surgical endoscopy journal 1

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New technology

Pathophysiological and clinical aspects of the CO2

pneumoperitoneum (CO2

-PP)

H. Gebhardt,1 A. Bautz,1 M. Ross,1 D. Loose,2 H. Wulf,2 H. Schaube1

Department of General and Thoracic Surgery, University of Kiel, Arnold-Heller-Str. 7, 24105 Kiel, GermanyDepartment of Anaesthesiology, University of Kiel, Arnold-Heller-Str. 7, 24105 Kiel, Germany

Received: 13 December 1996/Accepted: 8 January 1997

Abstract. Experimental studies demonstrated a severe car-diac load of the CO

2pneumoperitoneum caused by an ac-

celerated after- and a decreased preload. Patients displayingcardiovascular risks are therefore often rejected from lapa-oscopic surgery. Hence, the pathophysiological changes

and the intraoperative risk of the CO2

pneumoperitoneum inhigh-risk cardiopulmonary patients (NYHA IIIII, n 15)undergoing laparoscopic cholecystectomy are described.The changes in cardiac after- and preload seem to be due tohe elevated intraabdominal pressure rather than transperi-

oneally resorbed CO2 and are reversible by desufflation. Inone patient conversion to open operation had to be per-formed because of a severe drop in cardiac output and rightventricle ejection fraction. Mixed oxygen saturation waspredicting intraoperative worsening in this case. The de-

cribed pathophysiological changes may seem to be wellolerated even in high-risk cardiac patients. Monitoring of

hemodynamics should include an arterial catheter line andblood gas analyses. Pharmacologic interventions or pres-

ureless laparoscopic procedures might not be necessary asong as laparoscopic cholecystectomy is performed.

Key words: Laparoscopic surgery CO2 pneumoperito-neum Pathophysiology Intraoperative risk Moni-oring

The reduction in pain and pulmonary dysfunction achievedvia laparoscopic surgery decreases the potential for postop-erative (p.op.) complications and prolonged recovery. Pa-ients displaying cardiovascular risks or patients undergoingengthy operations should profit most from these benefits,ince preexisting diseases are not exacerbated as after lap-

arotomy. However, the scientific evaluation of the patho-physiological changes caused by CO

2pneumoperitoneum

(CO2

-PP) and elevated intraabdominal pressure (IAP) haslagged behind the clinical use of this technique. The intra-operative stress may be greater than under laparotomy sinceexperimental studies have demonstrated severe changes inheart rate, systemic vascular resistance, cardiac output, andpulmonary function [5, 6, 1618]. The increased intraab-dominal pressure led to a reduction of venous reflux fromthe periphery and squeezed the venous reservoir within theabdominal cavity. Cardiac afterload parameters, such as thesystemic vascular resistance, increased significantly. Estab-

lishing the pneumoperitoneum caused a 40% reduction incardiac output, raising concerns about the clinical use of thismethod [1, 5].

However, only few clinical studies have been under-taken to evaluate the pathophysiological changes since aninvasive monitoring is required to investigate the hemody-namic alterations observed in experimental studies. A rea-son for this might be that, so far, the majority of laparo-scopic operations have been performed in young andhealthy patients not allowing a substantial, invasive hemo-dynamic monitoring because of ethical and moral problems[1, 8, 9, 14]. Only a few studies have been done to evaluate

the indications and perioperative risks of laparoscopic sur-gery in high-risk cardiac patients.Despite the significant benefits, patients with cardiopul-

monary risk are therefore often rejected from laparoscopicsurgery. For further evaluation of the pathophysiology andthe safety of this method we investigated in a prospective,clinical study the pathophysiological changes caused byCO

2pneumoperitoneum that occur in patients with under-

lying heart and/or pulmonary diseases who undergo laparo-scopic cholecystectomy using an intensive, invasive hemo-dynamic monitoring throughout the operative procedures.

