Laparoscopic partial hepatectomy

This article describes the surgical techniques and indications of laparoscopic partial hepatectomy, which is not as widely available as laparoscopic cholecystectomy. Three patients with hepatocellular carcinoma and associated severe liver cirrhosis were candidates for this technique from July 1993 to August 1994. The tumor size was 4 cm or less and all the tumors were located in segment 5 or 8 which had grown nodularly and protruded from the liver surface. A microwave tissue coagulator was used for parenchymal dissection under ultrasonographic guidance in a gas-less method with or without low-pressure pneumoperitoteum of 4 mmHg. The principle of dissection consists of tissue coagulation and fragmentation with dissecting forceps. Three hepatectomies were performed uneventfully without blood transfusion and the patients rapidly returned to their preoperative conditions. The laparoscopic partial hepatectomy can be an option of treatment in selected cases where the tumor can be removed by minor, superficial resection.     

Activation of coagulation and fibrinolysis in open and laparoscopic cholecystectomy

BACKGROUND: Activation of coagulation and fibrinolysis occurs as a stress response to surgery and may predispose the patient to thromboembolic complications. Other components of the surgical stress response (cytokine release, neurohumoral response, etc.) have been shown to differ between laparoscopic and open cholecystectomy, and the aim of this study was to investigate the effects of laparoscopic and open surgery on the coagulation and fibrinolytic pathways. METHODS: Fourteen patients undergoing laparoscopic cholecystectomy and 12 patients undergoing open cholecystectomy had blood taken in the perioperative period for fibrinopeptide A (FPA) prothrombin fragment F1.2, antithrombin 3, tissue plasminogen activator (tPA) and its fast-acting inhibitor plasminogen activator inhibitor-1 (PAI-1 antigen and activity), and the euglobulin clot lysis time (ECLT). RESULTS: The only significant differences between the two groups occurred 6 h after surgery when the ECLT was longer (p < 0.005; Mann Whitney), and PAI-1 antigen and activity were higher (p < 0.01 and p < 0.001, respectively; Mann Whitney) after open cholecystectomy than laparoscopic cholecystectomy. CONCLUSIONS: Other changes in fibrinolysis and coagulation were similar for open and laparoscopic cholecystectomy. With respect to hemostasis, laparoscopic cholecystectomy does not increase the risk of thromboembolic complications compared to the conventional procedure.     

An ultrasonic scalpel for laparoscopic gynecologic surgery

In order to obtain good results in laparoscopic surgery the surgeon should be well trained and experienced and the equipment perfect. The recent innovation in laparoscopic surgery is the ultrasonically activated scalpel. Scissors make the working part of scalpel with one hand vibrating 55,000 Hz in a second. The effect reflects in braking hydrogen links and denaturation of proteins in instant haemostasis and coagulation in blood vessels, and there is no need of tying them up. Practically, there is no damaging of the surrounding tissues. The technique is easy to use. When performing laparoscopic vaginal hysterectomy and adnexectomy the ligamentum infundibulopelvicum and ligamentum rotundum are cut, and there the blood vessels are not thicker than 3 millimeters. As these ligaments are easy to reach with ultrasonically activated scalpel, we can say that this instrument is the ideal option for laparoscopic vaginal hysterectomy.     

Ultrastructural study of peripheral nerve injury induced by monopolar and bipolar diathermy

The effect of unipolar and bipolar electrocoagulation on human and albino rat peripheral nerves was examined by transmission electron microscopy. The greater auricular nerve obtained from operated patients and the femoral nerve of an albino rat were chosen for this study. The nerves were divided into three groups: controls, segments of nerves spot-coagulated with unipolar instruments, and segments of nerves spot-coagulated with bipolar instruments. Significant cell injury, expressed by marked damage of the Schwann cells, was induced by unipolar coagulation in both myelinated and unmyelinated nerves, in humans as well as in the albino rat. However, in bipolar-treated nerves, the Schwann cell architecture remained well preserved in both types of nerves. The results are in favor of bipolar electrocoagulation when applied in areas rich in neurovascular supplies.     

Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation

OBJECTIVE: To determine the long-term results of laparoscopic fenestration and coagulation of ovarian endometriomas and to compare them with the results of ovarian cystectomy performed by either laparotomy or laparoscopy. DESIGN: Case-control study. SETTING: Two university-affiliated hospitals. PATIENT(S): One hundred fifty-six premenopausal women with ovarian endometriomas of at least 3 cm in diameter (stage 3 and 4 endometriosis, revised American Fertility Society classification). INTERVENTION(S): Laparoscopic ovarian fenestration and coagulation (group 1, 80 patients); laparoscopic ovarian cystectomy (group 2, 23 patients); and ovarian cystectomy by laparotomy and microsurgical technique (group 3, 53 patients). MAIN OUTCOME MEASURE(S): Operative findings, recurrence rate, and cumulative clinical pregnancy rate (PR) over a 36-month follow-up period. RESULT(S): The mean (+/-SD) time to first pregnancy was significantly shorter in group 1 (1.4+/-0.2 years) than in group 2 (2.2+/-0.5 years) or group 3 (2.4+/-0.5 years). The difference between the cumulative clinical PR between the three groups was not statistically significant after 36 months of follow-up. The difference in the recurrence rate among groups 1, 2, and 3 was not statistically significant. CONCLUSION(S): Laparoscopic ovarian fenestration and coagulation of endometriomas leads to faster conception than ovarian cystectomy by laparotomy. Laparoscopic ovarian fenestration and coagulation of endometriomas is associated with cumulative clinical PRs and recurrence rates over 36 months that are similar to those associated with ovarian cystectomy.     

Haemostasis after partial hepatectomy using argon beam coagulation

The argon beam coagulator is a new device for haemostasis during and after surgery on parenchymatous organs. No data are available on its efficacy and tissue effect following hepatic resection. Blood loss, the time needed to achieve adequate haemostasis and histological findings after liver resection were assessed in 12 pigs using argon beam coagulation or suture ligation only, the mattress suture technique and tissue glue application. The treatment was randomly assigned to each of the four liver lobes in each pig. Median blood loss following argon beam coagulation was 13 (range 2-47) ml and after simple suture ligation 55 (range 2-260) ml (P < 0.02). The median time needed for adequate haemostasis following argon beam coagulation was 3 (range 2-7) min versus 14 (range 2-48) min in the control group (P < 0.005). There was no difference between argon beam coagulation and tissue glue, which were both superior to the use of mattress sutures. Argon beam coagulation resulted in less tissue damage than tissue glue or mattress suturing. The argon beam coagulator is an efficient device for achieving haemostasis following partial hepatectomy in the pig. It causes only a moderate tissue reaction.     

Perinephric abscess (presenting as abdominal pain) due to Listeria monocytogenes

The development of a haematoma after wide excision of breast tumours is not uncommon. Suction drainage is commonly used to prevent this but often increases the hospital stay and can create unsightly wounds. Argon beam coagulation is a new technique which permits large 'raw' areas to be coagulated with minimal tissue damage. We believe that this technique may reduce the development of haematomas and seromas after breast surgery. We present our initial results using argon beam coagulation after wide excision of breast tumours in 80 patients without suction drainage. One patient required a single aspiration of a seroma at the site of breast lump excision and none required surgical drainage. Argon beam coagulation appears a useful adjunct in breast surgery and may help reduce hospital stay.     

Laparoscopic colo-rectal surgery

Laparoscopic colorectal surgery was less invasive for patients although it was difficult to perform complete resection of colon combined with regional lymph node. The skillful manner of the laparoscopic surgery was required for the surgical team. The laparoscopic equipments, in order to perform curative dissection of mesenterium and intermediate lymph node, such as Ultrasonic-aspiration surgical unit (USU) or Harmonic scalpel laparoscopic coagulation shears (LCS), were useful for safer dissection of D2 regional lymph node. Meticulous manner of grasping forceps and special dissectors was made sufficient lymph node dissection. The reconstruction of extracorporeal anastomotic technique by hand or valtrac (biofragmentable anastomosis ring) were safer manner for anastomosis after resection of the right side colon. Reconstruction by double stapling technique of linear stapler and circular stapler was admired for anastomosis for left side colonic and rectal surgery. We had safely performed locar resection in 3, partial resection with Do dissection in 2, with D1 dissection in 14, with D2 dissection in 21 and right and left hemicolectomy in 1 each.     

