 North Graham Street, Suite 120, Portland, OR 97227, USA


AbstractBackground:This prospective study assesses the outcomeresults in 100 consecutive patients with gastroesophagealreflux disease (GERD) treated with a laparoscopic Toupetfundoplication.Methods:GERD was confirmed by 24-h pH study and/oresophagogastroduodenoscopy (EGD). Pre- and postopera-tive symptoms, operative times, and perioperative compli-cations were recorded on standardized data forms. Earlyfollow-up was at 3 months and late follow-up, including24-h pH, manometry, and EGD was at 22 months.Results:Preoperative symptoms included heartburn (92%),regurgitation (58%), water brash (39%), and dysphagia(39%). Mean operative time was 3.2 hours. There were noconversions to celiotomy and there were no mortalities. Theperioperative complication rate was 14%; 6% (5/83) of pa-tients reported heartburn at 3 months and 20% (15/74) at 22months. Early and late dysphagia was 20% (17/83) and 9%(7/74), respectively; 24-h pH testing was abnormal in 90%of symptomatic patients (9/10), 39% of asymptomatic pa-tients (12/31), and 51% overall.Conclusions:Despite early improvement in reflux symp-toms following laparoscopic Toupet fundoplications, thereis a high incidence of recurrent GERD. Symptomatic fol-low-up underestimates the true incidence of 24-h pH-documented reflux. Based on these results we cannot rec-ommend the laparoscopic Toupet repair for GERD patientswith normal esophageal motility.

Key words: Toupet — Fundoplication — Laparoscopic —Gastroesophageal reflux disease — Antireflux surgery —Prospective

Gastroesophageal reflux disease (GERD) is very commonin western countries. If inadequately treated, patients maydevelop complications with serious morbidity. Antirefluxsurgery has recently been advocated as a means of treatingmedically refractive GERD successfully and with low mor-bidity [3–5]. The advantages of a surgical approach includeeliminating the need for life-long medical therapy, improv-ing the quality of life, and minimizing the incidence ofadverse sequelae such as Barrett’s esophagus and strictureformation [2].

The laparoscopic Nissen fundoplication is probably thecurrent ‘‘gold standard’’ for surgical treatment of GERD.This procedure is, however, associated with several sideeffects, including transient or persistent dysphagia, inabilityto belch or vomit, and gas bloat [10]. Partial fundoplica-tions, as exemplified by the Toupet, have been suggested asan alternative procedure because they do not hyperaugmentthe lower esophageal sphincter (LES) to the same degree asthe Nissen and thus have fewer postoperative side effects.Several reports in the literature also suggest that the Toupetis equivalent to the Nissen in the elimination of GERDsymptoms [1, 7, 8]. Many of these reports have limitedlong-term objective follow-up.

The introduction of laparoscopic approaches to anti-reflux surgery may have created a paradigm shift with re-spect to indications and expectations for surgical treatmentof GERD and for the acceptance of postoperative symptomsamongst patients, referring physicians, and surgeons alike.Prior to the introduction of laparoscopic antireflux surgery,postoperative side effects related to the fundoplication weremore likely to have been accepted as a necessary nuisance,requisite to the elimination of a potentially life-threateningcondition. Perhaps because of a lower threshold for surgery,the low morbidity, and the minimal convalescence associ-ated with laparoscopic surgery, the side effects caused by afundoplication have been magnified. This may be drivingsurgeons to look for the ‘‘perfect’’ repair, a repair thatwould both prevent acid reflux and limit postoperative fun-doplication-related side effects. Toupet-type fundoplica-Correspondence to:L. L. Swanstrom

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tions have been advocated as such a repair. Although thisprocedure has been traditionally reserved for patients withesophageal motility abnormalities or an anatomy that didnot permit a complete wrap, it is possible that the Toupet iseffective as a primary treatment for all patients with GERDrequiring surgery.

This prospective study was performed to determinewhether the laparoscopic Toupet fundoplication is, in fact, apreferable repair for all patients with GERD, irrespective oftheir esophageal motility.

Methods

Patient selection

All patients were referred to the senior investigator for surgical evaluationof medically refractive GERD. After objective determination of reflux, thepatients were asked to participate in the study. One hundred consecutivepatients were treated with laparoscopic Toupet fundoplications. Patientswith type 2, 3, or 4 paraesophageal hernias were excluded.

Evaluation

Patients were entered into a prospective database that included pre- andpostoperative symptom assessment, 24-hr pH monitoring, esophageal ma-nometry, and esophagogastroduodenoscopy (EGD). Radionucleotide stud-ies were performed if it was suspected that delayed gastric emptying wasthe cause of reflux.

Intraoperative hospital data were recorded during the hospital stay andincluded operative time, blood loss, perioperative complications, andlength of hospital stay. Follow-up 24-h pH monitoring, esophageal ma-nometry, and EGDs were performed by our lab or by the referring gastro-enterologist. All data were collected on standardized forms and entered intoa computerized database.

Surgical procedure

All patients underwent a modified laparoscopic Toupet fundoplication per-formed by or under the direction of the senior investigator. The procedurehas been described elsewhere [11]. The key elements include a thoroughdissection of the esophageal hiatus, mobilization of the gastroesophagealjunction so that at least 3 cm of distal esophagus is below the diaphragmwithout tension, and routine division of the short gastric vessels. The hiataldefect is closed loosely by reapproximation of the crura posteriorly. Thefundic wrap is fixed posterolaterally to both the right and left crura and a56F bougie is passed through the gastroesophageal junction. The wrap isthen sutured to the right and left sides of the esophagus at the 2 and 10o’clock positions. This creates a 270° wrap with posterior abdominal fixa-tion.

Follow-up

Complications were recorded as they occurred. At 3 months postopera-tively patients were asked to complete a symptom assessment form. Ap-proximately 2 years postoperatively patients were recalled and once againasked to complete the symptoms assessment form and all patients wereasked to undergo repeated pH testing and manometry. Upper endoscopywas performed when clinically indicated.

Results

The patients were 62% male and 38% female with a meanage of 49 years (25–83). The mean short- and long-termfollow-up was at a mean of 3 and 22 months, respectively.

Primary preoperative symptoms included heartburn (92%),regurgitation (57%), water brash (39%), and dysphagia(39%). Ninety percent of patients were on proton-pumpinhibitors prior to surgery. Eight patients had had previousantireflux procedures; 100% of patients had preoperative24-h pH and manometry studies.

The presurgical LE pressure was a mean of 10.75mmHg (0–40) and the length was a mean of 1 cm (0–4).Abnormal motility was present in 8.4% of patients as evi-denced by low-amplitude (<40 mmHg) contractions,dropped peristalsis, or tertiary contractions; 24-h ambula-tory pH monitoring was abnormal in 91% of patients andthe mean DeMeester score was 46.5 (1–281). Endoscopi-cally confirmed esophagitis was present in 29% of patientsat their most recent EGD. Six patients were thought to havealkaline reflux. There were 11 patients with Barrett’sesophagus.

Operations averaged 3.2 h (1–6.5) with a mean bloodloss of 133 cc (30–680). There were no mortalities and noprocedures were converted to celiotomy. There were sixcomplications during surgery. Two of these complicationsrequired second laparoscopic operations: a posterior esoph-ageal perforation found by EGD on postoperative day 1 anda delayed small-bowel perforation from adhesiolysis. Meanlength of hospital stay was 2.8 days (1–44). One patientdeveloped adult respiratory distress syndrome after an ap-parently uncomplicated operation and required supportivecare for 44 days. Post hospitalization one patient requiredreadmission for nasogastric decompression to treat symp-toms of gas bloat. Operative, early, and late postoperativecomplications are listed in Table 1.

Some 83 patients returned for follow-up at 3 months and74 patients at 22 months. Six percent (5/83) and 20% (15/74) of patients complained of recurrent heartburn at earlyand late follow-up, respectively. Dysphagia, which was de-fined as any difficulty swallowing liquids or solids, was20% at 3 months and 9% at 22 months. One patient requiredesophageal dilation secondary to persistent dysphagia. Thepreoperative, early postoperative, and late postoperative re-flux symptoms are displayed in Fig. 1.

Of the 74 patients who followed up at 22 months, 32(43%) underwent repeat manometry. The mean postopera-tive LES pressure was 23.45 mmHg (6–100), which confersa 130% increase in peak LES pressure after Toupet fundo-plication. The mean postoperative LES length was 2 cm, a100% increase from preoperative.

Forty-one of 74 patients (55%) underwent repeat pHtesting at late follow-up. Ten of these patients were symp-tomatic and 31 were asymptomatic. Abnormal pH studieswere defined as an elevated DeMeester score; 90% (9/10) ofsymptomatic patients had an elevated DeMeester score and39% (12/31) of asymptomatic patients had an elevated De-Meester score. Overall, 51% of patients had an elevatedDeMeester score at 22-month follow-up. The average was39.8 (1–212), a decrease of 6.7 points from preoperativevalues.

Thirty-three of 74 patients (45%) underwent late follow-up endoscopy; 18% (6/33), or 8% overall (6/74), revealedesophagitis. All six patients were symptomatic. Overall,60% of patients had late objective data, either pH testing,manometry, or EGD. Pre- and postoperative pH, manome-try, and EGD data are summarized in Table 2.

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Seven patients were deemed complete surgical failures.This was defined as symptoms severe enough to cause em-ployment of proton pump inhibitors (four patients) or arepeat fundoplication (three patients). The mean time topostoperative resumption of medical therapy was 8 months.EGD revealed obvious wrap disruption in only two of thepatients who underwent repeat fundoplication. There wereno cases of thoracic herniation. Therefore, five patientswere refluxing through intact wraps.

Discussion

Nissen fundoplication has been the most widely acceptedprocedure for the treatment of medically refractive GERD

in patients with good esophageal motility. Partial wrap pro-cedures have generally been reserved for patients with im-paired esophageal motility [6, 7, 13]. There has been arecent growth in interest, however, in using partial wrapprocedures as an alternative to the Nissen. This was basedon reports which suggested a lower incidence of postopera-tive wrap-related complications and a similar success rate inpreventing reflux symptoms when compared to Nissen fun-doplications [7, 8, 13].

In fact, several studies have supported partial fundopli-cations as a primary surgical treatment for all GERD pa-tients requiring operative management. Two randomizedprospective trials carried out by centers experienced in par-tial fundoplication techniques compared open Nissen re-pairs to the Toupet and Lind fundoplications and foundequivalent or superior results with respect to both preven-tion of reflux and postoperative symptoms [7, 8]. Follow-upin the study comparing Nissen to Toupet fundoplication was5 years and included objective testing. There are no suchstudies which demonstrate similar long-term follow-up withlaparoscopic procedures. There have also been reportswhich contradict this and show a higher recurrence rate withpartial fundoplications.

The results of this study show that perioperative mor-bidity is low and short-term resolution of reflux symptoms

Table 2. Preoperative and postoperative (22-month) objective evaluationa

Test Preoperative Postoperative

24-hour pH studies:DeMeester score 46.5 (1–281) 39.8 (1–212)% with pH <4 greaterthan 5% of the time 91 51 n 4 41

Manometry:LES length (cm) 1 2LES pressure (mmHg) 10.75 23.45n 4 32

EGD% with esophagitis 29% 18%n 4 33

a Numbers are given as a mean value

Table 1. Intraoperative and postoperative complications

Complication Treatment n

Intraoperative complications Enterotomy Laparoscopic repair 3Pericardial tear Laparoscopic repair 1Esophageal

perforationMediastinal drainage 1

Bougie injury toesophageal mucosa

Blood transfusion 1

4 6 (6%)Postoperative complications (in hospital) ARDS, etiology

undeterminedSupportive 1

Delayed gastricemptying

Supportive 1

Dislodgedgastrostomy tube

Subfascial abscess drainage 1

Pleural effusion Thoracentesis 14 4 (4%)

Postoperative complications (after discharge) Nausea/vomiting Supportive 1Candida empyema Chest tube drainage 1Gas bloat Nasogastric decompression 1URI Antibiotics 1

44 (4%)Total 4 14 (14%)

Fig. 1. Reflux symptoms.

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is high following laparoscopic Toupet fundoplications.These are, in fact, very well tolerated repairs, physiologi-cally. We have also shown, however, a progressive failurein reflux control with a symptomatic recurrence rate of 20%at 22 months follow-up. This high rate is partially explainedby the fact that we had a broad definition of heartburn (anysubsternal burning) and made no attempt to grade its sever-ity. This finding, however, remains worrisome, as our fol-low-up is still early, and this number can be expected toincrease.

Even more concerning to us was the 51% reflux rate atlate follow-up based on 24-h pH testing. While this may beoverstating the true incidence of reflux if one assumes anegative bias in follow-up (i.e., the patients with refluxwould be the ones that return for testing), the minimumreflux rate would still be 21%, even if all of the abnormalpatients were in the tested group. In fact, we suspect that51% is probably relatively accurate, as over one-half of thetested patients were asymptomatic and, therefore, unlikelyto have returned only because of surgical problems.

The 39% incidence of abnormal 24-h pH studies inasymptomatic patients is of concern and the significance ofthis finding is currently unclear. Longer follow-up on thesepatients, including endoscopy, will be required to look forobjective evidence of reflux-related esophageal injury.These patients are probably at risk of eventually developingreflux-related symptoms or complications.

Our results are particularly discouraging when com-pared to our experience with laparoscopic Nissen fundopli-cations. Currently we have an 8% symptomatic failure rateand 4% recurrence rate with objective testing (n 4 225).We have not found a greatly increased incidence of post-operative wrap-related side effects. Our incidence of latedysphagia is only 3%.

It is unclear why our recurrence rates for documentedreflux and reflux symptoms after laparoscopic Toupet fun-doplications are higher than demonstrated with open Toupetfundoplication. It is possible that we are not replicating theopen repair laparoscopically, although every effort is madeto do so. In fact, we feel that laparoscopic fundoplicationtechniques offer improved visualization of the hiatus, easierand safer dissection, and more accurate suture placementcompared to the open counterpart and, therefore, shouldprovide the best results.

We have shown that laparoscopic Toupet fundoplica-

tions have a high rate of symptomatic failure at 2-year fol-low-up. This high failure rate is confirmed by objectivetesting. We have also demonstrated that there is a substan-tial number of asymptomatic patients who have demon-strable esophageal reflux by objective tests. Though theimplications of this asymptomatic reflux are currently un-clear, it is likely that many of these patients will go on tohave reflux related problems in the future. We believe thatthis information contraindicates the use of laparoscopicToupet fundoplications for patients with GERD and normalesophageal motility.

References

1. Boutelier P, Gosta J (1982) An alternative fundoplicative maneuver forgastroesophageal reflux. Am J Surg 143: 260–264

2. Crookes P, DeMeester T (1996) The diagnosis and treatment of gas-troesophageal reflux disease in a managed care environment. ArchSurg 131: 1021–1023

3. Cuschieri A, Hunter J, Wolfe B, Swanstrom L, Hutson W (1993)Multicenter prospective evaluation of laparoscopic antireflux surgery.Surg Endosc 7: 505–510

4. DeMeester T, Bonavina L, Albertucci M (1986) Nissen fundoplicationfor gastroesophageal reflux disease. Ann Surg 204: 9–20

5. Hunter J, Trus T, Branum G, Waring J, Wood W (1996) A physiologicapproach to laparoscopic fundoplication for gastroesophageal refluxdisease. Ann Surg 6: 673–684

6. Kahrilas P, Clouse R, Hogan W (1994) An American Gastroenter-ological Association Medical Position Statement on the clinical use ofesophageal manometry. Gastroenterology 107: 1865–1884

7. Kjell T, Silander T (1989) A long term randomized prospective trial ofthe Nissen procedure versus a modified toupet technique. Ann Surgery210: 719–724

8. Lundell L, Abrahamsson H, Ruth M, Rydberg H, Lonroth H, Olbi L(1996) Long-term results of a prospective randomized comparison oftotal fundic wrap (Nissen-Rossetti) or semifundoplication (Toupet) forgastro-oesophageal reflux. Br J Surg 83: 830–835

9. Mosnier H, Leport J, Aubert A, Kianmanesh R, Sbai Idrissi M,Guivarc’h M (1995) A 270 degree laparoscopic posterior fundoplastyin the treatment of gastroesophageal reflux. J Am Coll Surg 181:1088–1094

10. Negre J, Markkula H, Keyrilainen O, Matikainen M (1983) Nissenfundoplication. Am J Surg 146: 635–638

11. Swanstrom L (1996) Laparoscopic Partial Fundoplications. Problemsin General Surgery 13: 75–84

12. Swanstrom L, Wayne R (1994) Spectrum of gastrointestinal symptomsafter laparoscopic fundoplication. Am J Surg 167: 538–541

13. Walker S, Holt S, Sanderson C, Stoddard C (1992) Comparison ofNissen total and Lind partial transabdominal fundoplication in thetreatment of gastro-oesophageal reflux. Br J Surg 79: 408–412

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Importance of transesophageal echocardiography in directing thesurgical approach to atrial myxomas

The optimal operative approach to an atrial myxoma shouldprovide good exposure for complete resection of the tumorand its attachment, allow inspection of heart chambers formultiple tumors, and be safe and efficacious [2]. There isstill controversy concerning the best surgical approach toachieve this, and various incisions have been used includingleft atriotomy, biatrial, transseptal, and the superior trans-septal approach.

Each of these approaches has its drawbacks; for ex-ample, a left atriotomy alone may impede obtaining ad-equate excisional margins [3] while the biatrial approach isresponsible for a high incidence of arrhythmias and conduc-tion disturbances [2]. Furthermore, although the superiortransseptal approach allows good visualization of the inter-atrial septum, it is associated with an increased risk of post-operative bleeding and of damage to the blood supply to thesinus node [5].

It is the variability in the attachment point of atrialmyxomas that offers a challenge to the surgeon. While al-most every approach can provide adequate access to myxo-mas that arise from the interatrial septum, difficulties insurgical exposure can arise in the 15% to 40% of the atrialtumors that are attached elsewhere [2]. Clearly, therefore,there is no single approach that is ideal for every situation,and the technique may have to be individualized for eachcase.

Intraoperative transesophageal echocardiography (TEE)has become an integral part of cardiac surgical practice, andits application continues to evolve as more data becomeavailable [4]. TEE plays an important role in the diagnosisof atrial myxomas as well as in confirming the completeremoval of the tumor before closing the chest [1, 4]. How-ever, the importance of TEE in directing the surgical ap-proach to an atrial myxoma has not received enough em-phasis. Intraoperative TEE can be used to localize the site oforigin of the tumor; thus, the most appropriate line of inci-sion is selected so that this can be excised. This is illustratedby the following examples:

In case 1, a 65-year-old man was diagnosed to have anatrial myxoma by transthoracic echocardiography. On in-traoperative TEE (Fig. 1), the transverse plane of the leftatrium showed a pedunculated left atrial myxoma arisingvia a narrow stalk from the interatrial septum. Therefore,this tumor was easily excised through the right atrium byexcising a disc of the interatrial septum completely with thestalk and the tumor attached to it.

In case 2, however, intraoperative TEE (Fig. 2) in a71-year-old woman demonstrated a myxoma that had abroad-based attachment to the roof of the left atrium, im-mediately posterior to the superior vena cava and the aorta.The tumor had to be removed en bloc together with the fullthickness of the atrial wall. This was performed through avertical left atriotomy anterior to the right pulmonary veins,extended superiorly behind the superior vena cava, anteriorto the tumor attachment. The roof of the left atrium wasexcised as a whole with the myxoma and was repaired witha Dacron patch. In both cases histological examinationdocumented complete excision of the tumor.

Another advantage of intraoperative TEE is that it is nolonger necessary for the surgical incision to provide accessto all heart chambers. With TEE, all four chambers can beaccurately inspected, which obviates the need for a visualinspection. This is particularly beneficial if a minimallyinvasive approach (for example, through a parasternal inci-sion) is elected.

TEE has been established as a useful tool which cansignificantly enhance the cardiac surgeon’s diagnostic and

Fig. 1. Transesophageal echocardiography in transverse plane demonstrat-ing a left atrial pedunculated myxoma (Mx) prolapsing into left ventricle(LV) during diastole. The tumor is attached to the interatrial septum (ar-rows) via a narrow stalk.

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therapeutic accuracy and, in this context, direct the surgicalapproach to atrial myxomas.

References

1. Joffe II, Jacobs LE, Lampert C, Owen AA, Loli AW, Kotler MN (1996)Role of echocardiography in perioperative management of patients un-dergoing open heart surgery. Am Heart J 131: 162–176

2. Jones DR, Warden HE, Murray GF, Hill RC, Graeber GM, CruzzavalaJL, Gustafson RA, Vasilakis (1995) Biatrial approach to cardiac myxo-mas: a 30-year clinical experience. Ann Thorac Surg 59: 851–856

3. Kabbani SS, Jokhadar M, Meada R, et al. (1994) Atrial myxoma: reportof 24 operations using the biatrial approach. Ann Thorac Surg 58:483–488

4. Reeder GS, Khandheria BK, Seward JB, Tajik AJ (1991) Transesopha-geal echocardiography and cardiac masses. Mayo Clin Proc 66: 1101–1109

5. Vigano M, Grande AM, Gaeta R (1995) Superior transseptal approachto left atrial myxomas. Ann Thorac Surg 60: 1860–1861

M. Bashar IzzatA. P. C. Yim

Division of Cardiothoracic SurgeryDepartment of SurgeryThe Chinese University of Hong KongHong Kong

Fig. 2. Transesophageal echocardiography in transverse plane demonstrat-ing a broad-based myxoma (Mx) attached to the roof of the left atrium (LA),immediately posterior to the superior vena cava (VC) and the aorta (Ao).

1137

Initial results of a prospective trial of outpatientlaparoscopic cholecystectomy

P. K. Narain, E. J. DeMaria

Department of Surgery, Box No. 980475, Medical College of Virginia Hospitals, Virginia Commonwealth University,Richmond, VA 23298-0475, USA

Received: 3 April 1997/Accepted: 10 June 1997

AbstractBackground:Whether or not laparoscopic cholecystectomymay be performed safely as an outpatient procedure is con-troversial. In 1993, a protocol for outpatient laparoscopiccholecystectomy was instituted to determine the benefitsand safety of discharging patients within several hours ofsurgery.Methods:The initial 60 outpatient laparoscopic cholecys-tectomies performed by one surgeon in a hospital-basedoutpatient teaching facility between February 1993 to June1996 were prospectively studied.Results:Fifty-eight (97%) patients were discharged suc-cessfully after an average stay in the recovery room of 3 h.There were no deaths. Two patients required overnight ob-servation and three patients required readmission. Two pa-tients (3%) had cystic duct leak. The average hospital stayfor all patients undergoing laparoscopic cholecystectomy atthe institution (inpatient and outpatient) decreased from 3.2to 1.5 days and the average hospital cost decreased from$7,800 to $4,600 during this period.Conclusion:Laparoscopic cholecystectomy in an outpatientsetting is safe and cost-effective in healthy patients.

Key words: Laparoscopic cholecystectomy — Ambulatorysurgery — Outpatient

After first being performed by Phillipe Mouret of France inMarch 1987, laparoscopic cholecystectomy was introducedin the United States in 1988. Of the approximately 700,000cholecystectomies performed in the United States everyyear, now more than 80% are performed laparoscopically[15]. This rapid shift from open to laparoscopic cholecys-tectomy has been driven mainly by public demand. Thereasons for its universal acceptance include reduced pain,

smaller scars, earlier discharge from hospital, shorter con-valescence, and less cost.