Materials and methods

Fifteen patients with cardiopulmonary insufficiency stage II (n 9) andstage III (n 6), according to the classification of the New York HeartCorrespondence to: H. Gebhardt

SurgicalEndoscopy

Springer-Verlag New York Inc. 1997Surg Endosc (1997) 11: 864867


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Association, were scheduled for laparoscopic cholecystectomy and consid-

red as candidates for the study. Four of these patients suffered from a

valvular heart disease, eight an ischemic heart disease, and two from a cor

pulmonale as a result of pulmonary hypertension. Informed consent was

obtained from all participants. The characteristics of the patients and the

duration of the operation are presented in Table 1. The mean duration of the

CO2-PP was 68 12 min at an intraabdominal pressure (IAP) of 14 mmHg,

he mean age of the patients 66.7 14.3 years.

General anesthesia was induced with etomidate (0.2 mg/kg bodyweight i.v.), fentanyl (0.1 mg/kg body weight i.v.), succinylcholine (11.5

mg/kg body weight i.v.) and maintained with isoflurane (0.41 vol.%),

N2

O/O2

2:1, sufentanyl and vecuronium bromide (0.1 mg/kg body weight).

Mechanical ventilation (Draeger Cicero, Draeger Co., FRG) was per-

ormed with the respiratory rate adjusted to achieve normal arterial (3035

mmHg) and end-tidal pCO2 values. The invasive hemodynamic monitoringncluded a pulmonary artery Swan-Ganz Thermodilution catheter (Model

744 H-7.5 F, Baxter Int. Coop., USA) and a radial arterial catheter line (1.0,Argyle Mediport 2, Sherwood Int. Co., USA) for measurement of central-venous pressure (CVP), pulmonary arterial wedge pressure (PAWP), car-diac output (CO), right ventricle ejection fraction (RVEF), and mean ar-erial blood pressure (MAP) using on-line hemodynamic monitoring (Sire-ust 401-1 and 961, Siemens Corp., FRG). For an indirect measurement ofhe intrathoracal pressure changes, a catheter line was placed in the esopha-

gus (IEP) at the level of the right ventricle (Sirecust 401-1, Siemens Corp.,FRG). Calculated values like the systemic vascular resistance (SVR) wereobtained from CVP, CO, and MAP. By subtracting the IEP from the CVPhe transmural right atrial pressure (TMP) was obtained.

After induction of anesthesia hemodynamic and ventilatory parameterswere normalized to achieve SVR of less than 1,800 dyn s/cm5, CO ofmore than 3.9 l/min, and PCWP between 8 and 12 mmHg. The abdominalnsufflation of the CO2-PP at an intraabdominal pressure of 14 mmHg washen performed. Directly before and 2 min after establishing CO

2-PP a set

of data was obtained. Additional values under the pneumoperitoneum andfter desufflation of it were obtained every 5 min. A final set of data wereollected 90 min after desufflation of the abdomen.

In addition the end-tidal carbon dioxide concentrations (VEXPCO2)were measured and the positive end-expiratory pressure (PEEP), peak in-

piratory pressure (PEAK), as well as the inspiratory plateau phase (PLAT)

nd tidal volume (Vt) were protocolled by the respiratory system (DraegerCicero, Draeger Co., FRG). Arterial blood samples were analyzed with aadiometer ABL2 blood-gas analyser which was calibrated every hour for

measurement of arterial pCO2 (PaCO2) and O2 (PaO2).Statistical analysis was performed with a two-way analysis of variance

or repeated measures, and p values < 0.05 were regarded as significant.

Results

Significant hemodynamic but not ventilatory alterationswere observed in all patients. Already at 2 min after estab-lishing the CO

2pneumoperitoneum we noticed a significant

increase in the CVP from 15.5 2.9 mmHg to 22.4 3.4mmHg. This was followed by a decrease to 18.4 mmHg 2.4 mmHg during the elevated intraabdominal pressurecaused by the CO

2-PP. However, immediately after induc-

tion of the elevated IAP the intraesophageal (IEP) and theintrathoracal pressure increased even more strongly. As aresult the TMP (Fig. 1), a calculated value (CVP-IEP) giv-ing the actual information about precardial load, showed aconstant decrease throughout CO

2-PP from 15.2 3.4

mmMHg to 3 2.8 mmHg (45 min CO2

-PP). Only afterrelease of the pneumoperitoneum did these parameters ofcardiac preload returned to baseline, preinsufflation values(15 min after desufflation).