Description of a laparoscopic technique for treating patients with ovarian remnant syndrome

OBJECTIVE: A retroperitoneal approach for laparoscopic treatment of ovarian remnant syndrome was developed. DESIGN: Clinical study. SETTING: Department of Gynecology, Friedrich-Schiller-University Jena. PATIENT(S): During a 29-month period, seven consecutive patients with ovarian remnant syndrome were treated by laparoscopy. Patients were not preselected and preoperative, intraoperative, and postoperative data were registered prospectively. INTERVENTION(S): For removal of remnant ovaries we used a laparoscopic retroperitoneal approach that included complete dissection of the pelvic course of the ureter and coagulation and dissection of the infundibulopelvic ligament and of the uterine vessels. RESULT(S): In the first patient's case, the right ureter was injured during dissection, which was initiated too far distally between ovary and external iliac vessels. Thereafter, we changed our technique to start the dissection of the ureter at the pelvic brim. No subsequent patient had an intraoperative or postoperative complication. All patients reported fewer preoperative complaints and were free of recurrence by sonographic examination. CONCLUSION(S): Using a retroperitoneal approach laparoscopic resection of a remnant ovary may be a safe and effective technique.     

Laparoscopic splenectomy. How to make it easier using an innovative atraumatic suction grasper

BACKGROUND: With the evolution of laparoscopic surgery comes the need for specific instruments that apply traction to parenchymal tissue, like the spleen, without exposing the organ to the associated high risk of bleeding. To meet this need, we designed and developed a suction-cup grasper that allows easy grasping and manipulation of the spleen. Some of the difficulties usually encountered during laparoscopic splenectomy may be overcome by using this device. MATERIALS: The instrument consists of a cone-shaped, silicone rubber suction cup designed with an antislip internal surface. The cup is connected to a support arm with a flexible distal end that can be rotated. Traction is exerted with a commonly available suction system. The device is inserted through a 12-mm-diameter guide sheath. RESULTS: The two interventions performed with the atraumatic device were completed with laparoscopic technique. No complications arose during or after the operations. The average operating time was 110 min. The patients were discharged after 4 and 5 days postoperative, respectively. CONCLUSIONS: As a device specifically designed for grasping parenchymal organs, the atraumatic suction grasper affords the operator a faster and safer technique in laparoscopic splenectomy.     

One year follow-up of pulmonary rehabilitation in patients with pulmonary emphysema--physiological outcome

BACKGROUND AND STUDY AIMS: Laparoscopy combined with guided liver biopsy offers many advantages in the diagnosis and staging of chronic liver diseases and is superior to other diagnostic procedures. We developed a new minilaparoscopic technique and evaluated the utility of this minimally invasive laparoscopic system in the first 320 patients who underwent diagnostic assessment for liver disease or peritoneal carcinosis. PATIENTS AND METHODS: Between July 1996 and February 1998, minilaparoscopy, with analgesia and sedation was carried out in 320 patients. It was done using a 1.9-mm optical instrument, which was inserted through the same 2.75-mm trocar as the Veress needle used for inflating the pneumoperitoneum. Thus only a single puncture of the peritoneum was required. Liver biopsies, when indicated, were obtained under laparoscopic control with the Silverman needle through a short 2-mm additional trocar when the Menghini technique was used. RESULTS: Complication rates, patient discomfort and duration of procedure were extremely low with minilaparoscopy. We observed no serious complications, two complications that could be treated conservatively and technical difficulties in eight of 320 patients, which prevented liver biopsy in 2.8%. These minor difficulties all happened during the first 40 procedures, whereas after the initial 40 examinations of each investigator no further difficulties arose. CONCLUSIONS: This new minilaparoscopic technique allows a macroscopic and histological diagnosis of liver disease with minimal invasiveness, easy handling, excellent patient tolerance, and also a high degree of safety in patients with coagulation defects. Exploratory laparoscopy is an accurate and safe method for intra-abdominal diagnosis of liver diseases and peritoneal carcinosis.     