Initially, articles on laparoscopic cholecystectomy con-tained a long list of absolute and relative contraindications.With increasing experience these have changed dramati-cally. Increase in confidence has led to laparoscopic chole-cystectomy being performed in the outpatient setting. Al-though outpatient laparoscopic cholecystectomy has beenreported since 1990 [8, 9] many of the so-called outpatientprocedures included patients observed overnight [6]. Con-cerns have been raised in the literature about the safety ofthe procedure being performed on a true outpatient basis[11].

A protocol for outpatient laparoscopic cholecystectomywas instituted at the Medical College of Virginia hospitalsin 1993 to ascertain the feasibility, safety, and benefits ofdischarging patients several hours after surgery.


The first 60 laparoscopic cholecystectomies that were performed in a ded-icated outpatient facility affiliated with the Medical College of Virginia(MCV) hospitals between February 1993 and June 1996 were studiedprospectively. The indications for surgery were symptomatic cholelithiasis;acute, chronic, and acalculous cholecystitis; and biliary dyskinesia. Rela-tive contraindications to outpatient laparoscopic cholecystectomy werecommon bile duct dilatation, coagulopathy, pregnancy, cirrhosis, ASAgrade III and IV, and inadequate family support for the patient to be senthome. Patients were screened preoperatively by the surgeon and the anes-thesiologist. Laboratory tests included complete blood count and liverfunction tests. Other tests like coagulation profile, serum chemistry, chestx-ray, and EKG were performed if indicated. Patient education regardingthe outpatient nature of the procedure was initiated by the surgeon duringthe first clinic visit. The participation of a responsible adult identified as thecare giver for the early postoperative period was strongly encouraged.Patients arrived an hour before surgery on the day of operation. The out-patient aspect of the procedure was further reinforced by the surgical staffat this time.

Surgery was performed using intravenous induction and general inha-lation anesthesia with muscle relaxants. All patients received prophylacticantibiotics. The standard four-port technique was used. Later on this wasmodified to a 10-mm subcostal port and three 2-mm ports, using a 2-mmlaparoscope and instruments in a few patients. The open (Hassan) tech-Correspondence to:E. J. DeMaria

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nique was utilized to enter the peritoneum in patients with prior laparoto-my. Operative cholangiogram was performed selectively. All wounds wereinfiltrated with a 50:50 mix of 0.25% bupivacaine and 1% lidocaine with1:100,000 epinephrine.

Patients were given preemptive antiemetics in the preoperative periodand analgesics prior to the end of operation. They were discharged whenthey were tolerating fluids orally and when they were able to ambulate andvoid spontaneously. They were given a prescription for hydrocodone withacetoaminophen (Percocet) for pain in the postoperative period. Patientswere kept in hospital for overnight observation if there were technicalconcerns, unstable vital signs, excessive pain, nausea or vomiting, or uri-nary retention. All patients were contacted by telephone on the 1st post-operative day by a nurse and were seen by the surgeon in a week.

In order to assess the overall impact of this outpatient protocol theresults of outpatient surgery were compared to inpatient laparoscopic cho-lecystectomy performed at the institution. Procedures done by other sur-geons were included in studying the quarterly demographics of all outpa-tient and inpatient laparoscopic cholecystectomy patients. The averagehospital cost and charges to the patient for all laparoscopic cholecystecto-mies performed in the ambulatory and inpatient settings were similarlyanalyzed.

Results

The average age of the initial consecutive 60 patients was38.5 years. The range was 19 years to 63 years. The male tofemale ratio was 1:5. Nine patients (15%) had had previouslaparotomy.

The average operating time was 1.5 h, with a rangebetween 0.5 and 3.3 h (Fig. 1). The average recovery roomstay was 3 h, range 1.5–8.25 h (Fig. 2). No patient requiredconversion to open procedure. Eleven patients (18%) un-derwent cholangiography during surgery. Other proceduresperformed simultaneous with the laparoscopic cholecystec-tomy are listed in Table 1.

No mortality occurred postoperatively. Fifty-eight pa-tients (97%) were discharged home after meeting dischargecriteria. Of the two patients admitted for overnight obser-vation, one had excessive nausea and pain but was dis-charged uneventfully the next morning. The second patienthad a cystic duct leak that necessitated an ERCP and stentprocedure, following which she made an uneventful recov-ery.

Fifty patients (83%) did not require any medical atten-tion from the time of discharge to their routine follow-up

appointment. Six patients (10%) made an unscheduled visitto the emergency room or to their primary care doctor andthree of them (5%) were readmitted. One patient had acystic duct leak and went on to develop pancreatitis fromendoscopic stent placement that eventually resolved withconservative management. Two patients were admitted formanagement of pain. Altogether, eight patients (13%) suf-fered 10 minor complications (Table 2). Two complicationswere identified at the patient’s scheduled visit to the clinic.One patient had scrotal ecchymosis after having undergonean inguinal hernia repair simultaneous with the laparoscopiccholecystectomy. Another patient complained of nausea fora few days after surgery. There were no bile duct or bowelinjuries in this series. Outpatient status did not appear tocompromise the safety of the patients, even in the few whosuffered a complication.

Early in 1993, laparoscopic cholecystectomy was per-formed only in the inpatient facility at our institution. By1996, approximately 50% of all laparoscopic cholecystec-tomies were performed on an outpatient basis (Fig. 3). Theaverage length of stay for all patients having laparoscopiccholecystectomy between June 1993 and June 1996 de-creased from 3.2 days to 1.5 days (Fig. 4). The hospitalcharged an average of $5,811 for an outpatient laparoscopiccholecystectomy during this period. This was in contrast tothe $12,390 charged for an average inpatient laparoscopiccholecystectomy. The average hospital cost for all patientsundergoing laparoscopic cholecystectomy decreased duringthe protocol from $7,800 in the third quarter of 1993 to$4,600 in the second quarter of 1996 primarily as a result ofthe shift toward the outpatient facility (Fig. 5).

Fig. 1. Operation time for outpatient laparoscopic cholecystectomy per-formed at MCV hospitals between February 1993 and June 1996.

Fig. 2. Time spent in recovery room after outpatient laparoscopic chole-cystectomy performed at MCV hospitals between February 1993 and June1996.

Table 1. Procedures performed simultaneous with outpatient laparoscop-ic cholecystectomy

1. Liver biopsy 12. Appendectomy 13. Bilateral tube ligation 14. Ovarian cystectomy 15. Inguinal hernia repair 16. Incisional hernia repair 1

Total 6

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Discussion

Laparoscopic cholecystectomy has rapidly emerged as thestandard of care for symptomatic cholelithiasis. It is costeffective and safe and can be performed with morbidity andmortality rates similar to those for the open procedure [13,15]. There have been concerns, however, about it beingperformed as an outpatient procedure. Although same-daydischarge has been reported even after open cholecystecto-my [10], there has been a reluctance to perform laparoscopiccholecystectomy on an ambulatory basis [11].

The present study was undertaken to assess the safety ofperforming laparoscopic cholecystectomy in the outpatient

setting. Although small in size, the study was done prospec-tively on the first 60 consecutive patients. In this relativelyhealthy population group, more than 95% of the patientswere discharged home within 5 h of surgery and only twopatients required overnight admission. More than 80% ofthe patients did not require any unscheduled medical atten-tion in the postoperative period.

Of those patients who went home, only one had a seri-ous complication. Some complications following laparo-scopic cholecystectomy, like bleeding and pneumothorax,are detected early in the recovery room, whereas others, likebiliary leak, tend to go undetected for a few days. Saunderset al. found that patients with cystic stump leak presentedanywhere between postoperative day 1 and 7 [11]. There-fore even a hospital stay of 24 h or more would not obviatethe risk that the complication would develop following dis-charge [8, 14]. Two cystic duct leaks occurred in the currentseries and both patients were managed with endoscopicstent placement. One was reoperated to place a drain. Shedeveloped significant pancreatitis after the stent that re-solved slowly over time. There are no data on the incidenceof cystic duct leak in outpatient laparoscopic cholecystec-tomy. Wherry et al. reported 0.53% bile leak rate in theirlarge audit of military institutions [15]. In an equally largeaudit, Scott et al. had shown the biliary leak rate to be 0.4%[12]. Saunders et al. reported 7 (1.2%) cystic duct leaks in506 patients [11]. Our experience was similar to that ofAlbasini et al., who reported a 2% cystic stump leak with nobile duct injuries [1]. The small size of our series makes itdifficult to draw any meaningful conclusions. However, theoutpatient nature of the procedure did not seem to affect theoutcome adversely.

Our operating time was similar to that reported by others[8, 14]. The time spent in recovery room after surgery was,however, less than that reported by other authors. We had amean recovery time of 180 min, which was a much quickerdischarge than in other series which purportedly show out-patient procedure results. Reddick reported a mean stay of222 min [8], Farha et al. reported a mean recovery time of252 min [2], and Voitk had a mean recovery period of 7.5h [14]. Despite our earlier discharge, only three patientswere readmitted, one for biliary leak and two for pain andnausea. The readmit rate was similar to the 2% readmission

Table 2. Complications after outpatient laparoscopic cholecystectomy

Major:1. Cystic duct leak 2

Minor:1. Pain 42. Nausea 33. Urinary tract infection 14. Rash 15. Scrotal ecchymosis 1

Total 10 (in 8 patients)

Fig. 3. The number of outpatient laparoscopic cholecystectomies per-formed at MCV hospitals increased progressively during the study period.

Fig. 4. Mean stay in hospital after all laparoscopic cholecystectomies (in-patient and outpatient combined) performed at MCV hospitals decreasedover the course of study.

Fig. 5. Average combined cost of all laparoscopic cholecystectomies per-formed at MCV hospitals over the 3-year study period. The primary causeof decreased procedure cost was a shift to the outpatient facility.

1093

rate reported by Voitk [14], Farha et al. [2], and Saunders etal. [11]. Reddick, however, did not report any readmissions[8]. Greenburg et al. reported a similar 1.5% readmissionrate after both open and laparoscopic ambulatory generalsurgery procedures. Twenty-five percent of the admissionswere due to pain and 12% due to nausea and vomiting [4].

Fiorello et al. found that the only significant factor inpredicting successful early postoperative discharge was theduration of the procedure. The ambulatory group had amean operating time of 62 min compared to 82 min for thegroup that stayed overnight in their series [3]. They theo-rized that longer operations meant the need for longer re-covery periods with higher incidence of nausea, drowsiness,and atelectesis. We did not observe this difference. In ourseries, more than 75% of patients had an operation timegreater than 60 min, but only two patients required over-night admission. The addition of cholangiography or anadditional procedure which prolonged the operation did notincrease the likelihood of the patient staying overnight. One55-year-old patient in our series was able to go home 5 hafter a 3.2-h surgery. Another patient was discharged 1.8 hafter a 3.3-h surgery.

While the metabolic and stress hormonal responses aresimilar for open and laparoscopic cholecystectomy [7], theearlier recovery seen in laparoscopic surgery is likely to bedue to less pain. Strategies for pain control in our protocolincluded local infiltration of the wounds, preemptive anti-emetics, and adequate postoperative analgesia. Preemptiveantiemetics and analgesia are routinely used in our ambu-latory patient population with good results. Fiorello et al.similarly suggested the possible relation of local infiltrationof trocar sites to successful early discharge [3].

Over the 3-year period, the average stay in hospital afterlaparoscopic cholecystectomy (inpatient and outpatientcombined) has gradually decreased at our institution. Dur-ing this period the mean cost of the procedure has alsodecreased by 40%. This could partly be attributed to ahigher percentage of patients being operated on as outpa-tients. Whereas in 1993 all laparoscopic cholecystectomyprocedures were done as inpatients, at present 50% of thepatients undergoing laparoscopic cholecystectomy havetheir surgery in the outpatient facility. In 1990, Reddick andOlsen reported that only 45% of the patients they selected toundergo laparoscopic cholecystectomy could be dischargedon an outpatient basis [9]. Better results were reported byFiorello et al., who successfully discharged 61% of theirunselected patients within several hours after surgery [3],but they did not gather data prospectively. In our prospec-tive trial, we sent 95% of selected patients home and 75% ofthem within 4 h of surgery.

Greenberg et al. emphasized the importance of goodpatient selection and adequate support systems for success-ful ambulatory surgery [4]. Although age per se was not oneof our exclusion criteria (our oldest patient was 63 yearsold), patients with significant comorbidities were excludedfrom ambulatory surgery, including patients with ASAgrade III and IV. Careful screening at various levels in thepreoperative evaluation allowed inappropriate patients to beexcluded. Patient education and adequate support at home isintegral to good patient selection. Outpatient laparoscopiccholecystectomy is a relatively new concept and we foundthat many patients initially had doubts about the adequacy

of postoperative support with such early discharge. We be-lieve that education of the patients and their families in thepreoperative period, reassurance, and close postoperativecontact with the physician and nurses played a key role inthe success of our outpatient laparoscopic cholecystectomyprogram.

Our data suggest that it may be reasonable to do lapa-roscopic cholecystectomy in a freestanding outpatient cen-ter utilizing a carefully designed program such as ours toensure a high likelihood of successful early discharge andthe safety of the patient.

Conclusion

Outpatient laparoscopic cholecystectomy can be safely per-formed in a select group of patients with a high likelihoodof success using our selection criteria and protocol. Carefulpatient selection, patient education, and dedicated healthprofessionals are paramount for the safe practice of out-patient laparoscopic cholecystectomy [2, 14]. Divertinghealthy patients undergoing elective procedures to our out-patient facility appeared to significantly decrease costswithout compromising safety.

References

1. Albasini JLA, Aledo VS, Dexter SPL, Marton J, Martin IG, McMohanMJ (1995) Bile leakage following laparoscopic cholecystectomy. SurgEndosc 9: 1274–1278

2. Farha GJ, Green BP, Beamer RL (1994) Laparoscopic cholecystecto-my in a freestanding outpatient surgery center. J Laparoendosc Surg 4:291–294

3. Fiorello MA, Davidson PG, Fiorello M, D’Anna JA Jr, Sithian N,Silich RJ (1996) 149 ambulatory laparoscopic cholecystectomies. SurgEndosc 10: 52–56

4. Greenberg AG, Greenberg JP, Tewel A, Breen C, Machin O, Mcrae S(1996) Hospital admissions following ambulatory surgery. Am J Surg172: 21–23

5. Mckernnan JB, Stuto A, Champion JK (1996) New applications ofbipolar coagulation in laparoscopic surgery. Surg Laparosc Endosc6(5): 335–340

6. Moving to outpatient surgery: how do you compare? 1994 OntarioMinistry of Health and Ontario Hospital Association Joint policy andPlanning Committee, document 1-3, Don Mills, Ontario

7. Ortega AE, Peters JH, Incarbone R, Estrada L, Ehsan A, Kwan Y,Spencer CJ, Moore-Jeffries E, Kuchta K, Nicoloff JT (1996) A pro-spective randomized comparison of the metabolic and stress hormonalresponses of laparoscopic and open cholecystectomy. J Am Coll Surg183: 249–256

8. Reddick EJ (1992) Laparoscopic cholecystectomy in freestanding out-patient centers. J Laparoendosc Surg 2: 65–67

9. Reddick EJ, Olsen DO (1990) Outpatient laparoscopic laser cholecys-tectomy. Am J Surg 160: 485–487

10. Saltzstein EC, Mercer LC, Peacock JB, Dougherty SH (1992) Outpa-tient open cholecystectomy. Surg Gynecol Obstet 174(5): 173–175

11. Saunders CJ, Leary BF, Wolfe BM (1995) Is outpatient laparoscopiccholecystectomy wise? Surg Endosc 9: 1263–1268

12. Scott TR, Zucker KA, Bailey RW (1992) Laparoscopic cholecystec-tomy: a review of 12,397 patients. Surg Laparosc Endosc 2: 191–198

13. Shea JA, Healey MJ, Berlin JA, Clarke JR, Malet PF, Staroscik RN,Schwartz JS, Williams SV (1996) Mortality and complications asso-ciated with laparoscopic cholecystectomy: a meta-analysis. Ann Surg224: 609–620

14. Voitk AJ (1995) Routine outpatient laparoscopic cholecystectomy.CJS 382 (3): 262–265

15. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, Rich NM (1996)External audit of laparoscopic cholecystectomy in the steady stateperformed in medical treatment facilities of the Department of De-fense. Ann Surg 224(2): 145–154

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Laparoscopic management of lumbar hernia

A. Bickel, M. Haj, A. Eitan

Department of Surgery, Western Galilee Hospital, Nahariya, P.O. Box 21, 22100 affiliated to the Rappaport Faculty of Medicine, the Technion, IsraelInstitute of Technology, Haifa, Israel

Received: 10 November 1996/Accepted: 20 December 1996

Abstract. We describe (for the first time) a laparoscopicapproach to repair an acquired superior triangle lumbar her-nia in a morbidly obese woman by using prosthetic mesh.Such a technique provides an excellent anatomic view, thusavoiding injury to structures in proximity to the hernia dur-ing repair; eventually the well-known advantages of suchapproach result.

Key words: Lumbar hernia — Laparoscopy — Prostheticmesh

Hernias in the lumbar region are relatively rare; they vary inetiology, exact anatomic location, and method of surgicalrepair [1–9].

Numerous ‘‘open’’ procedures for lumbar hernia repairhave been suggested, depending on the size and etiology ofthe abdominal wall defect [2, 4, 5, 7, 9].

We present a case of acquired superior triangle lumbarhernia in a morbidly obese woman, which, for the first time,was repaired through the laparoscopic approach.

Case report

A 60-year-old morbidly obese woman (110 kg) was admitted because ofchronic left lumbar pain and a sensation of a growing mass. Physicalexamination revealed a sense of a left flank protruding mass and of impulseduring coughing. Lumbar hernia was suspected. Abdominal CT revealed adefect of the aponeurosis of the transverse abdominis muscle (lumbodorsalfascia) with protrusion of preperitoneal fat (Fig. 1).

Under general anesthesia the patient was placed on her right side.Insufflation with CO2 and introduction of a 30° laparoscope were doneabout 8 cm to the left of the umbilicus, at its level. The peritoneal cavitywas extremely fatty, with adhesions, but no peritoneal defect was seen. Asecond sleeve (5 mm) was introduced 6 cm below the first. The third sleeve(5 mm) was introduced 6–7 cm above the umbilicus level, at the anterioraxillary line. The adhesions were divided and the retroperitoneal space was

entered, while the left colon was easily mobilized medially, assisted by thegravitational force, due to the patients’ right decubitus position. The psoasmuscle was identified, and the left ureter was dissected and isolated. A 3× 3 cm round defect was discovered in proximity to the ureter, between thelevel of the iliac crest and the 12th rib (Fig. 2). An incarcerated retroper-itoneal fat was reduced and the borders of the opening were cleared. Afourth sleeve (12 mm) was introduced at the anterior axillary line near theiliac crest for the introduction of an hernia stapler. A 7 × 11 cmpiece ofProlene mesh was used to occlude the hernia defect, and was fixed to thelumbar abdominal wall by the hernia staples, carefully avoiding the ureter.

The postoperative sequelae were uneventful, and she was dischargedasymptomatic on the 3rd postoperative day. During 8 months of follow-up,neither recurrence of hernia nor any related complaints were recorded.

Discussion

Lumbar hernia in this case was first suspected on physicalexamination, but its exact location was found, during lapa-roscopy, to protrude through the superior lumbar triangle. Inthe absence of a history of trauma, infection, or previousoperation, we assume that it was a primary acquired hernia[3, 5, 6, 8, 9]. The superior lumbar triangle (Grynfelt-Lesgaft), together with the inferior (Petit) triangle, are thetwo most recognized among the possible areas of anatomicweakness that are contained in the lumbar region [1, 5]. Thesuperior lumbar triangle is bounded by the inferior marginof the 12th rib, along with the lower border of the serratusposterior inferior muscle, by the posterior free border of theinternal oblique muscle and by the quadratus lumborum andthe erector spinae muscles. The floor is formed by the trans-versalis fascia and the lumbosacral fascia, and the roof bythe latissimus dorsi. The laparoscopic approach for lumbarhernia has significant advantages, especially when the pa-tient is obese. It enables exact location of the anatomicdefect, avoiding the need for wide exploration and dissec-tion of the lumbar region through large incision. It providesan excellent anatomic view, thus avoiding injury to struc-tures in proximity to the hernia (ureter, nerves etc.) duringrepair. It possesses all the well-known advantages of thelaparoscopic approach (less postoperative pain, hospitalstay, and wound infection). In summary, the laparoscopicrepair using a prosthetic mesh is simple and logical, andseems to be effective for small and medium-size defects.Correspondence to:A. Bickel

Surg Endosc (1997) 11: 1129–1130

SurgicalEndoscopy


References

1. Abramson J (1990) Hernias. In: Schwartz SI, Ellis H (eds) Maingot’sabdominal operations. Prentice-Hall, pp 271–272

2. Bolkier M, Moskovitz B, Ginesin Y, Levin DR (1991) An operation forincisional lumbar hernia. Eur Urol 20: 52–53

3. Esposito TJ, Fedorak I (1994) Traumatic lumbar hernia: case report andliterature review. J Trauma 37: 123–126

4. Fakhry SM, Azizkhan RG (1991) Observation and current operativemanagement of congenital hernias during infancy. Surg Gynecol Obstet172: 475–479

5. Geis WP, Hodakowsky GT (1995) Lumbar hernia. In: Nyhus LM, Con-don RE (eds) Hernia. J B Lippincott, Philadelphia, pp 412–424

6. Pul M, Pul N, Gurses N (1991) Congenital lumbar (Grynfelt-Lesgaft)hernia. Eur J Pediatr Surg 1: 115–117

7. Shiki S, Kuwata Y, Kashihara E, Ueda U, Fuchimoto S, Orita K (1991)A case of superior lumbar hernia. Jpn J Surg 21: 696–699

8. Stevens KJ, Banuls M (1994) Iliolumbar hernia following bone grafting.Eur Spine J 3: 118–119

9. Sutherland RS, Gerow RR (1995) Hernia after dorsal incision into lum-bar region; a case report and review of the pathogenesis and treatment.J Urol 153: 382–384

Fig. 1. Abdominal CT demonstrating retroperitoneal fat protrudingthrough left lumbar abdominal wall defect.

Fig. 2. Intraoperative photograph showing the lumbar retroperitoneal ab-dominal wall defect:thick arrow—the hernia defect;long arrow—the leftureter following dissection and isolation;curved arrow—the psoas muscle.

1130

Original articles

Multicentric experience of the Belgian Group for Endoscopic Surgery(BGES) with endoscopic adrenalectomy

L. de Canniere,1 L. Michel,1 E. Hamoir,2 G. Hubens,2 M. Meurisse,2 J. P. Squifflet,2 P. Urbain,2 L. Vereecken2

1 Surgical Services, Mont-Godinne University Hospital (UCL), Yvoir B-5530, Belgium2 Belgian Group For Endoscopic Surgery, rue St Georges 13, 7181 Feluy, Belgium


AbstractBackground:Adrenalectomy is not a frequent operation.Therefore the newly developed laparoscopic approach issporadically performed by surgeons dealing with endocrinedisorders.Methods:Some 54 videoendoscopic adrenalectomies per-formed on 52 patients by five surgical teams between Oc-tober 1993 and December 1996 were prospectively evalu-ated.Results: Indications for endoscopic adrenalectomy werepheochromocytoma (n 4 17), primary hyperaldosteronism(n 4 15), Cushing’s adenoma or disease (n 4 7), nonse-creting adenoma (n 4 7), single metastasis from adenocar-cinoma (n 4 2), adenoma with dehydroepiandrostenedione(DHEAS) hypersecretion (n 4 3), and ACTH-secretingmetastases from a thymoma (n 4 1). Of the 54 adrenalec-tomies performed, 31 were of the left gland, 19 of the rightand two bilateral. Laparoscopic adrenalectomy was success-ful in 50 patients (96%). Median tumor size was 4 cm (range1.5–12), median operation duration was 80 min (range 59–360), and median postoperative stay was 4 days (range 2–13). One patient required blood transfusion.Conclusions:Endoscopic adrenalectomy can safely be per-formed—even sporadically—by surgeons well versed in ad-renalectomy techniques for endocrine disorders and trainedin endoscopic surgery.