The MAP increased initially (5 min CO2

-PP) after es-tablishing the CO

2-PP from 86 12 mmHg to 111 18

mmHg. PAP also increased from 22.1 4 to 32.2 5mmHg after 5 min. The MAP- and PAP-baseline valueswere reached before desufflation (45 min). Other afterloadparameters such as SVR (Fig. 2) rose from 1,770 224 to2,415 221 dyn s/cm5 immediately after induction ofCO

2-PP raised the elevated IAP, before any reasonable

amount of carbon dioxide was resorbed transperitoneally.These afterload parameters returned to almost normal val-ues of 1,615 241 dyn s/cm5 after about 60 min ofCO

2-PP.

As a consequence of these changes in cardiac after- andpreload, CO (Fig. 3) dropped after induction of CO

2-PP

from 3.7 0.6 to 2.8 0.4 l/min. This was followed by anincrease of up to 4.2 0.6 (30 min CO

2-PP). After desuf-

flation a peak increase of 5.04 0.78 l/min occurred. Theincrease in CO was accompanied by an increase in heartrate. Cardiac stroke volume decreased constantly through-

Table. 1. Patient characteristicsa

Age Sex

Operationtime(min) Cardiac disease NYHA Others

47 F 47 Aortic stenosis, P.myoc.inf. II3 F 71 I.H.D., C.C.P. III Diabetes mellitus II

67 M 88Mitral stenosis, heart block,

artrial fibrillationIII Peripheral vascular disease,

diabetes mellitus II

6 F 56 Idio.h.suba.st., left ventricu-lar hypertrophy II

75 F 91 I.H.D., stable angina II Hypertension

1 F 57P.myoc.inf., artrial fibrilla-

tionII

83 M 64 P.myoc.inf., C.C.P. II

46 F 74Tricuspidal insuff.,

P.myoc.inf.III Hypertension, diabetes melli-

tus II73 F 58 I.H.D., P.myoc.inf. II84 F 69 I.H.D., exertional angina II Hypertension51 F 74 Cor pulmonale, stable angina II COLD66 M 60 ACVB, heart block III Hypertension78 M 61 I.H.D., C.C.P. III63 F 68 Cor pulmonale, I.H.D. III COLD, diabetes mellitus II78 M 88 P.myoc.inf., I.H.D. II

P.myoc.inf., postmyocardial infarction; I.H.D., ischemic heart disease, C.C.P., congestive cardiomy-opathy; Idio.h.suba.st., idiopathic hypertrophic subaortic stenosis.

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out the CO2

-PP. The decrease in cardiac pre- and the in-crease in afterload led to a constant drop of the right ven-ricle ejection fraction (RVEF) from 45 3.4% to 33 2.1%

after 60 min of CO2

-PP (Fig. 4). In one patient the ejectionfraction dropped to 23% after 32 min of CO

2-PP, demand-

ng conversion to open operation. This patient began theoperation with a low CO of 2.98 l/min and a high SVR of2,254 dyn s/cm5. During the operation the mixed oxygen

aturation decreased significantly, reflecting inadequatepulmonary perfusion. After desufflation these parameterseturned to preinsufflation values within 4 min and the pa-ient did well during the postoperative course.

VexpCO2 increased from preinsufflation values of 238 14 ml/min to 298 28 ml/min (30 min after insufflation)

ince minute ventilation was adapted to maintain normalPaCO

2between 30 and 35 mmHg. PEEP values did not

how any significant changes. After establishing the CO2

-PP PLAT values increased significantly from 20 3.4 mbaro 27.5 2.7 mbar and PEAK values from 26.8 4.5 to 33.7

2.4 mbar. The changes in PEAK values were not regardedas significant.