Laparoscopy-guided biopsy in diagnosis of liver disorders in children

To determine the safety and advantages of laparoscopic liver biopsy in pediatric liver disorders, we reviewed the medical records of 80 children affected by liver disease of various etiologies who underwent this procedure from 1986 to 1996. The main indicators for laparoscopic biopsy were increased risk of bleeding (i.e., mild to moderate coagulation abnormalities in patients probably affected by cirrhosis) and/or previous poorly informative blind needle liver biopsy (65 cases), and the need for a large amount of liver tissue for biochemical assays (10 cases). After inspection of the liver surface, at least two core biopsies were performed using a Tru-cut needle. We encountered difficulties with the biopsy in only four cases, due to a hard consistency of the liver. Bleeding time from the liver orifice was greatly reduced by positioning a fibrin plug (50-120 s vs 5-10 s, on average). In 15 patients, a large excisional biopsy was also successfully performed. Our results confirm an important role for laparoscopy in the diagnosis of cirrhosis (30% of bioptic false negative diagnoses in this series) and show that in selected cases laparoscopy-guided needle or excisional biopsy is an easy, useful and safe alternative to percutaneous blind liver biopsy.     

Linkage between inflammation and coagulation: an update on the molecular basis of the crosstalk

Inflammation and coagulation cannot be considered as two separate processes, since there are several connecting points making them part of unique, defensive host response. The endothelium can be considered as the first link between inflammation and coagulation, since damaged endothelium during inflammation represents a surface where proteins involved in both coagulation and the development of inflammation are expressed. During inflammation, cytokines modulate the coagulation system by downregulating the expression of thrombomodulin and the activation of protein C pattern but, at the same time, they induce the expression of tissue factor, modifying, in this way, the balance between procoagulant and anticoagulant activities. At the same time, at the site of tissue injury, platelets become activated and release several mediators that modify tissue integrity. Thrombin, formed following activation of the coagulation cascade, is essential to promote haemostasis but also stimulates several cell functions, including chemotaxis and mitogenesis, which are responsible for the spreading of the lesion and the tissue repair process. Therefore, in the study of inflammation the involvement of the coagulation pathway has to be taken into account, since the interaction between coagulation and inflammation pathways is a critical issue.     

A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.     

Dynamic interstitial laser application for therapy of secondary liver tumors. An animal experiment study

Laser-induced interstitial thermotherapy (LITT) is a promising method of treating different types of tumors. To increase the effectiveness of LITT, a new thermo-controlled application system for minimal invasive intervention was designed. This laser system consists of a laser applicator 3 mm in diameter, insertion equipment and an Nd:YAG laser source. The power of the laser source is controlled dynamically by thermosensors in a water-cooling system of the laser applicator. In in vivo experiments in five pigs, within 10 min we found homogeneous coagulation regions in the liver that were of 3 cm and 5 cm in diameter. Via ultrasound we observed in real time the increasing coagulation zone that appeared as a hyperechogenic halo. However, due to perifocal edema, the real coagulation area was smaller than detected by ultrasound. Macroscopically and microscopically, the coagulation zones showed well-demarcated borders of the coagulation lesions, and the surrounding tissue appeared vital. The reparative reaction after irradiation was early fibrosis. In the course of 4 weeks, the surrounding scar capsule, containing fibrocytes, biliary ductules and collagen fibers enlarged. As a result, the coagulation necrosis became more and more fragmented between collagen fibers and was largely resorbed. The absence of complications in our animal experiments suggest that the technique of thermo-controlled laser light application is safe and useful in therapy for metastases that are not resectable.     

Laparoscopic anti-reflux surgery--report of experiences from Germany

This is a report on a questionnaire in Germany reflecting the activity in antireflux surgery, both in open and laparoscopic modifications in the time period of 1990 through 1995. It serves as an overview of the acceptance of diagnostic workup, indication, applied techniques, and different antireflux procedures. In a total of 104 representative hospitals, 2,036 patients were operated during this time. Almost 80% of the hospitals provide antireflux surgery in the open technique and only 1/3 of the hospitals have experience in the laparoscopic technique. There is a total rise in antireflux surgery during the last 5 years, since the number of laparoscopic antireflux operations rises constantly with a total amount of open operations of about 250 cases per year. In open surgery the most favourite technique is the Nissen-Rossetti procedure, while in laparoscopic technique the choice for the original Nissen, the Nissen-Rossetti, or the floppy Nissen technique is divided in almost equal parts.     