Key words: Laparoscopy — Adrenalectomy — Pheochro-mocytoma — Endocrine disorders — Retroperitoneum

Almost all abdominal procedures have been attempted lapa-roscopically. Despite their retroperitoneal location, kidneysand adrenals have also been reached by the blitz of endo-scopic surgery since 1992 [6]. However, adrenalectomy is

not a frequent operation. Therefore the newly developedlaparoscopic approach is sporadically performed by sur-geons dealing with endocrine disorders.

Since experience with endoscopic adrenalectomy is lim-ited and long-term results are not yet available [3, 6, 7, 9,12, 14], we conducted, within the framework of the ‘‘Bel-gian Group for Endoscopic Surgery (BGES),’’ a prospec-tive multicentric study in order to assess the benefits anddrawbacks of endoscopic adrenalectomy. The surgeons in-volved in this study were experienced in laparoscopic tech-niques and also familiar with the rules and potential draw-backs of open adrenal surgery for endocrine disorders.


Source of data

A checklist was sent to members of the BGES in order to collect data aboutvideoendoscopic adrenalectomy performed by surgeons already experi-enced with laparoscopic surgical techniques and open adrenalectomy forendocrine disorders. The report form includes information on the patient’sage, sex, and clinical features (preoperative risk factors, American Societyof Anesthesiology clinical status classification, previous abdominal sur-gery, preoperative diagnosis of adrenal disease, blood pressure data, pre-operative imaging techniques, patients’ coexisting conditions, and preop-erative pharmacological preparation). Data were also obtained concerningthe elected surgical technique (i.e., laparoscopic, retroperitoneoscopic, orboth), operation duration, transfusion requirement, morbidity, anesthesiol-ogy considerations, pathological results, hospital stay, and follow-up.

Validation

Data were acquired from five surgical teams. All cases were operated onbetween October 1993 and December 1996. The database was managed byproject coordinators designated by the board of the BGES.

Results

There were 34 women and 18 men with a median age of 44years (range 12–74). Of the 54 adrenalectomies performed,Correspondence to:L. Michel

SurgicalEndoscopy


31 were of the left gland, 19 of the right, and two bilateral.Table 1 gives the indications for videoendoscopic adrenal-ectomy. Twenty-five (48%) patients had undergone previ-ous abdominal operation, and five patients with multipleendocrine neoplasia syndrome (four pheochromocytomaand one Cushing’s disease) had previous contralateral adre-nal surgery. Thirteen patients (25%) demonstrated a bodymass index (weight in kilograms divided by height in meterssquared) higher than 30, which means that they were re-garded as being severely overweight [15]. The 52 patientspresented a total of 94 coexisting clinical risk factors. Pre-operative assignment risk according to the American Soci-ety of Anesthesiologists (ASA) physical status classificationwas as follows: ASA I (15 cases), ASA II (28 cases), ASAIII (nine cases).

All 52 patients had their abdomen explored preopera-tively by computed tomography (CT). Patients suspected ofhaving pheochromocytoma also had metaiodobenzylguani-dine (MIBG) scintigraphy. The initial endoscopic approachof the adrenal was transperitoneal in 49 patients (48 supra-colonic access and one transmesocolic access to the leftadrenal) and retroperitoneal in three patients. Forty-nine pa-tients were operated in the lateral decubitus position andthree in the intermediate position. Endoscopic adrenalecto-my was successful in 50 patients (96%). The two unsuc-cessful procedures involved bilateral procedures in one casefor Cushing’s disease and ACTH-secreting metastases froma malignant thymoma in another. Conversion was justifiedby bleeding in the first case and difficult endoscopic dis-section in the second case. Two patients were initially op-erated on by a retroperitoneoscopic approach (one for pri-mary hyperaldosteronism in the right adrenal ten years afterright nephropexy and one for nonfunctional adenoma in theleft adrenal) [1–3, 8, 10]. The upper pole of their kidney wasentangled by adhesions. During dissection of these adhe-sions the peritoneal layer was slightly torn, allowing CO2 toescape from the retroperitoneal space to the peritoneal cav-ity with the peritoneal layer falling on the endoscope. Infact, in these two cases the operation was easy to completeby the laparoscopic route because the retropneumoperito-neum had already created a large retroperitoneal workingspace, rendering further exposure of the adrenal simple andrapid. A third patient was completely operated by the ret-roperitoneoscopic route.

Median tumor size was 4 cm (range 1.5–12). Medianduration of procedure was 80 min (range 60–360). Medianpostoperative stay was 4 days (range 2–13). Postoperativecomplications were two pleural effusions and one basilarisartery thrombosis 2 weeks after surgery. One patient oper-

ated for a left pheochromocytoma and a 12-cm-diameterupper pole renal cyst had to be reoperated 12 h later forbleeding in the retroperitoneal space. Blood oozing wasfound and controlled laparoscopically. This patient was theonly one who required blood transfusion.

Median length of follow-up was 9 months (2–38months). One patient had a radical left nephrectomy becauseof lymph node recurrence in the hilum of the kidney from anadenocarcinoma of the lung. (Adrenalectomy had been per-formed 4 months before for a unique left adrenal metastasisfrom lung adenocarcinoma.) Another patient operated for aunilateral pheochromocytoma is demonstrating persistenceof elevated blood pressure and abnormal catecholaminelevel, related to a contralateral adrenal hyperplasia, that wasnot demonstrated despite appropriate preoperative imagingtechniques (i.e., CT scan and MIBG scintigraphy).

Discussion

The actual results of the BGES multicentric study show thatvideoscopic surgery of the adrenal glands can safely beperformed (success rate 96%). However, such proceduresshould be performed by surgeons who are already trained invideoendoscopic surgery and preferably well versed also inthe techniques of open adrenalectomy for endocrine disor-ders. The actual results compared also favorably with apreliminary report on the first 16 patients from the BGES(success rate was 88%) [4].

Performance of endoscopic or open adrenalectomy forendocrine disorders, especially pheochromocytoma, re-quires a complete preoperative endocrine and hemodynamicworkup. It also supposes close collaboration with the anes-thesiology and endocrinology teams, as well as preparationof the patients, if indicated, with antihypertensive medica-tions until the day of operation.

Modern imaging techniques, particularly CT scan, arereliable to precisely localize and define the adrenal lesions(i.e., unilateral or bilateral, lesion diameter, and extraadre-nal pheochromocytoma). In this BGES experience all pa-tients had a CT scan performed preoperatively. MIBG scin-tigraphy was also performed for patients suspected of hav-ing pheochromocytoma [13]. In fact, modern imaginginstruments probably explore the adrenal and extraadrenallesions more completely than the eyes and/or hands of thesurgeon. Consequently, in many cases, the surgical ap-proach can be direct and unilateral instead of what was thepast practice—complete surgical exploration of the abdomi-nal cavity, including visualization of both adrenal glandsand surgical search for potential extraadrenal localization. Amore selective approach elected on the basis of preoperativeimaging techniques reduces the incidence of morbidity re-lated to wide transperitoneal, retroperitoneal, or thoracoab-dominal approaches. It is therefore reasonable to wonderwhether the videoscopic approach could even further reducethe morbidity of adrenal surgery while increasing the com-fort for the patients.

So far our results demonstrate that videoendoscopicadrenal surgery performed—even sporadically—by sur-geons experienced in laparoscopic surgery is as safe as theopen approach, provided those surgeons are also familiarwith the rules and potential drawbacks of adrenal surgery.

Table 1. Indications for endoscopic adrenalectomy

Indication No. of patients

Pheochromocytoma 17Hyperaldosteronism 15Cushing’s adenoma 5Cushing’s disease (bilateral) 2DHEAS and cortisol hypersecretion 3Metastasis 2Nonfunctional adenoma 7ACTH-secreting metastases of thymoma (bilateral) 1Total 52

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The fact that only one patient required transfusion is anobjective testimonial that the videoendoscopic approachmeets several requisites for safety.

The value of removal of metastatic lesions within theadrenal gland is controversial. Despite the fact that in ourearly experience such metastatic lesions were removed, wethink that this indication cannot be justified. The same re-striction can be made for removal, whether endoscopicallyor by open surgery, of adrenal incidentalomas. In a recentstudy [11], criteria have been recommended for removal ofadrenal incidentalomas at high risk for malignancy: (1) di-ameter larger than 4 cm or increase in size at any reevalu-ation; (2) CT-scan picture of intratumoral necrosis, hemor-rhage, or irregular margins; and (3) high DHEAS levels.Adhering to these criteria allowed us to obtain a high inci-dence of clear-cut endocrine indications for adrenalecto-my—i.e., pheochromocytoma, Conn and Cushing syn-dromes, and elevated DHEAS represent 81% of the case-load. The remaining 19% of rather debatable indications inthe current series is low compared with other series [5].

Further studies are compulsory before any definite con-clusion can be drawn concerning long-term results of vid-eoendoscopic adrenalectomy and complete cure of endo-crine disorders by this mini-invasive surgical approach.More comparative data are also required to conclude thatendoscopic adrenalectomy allows decreased postoperativestay and/or reduced postoperative analgesic requirement. Inthis series, five patients presenting multiple endocrine neo-plasia syndrome had sustained in the past a contralateraladrenalectomy by open surgery. Concerning postoperativepain, they acted as their own control and unanimously de-clared that the endoscopic approach was far more comfort-able. On the other hand, postoperative stay longer than 1week in these patients was related to the initiation of hor-monal substitution treatment after bilateral adrenalectomy.

In conclusion, minimal access adrenalectomy does notmean minimization of surgical or anesthesiological risks. Itmay only portend better postoperative comfort for the pa-tient if the videoendoscopic surgeon is competent and skill-ful enough to successfully complete the operation in a rea-sonable length of operative time.

References

1. Brunt LM, Molmenti EP, Kerbl K, Soper NJ, Stone AM, Clayman RV(1993) Retroperitoneal endoscopic adrenalectomy: an experimentalstudy. Surg Laparosc Endosc 3: 300–306

2. Clayman RV, Kavoussi LR, Mc Dougall EM, Soper NJ, FigenshauRS, Chandhoke PS, Albala DM (1992) Laparoscopic nephrectomy: areview of 16 cases. Surg Laparosc Endosc 2: 29–34

3. de Cannie`re L, Lorge F, Rosie`re A, Joucken K, Michel L (1995) Fromlaparoscopic training on an animal model to retroperitoneoscopic orcoelioscopic adrenal and renal surgery in human. Surg Endosc 9: 679–701

4. de Canniere L, Michel LA, Hamoir E, Hubens G, Meurisse M, Squif-flet JP, Urban P, Vereecken L (1996) Videoscopic adrenalectomy:multicentric study from the Belgian Group for Endoscopic Surgery. IntSurg 81: 6–8

5. Gagner M (1996) Laparoscopic adrenalectomy. Surg Clin North Am76: 523–537

6. Gagner M, Lacroix A, Bolte E (1992) Laparoscopic adrenalectomy inCushing’s syndrome and pheochromocytoma. N Engl J Med 327: 1033

7. Gagner M, Lacroix A, Prinz RA, Bolte E, Albala D, Potvin C, Hamet

P, Kuchel O, Querin S, Pomp A (1993) Early experience with lapa-roscopic approach for adrenalectomy. Surgery 114: 1120–1124

8. Gaur DD, Agarwal DK, Purohit KC (1993) Retroperitoneal laparo-scopic nephrectomy: initial case report. J Urol 150: 1255

9. Heintz A, Junginger T, Bo¨ttger T (1995) Retroperitoneal endoscopicadrenalectomy. Br J Surg 82: 215

10. Kerbl K, Figenshau RS, Clayman RV, Chandhoke PS, Kavoussi LR,Albala DM, Stone AM (1993) Retroperitoneal laparoscopic nephrec-tomy: laboratory and clinical experience. J Endourol 7: 23–26

11. Osella G, Terzolo M, Borretta G, Magro G, Ali A, Piovesan A, PacottiP, Angeli A (1994) Endocrine evaluation of incidentally discoveredadrenal masses (Incidentalomas) J Clin Endocrinol Metab 79: 1532–1539

12. Pertsemlidis D (1995) Minimal-access versus open adrenalectomy.Surg Endosc 9: 384–386

13. Proye CA, Huart JY, Cuvillier XD, Assez NM, Gambardella B, Car-naille BM (1993) Safety of the posterior approach in adrenal surgery:experience in 105 cases. Surgery 114: 1126–1131

14. Stoker ME, Patwardhan N, Maini BS (1995) Laparoscopic adrenalsurgery. Surg Endosc 9: 387–391

15. Vanitallie TB, Woteki CE (1987) Who gets fat? In: Bender AE,Brooks LJ (eds) Body weight control. Churchill Livingstone, Edin-burgh, pp 39–52

Discussion

Dr. Roll: Which endoscopic approach do you think iseasier—the transabdominal or retroperitoneal?

Dr. Michel: Well, actually the three first cases were doneretroperitoneally, and I don’t recommend that approach.The retroperitoneal approach doesn’t improve the post op-erative recovery, but it does present more difficulties for thesurgeon, at least I think so. Out of 52 cases 49 were donetransperitoneally.

Dr. Siperstein:We’ve actually published a comparative se-ries where we utilized both the lateral and retroperitoneallaparoscopic approach for dealing with tumors. Our currentphilosophy is that for small tumors, less than 4 cm, it isprobably easier and faster to remove these via the retroper-itoneal approach, given that you’ve had experience doingthese procedures transabdominally before that.

Dr. Michel: I agree. The three cases we did retroperitoneallywere for small lesions. However, when you have to dealwith a big pheochromocytoma, I think you are better offusing the transperitoneal approach. Anyway, if you startretroperitoneally and if you have any trouble, because, forinstance, you tear the peritoneum, it’s very easy to convertto a transperitoneal approach. You don’t lose time. Youdon’t have to change the position of the patient. All thework that has been done retroperitoneally will help youwhen you convert to a transperitoneal approach. For thesethree cases we established retropneumoperitoneum by directpuncture without any control. Did you use ultrasonographyto place the Veress needle in the retroperitoneal space?

Dr. Siperstein:Our technique for entering the retroperito-neal space, with the patient in the prone jackknife positionis, to ultrasound through the back, to outline the kidneysposition so we know the relationship of the Gerota’s spaceto the twelfth rib, and then we use a direct viewing trocar,the so called Opti-View trocar, to enter Gerota’s space un-der direct vision, and then with balloon dissection createthat space. We found that to be a very safe and reproducibletechnique. I would not advocate entering that space withanything sharp.

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Final score in laparoscopic cholecystectomy

Cholangiogram 1207, no cholangiogram 116

T. M. Khalili, 1 E. H. Phillips,1 G. Berci,1 B. J. Carroll, 1 J. Gabbay,1 J. R. Hiatt1,2

1 Division of General Surgery, Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Boulevard,Los Angeles, CA 90048, USA2 Department of Surgery, UCLA School of Medicine, Los Angeles, CA, USA

Received: 3 April 1997/Accepted: 10 June 1997

AbstractBackground:The role of intraoperative fluorocholangiog-raphy (IOC) in laparoscopic cholecystectomy (LC) is con-troversial. We evaluated the use of IOC at an institutionwhere the study is performed routinely.Methods:Records of all patients undergoing LC during a3-year period ending January 1, 1996 were reviewed.Results:A total of 1207 patients received IOC, whereas 116patients did not. IOC findings were categorized as follows:normal, 1016 cases (84%); CBD stone, 149 cases (12.3%);anomalies, 23 cases (1.9%); duodenal diverticula, 10 cases(0.8%); ductal strictures, four cases (0.3%); and CBD di-verticula, 5 cases (0.4%). In the 116 patients who did notreceive IOC, 35 of the procedures could not be performed,whereas 81 were not attempted. Of the 149 IOC that showedCBD stones, two were false positives. Anomalies includedaccessory right hepatic ducts (11 cases), cystic ducts joiningthe right hepatic duct (seven cases), and abnormal cysticduct entries (five cases). Duct injuries occurred in 5 cases(0.4%), three before and two after IOC. Four injuries wereminor; IOC prevented CBD transection.Conclusions:Routine IOC is feasible, safe, accurate, andprovides critical information of immediate use during LC.By treating ductal stones at operation and identifying pa-tients without CBD stones, IOC minimizes need for post-operative studies, including endoscopic retrograde cholan-giography (ERC).

Key words: Laparoscopy — Laparoscopic cholecystecto-my — Common bile duct — Cholangiography

Over 60 years have passed since Mirizzi [24] first recom-mended routine intraoperative cholangiography during cho-lecystectomy. The purported advantages of cholangiogra-phy in Mirizzi’s day included identification of common bileduct (CBD) stones and reductions in negative duct explo-rations and ductal injuries. Later authors advocated a selec-tive approach, arguing that cholangiography added expense,introduced a risk of iatrogenic injury, and might lead tounnecessary common bile duct explorations; indications foroperative cholangiography (or for common bile duct explo-ration) were diligently memorized by generations of medi-cal students. Laparoscopic cholecystectomy has reignitedthe debate. The work of Berci et al. [4, 26], showing thatintraoperative cholangiography was feasible, safe, andwould detect a significant number of common bile ductstones and injuries, led to ade factoinstitutional policy ofattempted cholangiography in all patients. The present studywas undertaken to evaluate the use of this routine procedure.


We performed a retrospective review of all patients undergoing laparo-scopic cholecystectomy (LC) during the 3-year period ending January 1,1996. CBD stones were classified as suspected or unsuspected based uponhistory, liver chemistries, and ultrasonography. The technique of intraop-erative fluorocholangiography (IOC) has been described previously [5]. Allcholangiograms were interpreted initially by the operating surgeon in con-sultation with a radiologist, and final IOC readings were performed inde-pendently by an attending radiologist. Based on the final reading, IOC wereclassified as normal (free flow of contrast into duodenum, visualization ofright and left hepatic ducts, and absence of filling defects) or as showingCBD stones, ductal anomalies, duodenal diverticula, ductal diverticula, orductal strictures. Ductal anomalies included accessory ducts or abnormalentry of the cystic duct into the CBD; short cystic duct was not consideredan anomaly. The charts of all patients with abnormal IOC interpretationswere reviewed. All patients with common bile duct injuries were identified.

Results

The study group included 1323 patients, of whom 1207(91%) underwent IOC. Among the 116 (9%) patients whodid not receive an IOC, the procedure was not attempted in


Correspondence to:J. R. Hiatt

Surg Endosc (1997) 11: 1095–1098

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81 cases; thus, IOC was completed successfully in 97% ofpatients in whom it was attempted. In 1016 patients (84%),IOC was interpreted as normal. Characteristics of the patientgroups are shown in Table 1.

The most common abnormality was the presence ofCBD stones, which were seen in 149 of the patients (12.3%)who underwent IOC. These stones were unsuspected in 95(8%) and suspected in 54, based upon history, abnormalliver chemistries, or preoperative ultrasonography. Twocholangiograms were falsely positive (1.3%). Upon identi-fication of choledocholithiasis, laparoscopic CBD explora-tion was performed in 101 patients (8%); the remainder ofthe CBD stones were treated with postoperative endoscopictechniques, open explorations, or expectant management.

Ductal anomalies occurred in 23 patients (1.9%). Themost common anomaly was an accessory right hepatic duct(11 patients). The cystic duct joined the right hepatic duct inseven patients. Posterior or medial insertion of the cysticduct into the CBD was seen in five patients.

Duodenal diverticula were found in 10 patients (0.8%).The diverticulum was located in the periampullary region innine of the patients and in the second portion of the duo-denum in one. CBD diverticula, all in the distal duct, wereseen in five patients (0.4%). Strictures of the distal CBDwere observed in four patients (0.3%).

Common bile duct injuries occurred in five patients(0.4%). All occurred in patients who had undergone IOC;there were no known injuries in patients who did not receiveIOC (p 4 0.48). In two patients, the common bile duct wasmistaken for the cystic duct, and a choledochotomy wasmade to perform the cholangiogram. The error was recog-nized on the IOC, and CBD transection or excision wasavoided. Ductal injury occurred during common bile ductexploration, after IOC, in two patients. All of these patientsunderwent primary repair of the injury. The final patient hadMirizzi’s syndrome and required a choledochojejunostomyto reconstruct the bile duct.

The cost of an IOC was $300. This figure includes alloperative costs and is exclusive of professional fees.

Discussion

Collected series are summarized in Table 2. Advocates ofroutine cholangiography have argued that the procedure de-fines anatomy, demonstrates suspected and unsuspectedCBD stones, decreases the risk of retained stones, prevents

or decreases the magnitude of injury, and diminishes theneed for postoperative endoscopic retrograde cholangiogra-phy (ERC) for evaluation of pain syndromes. Opponentscontend that the low incidence of missed stones, occasionalfalse positives, increased cost, risk of iatrogenic injury, andwidespread availability of postoperative ERC and endo-scopic sphincterotomy (ES) make the procedure unneces-sary.

The experience reported here showed that routine IOCwas feasible (it was performed successfully in 97% of casesin which it was attempted), and safe (there were neitheriatrogenic injuries nor any instances of post-IOC pancreati-tis). CBD stones were unsuspected in 64% of patients inwhom they were found, allowing treatment during the pri-mary operation using laparoscopic techniques. Ductal inju-ries, which occurred in five patients, were identified by IOCin two cases, thus limiting their severity. All were treatedduring the first operation. In two cases where the commonduct was mistaken for the cystic duct and cannulated forIOC, the error was recognized on IOC, and CBD transectionor excision was avoided. Collected experiences with IOCduring LC are compared in Table 3.

Detection of unsuspected common bile duct stones isone of the major benefits of routine IOC. Proponents ofselective IOC have argued that a detailed history and liverchemistries will accurately predict CBD stones [1, 15]. Ourexperience and that of others [19] suggest that stones willoften be missed if IOC is omitted. Furthermore, 25–50% ofpatients with common bile duct stones will develop symp-toms and require treatment [17]. Stones found on IOC maybe treated using laparoscopic transcystic common bile ductexploration (LTCBE) at the primary operation [3, 16]; thisavoids the expense, morbidity, and uncertain long-term ef-ficacy of ERC/ES. In a recent review of patients undergoingES, Bergman [6] reported recurrent CBD stones in 13% andCBD stenosis in 9%, demonstrating that ES has significantlate complications.

Ductal injuries have occurred with increased frequencyin the laparoscopic era [10, 25, 31]. The most commoninjury occurs when the common bile duct is mistaken for thecystic duct. Moossa and others [25, 31] have reported that amajority of patients with CBD injuries did not undergocholangiography at the primary operation. If a choledo-chotomy is made to obtain an IOC, the injury is readilyidentified and repaired primarily [7]; this is in contrast to theinjury created when IOC is not obtained, the common bileduct is transected and excised, and the injury is recognizedwith the development of jaundice, cholangitis, or a similarseptic complication [7, 25].

A frequent argument against routine IOC has alwaysbeen the issue of cost-effectiveness, considering increasedoperative time and charges for the procedure and its inter-pretation. The argument is erroneous, since the lifetime costof treatment for a major CBD injury exceeds $300,000 [28].This figure dwarfs the charges for routine IOC, even if wewere to ignore the value of the abnormal cholangiogramsand to assume that the normal ones were unnecessary.