Discussion

Experimental pull-through manometries via V. femoralis upo V. cava superior under CO

2-PP in the sheep have already

demonstrated a reduction zone in the elevated IAP begin-

ning at the diaphragma along the basal parts of the thorax upto the level of the right atrium [5]. Only at that level theintravasal pressure within V. cava superior was like the IEPchanges plus the CVP. The compression of the basal parts ofthe thorax might be responsible for the increase in PLATand PEAK. This compression and the diaphragmatic eleva-tion decrease pulmonar functional residual capacity, ana-tomical deadspace, and size of airways [5, 14]. They mightalso be responsible for the augmented pulmonar resistanceunder CO

2-PP. However, there seem to be no significant

changes in PEAK, PEEP, PaO2

, and PaCO2

during laparo-scopic cholecystectomy as long as an adapted, controlled

mechanical ventilation is performed.The results of the pull-through manometries via V.

femoralis superior to V. cava superior and the alterations inTMP (Fig. 2) indicate that CVP alone is not an appropriateindicator of cardiac preload, since the observed increase iscaused by the elevated IAP carrying off into the basal partsof the thorax, altering CVP. As shown by the TMP, there isactually a constant decrease in cardiac preload during thepneumoperitoneum. This has to be kept in mind duringlaparoscopic procedures under CO

2-PP.

Other groups described a 40% reduction of the flowwithin intraabdominal V. cava and V. mesenterica as well as

a stasis and dilatation within common V. femoralis [2, 8,12]. These findings and the changes in TMP indicate a shiftof blood volume from the center to the periphery with theelevated IAP reducing blood flow within V. cava abdomi-nalis. This augments the decrease of cardiac preload and

Fig. 3. Cardiac output in high-risk cardiac patients (NYHA IIIII, n15) before (10 min, 0 min), during (060 min), and after (60120 min)CO2 pneumoperitoneum at an intraabdominal pressure of 14 mmHg.

Fig. 4. Right ventricle ejection fraction in high-risk cardiac patients(NYHA IIIII, n 15) before (10 min, 0 min), during (060 min), andafter (60120 min) CO2 pneumoperitoneum at an intraabdominal pressureof 14 mmHg.

Fig. 1. Transmural right atrial pressure (TMP) in high-risk cardiac patientsNYHA IIIII, n 15) before (10 min, 0 min), during (060 min), andfter (60120 min) CO2-pneumoperitoneum at an intraabdominal pressure

of 14 mmHg.

Fig. 2. Systemic vascular resistance in high-risk cardiac patients (NYHAIIII, n 15) before (10 min, 0 min), during (060 min), and after60120 min) CO2 pneumoperitoneum at an intraabdominal pressure of 14

mmHg.

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might be, in contrast to the findings of Safran and Ho et al.,one of the main causes of the observed changes in cardiacoutput [6, 16]. The venous stasis in the periphery might alsopromote venous thrombosis of the lower extremities. Inter-mittent sequential pneumatic compression, as suggested byMillard et al., reversed venous stasis within common femo-al vein, returning peak velocity to normal [12]. This might

be of special interest in preventing thrombosis in high-risk

patients or in the case of longstanding laparoscopic opera-ions.The parameters of cardiac afterload, as there is the SVR

and PAR, increased up to 35% also immediately after in-duction of the CO

2-PP before any reasonable amount of

CO2

was resorbed. During the time investigated, these pa-ameters returned to baseline values 60 min after insuffla-ion. The initial onset of hemodynamic alterations, the re-

verse effects after desufflation, and the results of the pull-hrough manometry as well as the TMP, indicate that the

observed hemodynamic changes are caused by direct effectsof the elevated IAP rather than systemic effects of trans-peritoneally resorbed CO

2as suggested by Ho et al. [6].