The laparoscopic sterilization of women

The optimal time for sterilization is 24-36 hours after childbirth or during the 8th week in the postpartum period. The surgical methods of sterilization of the ovarian ducts are simple, harmless, effective, reversible, economical, and voluntary. These considerations also apply to endoscopic methods. For the occlusion of ovarian ducts, electrical current (monopolar and bipolar) and mechanical means (Yoon ring, Hulka and Filshie clips) are used. Unipolar coagulation of the ovarian ducts is another method of surgical sterilization done by laparoscopy. The area of coagulation occupies about 1.5 cm. The length of bipolar coagulation is 10 times larger than the unipolar coagulation site. Patients can be released 4 hours or the next day after the operation. The frequency of complications with bipolar coagulation is low: burning occurs in 0.04-0.1% of cases and bleeding from the mesosalpinx in 0.16-0.5%. The incidence of pregnancy after the operation amounts to 0.1-0.4%. Mechanical methods of sterilization are also reliable, although they are not suitable for all women. For young women who may still want children it is uniquely expedient to employ the Hulka or Filshie clips. In the rest of the cases the Yoon ring can be used, which was first used in the US in 1972 and became popular subsequently. The rate of complications is rare with its use (0.12-3.75%), and pregnancy occurs in 0.08-0.4% of cases. The incidence of complications with the use of clips amounts to 0-0.71%, the pregnancy rate is 0-0.59%, and the possibility of reversal is 80-100%. This method is ideal for young women who do not want to use other contraceptives and who want to have more children.     

Posterior pars plana high frequency capsulotomy

In special forms of complicated secondary cataract, especially after a cataract operation in eyes with proliferative disease and after a cataract operation associated with pars plana vitrectomy and silicone oil instillation, surgical capsulotomy must be performed. METHODS: We developed a new surgical technique for posterior capsulorhexis via pars plana by using the high-frequency capsulotomy method developed by Kl?ti. We analyzed 14 consecutive patients undergoing late pars plana capsulotomy using a specially designed instrument for radiofrequency capsulorhexis. The indication for surgical capsulotomy was extreme secondary cataract; in 6 eyes fibrosis was associated with vascularizations. RESULTS: The high-frequency technique for posterior capsulotomy allowed reliable and precise tissue cutting. The cutting required minimal application of pressure to the capsule, and therefore damage to zonula fibers is minimized. Furthermore, use of the radiofrequency technique permitted hemostatic incision in vascularized membranes by inducing a fine coagulation margin. CONCLUSIONS: Posterior capsulorhexis using radiofrequency offers precise and effective tissue cutting if surgical capsulotomy is necessary.     

Treatment of adnexal torsion using operative laparoscopy

The aim of this work was to clarify the value and application of operative laparoscopic treatment for adnexal torsion. We included in our study all patients (n = 27) who presented with an intra-operative diagnosis of torsion of the adnexa between January 1989 and May 1995. A total of 28 adnexal torsions were treated. Treatment was carried out by laparoscopic surgery in 75% of cases (21 torsions): in one-half of the cases (14 torsions) it was possible to achieve conservative laparoscopic treatment. The nature of the lesions and the experience of the surgeons are two factors which closely govern the outcome of surgical treatment. For those patients presenting a benign pathology, laparoscopic surgery was used to treat 84% of cases in the series. All the patients presenting a benign pathology and operated upon since 1993 have received laparoscopic surgical treatment. No major complications (peritonitis, thrombotic emboli, coagulation problems) were observed after conservative laparoscopic surgery. These results demonstrate that, provided the surgeons are sufficiently experienced, treatment by conservative laparoscopic surgery for adnexal torsion is both safe and reliable. In the years to come more work must be done to assess the vitality of the adnexa so that as many patients as possible can benefit from conservative treatment.     

Laparoscopic subtotal cholecystectomy

Subtotal cholecystectomy is a definitive and safe operation to treat diseases of the gallbladder, whenever there are major difficulties in dissection from the liver. Described herein is successful experience with 6 patients using this technique, through the laparoscopic approach. In cases with severe inflammatory changes, gallbladder embedded in liver tissue, and liver cirrhosis, they enabled reduction of operative time and avoidance of excessive bleeding that could have caused the conversion of the laparoscopic approach to open laparotomy.