The experience reported here is of particular relevanceto the ‘‘routine’’ laparoscopic cholecystectomy, where thereis no evidence of CBD stones, acute inflammation, or othercomplicating factors. The surgeon may reason that ductalstones, if found intraoperatively, require extraction by a

Table 1. Characteristics of patients

n (%)Age, (yr)(range)

Gender(% F)

Cholangiogram 1207 55 (11–99) 67Normal 1016 (84) 54 (11–97) 67Abnormal 191 (16) 61 (19–99) 69

Common duct stone 149 (12.3) 61 (19–99) 69Anomaly 23 (1.9) 49 (22–82) 74Duodenal diverticulum 10 (0.8) 79 (68–93) 70Ductal stricture 4 (0.3) 68 (50–92) 57Ductal diverticulum 5 (0.4) 61 (43–78) 60

No cholangiogram 116 51 (13–85) 74Totals 1323 55 (11–99) 68

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technically challenging and often unavailable modality(LTCBDE); if found postoperatively, they are easily treatedwith ERC/ES by his gastroenterologic colleague. The sur-geon thus surrenders his right to treat this portion of thebiliary tract despite the inherent superiority and safety ofCBD stone treatment during the initial operation and thelikelihood of evolving technology that will make LTCBDEeasier and more applicable. Once lost, the common duct willnot be regained, and 100 years of work by surgeons willhave been squandered.

In summary, routine IOC during LC is feasible, safe,accurate, and provides critical information of immediate useduring laparoscopic cholecystectomy. By treating ductalstones at operation, identifying patients without commonbile duct stones, and defining anatomic variations, IOCminimizes the need for postoperative studies, includingERC.

References

1. Barkun AN, Barkun JS, Fried FM, Ghitulescu G, Steinmetz O, PhamC, Meakins JL, Goresky CA (1994) Useful predictors of bile ductstones in patients undergoing laparoscopic cholecystectomy. Ann Surg220: 32–39

2. Barkun JS, Fried GM, Barkun AN, Sigman HH, Hinchey EJ, GarzonJ, Wexler MJ, Meakins JL (1993) Cholecystectomy without operativecholangiography. Ann Surg 218: 371–379

3. Berci G, Morgestern L (1994) Laparoscopic management of commonbile duct stones: a multi-institutional SAGES study. Surg Endosc 8:1168–1175

4. Berci G, Sackier JM, Paz-Partlow M (1991) Routine or selected in-traoperative cholangiography during laparoscopic cholecystectomy.Am J Surg 161: 355–360

5. Berci G, Shore JM, Hamlin JA, Morgenstern L (1975) Operative fluo-roscopy and cholangiography. Am J Surg 135: 32–35

6. Bergman JJGHM, Mey S, Rauws EAJ, Tijssen JGP, Gouma DJ, Tyt-gat GNJ, Huibregtse K (1996) Long term follow-up after endoscopic

sphincterotomy for bile duct stones in patients younger than 60 yearsof age. Gastrointest Endosc 44: 643–649

7. Carrol BJ, Friedman RL, Liberman MA, Phillips EH (1996) Routinecholangiography reduces sequelae of common bile duct injuries. SurgEndosc 10: 1194–1197

8. Carrol BJ, Phillips EH, Rosenthal R, Gleischman S, Bray JF (1996)One hundred consecutive laparoscopic cholangiograms: results andconclusion. Surg Endosc 10: 319–323

9. Clair DG, Carr-Locke DL, Becker JM, Brooks DC (1993) Routinecholangiography is not warranted during laparoscopic cholecystecto-my. Arch Surg 128: 551–555

10. Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD,Baker ME, Newman GE, Cotton PB, Meyers WC (1992) Mechanismsof major biliary injury during laparoscopic cholecystectomy. Ann Surg215: 196–202

11. Flowers JL, Zucker KA, Graham SM, Scovill WA, Imbembo AL,Baily RW (1992) Laparoscopic cholangiography: results and indica-tions. Ann Surg 215: 209–216

12. Ganey JB, Johnson PA, Prillaman PE, McSwain GR (1986) Chole-cystectomy: clinical experience with a large series. Am J Surg 151:352–357

13. Gerber A, Apt MK (1982) The case against routine operative cholan-giography. Am J Surg 143: 734–736

14. Gregg RO (1988) The case for selective cholangiography. Am J Surg155: 540–544

15. Hauer-Jensen M, Karssen R, Nygaard K, Solhein K, Amlie E, HavigO, Viddal KO (1985) Predictive ability of choledocholithiasis indica-tors. Ann Surg 202: 64–68

16. Hunter JG, Soper NJ (1992) Laparoscopic management of commonbile duct stones. Surg Clin North Am 72: 1077–1097

17. Johnson A, Hosking S (1987) Appraisal of the management of com-mon bile duct stones. Br J Surg 74: 555–560

18. Kakos GS, Tompkins RK, Turnipseed W, Zollinger RM (1972) Op-erative cholangiography during routine cholecystectomy. Arch Surg104: 484–488

19. Kitahama A, Derstein MD, Overby JL, Kappelman MD, Webb WR(1986) Routine intraoperative cholangiogram. Surg Gynecol Obstet162: 317–322

20. Koo KP, Traverso LW (1996) Do preoperative indicators predict thepresence of common bile duct stones during laparoscopic cholecys-tectomy? Am J Surg 171: 495–499

21. Korman J, Cosgrove J, Furman M, Nathan I, Cohen J (1996) The role

Table 2. Collected series

Cholangiography ApproachNo. ofseries References

No. ofpatients

Cholangiogram

No. attempted (%)a No. successful (%)a

Routine Open 8 18, 19, 26, 27, 30, 33, 34, 35 3040 2895 (95.5) 2821 (92.8)Laparoscopic 8 4, 11, 22, 28, 29, 32, 36 2378 2351 (98.9) 2163 (91.0)

Selective Open 5 12, 13, 14, 23, 38 5255 ND 977 (18.6)Laparoscopic 4 2, 9, 21, 37 2015 ND 387 (19.2)

a Percentages exclude series [16, 28] for which numbers of cholangiograms were not given

Table 3. Intraoperative fluorocholangiography in laparoscopic cholecystectomy

Author (ref.) YearNo. ofpatients CBD stones LTCBDE Anomalies CBD injuries

% % % %Phillips et al. (29) 1990 58 10.7 1.8 5.9 1.7Sackier et al. (32) 1991 516 7.5 4.5 7.3 0.2Flowers et al. (11) 1992 165 4.4 0 1.1 0.3Traverso et al. (36) 1994 624 5.1 1.9 39 0.3Lezoche et al. (22) 1994 500 6.1 ND 2.3 0Carrol et al. (8) 1996 100 15.0 15 6.0 0Current study 1997 1323 12.3 8.3 1.9 0.4

CBD, common bile duct; LTCBDE, laparoscopic transcystic common bile duct exploration

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of endoscopic retrograde cholangiopancreatography and cholangiog-raphy in the laparoscopic era. Ann Surg 223: 212–216

22. Lezoche E, Paganini A, Guerrieri M, Carlei F, Lomanto D, Sottili M,Nardovino M (1994) Technique and results of routine dynamic chol-angiography during 528 consecutive laparoscopic cholecystectomies.Surg Endosc 8: 1443–1447

23. Mansberger JA, Davis JB, Scarborough C, Bowden TA (1988) Selec-tive intraoperative cholangiography: a case for its use on an anatomicbasis. Am Surg 54: 31–33

24. Mirizzi PL (1937) Operative cholangiography. Surg Gynecol Obstet65: 702–710

25. Moossa AR, Easter DW, Sonnenberg EV, Casola G, D’Agostino H(1992) Laparoscopic injuries to the bile duct: a cause for concern. AnnSurg 215: 203–208

26. Morgenstern L, Wong L, Berci G (1992) Twelve hundred open cho-lecystectomies before the laparoscopic era: a standard for comparison.Arch Surg 127: 400–403

27. Pagana TJ, Stahlgren LH (1980) Indications and accuracy of operativecholangiography. Arch Surg 115: 1214–1215

28. Phillips EH (1993) Routine versus selective intraoperative cholangi-ography. Am J Surg 165: 505–507

29. Phillips EH, Berci G, Carroll B, Daykhovsky L, Sackier J, Paz-PartlowM (1990) The importance of intraoperative cholangiography duringlaparoscopic cholecystectomy. Am Surg 12: 792–795

30. Rolfsmeyer ES, Bubrick MP, Kollitz PR, Onstad GR, Hitchcock CR(1982) The value of operative cholangiography. Surg Gynecol Obstet154: 369–371

31. Rossi RL, Schimer WJ, Braasch JW, Sander LB (1992) Laparoscopicbile duct injures: risk factors, recognition, and repair. Arch Surg 127:596–602

32. Sackier JM, Berci G, Phillips E, Carroll B, Shapiro S, Paz-Partlow M(1991) The role of cholangiography in laparoscopic cholecystectomy.Arch Surg 126: 1021–1026

33. Saltzstein EC, Evani SV, Mann RW (1973) Routine operative chol-angiography: analysis of 506 consecutive cholecystectomies. ArchSurg 107: 289–291

34. Shively EH, Wierman TJ, Adams AL, Romines RB, Garrison RN(1990) Operative cholangiography. Am J Surg 159: 380–384

35. Thurston OG (1974) Nonroutine operative cholangiography. ArchSurg 108: 512–513

36. Traverso LW, Hauptmann EH, Lynge DC (1994) Routine intraopera-tive cholangiography and its contribution to the selective cholangiog-rapher. Am J Surg 167: 464–468

37. Voyles CR, Sanders DL, Hogan R (1994) Common bile duct evalua-tion in the era of laparoscopic cholecystectomy. Ann Surg 219: 744–752

38. Wilson TG, Hall JC, Watts J (1986) Is operative cholangiographyalways necessary? Br J Surg 73: 637–640

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Laparoscopic fundoplication to enhance pulmonary function inchildren with severe reactive airway disease and gastroesopheagalreflux disease

S. S. Rothenberg, D. Bratton, G. Larsen, R. Deterding, H. Milgrom, S. Brugman, M. Boguniewicz, S. Copenhaver,C. White, J. Wagener, L. Fan, J. Chang, T. Stathos

National Jewish Center for Immunology and Respiratory Medicine, The Children’s Hospital, Columbia Presbyterian/St Luke’s Medical Center forChildren, Denver, CO, 80218 USA

Received: 25 March 1997/Accepted: 5 July 1997

AbstractBackground:The relationship between severe reactive air-way disease (RAD) and gastroesophageal reflux disease(GERD) has been noted but the relationship is poorly un-derstood. This study reports our experience with laparo-scopic fundoplication and it’s effect on the pulmonary statusof children with severe steroid-dependent reactive airwaydisease.Methods:Fifty-six patients with severe steroid-dependentRAD and medically refractory GERD underwent laparo-scopic Nissen fundoplications. Mean age was 7 years andmean weight was 20 kg. All patients had the procedurecompleted successfully laparoscopically with an averageoperative time of 62 min. Average hospital stay was 1.6days.Results:Forty-eight of 56 patients noted significant im-provement in their respiratory symptoms in the first week.Fifty of 56 patients have been weaned off their oral steroidsand four others have had a greater than 50% decrease intheir dose. Sixteen patients had a documented increase intheir FEV1 in the initial postoperative period (avg. 26%).Conclusion: Patients with steroid-dependent RAD andGERD refractory to medical management show improve-ment in their respiratory status following fundoplication andthe majority can be weaned off of their oral steroids. Lap-aroscopic techniques allow this procedure to be performedsafely even in this high-risk group of patients.

Key words: Asthma — Gastroesophageal reflux — Fundo-plication — Children — Laparoscopic

Previous studies have shown that many children with severereactive airway disease (RAD) also have clinically signifi-cant gastroesophageal reflux disease (GERD) [7, 9, 13, 14].However, the interrelationship between these two diseaseprocesses has not been clearly defined. These patients areoften steroid dependent because of their RAD and on highdoses of antireflux medications without adequate control oftheir GERD. This may be in part due to the high intraab-dominal pressures generated by obstructive airway disease,a higher incidence of hiatal hernia, and the use ofb-adrenergic drugs or other asthma medications which mayinhibit the lower esophageal sphincter [11, 12]. What is lessclear is the impact their poorly controlled GERD has ontheir respiratory symptoms. Previous studies have suggestedthat GERD affects the respiratory system in two majorways. One is through direct aspiration and irritation of therespiratory mucosa and bronchial smooth muscle [1, 2]. Thesecond is via a vagal reflex which results in bronchospasmwhen the lower esophagus is irritated by acid [8, 10]. Whilemedical therapy has often proven to be ineffective in con-trolling reflux in these patients, surgical therapy was rarelyrecommended because of concern over how these patientswith significant respiratory compromise would tolerate amajor upper abdominal surgery. This study evaluates theimpact of the surgical correction of proven GERD in pa-tients with severe steroid-dependent RAD using laparoscop-ic techniques.

Methods

From August 1993 to January 1997 some 56 patients with severe steroid-dependent RAD were evaluated and treated for severe GERD unresponsiveto medical management (H2-blockers, cAMP inhibitors, and prokineticagents). Ages ranged from 1 month to 19 years (mean 7 years). Weightranged from 3.0 to 100 kg (mean 20 kg). All patients were on oral steroidsat the time of evaluation and surgery. Doses were weight and age depen-dent but were as high as 3 mg/kg/day of prednisone. All patients were onmultiple inhaler therapy and 30 patients also received inhaled steroids.


Correspondence to:S. S. Rothenberg, 1601 E 19th Avenue, Suite 5200,Denver, CO 80218, USA

Surg Endosc (1997) 11: 1088–1090

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Forty-two of the patients had nocturnal asthma and all had been hospital-ized at least once (range 1–8) for their airway disease in the last year.Reflux was documented by UGI in 42 patients, by bronchial washings in10 (positive for lipid-laden macrophages), and by 24-h pH probe in 48.DeMeester scores [6] ranged from 10 to 146 with a direct associationbetween reflux episodes and increased respiratory symptoms noted in 34patients. All patients underwent a laparoscopic Nissen fundoplication. Thetechnique involved the use of five ports in a standard configuration aspreviously described [16]. Port and instrument size were either 5 mm or 3.4mm depending on the size of the patient. One 10-mm port was placed inpatients over 10 kg to allow for the use of the Harmonic scalpel (EthiconEndosurgery Inc., Cincinnati, Ohio). Eighteen of the 56 patients had theRosetti modification of the Nissen fundoplication [15].

Results

The average operative time for the fundoplication was 62min (range 35–180 min). Twenty-nine patients underwentadditional procedures at the same time including gastros-tomy tube placement (n 4 7), thoracoscopic lung biopsy (n4 3), and assorted other procedures (n 4 9). All patientswere extubated at the end of the procedure and there wereno episodes of significant respiratory compromise in theinitial postoperative period. There were three intraoperativecomplications (5.4%), including one esophageal and onegastric perforation, both repaired laparoscopically. The thirdwas a left pneumothorax which was treated by needle aspi-ration prior to extubation in the operating room withoutfurther sequelae. No procedures were converted to openlaparotomy. There were three postoperative complications(5.4%). These included two gastrostomy site infections andone case of severe dysphagia requiring esophageal dilata-tion. Hospital stay averaged 1.4 days (range 1–4 days) andwas 1.2 days for patients undergoing a Nissen only. Therewas one late complication of a wrap failure at 16 months.This was accompanied by a worsening of the patient’sasthma symptoms. The patient’s symptoms improved with alaparoscopic repair of her fundoplication. Twenty-eight pa-tients were considered old enough to verbalize their ownassessment of their respiratory status postoperatively. Theothers were assessed based on the evaluation of their pri-mary care giver. Forty-eight of 56 patients noted significantsymptomatic improvement in their respiratory status in the1st postoperative week. Fifty-two of 56 have noted symp-tomatic improvement at follow-up 2–41 months postopera-tively (avg. 17 months). This was objectively born out by adecrease in the need for rescue bronchodilator treatments in50 of 56 patients (89%) by greater than 50% in most cases.Forty of 42 patients (95%) have noted a disappearance orsignificant decrease in their nocturnal asthma symptoms.Fifty of 56 patients (85%) have been weaned off their oralsteroids and four of the remaining six have had their dosereduced by greater than 50%. Pre- and postoperative (2–4weeks) pulmonary function tests were available for com-parison in 16 patients. Of note, there was no significantdecrease in pulmonary function immediately following lap-aroscopic fundoplication and in addition FEV1 improvedbetween 8 and 98% (avg. 26%).

Discussion

The relationship between GERD and respiratory disease ininfants and children has been shown to be present in many

forms [9, 14]. Infants often present with severe episodes ofapnea and bradycardia and reflux may play a role in suddeninfant death syndrome. Reflux may also present as recurrentbouts of pneumonia or sinus infections and in some childrencan result in significant failure to thrive. However, the in-teraction between GERD and patients with steroid-dependent RAD remains somewhat unclear. A number ofstudies have attempted to define the relationship but oftenthe findings have been conflicting. A direct relationship wasshown by Larsen et al. in a study of children with severeasthma who had a nocturnal component [5]. They per-formed intraesophageal infusions of normal saline followedby infusion of 0.1 HCl during two periods of the normalsleep cycle. While the saline infusion had no effect, the acidinfusion caused changes in breathing pattern consistent withbronchoconstriction and in some cases caused overt wheez-ing. Several studies have shown that intensive medical man-agement of GERD often fails to have any impact on thepatient’s respiratory status [17]. Shapiro et al. documentedsignificant GERD in 47% of a group of steroid-dependentasthmatics but failed to show an improvement in their air-way disease during a 3-week period of intensive medicaltherapy for their GER. There are numerous other studieswhich suggest a correlation between GER and worseningrespiratory symptoms in a select group of patients with se-vere asthma, but the benefits of antireflux therapy remainunclear [11, 13]. Folgia et al. [7] have suggested that in thissubset of patients, medical therapy may be inadequate andsurgical correction may be more efficacious. They showedthat while only 30% of patients with severe asthma or re-current pneumonia and GERD showed improvement onmedical therapy, over 90% of those who failed medicaltherapy had symptomatic improvement of their respiratorysymptoms following fundoplication. This and other similarstudies suggest that in this subset of patients medicaltherapy may be inadequate in interrupting the reflex path-way between esophageal irritation and bronchoconstrictionbut that surgical correction may act as a more effectivebarrier.

In our study all of the patients had steroid-dependentRAD and had failed medical management of their GERD.Previously these patients might not have been consideredcandidates for fundoplication because of the high morbidityof a major upper abdominal procedure in patients with al-ready-compromised respiratory function and the unclearbenefits of correcting GERD as it relates to RAD. However,the ability to perform the procedure safely laparoscopicallyas shown in both adult and pediatric trials [3, 4, 16] allowedus to be more aggressive in offering surgical correction inthis high-risk group. In this series we have performed 56fundoplications without a postoperative pulmonary compli-cation, and in fact the vast majority of patients noted asignificant symptomatic improvement in their breathing inthe initial postoperative period. This has been documentedin some patients by an improvement in their FEV1.

All the patients have been taken off their antirefluxmedication and over 90% have been weaned off or had asignificant decrease in their steroid dose. There has been amarked decrease in the need for prn bronchodilator treat-ments and nearly all patients have had a significant im-provement in their nocturnal RAD symptoms. Many of thepatients also relate that minor asthma attacks which would

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often progress into severe episodes requiring hospitalizationare now easily controlled with inhaler therapy. While thefollow-up period is not long enough to draw definitive con-clusions, there does seem to be a decreased incidence ofhospitalization.

While the exact relationship between GERD and severeRAD is still unclear, this study suggests that in many casesthere is a direct interaction in the pathophysiology betweenthe two disease processes and that GERD has a significantadverse affect on the severity of RAD. It also appears clearthat in these cases surgical fundoplication is superior to amedical antireflux regime in interrupting this relationship.In addition laparoscopic techniques allow for the proceduresto be performed safely even in this high-risk group of pa-tients.

While this study pertains primarily to children andyoung adults, it is likely that similar benefits might also beobtained in older patients. Those patients with a long historyof RAD and nocturnal asthma as well as childhood historyof failure to thrive or recurrent respiratory infections maywell have clinically silent GERD. Further study and follow-up will be necessary to determine the exact pathways ofinteraction between reflux and bronchospasm and to definethat group of patients who are most likely to benefit fromsurgical correction.

References

1. Barish CF, Wu WC, Castell DO (1985) Respiratory complications ofgastroesophageal reflux. Arch Intern Med 145: 1882–1888

2. Berquest WE, Rachelefsky GS, Kadden M (1981) Gastroesophagealreflux associated with recurrent pneumonia and chronic asthma inchildren. Pediatrics 68: 29–35

3. Collins JB, Georgeson KE, Vincente Y, et al (1995) Comparison ofopen and laparoscopic gastrostomy and fundoplication in 120 patients.J Pediatr Surg 30: 1065–1071

4. Cushieri A, Hunter J, Wolfe B, et al (1993) Multicenter prospectiveevaluation of laparoscopic antireflux surgery. Preliminary report. SurgEndosc 7: 505–510

5. Davis RS, Larsen GL, Granstein MM (1983) Respiratory response tointraesophageal acid infusion in asthmatic children during sleep. J AllClin Immunol 72: 393–398

6. DeMeester TR, Wang CL, Wernly JA, et al. (1980) Technique, indi-cations, and clinical use of 24-hour pH monitoring. J Thorac Cardio-vasc Surg 79: 656–670

7. Folgia RP, Fonkalsrud EW, Ament ME, et al. (1980) Gastroesophagealfundoplication for the management of chronic pulmonary disease inchildren. Am J Surg 140: 72–79

8. Gustafson PM, Kjellman NI, Tibbling L (1990) Bronchial asthma andacid reflux into the distal and proximal esophagus. Arch Dis Child 65:1225–1228

9. Herbst JJ, Hillman BC (1993) Gastroesophageal reflux and respiratorysequelae. In: Pediatric respiratory disease: diagnosis and treatment.WB Saunders, pp 521–532

10. Irwin RS, Curley FJ, French CL (1993) Difficult to control asthma.Contributing factors and systemic management protocols. Chest 103:1662–1669

11. Malfroot A, Dab I (1995) Pathophysiology and mechanism of gastro-esophageal reflux in childhood asthma. Pediatr Pulmonol Suppl 11:55–56

12. Mansfield LE (1989) Gastroesophageal reflux and repiratory disor-ders: a review. Ann Allergy 62: 158–163

13. Martin ME, Grunstein MM, Larsen GL (1982) The relationship ofgastroesophageal reflux to nocturnal wheezing in children withasthma. Ann Allergy 49: 318–322

14. Orenstein SR, Orenstein DM (1988) Gastroesophageal reflux and re-spiratory disease in children. J Pediatr 112: 847–858

15. Rossatti M, Allgower M (1973) Fundoplication for the treatment ofhiatal hernia. Prog Surg 12: 627–630

16. Rothenberg SS. Experience with two hundred and twenty consecutiveNissen fundoplications in infants and children. J Pediatr Surg (in press)

17. Shapiro GG, Christie DC (1979) Gastroesophageal reflux in steroiddependant asthmatic youths. Pediatrics 63: 207–212

Discussion

Dr. Hunter: This may not directly pertain to your asthmat-ics, but one of the things that I’ve been very curious aboutin the pediatric population is that you generally have a largenumber of neurologically impaired children in this group,many of whom have difficulties with vomiting. One of thethings we have seen in the adult population is the para-esophageal herniation that is associated with vomiting. Youdidn’t really show that any of your wraps degraded. If youlook at your whole lap-Nissen experience in children, haveyou had many wraps degrade, especially in the neurologi-cally impaired children—have they had any more difficultywith disruption of the fundoplication?

Dr. Rothenberg: Yes, the total series now is about 250patients up to 18 years of age. There’s been about a 2.5%failure rate, and the majority of them are neurologicallyimpaired patients. Three of these patients developed signifi-cant paraesophageal hernias and herniated the wrap up intothe chest.