Kashtan et al. and Leighton et al. described similar changesafter hydroperitoneum, helium or nitrous oxide pneumo-peritoneum in the dog, further suggesting that the elevatedAP is the main cause [7, 10]. The CO

2-PP, and the elevated

AP, also lead to an initial release of epinephrine, norepi-nephrine, and vasopressin as soon as 5 min after insuffla-ion. The elevated catecholamine levels returned to baseline

values only after desufflation [11, 13]. The observedchanges in cardiac afterload, which are also described byKoksoy et al. [9], are therefore not only due to direct effectsof the elevated IAP on the vascular system but also to in-creased catecholamine levels augmenting systemic vascularesistance.

The changes in cardiac pre- and afterload caused theobserved alterations in CO (Fig. 3) and RVEF (Fig. 4).These might be critical for the organism, since cardiac wallension and oxygen demand increase. Simultaneously, coro-

nary perfusion is reduced because of a reduced stroke vol-ume and shortened diastolic filling time during tachycardia.Hypovolemia, aggravating these hemodynamic changes,

hould therefore be avoided as long as CO2

-PP is used foraparoscopic procedures.

However, these data show that these changes are toler-ated, and most of the patients with myocardial insufficiency

espond well to CO2-PP. Only in one patient did conversiono open operation have to be performed because of a severe

drop in CO and RVEF. In this case a reduced mixed oxygenaturation and an increase in SVR was predicting intraop-

erative worsening. The effects were easily reversible byaking away the elevated IAP by removing the CO

2-PP.

Despite the described pathophysiological alterations ofhe CO

2-PP, laparoscopic surgery might be safely per-

formed even in high-risk cardiac patients as long as carefulperioperative monitoring and controlled mechanical venti-ation are performed. The intraoperative monitoring shouldnclude an arterial catheter line, in-line capnography for

VEXPCO2, and a close look at the mixed oxygen saturationpredicting intraoperative worsening. Safran et al. recom-

mended the use of a pulmonary arterial catheter line [16].We do not regard this as mandatory any more since themixed oxygen saturation reflected inadequate perfusion andthe increase in systemic vascular resistance as well as thedrop in CO and RVEF. Extraperitoneal carbon dioxide in-sufflation, pharmacologic interventions, or so-called pres-sureless laparoscopic procedures, as described by Feigh andChin et al., Rademaker et al. as well as Paolucci and Gutt,

might not be necessary as long as laparoscopic cholecys-tectomy is performed [3, 4, 15, 18].

References

1. Bannenberg JJ, Rademaker BM, Grundeman PF, Kalkman CJ, MeijerDW, Klopper PJ (1995) Hemodynamics during laparoscopy in thesupine or prone position. An experimental study. Surg Endosc 2: 125127

2. Beebe DS, McNavin MP, Boyle M (1991) Evidence of venous stasisafter abdominal insufflation for laparoscopic surgery. Anaesthesiol77(3A): 144148

3. Chin AK, Eaton J, Tsoi EKM, Smith RS, Fry WR, Henderson J,McColl MB, Moll FH (1994) Gasless laparoscopy using a planar lift-

ing technique. J Am Coll Surg 178: 4014034. Feig BW, Berger DH, Dougherty TB, Dupuin JF, Bartholomew HSI,

Hickey RC, Ota DM (1994) Pharmacologic intervention can reestab-lish baseline hemodynamic parameters during laparoscopy. Surgery116: 733741

5. Gebhardt JH, Fandrich F, Ross M, Schaube H, Loose D (1996) Intra-operative risk and hemodynamic effects of the CO

2-pneumo-peritoneum in laparoscopic surgery. An experimental study. Min InvasTher Allied Technol 5: 207210

6. Ho HSH, Saunders CJ, Corso FA, Wolfe BM (1993) The effects ofCO2-pneumoperitoneum on hemodynamics in hemorrhaged animals.Surgery 114(2): 381388

7. Kashtan J, Gren JF, Parson EQ, Holcroft JW (1981) Hemodynamiceffects of increased intraabdominal pressure. J Surg Res 30: 249256