Dr. Salky: What is bronchopulmonary dysplasia in relationto adult disease, as most of us are adult surgeons?

Dr. Rothenberg: I think bronchopulmonary dysplasia issomething that develops often in premature infants as aresult of their immature lungs and hyaline membrane dis-ease. They often have an O2 requirement early in life, andbasically have what we call ‘‘twitchy’’ lungs. I think manypatients who have bronchopulmonary disease are the oneswho go on later in life to be classified as having asthma. Thereason I put these patients together is because many of them,as infants, are treated with steroids to help wean them offtheir oxygen. It appears that a fundoplication in these pa-tients who have reflux, documented reflux, tends to helpthese patients, as well, get off their steroids and decreasetheir O2 requirement.

Dr. Peters: I understand that there’s an epidemiologic ex-plosion in childhood asthma. There was a three page dis-sertation on it in theLos Angeles Timesnot too long ago.Does reflux disease have anything to do with what we’reseeing in adults in Barrett’s esophagus, as well, and hasanybody entertained the possibility that that could be refluxdisease?

Dr. Rothenberg: Well, we’ve gotten more and more ag-gressive at looking at these kids. I see a unique population.A lot of patients are referred into a center in Denver calledNational Jewish Hospital, which is a nationally knownasthma center, and they, for years, have known that thesekids all had reflux, but never really thought there was muchof a correlation, and part of it was that, no matter how theytreated them medically, it never got rid of their reflux, andit didn’t seem to make any difference with their asthma. Ithink there’s really a difference in how these kids respond tomedical management or surgical management, and I thinkthey respond much better to a surgical fundoplication. Anypatient with significant asthma I think warrants a work-up tosee if they do have reflux.

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Case reports

Laparoscopically assisted radical sacrococcygectomy

A new operative approach to large sacrococcygeal chordomas

K. C. Conlon,1 P. J. Boland2

1 Gastric and Mixed Tumor Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA2 Orthopedic Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA

Abstract. Laparoscopic rectal mobilization and hypogas-tric arterial isolation were combined with a posterior sacro-coccygectomy for the resection of a large sacrococcygealchordoma in two patients. The laparoscopic procedure asdescribed was uneventful in both cases. There was no post-operative morbidity associated with the laparoscopic proce-dure. The combination of laparoscopic pelvic dissection andradical posterior sacrococcygectomy is safe, effective, on-cologically sound, and should be considered for all patientswith a large proximal sacrococcygeal chordoma.

Key words: Laparoscopy — Chordoma — Sacrum — Coc-cyx

Chordomas are uncommon malignant tumors derived fromremnants of notochordal tissue. They account for approxi-mately 3–4% of all primary bone tumors. Scandinavianstudies have estimated an annual incidence of 0.5 per mil-lion [11, 23]. The sacrococcygeal region is the predominantsite, accounting for 50% of cases [17, 22, 31]. Approxi-mately 35% are situated at the sphenooccipital region; theremaining 15% are distributed along the mobile spine [5, 8,22]. Sacrococcygeal chordomas are twice as common inmales as in females, presenting principally in the sixth andseventh decades of life [2, 14, 17, 24, 26, 31].

They are considered to be slow growing, locally inva-sive tumors, which, particularly in the sacrococcygeal area,can reach a significant size before becoming clinically evi-dent [13, 26]. Surgery is the mainstay of therapy [1, 4,12–15, 19, 26, 28, 30, 31, 33, 34]. For sacrococcygeal chor-domas, complete excision with negative surgical marginsappears to offer the best chance of cure [2, 12, 16, 22].However, this is often difficult to achieve due to the tumorsize, local infiltration, and the surgeon’s desire to preserveneurological function and pelvic stability. The role of adju-

vant chemotherapy and radiotherapy remains controversial[2, 12, 15, 17, 24, 29].

Currently, three basic surgical approaches exist: sequen-tial anterior laparotomy and posterior sacrectomy [30, 31], asynchronous abdominosacral approach [13, 19, 21, 28], or aposterior sacrococcygectomy alone [14, 26]. Both abdomi-nal approaches allow assessment of intraabdominal tumorextension, plus creation of a colostomy, mobilization of theureter, and control of the iliac vessels. However, the result-ant incision and postoperative ileus add to the morbidity ofthe procedure. These are avoided by using a posterior ap-proach alone, particularly for small tumors not extendingabove S-3. For larger lesions extending above S-3, or withan anterior extension into the presacral space, a posteriorapproach alone may compromise tumor clearance and riskuncontrollable hemorrhage from inadvertent damage to theiliac or median sacral vessels [6].

An alternative method of pelvic dissection has recentlybeen developed [25]. Techniques for the laparoscopic mo-bilization of the rectum in benign and malignant diseasehave been reported [9, 10, 18]. These minimal-access sur-gical techniques offer the surgeon the ability to replicateopen surgical dissection with potential reduction in postop-erative morbidity. We were anxious to apply this approachto the treatment of large sacral tumors. This paper details thetechnique developed, and the results obtained, in the firsttwo patients treated with a laparoscopically assisted radicalsacrococcygectomy for malignant chordoma.


Patient 1

The patient, a 66-year-old male Caucasian, presented to our institution witha 6-month history of lower back pain and a buttock mass. There were nogastrointestinal, genitourinary, or neurological symptoms apart from thepain. Clinical examination was normal aside from a palpable left buttockmass. A computerized tomographic (CT) scan of the pelvis revealed a 10× 10 cm mass with destruction of the sacrum and coccyx. Magnetic reso-nance imaging (MRI) demonstrated a large multilobulated mass extendingCorrespondence to:K. C. Conlon

SurgicalEndoscopy


anteriorly into the presacral space but not involving the rectum. Posteriorly,it was noted to extend into the subcutaneous fat and to directly invade theleft gluteus musculature. Direct involvement of the thecal sac was notpresent. A tru-cut biopsy was consistent with a malignant chordoma.

Patient 2

An 80-year-old female presented with a 3-year history of constipation andlow back pain. Three months prior to presentation, she developed perianalnumbness and noticed a right buttock mass. Systems review apart from thepresenting symptoms was negative. In particular, she denied any bowel orbladder incontinence. Karnosky performance status was >90%. Physicalexamination revealed a 15 × 15 cm right buttock mass which was fixed andnontender. On rectal examination a large mass was palpable posteriorly.Aside from diminished perianal sensation, the neurological examinationwas normal. Plain radiographs showed extensive bony destruction of thesacrum. MRI scan demonstrated a 20 × 15 cm sacral tumor extending upto and including the S-2 segment with a large posterior soft-tissue com-ponent invading the gluteus maximus bilaterally and extending into thesubcutaneous tissue on the right (Figs. 1 and 2). There was also a largeanterior intrapelvic component, displacing the rectum anteriorly. An openbiopsy had been performed, which confirmed the diagnosis of malignantchordoma.

Operative technique

Laparoscopy was performed under general anesthesia. The patient wasplaced supine on the operating table, with a small pelvic lift. A warmingblanket was utilized to maintain a normal body temperature. An ‘‘open’’surgical technique for carbon dioxide insufflation was used. A 1-cm sub-umbilical incision was made exposing the abdominal wall fascia. Theperitoneum was opened under direct vision, and a 10/11-mm Hasson-typetrocar was inserted (Endopath, Ethicon Endo-Surgery, Cincinnati, OH).This was attached to a high-flow carbon dioxide insufflator (Karl StorzEndoscopy-America, Inc., Culver City, CA) and the intraabdominal pres-sure was noted. Initial pressure was less than 3 mmHg. Carbon dioxide(CO2) insufflation was commenced through this trocar to an intraabdomi-nal pressure of 14 mmHg. A 30° angled telescope was then inserted and alaparoscopic examination of the peritoneal cavity was performed.

A multiport technique was used. Figure 3 illustrates the placement ofthe operative ports. The surgeon stood on the patient’s right, with monitorsplaced at the level of the pelvis. The patient was then placed in a deepTrendelenburg position, rotated slightly to the left. The small bowel wasexcluded from the pelvis. The sigmoid colon was mobilized in a standard

fashion (Fig. 4). The ureter and iliac vessels were identified. The dissectionwas carried along the lateral pelvic side wall until the hypogastric arterywas exposed. When this was completed a red rubber catheter was broughtthrough the mesentery of the rectum to aid traction. This maneuver freeda port site for other dissecting instruments.

The patient was then rotated toward the left-hand side. The rectum wasretracted anteriorly and to the left by gentle traction on the red rubbercatheter. The peritoneum along the right pelvic side wall was incised in ananalogous manner to the left. The iliac vessels and ureter were exposed.The peritoneal dissection was continued cranially to the bifurcation of theaorta, exposing the sacral promontory and the concavity of the sacrum (Fig.5). A retractor inserted suprapubically aided the retraction of the mesorec-tum from the sacrum, displaying the presacral space. The avascular, areolarplane between the presacral fascia and the mesorectal fascia was identified,and sharp dissection was performed. Meticulous hemostasis is essential forthis portion of the dissection and was easily achieved with electrocautery.The median sacral vessels were clipped and divided at this point. Sharpdissection continued in a plane anterior to the tumor (Fig. 6). Magnificationand the use of the 30° laparoscope greatly facilitated this maneuver. Pos-teriorly, the dissection continued until the tumor was separated from therectum. To complete mobilization of the rectum, dissection was continuedalong both lateral pelvic side walls. The lateral suspensory ligaments weredivided. At this stage the rectum was completely separated from the sa-crum.

The ureters were mobilized laterally for protection. Vessel loops wereplaced around the common iliac arteries bilaterally for emergency vascularcontrol following sacral transection. In the second patient, the hypogastricarteries were ligated in continuity, with nonabsorbable silk sutures. Thelaparoscopic procedure was completed by the placement of 4 × 4 gauzepacks (inserted through a 10-mm port) into the presacral space whichprotected the rectum during sacral transection (Fig. 7).

Carbon dioxide insufflation was discontinued, and the operative portswere removed under direct vision. The fascia of the 10-mm ports wereclosed using absorbable suture. Subcuticular sutures were used for all theport sites and dry dressings were applied.

The patient was then turned into the prone position. A longitudinal skinincision was made, extending from the spinous process of L-4 to the tip ofthe coccyx. Lateral cutaneous flaps were raised. The gluteal muscles weredivided lateral to the tumor. The superior and inferior gluteal vessels weredivided and ligated. The paraspinal muscles were divided at the level of S-1and were dissected subperiosteally to expose the lower lumber and uppersacral laminae. The sciatic notch was identified laterally, and followingidentification of the sciatic nerve, the piriformis muscles were transected.The anococcygeal ligament was divided. The anal canal and lower rectalmobilization was performed by finger dissection, completing the anteriordissection. The sacrotuberous and sacrospinous ligaments were divided. Awide upper sacral laminectomy was performed. The S-1 nerve roots wereidentified and a foraminotomy was performed bilaterally. The distal dural

Fig. 1. Sagittal MRI (T1-weighted image) of patient 2. Demonstrating alarge tumor extending to the upper level of S2.

Fig. 2. Axial MRI of the same patient ([2). Showing anterior, lateral,and posterior extent of the tumor.

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sac was mobilized, doubly ligated, and divided. Using an osteotome thesacrum was amputated between S-1 and S-2. The osteotome was guidedanteriorly with a finger placed anteriorly and superiorly through the sciaticnotch. The S-1 nerve roots were preserved bilaterally. The remaining soft-tissue connections including the levator-ani muscles were divided and thespecimen was excised. Following removal of the specimen, the laparo-scopically inserted packs and vessel loops were removed. A Mersilenemesh was placed in the resultant defect to prevent rectal herniation. Thewound was closed primarily.

Results

The laparoscopic procedure was uneventful in both cases.Blood loss was minimal during the pelvic dissection (est. 25ml/case). Overall estimated blood loss was less than 1,000ml in case 1 and approximately 7,000 ml in the second case.In this latter case, the tumor was enormous and bleedingwas encountered mainly from the bone and epidural vesselsrather than during the soft-tissue dissection.

There were no postoperative complications related to

the laparoscopic procedure. The first patient made an un-eventful recovery; diet commenced on the 2nd postopera-tive day. The second patient developed a small intracerebralhemorrhage postoperatively, resulting in intermittent con-fusion and aphasia which has completely resolved. Enteralfeeding was commenced on the 4th postoperative day.

Pathology of the resected specimens revealed malignantchordoma in both cases. Soft-tissue margins were negativefor tumor; however, in the first case the right ileal bonymargin was found to be microscopically positive for tumor.This patient received postoperative radiotherapy.

Both patients are ambulatory and free of disease at 18months follow-up.

Discussion

It is accepted by most authors that in the absence of meta-static disease, wide local extirpation of the tumor with nega-

<

Fig. 3. Laparoscopic port placement. A 30° telescope is used with thesurgeon standing on the patient’s right-hand side.

Fig. 4. Sigmoid mobilization. The sigmoid colon is retracted to the rightand sharp dissection is commenced along the left lateral abdominal wall.The ureter and iliac vessels are identified.

Fig. 5. Sacral promontory. Dissection is started at the bifurcation of theiliac artery on the right. The sacral promontory is identified and the pre-sacral space is entered.

1120

tive surgical margins offers the best chance for long-term,disease-free survival [1, 4, 12–15, 19, 26, 28, 30, 31, 33,34]. This is performed while maintaining pelvic stabilityand preserving as many of the sacral nerve roots as possibleso as to minimize the resultant neurological disability [30].

Traditionally, an anterior celiotomy was combined in atwo-phase procedure with a radical sacrococcygealectomyfor proximal sacral lesions. This approach enabled the sur-geon to assess the intraabdominal extent of the tumor, mo-bilize and protect the rectum, gain pelvic vascular control,and if required perform either an end- or defunctioning co-lostomy prior to the sacral resection. This technique, whileeffective, required repositioning the patient intraoperatively,was associated with longer operative time, and increasedpostoperative morbidity [30, 31].

A synchronous abdominal and transacral surgical ap-proach was described by Localio and co-workers [19]. Si-multaneous pelvic dissection to obtain rectal mobilizationwith vascular control and posterior dissection for sacral mo-bilization allowed the tumor to be removed en bloc with awide margin of resection. They reported their experiencewith five patients with chordoma, three of whom had theirtumor completely excised. Simpson and colleagues [28] re-cently reported a combined extended ilioinguinal and pos-terior approach in six patients with proximal chordoma. Awide margin of resection was achieved in five patients, allof whom remain disease free at a median follow-up of 30months. An additional six patients with other malignanttumors also underwent this procedure. Overall operativemortality was low (8%), but major wound complicationsoccurred in seven patients (58%).

A posterior approach alone would avoid the morbidityof an anterior or extended incision. MacCarty et al. [20] firstdescribed such an approach for the treatment of sacrococ-cygeal chordomas. More recently, this approach has gainedin popularity. Samson and associates [26] reported 21 cases

treated at the Massachusetts General Hospital between 1972and 1992. All patients underwent a posterior sacrococcy-gectomy, 11 of whom had a resection involving either S1 orS2. Five patients (24%) had a separate exploratory laparot-omy and colostomy formation. Sixteen patients (76%) re-ceived adjuvant radiation therapy. A wide excision wasachieved in ten patients, a wide contaminated excision inone case, a marginal excision in three patients, and an in-tralesional margin obtained in the remaining seven patients.Wound complications were seen in 33% of patients. Anactuarial 5-year disease-free survival of 77% was reported.Gennari and colleagues [12] described eight cases in whicha posterior approach alone was utilized to perform resectionthrough S2. There were no serious intraoperative complica-tions recorded; however, five patients (63%) had local re-currences at a median follow-up of 41 months. While avoid-ing the morbidity of the anterior celiotomy, both these stud-ies illustrate the difficulty in obtaining gross tumorclearance by using a posterior approach alone.

The laparoscopic technique described in this reportcombines the advantages of the anterior celiotomy whileavoiding the morbidity of the abdominal incision. Since theintroduction of laparoscopic cholecystectomy in the late1980s, many endosurgical procedures have been demon-strated to have decreased surgical morbidity and to lead toreduced hospital stay, shorter recovery, and an improvedquality of life. In oncological practice, laparoscopic tech-niques have been proposed for the diagnosis, staging, pal-liation, and treatment of various malignancies [3, 7, 27].

Using a multiport technique, a full examination of theabdomen and pelvis is possible. The pelvic viscera can bedissected away from the tumor sharply, under direct vision.In both our cases, the magnification obtained with the lapa-roscope facilitated mobilization of the rectum from the tu-mor, allowing us to obtain negative soft-tissue pathologicalmargins. If rectal involvement is suspected, division of the

Fig. 6. Pelvic dissection. A Babcock for-ceps is used to retract the rectum, allow-ing dissection in the presacral space. Thetumor is separated from the mesorectumby sharp dissection.

Fig. 7. Placement of gauze packs. Gauzepacks are placed upon completion of theanterior dissection to protect the rectumduring sacral transection.

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bowel and colostomy formation can easily be performedusing laparoscopic techniques. The ureters can be identifiedand mobilized laterally, this is particularly important inlarge tumors with a substantial anterior component such asour second case. Vascular control can also be achieved. Inboth our cases, medial sacral vessels were divided, and theinternal iliac vessels were controlled with vessel loops. Inour second case, we ligated the internal iliac vessels asadvocated by Sung and colleagues [32]. This resulted inminimal hemorrhage during the anterior or soft-tissue dis-section, with most of the blood loss occurring from osteo-porotic bone and epidural vessels.

Not all patients are suitable for the approach describedin this article. Those who are obese or have a history of prioropen-pelvic or gynecologic surgery should be consideredfor an open procedure. In addition, previous pelvic irradia-tion is a relative contraindication due to the obliteration oftissue-planes and to the presence of visceral adhesions,which commonly occur.

In summary, this paper details a novel way to approachlarge sacral chordomas, combining minimal-access surgicaltechniques to mobilize the rectum and obtain pelvic vascu-lar control with a radical posterior sacrococcygectomy. Webelieve that this combination is safe, effective, oncologi-cally sound, and should be considered for all patients withlarge proximal sacrococcygeal chordomas.

Acknowledgment.The authors wish to thank Ms. Christine A. Schaar forthe illustrations in this manuscript. This work was partially supported bythe Milton Ludmar Memorial Fund, the Lillian Wells Foundation, theBernice and Milton Stern Foundation.

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27. Shimi S, Banting S, Cuschieri A (1992) Laparoscopy in the manage-ment of pancreatic cancer: endoscopic cholecystojejunostomy for ad-vanced disease. Br J Surg 79: 317–319

28. Simpson AHRW, Porter A, Davis A, Griffin A, McLeod RS, Bell RS(1995) Cephalad sacral resection with a combined ilioinguinal andposterior approach. J Bone Joint Surg 77: 405–411

29. Spratt JS, Martin AE, McKeown J (1981) Sacral chordoma: a casestudy and review. J Surg Oncol 18: 101–103

30. Stener B, Gunterberg B (1978) High amputation of the sacrum forextirpation of tumors: principles and technique. Spine 3: 351–366

31. Sundaresan N, Huvos AG, Krol G, Lane JM, Brennan M (1987) Sur-gical treatment of spinal chordomas Arch Surg 122: 1479–1482

32. Sung HW, Shu WP, Wang HM, Yuai SY, Tsai YB (1987) Surgicaltreatment of primary tumors of the sacrum. Clin Orthop 215: 91–98

33. Touran T, Frost DB, O’Connell TX (1990) Sacral resection: operativetechnique and outcome. Arch Surg 125: 911–913

34. Xu WP, Song XW, Yue SY, Cai YB, Wu J (1990) Primary sacraltumors and their surgical treatment: a report of 87 cases. Chin Med J103: 879–884

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Laparoscopic colposuspension using mesh reinforcement

R. A. Birken, P. L. Leggett

Houston Northwest Medical Center, 710 FM 1960 West, and Tops Surgical Specialty Hospital, 17080 Red Oak, Houston, TX 77090, USA

Received: 27 January 1997/Accepted 4 June 1997

AbstractBackground:For patients with stress urinary incontinence,surgical reestablishment of the bladder neck has provedamenable to a laparoscopic approach, which shortens hos-pitalization and reduces tissue trauma. The use of meshreinforcement to improve the durability of colposuspensioncan refine this proven procedure even further.Methods:We performed laparoscopic Burch colposuspen-sion on 54 patients with stress urinary incontinence andcompared our results with those of other investigators.Results:All patients reported resolution of incontinencepostoperatively: 83.3% received no supplementary medica-tion while 16.7% took antispasmodic-anticholinergic medi-cations. Two cases required conversion to an open proce-dure. Hospital stay declined from 2.7 days (first quartile) to1.9 days (last quartile) (average, 2.3 days). Complicationswere rare, and in a 28-month follow-up, no reoperationswere required.Conclusion: Laparoscopic Burch colposuspension usingmesh reinforcement provides durable resolution of stressincontinence with low risk of conversion, short hospitaliza-tion, and few complications.

Key words: Burch colposuspension—Colposcopy—Laparoscopic surgery—Stress urinary incontinence—Urethropexy

Stress urinary incontinence is a common problem that af-fects 10 million middle-aged women nationwide and costs$10.3 billion annually to manage [10]. Stress inconti-nence—the involuntary discharge of urine when intraab-dominal pressure increases—occurs when the pressure oflaughing, coughing, or straining pulls on the bladder orificeand opens it, even though the sphincteric mechanism isintact. Lack of anatomic support displaces the bladder neck,making it hypermobile and susceptible to these pressures, aswell as to irritative bladder symptomatology. Correction of

this condition requires reestablishing the bladder neck ana-tomically, ensuring reliable fixation without outlet obstruc-tion.

The surgical approaches include anterior colporrhaphy,sling procedures, colposuspensions and transvaginal needlesuspension procedures [2, 9, 12, 16, 18]. Electrical stimu-lation of the muscles of the pelvic floor has also been em-ployed to improve or cure stress incontinence [15]. In fact,it has been estimated that more than 100 surgical ap-proaches have been described [3]. Of these, the Burch col-posuspension has been called the ‘‘gold standard’’ for blad-der neck suspension. It is one of the most popular and mostsuccessful operative procedures for the surgical resolutionof stress urinary incontinence [11]. Not unlike the variationsevidenced in the broad spectrum of laparoscopic and opensurgical approaches to urinary incontinence resolution,there are variations in the performance of the laparoscopicapplication of the Burch procedure itself. Approaches maybe intraperitoneal or extraperitoneal, and modificationshave included a laparoscopic approach and the use of meshfor urethrovesical reinforcement [9, 17, 20].

Applying laparoscopic technique to the surgical solu-tions for stress urinary incontinence has, as with its otherapplications, reduced tissue trauma, helped eliminate thepain related to wound healing, and decreased the time re-quired for hospitalization and recovery [6, 7]. To evaluatethe clinical effect of laparoscopic Burch colposuspension,we report here our experience with 54 patients with stressurinary incontinence who were treated with the laparoscopicBurch procedure and the use of mesh reinforcement. Wealso compared our experience with that of other investiga-tors using this approach.


All patients suffered from involuntary discharge of urine because of ananatomic displacement of the bladder. A diagnosis of genuine stress uri-nary incontinence was based on physical examination, review of clinicalhistory, and urodynamic studies. After standard preoperative studies werecompleted and reviewed, each patient was scheduled for surgery. At sur-gery, patients were placed in a modified lithotomy position at a steepTrendelenburg angle with plantar surfaces of the feet apposed. Genitouri-nary operative sites were swabbed with Betadine solutions, dried, anddraped.

Correspondence to:R. A. Birken, 17070 Red Oak Dr., Suite 201-A, Hous-ton, TX 77090, USA

Surg Endosc (1997) 11: 1111–1114

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With the patient under general anesthesia, we place a 10- or 15-mlFoley catheter in the bladder to drain it during surgery. On the midline, 1to 2 cm below the umbilicus, we insert a Veress needle and insufflate theperitoneum to∼15 mm Hg. After making three incisions for trocars, weplace 2-0 Vicryl pursestring sutures in each before inserting the trocars.These are left untied, yet ready for closure. Then we placed the threetrocars through small incisions: a 10-mm trocar at the subumbilical site andtwo 12-mm trocars, one on the umbilical plane 10 cm left of the umbilicusand another in the lower left quadrant.

Using the subumbilical port for the laparoscope, we identify the bladderand the obliterated umbilical ligaments. We make bilateral transverse in-cisions in the peritoneum, about 2 cm above the bladder, between the roundligaments and the umbilical ligaments.

To access the retropubic space and expose Cooper’s ligament, wedissect the tissue, dividing the layers and exposing the retropubic space(Fig. 1). With the ligament exposed, we perform the procedure. Electro-cautery controls bleeding, ensuring good visualization. With the neck ofthe bladder and the endopelvic fascia in view, the surgeon inserts a fingerwithin the vaginal vault to assess the defect tactually and to maneuver thebladder neck into proper position. Depending on the degree of displace-ment, we will use one or two 1 × 3–cm strips of Prolene mesh (of the typetypically employed in hernia repair) to suspend the neck from Cooper’sligament. Typically, two strips are placed, each one lengthwise on eachside of the neck, extending in spokelike fashion from the paravaginal fascia2 cm away from the base of the neck outward to the ligament. Five to eighttitanium staples fired from an EMS Disposable Endostapler hold the meshin place. Pushing up against the bladder neck with a finger through the topof the vaginal vault relieves the tension of the defect, properly positions thebladder neck for placement, and assists in controlling stapling. Sides arecompleted one at a time (Figs. 2 and 3). The mesh and endostapler areproducts of Ethicon (Sommerville, NJ, U.S.A.).

To ensure an intact bladder free of injury, we fill it with methylene bluesolution. This evaluation concludes the suspension procedure. We thenperform culdoplasty, if necessary, with the use of 2-0 Ethibond suture (Fig.4). The peritoneum is closed with a pursestring suture of 2-0 Vicryl on eachside. The sutures placed early in the operative procedure are tied when thetrocars are removed, providing good fascial closure and excellent control ofhemostasis. We then give indigo carmine dye intravenously and performcystoscopy to evaluate ureteral function.

Results

Fifty-four women, 32 to 77 years of age, underwent lapa-roscopic Burch colposuspension between June 1994 andMay 1996.

All patients reported resolution of their incontinence infollow-up visits 2–6 weeks after surgery; 45 (83.3%) re-ceived no supplementary medication and nine (16.7%) tookantispasmodic-anticholinergic medication, such as hyoscya-mine sulfate (e.g., Levsinex or Levbid). Follow-up extended

from 5 to 28 months (average, 14 months), and no patienthas required reoperation.

In addition to colposuspension, 41 patients (75.9%) un-derwent culdoplasty, 15 (27.8%) vaginal hysterectomy, 13(24.1%) bilateral salpingo-oophorectomy, and five (9.3%)colporrhaphy. There were two conversions to a traditional

Fig. 1. The retropubic space is exposed by dissection. Fig. 2. The mesh, stapled to Cooper’s ligament, reinforces suspension ofthe bladder neck.

Fig. 3. The suspension is completed on the left side.

Fig. 4. In culdoplasty, after the ligaments are approximated and the suturesare tied extracorporeally, the second ligature is placed to complete theprocedure.

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open procedure because of extensive pelvic adhesions thatprevented adequate exposure endoscopically.

Overall, average hospital stay was 2.3 days (range, 1–5days). Dividing the patients in quartiles showed that theaverage hospital stay declined over time∼30%, from 2.7days in the first quartile to 1.9 days in the fourth. Thepercentage of patients requiring medication for completeresolution also declined from 30.8% in the first quartile to14.2% in the fourth after dropping to a low of 7.7% in thethird quartile.

Postoperative complications were few: one patient ex-perienced postoperative bladder retention, but it quickly re-solved, and postoperative urinary tract infections were rare.None of our patients developed significant detrusor insta-bility postoperatively.

Discussion

Stress incontinence in women, though not a physically lim-iting disability, has been shown to affect lifestyle dramati-cally and affect psychological health adversely, especiallyself-esteem [8]. Although medical management is the front-line therapy and proves successful in the majority of pa-tients, some cases require surgical intervention. In otherinstances, coexistent gynecological pathology requiring sur-gery creates the opportunity to correct borderline cases.

In a comparison of methods, Black and Downs [1] foundin a review of 34 studies that colposuspension was moreeffective than needle suspension in curing or improvingstress incontinence. They concluded that, in general, 85% ofpatients undergoing colposuspension can expect to be con-tinent 1 year after surgery, whereas only 50–70% of thoseundergoing needle suspension can anticipate continence at 1year. In general, colposuspension cure rates range from100% to 71%, while those for needle suspension and thesling procedure drop from a high of 100% to as low as 40%[1]. Furthermore, in a study of five reports comparing col-posuspension methods (the Burch procedure versus theMarshall-Marchetti-Kranz procedure), the Burch procedurewas deemed superior, but the difference failed to be statis-tically significant. When the review of the comparison ofcolposuspension methods was enlarged to include eightstudies in all, still no one method emerged as statisticallysignificantly different. All were small studies. These find-ings indicate the importance of designing large prospectivestudies that incorporate long-term follow-up.

In our series, all 54 patients undergoing laparoscopicBurch colposuspension with reinforcing mesh reportedresolution of their symptoms; only nine (16.7%) of themrequired medication to ensure complete continence. Otherreports on patients undergoing this procedure do not providethe number of those who relied on medication postopera-tively. Of the three published reports of patients who un-derwent the Burch adaptation incorporating mesh, one, in-cluding 59 patients, reported no failures [20]; another, in-cluding 40 patients, reported resolution or improvement ofsymptoms in all patients [11]; and a third, with 30 patients,reported success in 29 cases, based on a physical examina-tion and a patient questionnaire [17]. These expressions ofoutcome, because of their lack of specificity as well as theabsence of an objective measure (a fault from which our

own study suffers) make comparison difficult. However,from patient reports, it is clear that the procedure bringssymptomatic resolution in almost all women undergoingtreatment.

The durability of that response, because of the newnessof the procedure, is difficult to assess. In our own study, wehave followed patients forø28 months (average, 14months), and no reoperations have been required. Otherinvestigators who employed mesh likewise report no fail-ures or reoperations; however, follow-up has been brief.Minor postoperative complications were self-limiting. Wecan hope for additional reports on these patients in order tobetter assess the durability of the success of the procedure.

In our series, two patients required conversion to anopen procedure (3.7%), a rate lower than that reported byothers, both with larger and smaller series. Though in 1996Radomski and Herschorn [14] reported a conversion rate of26.1% in 46 patients, Frankel, writing in response to theirexperience, reported a conversion rate of 6% in 166 patients[4]. At issue was whether previous pelvic surgery was acontraindication to laparoscopic urethropexy. Cooper et al.[3] reported a conversion rate of 11.5% in 113 patients,further noting that most of these conversions occurredwithin the first quartile of patients. Our conversions alsooccurred early—within the first 40%—and were cases inwhich pelvic adhesions prevented clear viewing.

Though ours is not a comparative study, other investi-gators have found patients undergoing laparoscopic urethro-pexy to require less postoperative analgesia and a shorterhospital stay, and to enjoy a quicker return to normal ac-tivity than those undergoing open urethropexy [13]. Hospi-talization, which dropped over time, was much briefer thanthe 5–10 days required for the open procedure [5, 19], andit would remain briefer today, even though stays todaywould no doubt be shorter than ones from 1979 and 1989.(One of our patients undergoing the open procedure stayedonly four days.)

Overall, the Burch procedure has proved a reliablemethod of urethropexy, posing little untoward risk to thepatient and providing effective relief of symptoms that, ac-cording to our follow-up, is lasting. The laparoscopic ap-proach extends to the patient the benefits of a shorter hos-pital stay, smaller wounds, and low risk of conversion. Forthe physician, the laparoscopic approach makes identifica-tion of anatomical landmarks and control of bleeding easier.The adaptation of employing mesh provides a broader sur-face of attachment, better support, and is believed to beresponsible for the consistently good results reported bythose using this method.

Acknowledgment:We acknowledge with grateful appreciation the contri-bution our nurses, Rebecca Churchill-Winn,R.N., CNOR, CRNFA, and JudithGherdovich,LVN, make to successful surgical and clinical patient care.

References

1. Black NA, Downs SH (1996) The effectiveness of surgery for stressincontinence in women: a systematic review. Br J Urol 78: 497–510

2. Burch JC (1968) Cooper’s ligament urethrovesical suspension forstress incontinence. Am J Obstet Gynecol 100: 764–772

3. Cooper MJW, Cario G, Lam A, Carlton M (1996) A review of results

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in a series of 113 laparoscopic colposuspensions. Aust NZ J ObstetGynaecol 36: 44–48

4. Frankel G (1996) Re: Laparoscopic Burch bladder neck suspension:early experience [letter]. J Urol 155: 1447

5. Korda A, Ferry J, Hunter P (1989) Colposuspension for the treatmentof female urinary incontinence. Aust NZ J Obstet Gynaecol 29: 146–149

6. Lam AM, Jenkins GJ, Hyslop RS (1995) Laparoscopic Burch colpo-suspension for stress incontinence: preliminary results. Med J Austra-lia 162: 18–21

7. Langebrekke A, Dahlstrom B, Eraker R, Urnes A (1995) The laparo-scopic Burch procedure: a preliminary report. 74: 153–155

8. Lagro-Janssen T, Smits A, Van Weel C (1992) Urinary incontinence inwomen and the effects on their lives. Scand J Prim Health Care 10:211–216

9. Marshall VF, Marchetti AA, Krantz KE (1949) THe correction ofstress incontinence by simple vesico-urethral suspension. Surg Gyne-col Obstet 88: 509–518

10. McDougall EM, Klutke CG, Cornell T (1995) Comparison of trans-vaginal versus laparoscopic bladder neck suspension for stress urinaryincontinence. Urology 45: 641–646

11. Ou CS, Presthus J, Beadle E (1993) Laparoscopic bladder neck sus-pension using hernia mesh and surgical staples. J Laparoendosc Surg3: 563–566

12. Pereyra AJ (1959) A simplified surgical procedure for the correction ofstress incontinence in women. West J Surg Obstet Gynecol 67: 223–226

13. Polascik TJ, Moore RG, Rosenberg MT, Kavoussi LR (1995) Com-parison of laparoscopic and open retropubic urethropexy for treatmentof stress urinary incontinence. Urology 45: 647–652

14. Radomski SB, Herschorn S (1996) Laparoscopic Burch bladder necksuspension: early results. J Urol 155: 515–518

15. Ramahi A (1995) Electrical stimulation of pelvic floor muscles for thetreatment of urinary incontinence. American Urogynecologic SocietyQuarterly Report 13: 1–3

16. Raz S (1981) Modified bladder neck suspension for female stressincontinence. Urology 17: 82

17. Shanberg AM, Gweon P, Chamberlin D (1996) Laparoscopic Prolenemesh suspension of the bladder neck in patients with types I and IIurinary stress incontinence [abstract]. J Urol (Suppl) 155: 490A

18. Stamey TA (1973) Endoscopic suspension of the vesical neck forurinary incontinence. Surg Gynecol Obstet 136: 547–556

19. Stanton SL, Cardozo LD (1979) Results of the colposuspension op-eration for incontinence and prolapse. Br J Obstet Gynaecol 86: 693–697

20. von Theobald P, Barjot P, Liegeois P, Herlicoviez M, Levy G (1994)La colposuspension selon la technique de Burch par coelioscopie [ab-stract]. Presse Med 23: 1301–1303

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Splenic rupture from colonoscopy

We read with interest the paper by Espinal and associates[2] where two new cases of splenic injury during colonos-copy were added to a review of 15 patients previously re-ported in the English language literature. In addition to par-tial capsular avulsion as the main mechanism of injury,endoscopic techniques such as ‘‘slide-by’’ and ‘‘hooking’’were cited as contributing factors.

Speaking of splenic rupture during colonoscopy in theabsence of bowel perforation, a further potentially danger-ous maneuver is the exertion by the endoscopist of outerpressure on the left hypochondrium to straighten the splenicflexure. A 70-year-old woman underwent emergency sple-nectomy 6 h after an apparently ‘‘easy’’ surveillance colo-noscopy without biopsy. Two fractures (4 cm long × 2 cmdeep, and 2 cm long × 1 cm deep) were observed on theupper and lower pole of the convex surface of the spleen,respectively. Her recovery was uneventful and histologyshowed normal parenchyma [1]. A note of caution must beexpressed about the risks of this maneuver, which should be

enumerated among the possible mechanisms of spleen in-jury during colonoscopy.

References

1. Arnaud JP, Bergamaschi R, Casa C, Boyer J (1993) Splenic rupture:unusual complication of colonoscopy. Colo-proctology 6: 356–357

2. Espinal EA, Hoak T, Porter JA, Slezak FA (1997) Splenic rupture fromcolonoscopy. A report of two cases and review of the literature. SurgEndosc 11: 71–73

R. Bergamaschi1

J. P. Arnaud2

1National Center for Advanced Laparoscopic SurgeryTrondheim University Hospital7006 Trondheim, Norway2Department of Visceral SurgeryAngers University Hospital49033 Angers, France

Surg Endosc (1997) 11: 1133

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New endoscopic methods for the detection of early colorectal cancer

What are we doing?

The advent of new endoscopic techniques has contributed tothe increase in the detection of early colorectal cancers [1].Using a similar approach to one already used for early gas-tric cancers, endoscopic mucosal resection or strip biopsyhas been used to treat early colorectal cancer. Kudo andcolleagues [1] from Japan have developed a number of en-doscopic techniques and concepts that have allowed thedetection of what they term ‘‘early colorectal cancer’’ and‘‘cancer de novo.’’ One such method uses chromoscopictechniques with indigo-carmine, which has made possiblethe detection of early, diminutive, flat carcinomas that couldbe missed by conventional colonoscopy. Studying theseearly, flat, and depressed colorectal lesions, Kudo and hiscolleagues developed a classification system and proposedthe use of magnification and stereomicroscopy to improvethe detection of these lesions. The detailed method and tech-nique were well described in their recent publication [2].

To date, there have been no prospective randomizedtrials comparing the endoscopic vs surgical resection ofearly colorectal cancers. However, it is easy to understandthe benefits of avoiding surgical resection in any patientwho can be cured by endoscopic means.

As colorectal surgery is a specialty involving clinical,surgical, and endoscopic management of patients, it is ourbelief that those performing colonoscopy should be wellinformed of new endoscopic techniques to improve the de-tection of these early colorectal lesions.

As the scope of technology widens, the aim of modernmedicine is to focus on the prevention of any potentialdisease by earlier detection, with no added cost to the pa-tient and reduced morbidity and mortality.

All endoscopists must be made aware of any new tech-nology which can contribute to the decrease in the greatnumber of colorectal cancers, which still account for anenormous number of deaths worldwide.

References

1. Kudo S, et al (1995) Depressed type of colorectal cancer. Endoscopy27: 54

2. Kudo S (ed) (1996) Early colorectal cancer. Detection of depressedtypes of colorectal carcinoma. Igaku-Shoin, New York

L. Oliveira 1

S. D. Wexner2

1Department of Colorectal Surgery,Mario Kroeff Hospital,Rio de Janeiro, Brasil

2Department of Colorectal Surgery,Cleveland Clinic Florida,Fort Lauderdale, FL, USA

Surg Endosc (1997) 11: 1134

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Utility of transesophageal echocardiography and pulmonary arterycatheterization during laparoscopic assisted abdominal aorticaneurysm repair

A. J. D’Angelo, R. G. Kline, M. H. M. Chen, V. J. Halpern, J. R. Cohen

Department of Surgery, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040, USA

Received: 27 March 1997/Accepted: 5 July 1997

AbstractBackground:Advanced laparoscopic procedures are morecommonly performed in elderly patients with cardiac dis-ease. There has been limited data on the use of pulmonaryartery catheters (PAC) and transesophageal echocardiogra-phy (TEE) to monitor hemodynamic changes.Methods:We prospectively studied eight patients under-going laparoscopic assisted abdominal aortic aneurysm re-pair. All patients had a PAC and all but one had an intra-operative TEE. Data included heart rate (HR), temperature(temp), pulmonary artery systolic (PAS) and diastolic(PAD) pressures, mean arterial pressure (MAP), central ve-nous pressure (CVP), pulmonary capillary wedge pressure(PCWP), cardiac index (CI), mixed venous oxygen satura-tion (MVO2), and oxygen extraction ratio (O2Ex) and wasobtained prior to induction, during insufflation, after desuf-flation, during aortic cross-clamp, and at the end of theprocedure. End diastolic area (EDA), a reflection of volumestatus, was measured on TEE. ANOVA was used for dataanalysis.Results:No changes were noted in HR, temp, PAS, PCWP,CI, MVO2, and O2Ex. PAD and CVP were greater duringinsufflation compared with baseline and aortic cross-clampwithout associated changes in EDA. MAP was higher atbaseline compared with all other times during the proce-dure.Conclusions:Insufflation increased PAD and CVP. How-ever, volume status as suggested by EDA and PCWP did notchange. These data question the reliability of hemodynamicmeasurements obtained from the PAC during pneumoperi-toneum and suggest that TEE may be sufficient for evalu-ation of volume status along with the added benefit oftimely detection of ventricular wall motion abnormalities.

Key words: Laparoscopy — Vascular — Abdominal aorticaneurysm

Advances in laparoscopy have resulted in complex proce-dures being performed on more elderly patients with coex-isting cardiac disease. The growing experience with themultiple laparoscopic approaches has introduced an ex-panded awareness of the physiologic implications of pneu-moperitoneum. Although peritoneal insufflation is well tol-erated in a young and healthy population, recent studieshave shown significant alterations in cardiac performanceduring laparoscopy [3, 5, 7]. There has been limited andconflicting data comparing the available intraoperativemeans of monitoring, especially in patients with significantcoexisting cardiopulmonary disease [5, 8].

For the laparoscopically assisted abdominal aortic an-eurysm (L-AAA) repairs at our institution, we have recentlydeveloped a policy of monitoring these patients intraopera-tively with both transesophageal echocardiography (TEE)and pulmonary artery catheterization (PAC). This studypresents the preliminary findings in the first eight patientsstudied with this protocol.


We are currently performing L-AAA repair under institutional reviewboard approval. In November 1995 we adopted a policy of monitoring allpatients with both TEE and PAC. In the subsequent 12 months eightpatients underwent L-AAA.

The patient selection criteria and operative technique have been pre-viously described [1]. Selection criteria included patients undergoing elec-tive infrarenal AAA repair with a tube graft. Patients were excluded if theyhad a contraindication to laparoscopy or refused to participate in the study.We have recently modified some of the operative techniques. Briefly,lower extremity pneumatic compression devices were applied and patientswere placed in Trendelenburg position with the legs straight and abducted.The operating surgeon was positioned between the legs while the cameraholder (first assistant) and the third assistant stood to the left of the patient.The bowel retractor (second assistant) stood on the right.

A 1-cm supraumbilical midline cutdown was performed and underdirect vision the peritoneal cavity was entered. A modified Glassman vis-cera retainer ‘‘fish’’ (Adept-Med) was then inserted directly into the peri-toneal cavity. A Hasson cannula was introduced and a pneumoperitoneumwas obtained to 15 mmHg. Under direct visualization five 10-mm trocarsCorrespondence to:J. R. Cohen

Surg Endosc (1997) 11: 1099–1101

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were inserted (Fig. 1). A 30° laparoscope was inserted into port A. Theoperating surgeon used ports B and C for dissection. Using ports D and E,the small bowel was retracted to the right and cephalad with the ‘‘fish,’’thus exposing the aneurysm. Port F was used for suction or additionalretraction as needed. The retroperitoneum at the level of the deuodenumwas opened with a combination of electrocautery and blunt dissection. Thesite of aortic cross-clamping at the neck of the aneurysm just inferior to theleft renal vein was identified and the anterior, medial, and lateral surfacesdown to the vertebral bodies were laparoscopically dissected. Uponcompletion of the neck dissection, the right and left common iliac vesselswere dissected.

At the end of the laparoscopic dissection, the trocars were removed andan 8–11-cm incision was made at the level of the umbilicus. Through thisincision, a Creech endoaneurysmorrhaphy was performed using standardopen instruments [2]. After 5,000 U of heparin was given, the iliac vesselswere occluded with straight Fogarty clamps introduced through incisions Band C and the neck was controlled with an aortic cross clamp introducedthrough incision E. The aneurysm was opened and the ostia of the inferiormesenteric and lumbar vessels were oversewn. A polytetrafluoroethylene(PTFE) tube graft was sewn into place. The aortic wall was closed over thegraft and the retroperitoneum was closed over the aneurysm sac. All portsites were closed with 0 polyglactin sutures with an Endoclose (U.S. Sur-gical, Norwalk, CT) and the abdominal wound was closed with #1 poly-dioxanone. Postoperatively, all patients were brought to the ICU.

All patients were admitted on the day of surgery. An arterial line andPAC were inserted prior to the induction of anesthesia. Data obtainedincluded heart rate (HR), temperature (temp), pulmonary artery systolic(PAS) and diastolic (PAD) pressures, mean arterial pressure (MAP), cen-tral venous pressure (CVP), pulmonary capillary wedge pressure (PCWP),cardiac index (CI), mixed venous oxygen saturation (MVO2), and oxygenextraction ratio (O2Ex). After laryngoscopy and tracheal intubation, a TEEtransducer probe was inserted. Following initial examination of the heartand great vessels, the probe was positioned to monitor a transgastric, trans-verse-plane, short-axis view of the midpapillary level of the left ventricle.End diastolic area (EDA) and end systolic area (ESA) were measuredoff-line with manual planimetry. The percent ejection fraction area (%EFa)was determined from the formula %EFa 4 [EDA − ESA)/EDA] * 100.These PAC and TEE data were subsequently obtained during insufflation,after desufflation but prior to infrarenal aortic cross-clamping, during aorticcross-clamping, and then at the end of the procedure when hemostasis hadbeen achieved.

ANOVA analysis was used to determine statistical significance whichwas accepted forp < 0.05.

Results

Eight patients underwent attempted L-AAA during thestudy period. Seven were completed successfully. One pa-tient was converted to an open AAA repair secondary toadhesions which had formed from a previous hysterectomy.That patient’s data was still used for analysis since we wereable to obtain hemodynamic parameters during pneumo-peritoneum. One patient did not have a TEE during theprocedure because of technical problems with the equip-ment. There were no mortalities in this series.

Mean operative time was 3.77 ± 1.0 h. The mean aneu-rysm size was 5.5 cm and the average age was 70.6 years.No changes were noted in HR, temp, PAS, PCWP, CI,MVO2, and O2Ex. There were also no changes in ESA,EDA, and %EFa (Table 1). However, both PAD and CVPwere greater during insufflation than during baseline (Fig.2). MAP was significantly greater at baseline compared toall other times during the procedure (Table 1).

Discussion

The use of laparoscopy has increased exponentially inrecent years, especially for older and more debilitatedpatients. Understanding the hemodynamic effects of pneu-moperitoneum has become of paramount importance. Intra-operative monitoring of such patients has traditionally in-cluded intraarterial and pulmonary artery catheters. How-ever, the accuracy of the hemodynamic parameters obtainedfrom these devices during pneumoperitoneum has beenquestioned in the recent literature [5]. The addition of TEEhas expanded the wealth of available intraoperative infor-mation, allowing for timely management of any adverseevents.