8. Kazuhiro I, Tetsuto T, Hirotoshi W, Yasuhiro T (1994) Intraabdominal

venous pressure during laparoscopic cholecystectomy. HBP Surg 8:1317

9. Koksoy C, Kuzu MA, Kurt I, Kurt N, Yerdel MA, Tezcan C, Aras N(1995) Hemodynamic effects of pneumoperitoneum during laparo-scopic cholecystectomy: a prospective comparative study using bio-impedance cardiography. Br J Surg 82(7): 972974

10. Leighton TA, Liu SY, Bongard FS (1993) Comparative cardio-pulmonary effects of carbon dioxide versus helium pneumoperito-neum. Surgery 113: 527531

11. Mikami O, Kawakita S, Fujise K, Shingu K, Takahashi H, Matsuda T(1996) Catecholamine release caused by carbon dioxide insufflationduring laparoscopic surgery. J Urol 155(4): 13681371

12. Millard JA, Hill BB, Cook PS (1993) Intermittent sequential pneu-matic compression in prevention of venous stasis associated withpneumoperitoneum during laparoscopic cholecystectomy. Arch Surg

128: 91491913. Punnonen R, Viinamaki O (1982) Vasopressin release during laparos-

copy: role of increased intraabdominal pressure. Lancet 16: 17517614. Puri GD, Singh H (1992) Ventilatory effects of laparoscopy under

general anaesthesia. Br J Anaesth 68: 21121315. Rademaker BM, Meyer DW, Bannenberg JJ, Klopper PJ, Kalkman CJ

(1995) Laparoscopy without pneumoperitoneum. Effects of abdominalwall retraction vs. carbon-dioxide insufflation on hemodynamics andgas exchange in pigs. Surg Endosc 9(7): 797801

16. Safran DB, Orlando R III (1994) Physiological effects of the pneu-moperitoneum. Am J Surg 167: 281286

17. Westerband A, van de Water JM, Amzallag M (1992) Cardiovascularchanges during laparoscopic cholecystectomy. Surg Gynecol Obstet175: 535538

18. Wright DM, Serpell MG, Baxter JN, ODwyer PJ (1995) Effect ofextraperitoneal carbon dioxide insufflation on intraoperative blood gasand hemodynamic changes. Surg Endosc 9(11): 11691172

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ccording to a lately described technique [1]. All ileocolic and colorectalnastomoses were checked for leaks with air pressure, respectively, via aolonoscope or submerging the pelvis in saline and insufflating via a 50-ml

yringe. Fascial closure of all trocar sites was performed regardless of theannula size. All specimens were sent for histology.

Morbidity was defined after the Troidl Classification [22]. Criteria fordischarge were the same after OC and LCR. Patients were dismissed tol-

rating oral solid food intake, after the passage of one bowel movement,nd with no evidence of sepsis. Data were expressed as mean standardrror of mean and calculated by a statistical software program (Harvard

Graphics 1.0Software Publishing Corp., 1991). Students t-test, Fishersxact test, and chi-squared test were used where appropriate. Statisticalignificance was set at p < 0.05.

Results

The LCR and OC patient groups were not significantly dif-ferent with regard to age, weight, ASA grading, type ofesection, previous minor abdominal surgery (cholecystec-omy and/or appendectomy), and indications for surgeryTable 1). Conversion rate was 2% (1/54) in patients un-

dergoing left LCR. Laparoscopy was deliberately abruptedn a 53-year-old obese (body mass index [BMX] 30) man

presenting with stenosing diverticular disease of the sig-moid because operating time had reached 4 h. The thicknessof the mesentery and the presence of small bowel in thepelvis accounted for the duration of the resection. This pa-ient had postoperative ileus during 5 days and delayed

wound healing which recovered without further surgery.There were no deaths. Intraoperative complications oc-

curred in three patients (3%). A 63-year-old man presentingwith stenosing diverticular disease of the sigmoid had anend-to-side colorectal anastomosis performed with a 28-mmcircular stapler. During per anum extraction of the circular

tapler, the anvil was accidentally detached and subse-quently removed with forceps. Residual disease left behindat the transection site of the sigmoid rectum probably madet easier to staple the anastomosis on the anterior rectal wall.