The use of intraoperative TEE has increased in recentyears. It has a very high sensitivity for myocardial ischemiawhich manifests as wall motion abnormalities. In addition,it has been shown to be a valuable adjunct for volumeresuscitation in patients undergoing infrarenal AAA repair[4].

As we completed the first ten patients to undergo L-AAA, it came to our attention that the pulmonary arterypressures always appeared to increase during insufflationand decrease with desufflation. If this were so, then thehemodynamic variables measured during pneumoperito-neum would not reflect the true volume and pressure status.This prompted the current study to add TEE and comparethe data with those obtained from PAC.

No changes were noted in HR, temp, PAS, PCWP, CI,MVO2, and O2Ex. Of importance is that temperature did notchange during the procedure. Open AAA repair is associ-ated with postoperative hypothermia, which can be associ-ated with hemodynamic compromise and coagulopathy [6].The conditions under which L-AAA is performed allow forminimal heat loss. The laparoscopic portion is done with awarming insufflator. The minilaparotomy used to sew in thegraft does not result in significant heat loss. The normother-

Fig. 1. Placement of trocars for aortic dissection and location of theminilaparoromy.A, camera;B, dissector;C, dissector;D, bowel retractor;E, bowel retractor;F, suction.

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mia results in a smoother postoperative course and fewerbleeding complications.

The MAP was significantly greater at baseline than atany other time during the procedure. The baseline measure-ments were taken prior to induction of anesthesia. Patientanxiety can produce an artificially elevated blood pressure.Inhalational anesthetics produce peripheral vasodilation aswell as cardiac depression. The combination of these twofactors is the likely cause for the difference seen. We havesince changed the timing of baseline measurements to justafter the induction of anesthesia but prior to skin incision fora more accurate comparison to the measurements obtainedduring the procedure.

The PAD and CVP increased significantly when com-pared to baseline. However, the PCWP and more impor-tantly the EDA on TEE did not change. The PAC measurespressures in the pulmonary arterial tree. While volume sta-tus is the primary determinant of PAD, other factors influ-ence the parameters measured. Positive pressure ventilationwill artificially increase the measured pressures. Pneumo-peritoneum causes the diaphragm to be elevated, which in-creases the pressure in the thoracic cavity, which in turn isreflected in the variables obtained with a PAC.

TEE is a monitoring device which is independent ofintrathoracic pressure. Ventricular function and filling canbe monitored on a continuous basis. Any adverse effect thatpneumoperitoneum will have on preload or ventricular con-tractility is quickly and readily seen.

Our data showed that there was no significant increasein preload during any part of the procedure as measured bythe EDA on TEE. The EF%a was also unchanged. The EDAobtained during TEE has been shown to be a reliablemethod of determining intravascular volume status [9]. Inaddition, the ability to detect ventricular contractility andmyocardial ischemia as manifested by wall motion abnor-malities may prove TEE to be a superior method of moni-toring these patients intraoperatively.

Given the changes seen with PAD and CVP, which areprobably inaccurate due to artificial elevation from pneu-moperitoneum, TEE may be a better alternative to monitorcardiac status and should be considered in patients withcoexisting cardiac disease undergoing laparoscopic proce-dures.

References

1. Chen MHM, D’Angelo AJ, Murphy EA, Cohen JR (1996) Laparo-scopically assisted abdominal aortic aneurysm repair: a report of 10cases. Surg Endosc 10: 1136–1139

2. Creech O (1966) Endoaneurysmorrhaphy and treatment of aortic an-eurysms. Ann Surg 164: 935–946

3. Dorsay DA, Greene FL, Baysinger CL (1995) Hemodynamic changesduring laparoscopic cholecystectomy monitored with transesophagealechocardiography. Surg Endosc 9: 128–134

4. Gillespie DL, Connelly GP, Arkoff HM, Dempsey AL (1994) Leftventricular dysfunction during infrarenal abdominal aortic aneurysmrepair. Am J Surg 168(2): 144–147

5. Harris SN, Ballantyne GH, Luther MS, Perrino AC Jr (1996) Alter-ations in cardiovascular performance during laparoscopic colectomy: acombined hemodynamic and echocardiographic analysis. AnesthAnalg 83: 482–487

6. Kahn H, Faust G, Richard R, Doscher W, Cohen JR (1994) Hypother-mia and bleeding during abdominal aortic aneurysm repair. Ann VascSurg 8(1): 6–9

7. McLaughlin JG, Scheeres DE, Dean RJ, Bonnell BW (1995) Theadverse hemodynamic effects of laparoscopic cholecystectomy. SurgEndosc 9: 121–124

8. Portera CA, Compton RP, Walters DN, Browder IW (1995) Benefitsof pulmonary artery catheters and transesophageal echocardiographicmonitoring in laparoscopic cholecystectomy patients with cardiac dis-ease. Am J Surg 169(2): 202–206

9. Swenson JD, Harkin C, Pace NL, Astle K, Bailey P (1996) Trans-esophageal echocardiography: an objective tool in defining maximumventricular response to intravenous fluid therapy. Anesth Analg 83:1149–1153

Table 1. Results of attempted L-AAA

Baseline Insufflation Desufflation Cross clamp Closure

HR 71.6 ± 11.1 64.0 ± 8.9 64.4 ± 9.2 63.9 ± 11.2 64.1 ± 9.3Temp © 36.3 ± 0.5 35.5 ± 0.4 35.0 ± 0.6 35.1 ± 0.7 34.9 ± 0.7PAS (mmHg) 31.6 ± 12.5 34.6 ± 5.6 31.8 ± 4.4 29.3 ± 5.6 36.4 ± 6.4MAP (mmHg) 104.4 ± 15.0* 92.5 ± 9.0 84.6 ± 9.8 83.4 ± 12.1 87.5 ± 7.4PCWP (mmHg) 14.9 ± 10.4 19.9 ± 3.9 17.0 ± 4.5 15.6 ± 7.6 18.8 ± 2.7CI (l/min/m2) 2.8 ± 0.5 2.6 ± 0.6 2.9 ± 0.5 2.7 ± 0.5 3.2 ± 0.9MVO2 (pO2) 43.6 ± 5.1 44.0 ± 5.0 48.8 ± 7.9 43.6 ± 7.0 48.0 ± 6.9O2Ex (%) 19 ± 6 21 ± 5 17 ± 5 19 ± 6 19 ± 6ESA (cm2) 6.7 ± 5.9 7.0 ± 6.9 7.4 ± 6.1 7.7 ± 5.8 7.7 ± 6.8EDA (cm2) 13.0 ± 7.9 12.4 ± 7.9 14.4 ± 7.7 13.5 ± 8.5 14.6 ± 9.5%EFa

a 53.1 ± 20.0 49.8 ± 24.5 52.3 ± 19.4 45.9 ± 17.5 52.3 ± 16.9

* p < 0.05 compared to all other values of MAPa %EF is the estimated ejection fraction area determined by the formula: [(EDA − ESA)/EDA]*100

Fig. 2. *p < 0.05 compared to baseline in both groups.

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Intraoperative ultrasound assessment in management of complexpancreatic pseudocysts

M. R. Back,1 M. Sadra,1 M. E. Dempsey,2 R. Sinow,2 S. R. Klein1

1 Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA2 Department of Radiology, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA

Received: 19 June 1996/Accepted: 27 October 1996

Abstract. Preoperative imaging studies and operative in-spection may provide insufficient information to appropri-ately manage certain complex pancreatic pseudocysts. In-traoperative ultrasound accurately identifies and localizesperipancreatic fluid collections, cyst wall thickness, paren-chymal and ductal anatomy, and relationships to adjacentvisceral and vascular structures. Adjunctive use of intraop-erative ultrasonography altered the surgical management inthe clinical case described herein and is advocated for as-sessment of problematic pancreatic pseudocysts.

Key words: Intraoperative ultrasound — Pancreatic pseu-docyst — Internal drainage — Roux-en-Y cystojejunos-tomy

Refinements in transcutaneous ultrasonography, computedtomography (CT), and endoscopic retrograde cholangiopan-creatography (ERCP) now provide adequate evaluation ofmost pancreatic pseudocysts with regard to the necessity forand proposed route of operative drainage. Preoperativeplanning and intraoperative management may prove diffi-cult with complex pseudocysts possessing multiple fluidcollections, ill-defined retroperitoneal locations, unclearanatomic relationships to adjacent visceral and vascularstructures, or characteristics suspicious for a cystic pancre-atic neoplasm. Further operative delineation of complexpseudocysts has relied upon interpretation of contrast cys-tography performed after blind needle aspiration throughperipancreatic retroperitoneal tissues and cyst walls. Intra-operative ultrasound imaging has been utilized mainly byJapanese [3] and German [4] authors for inflammatory andneoplastic pancreatic, hepatic, and biliary diseases with a

relative paucity of descriptions by American surgeons [5,6]. Herein, we report a case requiring adjunctive use ofintraoperative ultrasound to fully define and localize a com-plex pancreatic pseudocyst and facilitate appropriate inter-nal drainage via a Roux-en-Y cystojejunostomy.

Case report

A 40-year-old Latino male presented to Harbor-UCLA Medical Centerwith his second episode of acute alcohol-induced pancreatitis. He requiredendotracheal intubation in the Emergency Department secondary to respi-ratory distress and early pulmonary artery catheter monitoring during re-suscitation. He manifested six of Ranson’s criteria in addition to hyper-amylasemia in the first 48 h of hospitalization. Initial abdominal CT scanrevealed an extensive pancreatic inflammatory process without necrosisextending down the left paracolic gutter. The patient developed a polymi-crobial pneumonia believed due to an early aspiration episode requiringmultiple antibiotics and 3 weeks of mechanical ventilation. Repeat abdomi-nal CT scan 3 weeks after admission showed evolving liquefaction of theperipancreatic inflammation. The patient’s 4 weeks of intensive care man-agement were complicated by candidal and staphyloccocal epidermidis lineinfections. After several weeks of bowel rest, enteral feeds were resumedwith subsequent intermittent hyperamylasemia requiring continued hyper-alimentation. Despite overall improvement in the patient’s condition andresolution of sepsis, oral feeds after 5–6 weeks of hospitalization wereassociated with progressive gastroesophageal reflux symptoms and left-sided abdominal pain. A third abdominal-pelvic CT scan demonstrated aninflammatory fluid collection within the gastrosplenic ligament, which hada poorly defined wall (Fig. 1A). Contiguous, but more inferior, a 15 × 11× 14 cm fluid collection with a∼5-mm wall was identified. This collectionextended from the tail of the pancreas involving the left anterior pararenalspace and left paracolic gutter (Fig. 1B). Multiple septations were seenwithin the pseudocyst as it tracked into the pelvis within the retroperito-neum (Fig. 1C). Based on the patient’s symptomatology, pseudocyst en-largement, and apparent wall ‘‘maturation,’’ exploratory laparotomy withintent of internal drainage was performed 7 weeks after admission.

At operation, obliteration of the lesser sac was confirmed and thedescending colon and supporting mesentery were elevated and denselyadherent to the left paracolic inflammation overlying the extensive retro-peritoneal pseudocyst. As there was no palpable indentation into the pos-terior gastric wall even following anterior gastrotomy, intraoperative ul-trasound was performed to evaluate the ill-defined retrogastric fluid col-

Correspondence to:M. R. Back, Section of Vascular Surgery, Departmentof Surgery, College of Medicine, University of Florida, PO Box 100286,Gainsville, FL 32610-0286, USA

Surg Endosc (1997) 11: 1126–1128

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lection seen on the preoperative CT scan 5 days prior to surgery. The examwas performed using an ATL Ultramark4 (ATL, Bothell, WA) scannerwhich was placed in a sterile sleeve with methylcellulose gel coupling. The7.5-MHz sector transducer was inserted into the stomach through the an-terior gastrotomy. Imaging directly through the posterior gastric wall, noinflammatory fluid collection could be identified, suggesting interval reso-lution prior to surgery. Further imaging, however, of the left anterior para-renal space and left paracolic gutter did confirm and better define themultiseptated pseudocyst seen on the previous CT scan (Figs. 2 and 3).

Without a significant retrogastric component identified by ultrasonog-raphy, an alternative site for internal pseudocyst drainage was selectedalong the dependent portion of the large left paracolic cystic collection.Because drainage at this site required penetration of the adherent overlyingsigmoid mesentery, ultrasonography identified vessels to be avoided. Grainstain of aspirated cloudy pseudocyst fluid revealed no organisms althoughfinal cultures grew out staphylococcal epidermidis. Following further fluiddecompression through the cyst wall and retrieval of free tissue debris fromthe large paracolic cavity, a Roux-en-Y cystojejunostomy was constructedwith interrupted, single-layer, absorbable suture. Ultrasonography con-firmed collapse of all cystic collections after completion of the cystoen-terostomy. The patient recovered uneventfully from surgery and resumedoral feeds without adverse sequelae. A final abdominal CT scan 1.5 weeksafter operation documented continued collapse of the pseudocyst. Thepatient remained asymptomatic at follow-up 6 months after surgery.

Discussion

The imaging advantages afforded intraoperative ultrasoundover preoperative transabdominal studies are directly re-lated to the necessary distance traversed by the sound beam.Intraoperative transducers may be placed nearly directly onthe tissue to be scanned, thus avoiding beam scattering bythe abdominal wall and intervening adipose tissue andbowel gas. Intraoperative ultrasonography of the pancreasrequires beam penetration depths of 4–6 cm typically,which allows use of higher-frequency transducers (5–7.5MHz). The improved image resolution with limited beamattenuation at shallower penetration depths provides de-tailed anatomic inspection of retroperitoneal structures. Byallowing direct ultrasonic insonation of the pancreas andsurrounding tissues the technique obviates reliance on blindneedle aspiration and attempted contrast cystography withthe potential risk of inadvertent injury to important adjacentvisceral and vascular structures. Radiographic interpretationof cystograms and comparison with pseudocyst findings onpreoperative CT scans or ultrasonography may be problem-atic. Intraoperative ultrasound can be performed directlyupon the pancreas after transection of the gastrocolic omen-tum. If inflammation obliterates the lesser sac, scanning isaccomplished through adjacent structures such as gastrohe-

patic and gastrocolic ligaments, transverse mesocolon, du-odenum, or posterior gastric wall after gastrotomy.

Operative findings in the majority of cases confirm ana-tomic details provided by preoperative imaging studies andare usually sufficient to determine appropriate drainage forpancreatic pseudocysts. The utility of adjunctive intraopera-tive ultrasonography is measured in it’s ability to alter sur-gical management by providing unique anatomic informa-tion not delineated by preoperative imaging. Indications forintraoperative ultrasonography encompass certain subsets ofcomplex pseudocysts seen on preoperative studies whereanatomical detail is inadequately defined as well as caseswhere operative findings do not coincide with preoperativepredictions and further assessment is required.

Intraoperative ultrasound enables localization or exclu-sion of peripancreatic fluid collections poorly defined bypreoperative studies or not clearly evident by inspection orpalpation. The technique assists identification of pseudocystanatomic relationships to adjacent visceral and vascularstructures. Intraoperative ultrasound is particularly valuablein assessing pseudocyst adherence to posterior gastric orduodenal walls to facilitate safe construction of a cystoen-teronostomy. Failure of pseudocyst adherence to the poste-rior gastric wall occurs in approximately one-quarter ofcases, according to Bradley [2], despite preoperative imag-ing suggesting such as a relationship. Lack of pseudocystadherence as demonstrated by intraoperative ultrasound inour case required an alternative route of drainage. Afterpseudocyst localization intraoperative ultrasound assists se-lection of optimal drainage sites by evaluating the adequacyof cyst wall thickness and the presence of vessels within thewall. Presence of color-flow Doppler and duplex scanningcapabilities combined with B-mode ultrasound images mayaid identification of smaller vascular structures. Assessmentof pancreatic parenchyma by intraoperative ultrasound mayalso reveal dilatations of the pancreatic duct and luminalstone formation that could predict recurrent inflammatoryepisodes and necessitate later surgical intervention.

Multiple septated fluid collections exist within peripan-creatic pseudocysts in at least 10% of cases [1]. While theanatomic distribution of the cystic process may be welldefined by preoperative ultrasonography or CT scans, com-munications between fluid collections are infrequently dem-onstrated. Intraoperative ultrasound may reveal such intra-cystic communications and septations but more importantlycan evaluate residual fluid collections after operative de-compression of adjacent pseudocysts and determine the

Fig. 1. Axial post contrast CT images through abdomen and pelvis obtained preoperatively.A Image within upper abdomen demonstrating inflammatoryfluid collection within the gastrosplenic ligament.B Pseudocyst extending from region of tail of pancreas into left anterior pararenal space.C Multipleseptations within pseudocyst as it is seen to extend into the pelvis within the retroperitoneum.

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need for surgical fenestration of internal septations or sepa-rate routes of drainage. If there exists concern for a cysticpancreatic neoplasm when an inflammatory etiology is lack-ing, intraoperative ultrasound may provide additional ana-tomic detail to assist differentiation of solid and cystic com-ponents of the lesion and identify suspicious sites for safebiopsy. Needle or incisional biopsy and ultrasound findingsassist appropriate choice of drainage or resectional therapy.

The operator-dependent nature of ultrasonography re-quires multidisciplinary communication between surgeonand radiologist. Surgeons, however, should be encouragedto familiarize themselves with ultrasound techniques andimage interpretation. This operative adjunct is relativelysimple to perform and is not time consuming, but it doesrequire availability of ultrasound probe and scanner, sterileplastic sleeves or gas sterilized probes, and gel or saline foracoustic coupling. Intraoperative ultrasonography is a use-

ful addition to the armamentarium of techniques availablefor management of problematic pancreatic pseudocysts.

References

1. Bradley EL (1982) Complications of pancreatiitis. WB Saunders, Phila-delphia, PA

2. Bradley EL (1995) Pancreatic pseudocyst. In: Cameron JL (ed) Currentsurgical therapy. 5th ed. Mosby, St. Louis, MO, pp 428–431

3. Miyashita T, Suzuki T, Uchida K (1982) Intraoperative ultrasonographyfor pancreatic surgery. J Clin Surg 37: 63–71

4. Printz H, Klotter H, Nies C, Hasse C, Neurath M, Sitter H, RothmundM (1992) Intraoperative ultrasonography in surgery for chronic pan-creatitis. Int J Pancreatol 12: 233–237

5. Sigel B, Coelho JCV, Donahue PE, Nyhus LM, Spigos DG, Baker RJ,Machi J (1982) Ultrasonic assistance during surgery for pancreaticinflammatory disease. Arch Surg 117: 712–716

6. Sigel B, Machi J, Kikuchi T, Anderson KW, Horrow M, Zaren HA(1987) The use of ultrasound during surgery for complications of pan-creatitis. World J Surg 11: 659–663

Fig. 2. Intraoperative ultrasound of multiseptated retroperitoneal pseudocyst in left paracolic gutter with internal reflections from tissue debris.ALongitudinal section.B Transverse section.

Fig. 3. A Transverse ultrasound section of pancreas imaged through posterior gastric wall with no intervening inflammatory fluid collection visible.BDuplex scanning confirms continuous flow signal through splenic vein posterior to the pancreatic body.

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Endoscopic nasobiliary drainage for bile duct injury afterlaparoscopic cholecystectomy

K. Hanazaki,1 H. Sodeyama,1 Y. Sode,1 M. Miyazawa,1 S. Yokoyama,1 M. Wakabayashi,1 N. Kawamura,1

M. Ohtsuka,1 T. Miyazaki,1 Y. Matsuda2

1Department of Surgery, Nagano Red Cross Hospital, 1512-1 Wakasato, Nagano 380, Japan2Department of Internal Medicine, Nagano Red Cross Hospital, 1512-1 Wakasato, Nagano 380, Japan

Received: 29 May 1996/Accepted: 28 September 1996

AbstractBile duct injuries are a potential complication of laparo-scopic cholecystectomy (LC). A patient who underwentsuccessful endoscopic nasobiliary drainage (ENBD) for abile duct injury sustained during LC is presented. Of par-ticular note, the patient also had Chilaiditi’s syndrome. A59-year-old woman was admitted with symptomatic chole-cystolithiasis and Chilaiditi’s syndrome. LC was performed.Postoperatively, the patient complained of abdominal dis-comfort. Laboratory examination revealed cholestasis. Bil-ious material began spilling from an intraabdominal drain.Subsequent endoscopic retrograde cholangiopancreatogra-phy (ERCP) showed bile leakage. ENBD was performed.Repeat ERCP 10 days later failed to show a bile leak orstenosis of the common bile duct. The patient improvedrapidly and had no complaints after the procedure. ENBD isa useful endoscopic technique to prevent peritonitis frombile leakage after LC. Chilaiditi’s syndrome is not a con-traindication for LC.

Key words: Bile duct injury — Laparoscopic cholecystec-tomy — Endoscopic nasobiliary drainage — Chilaiditi’ssyndrome

The incidence of bile duct injury after laparoscopic chole-cystectomy (LC) has recently been reported [8, 11, 13] torange between 0.25 and 0.5%. This complication occursmore frequently LC than with open cholecystectomy (OC),in which the incidence is one in 1,000 [13]. Several recentreports [5, 14] have suggested that a significant percentageof patients with a bile duct injury after LC can be treated byinterventional endoscopic retrograde cholangiopancreatog-raphy (ERCP) with endoscopic sphincterectomy (EST) or

stent placement [5, 14]. Herein is presented a report ofsuccessful endoscopic nasobiliary drainage (ENBD) for abile duct injury after LC in a patient with Chilaiditi’s syn-drome [3]. There have been no previous reports of the suc-cessful treatment of a leak from a bile duct injury usingENBD alone. This is also the first case report of LC forcholecystolithiasis in a patient with Chilaiditi’s syndrome.

Case report

A 59-year-old woman was admitted to our hospital with symptomaticcholecystolithiasis. On physical examination, the patient had slight tender-ness in the right upper quadrant of the abdomen. A chest radiograph re-vealed bowel gas under the right hemidiaphragm (Fig. 1). Abdominalcomputed tomography (CT) demonstrated interposition of the bowel be-tween the liver and diaphragm (Fig. 2). Abdominal ultrasonographyshowed gallbladder stones with acoustic shadowing. Helical CT revealedbowel shadows anterior to the gallbladder and no anomalies of the cysticduct–common bile duct (CBD) junction (Fig. 3). Preoperatively, the diag-nosis was cholecystolithiasis with Chilaiditi’s syndrome. There were noabnormal laboratory findings on admission. LC was performed 8 days afteradmission. The bowel anterior to the liver and gallbladder characteristic ofChilaiditi’s syndrome was easy to remove using the laparoscopic instru-ments. Intraoperative cholangiography (IOC) was not performed becauseof severe wall thickening of the cystic duct–CBD junction. The operationwas uneventful, with no evidence of bile duct injury. The histologic find-ings were consistent with chronic cholecystitis. Postoperatively, the patientcomplained of abdominal discomfort. Approximately 12 h after LC, shehad an excessive amount of bilious drainage from a Penrose drain that hadbeen placed through one of the subcostal trocar sites. Laboratory exami-nation revealed cholestasis 3 days after LC. The serum glutamic oxalo-acetic transaminase concentration was 53 IU/l (normal; 8 to 32 IU/l), theserum glutamic pyruvic transaminase concentration was 53 IU/l (normal; 5to 35 IU/l), and the total bilirubin concentration was 4.3 mg/dl (normal; 0.2to 1.0 mg/dl). ERCP showed bile leakage from the cystic duct–CBD junc-tion (Fig. 4). ENBD was performed and continued for 10 days. ERCP 10days later did not show any bile leakage from or stenosis of the CBD (Fig.5). The patient improved rapidly and had no complaints after the proce-dure.

Discussion

The superiority of LC over OC has been evidenced by thelower complication rate of this new gold-standard opera-Correspondence to:K. Hanazaki

Surg Endosc (1997) 11: 1123–1125

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tion. However, bile duct injury is always a potential com-plication of cholecystectomy [6]. The treatment of bile leak-age after OC by EST or stent placement has been reportedto yield acceptable results, especially when the patient isreferred early [7]. Several recent reports have suggested thatERCP with sphincterotomy and stenting is an effectivetreatment for a bile leak after LC [5, 14]. In these studies,success rates as high as 83 to 100% were reported. Theseresults show that the guidelines for decompression of thebiliary tree after OC can also be applied after LC.

In the case presented here, IOC was not performed be-cause of the severe inflammatory changes in the wall of thecystic duct–CBD junction. Therefore, bile leakage was not

detected intraoperatively. Postoperatively, the patient hadabdominal symptoms with bilious drainage and cholestasis.The leak was confirmed by ERCP and treated by ENBD.The clinical presentation of postoperative bile duct injury ischaracterized by cholestasis, jaundice, persistent bile leak-

Fig. 1. Chest radiograph showing bowel gas under the right hemidia-phragm.

Fig. 2. Abdominal computed tomography revealing interposition of thebowel between the liver and the diaphragm.

Fig. 3. Helical computed tomography revealing bowel shadows anterior tothe gallbladder without anomalies of the cystic duct–common bile ductjunction.

Fig. 4. Postoperative endoscopic retrograde cholangiopancreatographyshowing bile leakage from the cystic duct–common bile duct junction.

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age through abdominal drains, and sepsis [4]. More impor-tant, however, is the occasional occurrence of an initialsymptom-free period, which can be misleading. This symp-tom-free period can last for several days to weeks, afterwhich the patient develops cholestasis [5]. In our case, aPenrose drain which had been placed through a subcostaltrocar site revealed the bile leak at an early stage. Thus, itcould be argued that a drain should be placed in the gall-bladder bed in the uneventful LC.

In the endoscopic treatment of bile leaks after LC, allpreviously reported patients have been treated by EST and/or stent placement following ERCP. Lin et al. [9] havereported that ENBD is an effective treatment for acute, cal-culus, and suppurative cholangitis. Emergency decompres-sion of the CBD is a life-saving procedure for patients withperitonitis due to a bile leak or suppurative cholangitis. Werecommend ENBD prior to other forms of decompression.EST and stent placement should be employed only afterclinical improvement is seen with ENBD. Interventionalendoscopic techniques are technically more difficult andrequire more time than ENBD.

Of particular interest, our patient also had Chilaiditi’s

syndrome [6]. This condition, which is characterized byinterposition of small or large bowel between the liver anddiaphragm, is a rare anomaly [10, 12]. The incidence rangesfrom 0.025 to 0.28% in the general population, and in-creases with age, occurring in about one of 50,000 adults[10]. There have been no previous reports of LC in patientswith cholecystitis and Chilaiditi’s syndrome. The laparo-scopic removal of the bowel from between the liver and thediaphragm was not difficult. There appears to be no absolutecontraindication to LC in patients with cholecystitis andChilaiditi’s syndrome. It has recently been reported that thissyndrome may be associated with abdominal complaintswhich could require an emergency or elective operation [1,2, 10, 12]. Consequently, further study is necessary to de-fine the indications for LC in these patients.

In conclusion, ERCP is a powerful diagnostic and thera-peutic tool in the management of laparoscopic biliary inju-ries. ENBD following ERCP may be the first choice foremergent decompression to prevent peritonitis from bileleakage.

References

1. Bishop CCR, Whitehead SM, Jackson BT (1987) Misdiagnosis of theChilaiditi’s syndrome. Br Med J 295: 1655

2. Brenner M, Penschuck C (1981) Incarcerated Chilaiditi disease. A rareindication for surgery. Chirurg 52: 454–456

3. Chilaiditi D (1910) Zur Frage der Hepatoptose und Ptose im allge-meinen im Anschluss an drei Falle von temporarer, partieller Leb-erverlagerung. Fortschr Gediete Rontgenstr Nuklearmed 16: 173–208

4. Collins PG, Goey TF (1984) Iatrogenic biliary stricture: presentationand management. Br J Surg 71: 900–902

5. Davids PHP, Ringers J, Rauws EAJ, de Wit LT, Huibregste K, van derHeyde MN, Tytgat GNJ (1993) Bile duct injury after laparoscopiccholecystectomy: the value of endoscopic retrograde cholangiopan-creatography. Gut 34: 1250–1254

6. Jatzko GR, Lisborg PH, Pertl AM, Stettner HM (1995) Multivariatecomparison of complications after laparoscopic cholecystectomy andopen cholecystectomy. Ann Surg 221: 381–386

7. Kozarek RA, Traverso LW (1991) Endoscopic stent placement forcystic duct leak after laparoscopic cholecystectomy. Gastrointest En-dosc 37: 71–73

8. Larson GM, Vitale GC, Casey J, Evons JS, Gilliam G, Heuser I,McGee G, Kao M, Scherm MJ, Voyles CR (1991) Multipractice analy-sis of laparoscopic cholecystectomy in 1983 patients. Am J Surg 163:221–226

9. Lin XZ, Chang KK, Shin JS, Lin CY, Lin PW, Yu CY, Chou TC(1993) Emergency endoscopic nasobiliary drainage for acute calculoussuppurative cholangitis and its potential use in chemical dissolution. JGastroenterol Hepatol 8: 35–38

10. Risaliti A, De Anna D, Terrosu G, Uzzau A, Carcoforo P, BresadolaF (1993) Chilaiditi’s syndrome as a surgical and nonsurgical problem.Surg Gynecol Obstet 176: 55–58

11. Scott TR, Zucker KA, Bailey RW (1992) Laparoscopic cholecystec-tomy: a review of 12397 patients. Surg Laparosc Endosc 2: 191–197

12. Takagi Y, Abe T, Nakada T, Matsuura H, Yasuda K (1995) A case ofChilaiditi’s syndrome associated with strangulated volvulus of the sig-moid colon. Am J Gastroenterol 90: 1905

13. The Southern Surgeons Club (1991) A prospective analysis of 1518laparoscopic cholecystectomies. N Engl J Med 324: 1073–1078

14. Vitale GC, Stephens G, Wieman TJ, Larson GM (1993) Use of endo-scopic retrograde cholangiopancreatography in the management of bil-iary complications after laparoscopic cholecystectomy. Surgery 114:806–814

Fig. 5. Endoscopic retrograde cholangiopancreatography 10 days after en-doscopic nasobiliary drainage did not show bile leakage or stenosis of thecommon bile duct.

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Letters to the editor

A simple and useful method for retracting the left liver lobe

The left lobe of the liver needs to be constantly retractedupward while laparoscopic dissection of the esophageal hia-tus is being performed in a variety of operations, such asvagotomy, fundoplication, and esophageal myotomy. Manysurgeons advocate using the suction and irrigation tubepassed through the subxiphoid or the right subcostal trocarfor retraction [2, 3, 5]. Different types of liver retractors,either expandable or malleable [1, 2, 4], have been de-signed. However, these various techniques carry disadvan-tages of one form or another, including the serious risk ofinadvertent liver laceration, the need for an extra pair ofhands (or a mechanical arm to maintain it in position), or therequirement of expensive instruments which have to bepassed through 10-mm ports.

A simple technique using the readily available graspingforceps is described. A self-locking atraumatic graspingforceps is inserted through an epigastric 5-mm trocar about5 cm from the xiphisternum. With the left lobe of theliver elevated by another forceps inserted through a lateralworking port, the grasping forceps is advanced into thehiatal area to grasp the uppermost muscle fibers of thecrus of the diaphragm (or above). Liver retraction andexposure of the hiatus could be further enhanced by de-pressing the handle of the grasper. The locked grasper, oncepositioned optimally, may be held in place automaticallyby securing it to the surgical drapes using a towel clip(Fig. 1).

This technique has added advantages, such as small portwound, elimination of the risk of instrumental injury to theliver, and unimpeded movement of the working instrumentsboth inside and outside the abdominal cavity. It has beensuggested in one surgical text that in the absence of a spe-cially designed liver retractor, it might be necessary to di-vide the triangular ligament of the left liver lobe [1]. Thedescribed technique affords excellent exposure and obviatesthe need for detaching the diaphragmatic connections of theleft lobe of the liver.

W.T. NgH.C. Yeung

Department of SurgeryYan Chai HospitalTsuen WanHong Kong

Fig. 1. The left liver lobe is retracted upward by a grasping forceps. Noteits tip holds onto the diaphragm while its handle is held in place by beingsecured to the surgical drapes using a towel clip.

SurgicalEndoscopy


References

1. Bailey RW, Zucker KA (1993) Laparoscopic management ofpeptic ulcer disease. In: Zucker KA, Bailey RW, Reddick (eds) Surg-ical laparoscopy update. Quality Medical, St Louis, MO, pp 241–86

2. Dubois F (1992) Laparoscopic vagotomy. In: Cushieri A, Buess G,Perissat J (eds) Operative manual of endoscopic surgery. Springer-Verlag, Berlin, pp 254–262

3. Katkhouda N, Mouiel J (1991) A new technique of surgical treatment ofchronic duodenal ulcer without laparotomy by videocoelioscopy. Am JSurg :361–364

4. Martin IG, Dexter SPL, Marton J, Gibson J, Asker J, Firullo A, Mc-Mahon MJ (1994) Fundus-first laparoscopic cholecystectomy. Surg En-dosc 9: 203–206

5. Reters J, DeMeester T (1994) Minimally invasive surgery of the foregut(minimally invasive approaches to ulcer therapy). Quality Medical, St.Louis, MO

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Transcystic biliary decompression after direct laparoscopic explorationof the common bile duct

C. Hensman, G. Crosthwaite, A. Cuschieri

Department of Surgery and Surgical Skills Unit, Ninewells Hospital and Medical School, University of Dundee, Tayside DD1 9SY, Scotland


AbstractBackground:A purpose-designed transcystic common bileduct (CBD) decompression cannula is described for use asan alternative to T-tube insertion following laparoscopicdirect CBD exploration. This permits safe primary closureof the choledochotomy.Methods: Following direct supraduodenal laparoscopicclearance of large common bile duct stones, the biliary de-compression cannula is inserted percutaneously inside itspeel-away sheet over a guide-wire into the CBD via thecystic duct. When in place, the cannula is secured to thecystic duct by two catgut extracorporeal Roeder knots andthe choledochotomy is then closed. The terminal multiper-forated S-shaped segment of the Cuschieri biliary decom-pression cannula prevents postoperative dislodgement.Results:Transcystic decompression of the extrahepatic bil-iary tract using the Cuschieri cannula has been used in 12patients who underwent laparoscopic supraduodenal CBDexploration for large or occluding stones. There was noinstance of postoperative dislodgement of the cannula andall patients had effective drainage of the common bile duct(average 300 ml bile per 24 h). The procedure was uncom-plicated in all but one patient who developed self-limitingleakage from the CBD suture line in the early postoperativeperiod. The median hospital stay after surgery was 4 days,with a range of 3 to 10 days. The cystic duct decompressioncannula was capped and sealed under an occlusive dressingat the time of discharge. Removal of the cannula was carriedout without any complications as a day case 11–16 daysafter surgery.Conclusions:Transcystic biliary decompression is safe andeffective. The experience with is use indicates that com-pared to T-tube drainage, transcystic decompression mayaccelerate recovery and reduce the hospital stay in patientsfollowing laparoscopic direct exploration of the CBD. Itsinsertion is less technically demanding than placing a T-tube through the choledochotomy. Transcystic decompres-

sion with complete primary closure of the CBD realizes thefull benefits of the single-stage management of commonbile duct calculi and permits confirmation of complete stoneclearance after surgery.

Key words: Common bile duct — Transcystic biliary de-compression — Direct laparoscopic exploration

Several reported studies have revealed the feasibility,safety, and efficacy of open single-stage laparoscopic treat-ment of patients with gallstones who also harbor ductalcalculi [1, 2, 6, 7, 10, 11, 14, 15]. The preliminary findingsof a randomized, controlled clinical trial show documentedadvantages, i.e., reduced hospital stay and avoidance of un-necessary ERCP with single-stage surgical managementcompared to the two-staged approach [5]. Whenever pos-sible, the transcystic technique is used to achieve ductalclearance laparoscopically, but when this fails, and in thepresence of large occluding calculi, a laparoscopic supra-duodenal exploration of common bile duct (CBD) isneeded. Following clearance, most laparoscopic surgeonsclose the choledochotomy around a T-tube as in open sur-gery. This appears to delay recovery, and in the EAESstudy, the median hospital stay of patients treated by lapa-roscopic direct CBD exploration was 10 days as opposed to5.5 days after transcystic clearance [5]. The use of a T-tubeto drain the CBD following laporoscopic exploration istechnically demanding and reduces the benefits of the mini-mal access approach.

Primary closure of the CBD without decompressiondrainage is practiced by some laparoscopic surgeons but thisis not considered orthodox practice for two reasons. In thefirst instance, manipulations inside the lower end of theCBD are followed by temporary obstruction due to periam-pullary edema in the first few days after surgery [9]. Sec-ondly, primary closure without decompression precludespostoperative cholangiography to confirm complete ductalclearance.Correspondence to:A. Cuschieri

Surg Endosc (1997) 11: 1106–1110

SurgicalEndoscopy


For many years during open biliary surgery, we havepracticed decompression of the CBD after direct explorationby inserting a cannula into the CBD followed by primaryclosure of the duct [3]. This practice has been extended tolaparoscopic duct exploration. Initially, we used an infantenteric feeding Portex tube (Fr. 7) for this purpose [16] butencountered problems with dislodgement of the tube post-operatively in some patients. This led to the design of alaparoscopic cystic duct biliary decompression cannulawhich overcomes this problem and provides more efficientdrainage. This paper reports our experience in patients un-dergoing laparoscopic direct CBD exploration with cysticduct decompression of the biliary tract and primary closureof the supraduodenal choledochotomy.


Laparoscopic CBD drainage catheter set

The Cuschieri biliary decompression set (Cook Surgical, Bloomington,U.S.A) consists of a specially designed 1-m-long silicon cannula with aluer lock connection at the proximal end and a distal perforated S-shapedsegment with a terminal opening. The S bend prevents postoperative dis-lodgement of the functional segment of the cannula from the CBD whilethe multiple perforations ensure efficient bile drainage. The cannula isavailable in three sizes—Fr. 5, 7, 8. The biliary decompression cannula wasdesigned for percutaneous insertion and its deployment system consists of

a needle, a 0.035-mm floppy guide-wire, a dilator, and a peel-away sheath(Fig. 1A,B).

Technique of insertion and fixation of cannula

Following supraduodenal exploration of the CBD and confirmation ofstone clearance by flexible choledochoscopy, the needle and guide-wire areinserted through the parietes in a suitable site in the right flank. The needleis then removed, leaving the guide-wire in situ. The dilator with the peel-away sheath is introduced into the peritoneal cavity over the guide-wire(Fig. 2). The dilator is then replaced by the biliary decompression cannula,which is threaded over the guide-wire and through the peel-away sheath. Alength of guide-wire (circa 5.0 cm) is inserted into the cystic duct andthence into the CBD, and the biliary decompression cannula is then rail-roaded by means of a grasper over it until the perforated S-shaped terminalsegment is beyond the cystic–common duct junction (Fig. 3). The guide-wire is then removed and a saline syringe is attached to the luer externalfitting of the cannula. The position of the terminal segment of the decom-pression cannula inside the CBD is checked through the choledochotomy,and if correct, the cannula is fixed to the cystic duct and to the parietes.Fixation of the drainage cannula to the cystic duct is achieved by twoRoeder 0-gauge chromic catgut knots (Fig. 4). The first is close to thecystic duct–CBD junction [12]. The second Roeder knot is placed a fewmillimeters further laterally. Saline irrigation through the cannula is main-tained during the locking of the Roeder knots by the push rod to preventovertightening and occlusion of the cannula. A loose loop of cannula is leftbetween the cystic duct fixation point and the parietes before the cannulais secured externally to the skin near the exit hole by two nonabsorbablesutures.

Closure of the choledochotomy

Saline irrigation is maintained during closure of the choledochotomy,which is carried out with interrupted or continuous 4/0 Polysorb (USSC,Norwalk, CT, USA) mounted on a ski needle using an intracorporealmicrosurgical technique [4] (Fig. 5). On completion, the common duct isflushed through the transcystic cannula to check for leaks and a completioncholangiogram is performed. If this confirms ductal clearance, the cysticduct is transected between the lateral catgut ligature and the clipped neckof the gallbladder. A silicon subhepatic drain leads to the closed choledo-chotomy.

Patients

Twelve patients, two males and three females, aged 54–72 years, all withlarge CBDs, underwent laparoscopic supraduodenal CBD during laparo-

Fig. 1. aCuschieri transcystic biliary decompression set.b Close-up of theS-shaped terminal segment.

Fig. 2. The drainage cannula is threaded over the guide-wire into theperitoneal cavity.

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scopic cholecystectomy with primary closure of the choledochotomy anddecompression of the biliary tract by means of a cystic duct decompressioncannula. All had clinical jaundice with raised alkaline phosphatase at thetime of the intervention. Preoperative ultrasound examination confirmed adilated intrabiliary tree. All patients were ASA category I or II and nonehad clinical evidence of ascending cholangitis. Two patients had undergoneunsuccessful endoscopic stone extraction due to inability to cannulate thebile duct. Preoperative preparation was with intravenous cystalloid hydra-tion, bladder catheterization, and forced diuresis with mannitol. An intra-muscular injection of synthetic vitamin K analogue was administered 24–48 h after surgery. All patients received single-dose antibiotic prophylaxisduring induction of general anesthesia. The tube cholangiogram was re-peated postoperatively in all the patients.

Results

Operative outcome

The triangle of Calot was dissected in a standard fashionutilizing the four-port Dundee technique [13]. When the

surgeon was confident of the anatomy, the cystic artery wasdouble clipped and divided. Cystic duct fluorocholangiog-raphy using a digitized C-arm was performed using a Fr. 4or 5 ureteric catheter inside a cholangiogasper (Storz, Tut-tlingen, Germany) in all patients. The biliary radiologicalpathology is outlined in Table 1.

The technique of CBD stone clearance varied. Only theanterior aspect of the CBD was dissected and stay sutureswere not used. The peritoneum and underlying fascial layerover the supraduodenal portion of the CBD was divided anda longitudinal choledochotomy was performed. The size ofthe opening in the CBD was always smaller by approxi-mately 30% than the largest stone in the individual patient.Because of the high elastin content of the CBD, a choledo-chotomy can be stretched to allow delivery of a stone. Theadvantages of a small choledochotomy include less devacu-larization and reduced suturing time. The ductal calculiwere cleared from the CBD by various means. Bimanualcompression of the duct from below using two atraumaticgraspers with massage of the stones into and then out of thecholedochotomy was successful in five; Fogarty balloondislodgement occurred in six; and one patient required avisually guided Dormia basket extraction using a 5-mmflexible choledochoscope (Storz, Tuttlingen, Germany).Following ductal stone extraction, all patients had comple-tion choledochoscopy, which indicated total clearance in 11patients. In one patient a missed stone was located near thecommon hepatic bifurcation and was removed at the sameprocedure.

Postoperative course

The cystic duct cannula was left on free drainage for thefirst 48 h utilizing a closed drainage system. The averageoutput of bile via the biliary decompression cannula was300 ml per 24 h period. The subhepatic drain was removedon the 3rd day in all but one patient (day 8).

A postoperative cholangiogram was performed in allpatients via the cystic duct cannula 48 h post surgery (Fig.6). The cystic decompression cannula was sealed and cov-

Fig. 3. Insertion of decompression cannula held in a grasper through thecystic duct over the guide-wire.

Fig. 4. Fixation of the biliary decompression cannula to the cystic duct bycatgut Roeder knots.

Fig. 5. Closure of the choledochotomy.

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ered with an occlusive dressing in 11 patients as the chol-angiogram was normal and there was no bile drainage fromthe subhepatic drain. The subhepatic drain was removed thenext day (3rd day). In one patient the cholangiogram dem-onstrated leakage from the CBD suture line. This was ac-companied by bile drainage from the subhepatic drain. Thiscomplication was managed conservatively as ultrasound ex-amination showed no internal collection and the patient wasafebrile. The bile leakage dried up within 8 days. Anotherpatient developed patchy atelectasis which progressed to achest infection requiring antibiotic treatment. The medianhospital stay was 4.0 days with a range of 3 to 10 days and80% of patients were discharged within 5 days post surgery.The patients returned to hospital for removal of the cysticduct drainage cannula 11–16 days after surgery and werekept for observation in hospital for a period of 3–4 h. Nonedeveloped any symptoms of bile leakage into the peritonealcavity during this observation period or thereafter.

Discussion

This experience with the Cuschieri cystic duct biliary de-compression cannula as an alternative to T-tube drainagehas demonstrated that the technique is safe and easy todeploy. The provision of an effective decompression of thebiliary tract is demonstrated by a low suture-line bile leak-age rate of 8% despite the narrow caliber of the system (Fr.5–8).

The placement of a T-tube after direct supraduodenalCBD exploration is technically demanding and time con-suming. It carries a significant morbidity due to dislodge-ment and infection, which may delay discharge from hos-pital. Furthermore, T-tube drainage of narrow ducts cancontribute to late stricture formation [8]. Although there areno comparative data, T-tube insertion after laparoscopic di-rect CBD exploration appears to detract from the advan-tages of the minimal access approach. The median postop-erative stay of 10.5 days observed in the EAES trial [5] isindicative of this detrimental effect.

Previous debimetric studies have documented a tempo-rary hold-up at the lower end of the CBD due to sludge,fibrin debris, or edema following manipulations to extractductal calculi [9]. Thus temporary decompression is advis-

able in the prevention of postoperative bile leakage from thecholedochotomy suture line. In addition, the postoperativetube cholangiogram provides the only reliable means fordetecting retained stones. Thus, although some surgeonshave practiced primary repair after laparoscopic direct CBDexploration, this cannot be regarded as standard orthodoxsurgical practice. Decompression of the biliary tract by thetranscystic cannula facilitates closure of the choledo-chotomy, because, contrary to T-tube insertion, there is nolong tube in front of the suture line. The closure of the bileduct either by continuous or interrupted suturing is thusquicker and more precise.

The cystic duct biliary decompression cannula alsoserves as a safe access to the CBD for subsequent imagingor intervention. If retained ductal stones are documented inthe postoperative period, flushing, fluoroscopic basket ex-

Table 1. Common duct pathology at operation

Sex, age(years)

CBD diameter(mm)

No. ofCBD stones

Stone size(mm)

F, 54 15.0 1 20F, 62a 12.0 4 8–15M, 49 10.0 3 6–12F, 68 20.0 8 10F, 54 15.0 3 5–11M, 69 18.0 1 15F, 46 11.0 5 10F, 72a 18.0 6 6–15F, 61 12.0 2 8–10F, 52 15.0 7 10F, 51 11.0 4 8F, 57 16.0 3 12

a Failed attempts at endoscopic stone extraction

Fig. 6. Postoperative cholangiogram.

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traction by the Burhenne technique, or lithotripsy all con-stitute viable management options. If endoscopic stone ex-traction is preferred, the insertion of a guide-wire throughthe cannula into the bile duct and then the duodenum willserve as an excellent guide for the endoscopic sphincterot-omy. The cannula was designed specifically with this inmind.

The cystic duct decompression cannula can also beplaced in the CBD as a means of safe access in patientswhen there is doubt about the clearance of stones after tran-scystic exploration of the CBD.

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