A barium enema carried out 6 months after surgery revealedan asymptomatic anastomotic stenosis. Two of 41 patients

5%) with ileocolostomy had intraoperative air leaks atcolonoscopy with air pressure. Each of two anastomoseswas reinforced with sutures.

Postoperative complications occurred in four of 94 pa-

tients (4.2%) (Table 2). A patient with a superficial abscessat the infraumbilical site was readmitted for incision anddrainage. Morbidity rates (4 vs 3, p 0.48) were not sig-nificantly different in the LCR and OC groups. Table 3compares the two patient groups with respect to operatingtime, first flatus, length of stay, and operating room, ward,and total hospital costs.

Discussion

A note of caution about the risk of replacing traditionalcolectomy with two operations has been expressed [19].However, in spite of some criteria that have been given todefine laparoscopy-assisted colectomy [11, 23], one canhardly see how laparoscopy-assisted procedures actuallydiffer from electively converted operations. Vascular and/orbowel division and/or anastomosis fashioning are often per-formed extracorporeally through a minilaparotomy.However, speaking beyond definitions, it is recommendableto keep conversion rates to a minimum. In fact, convertedprocedures appear to be associated with high morbidityrates [20]. Thus, a policy of attempting all colon resectionslaparoscopically should be discouraged. Reported conver-sion rates vary from 3% to 48% depending on definition,patient selection, which phase of the learning curve, and thebowel segment to be resected [20]. Zucker et al. [24] re-ported a 3% conversion rate in patients selected based ontheir ability to understand the rationale for the celioscopicapproach, provided the absence of morbid obesity and pre-vious extensive abdominal surgery. Milson et al. [12]achieved a 9.3% conversion rate operating on healthy non-obese patients requiring surgery limited to one colon seg-

ment. Reissman et al. [17] had a 7% conversion rate inunselected patients. Low conversion rates should be accom-plished via careful preoperative patient selection backed byextensive experience with open colorectal surgery, and ofcourse not by excesses of zeal in trying to postpone a nec-essary conversion.

Claims of shorter postoperative ileus, earlier oral solidintake, and reduced hospital stay after LCR [4, 6, 10] havebeen supported by a few subsequent controlled studies [5,13, 15]. However, data from a recent prospective study [9]could not fully confirm that LCR leads to shorter transientpostoperative gastrointestinal hypomotility. Moreover, it

has been shown that early oral intake is possible after opencolorectal surgery [3]. Therefore, it might be very difficultto provide evidence of significant differences in timing fordischarge after open and laparoscopic surgery. Shorter hos-

Table 1. Demographics of the patientsa

LCR(n 95)

OC(n 90) p

Age (years) 64 9.8 65 9.2 NSWeight (kg) 80 15.2 79 13.6 NSASA grade, I:II 70:25 66:24 NSResection type, right: left 41:54 39:51 NSndications for surgery

Diverticular disease 48 (50) 35 (38.5) NSCrohns disease 39 (41) 38 (42.2) NSVillous adenoma 4 (4.2) 9 (10) NSVolvulus 3 (3.1) 8 (8.8) NSIschemic colitis 1 (1) (0) NS

Previous surgeryb 12 (12.6) 10 (11.1) NS

Mean values the standard error of the mean (SEM); values in paren-heses are percentages; NS, not significantPrevious cholecystectomy and/or appendectomy

Table 2. Morbidity after Troidl classification [21]

StageLCR(n 94)

OC(n 90)

II Air leaks 2Anvil detached 1

III Pleural effusion 1 1Deep vein thrombosis 2Urinary retention 1

IV Wound hematoma 1Wound abscess 1

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pital stay after LCR represents scanty evidence when it iscompared with a length of stay of 11 days [14] or 12.2 days7] following traditional colectomy. As stated elsewhere16], better cosmesis is, for the time being, the only proven,

but often irrelevant, benefit of LCR. Nevertheless, it mustbe acknowledged that laparoscopic surgery has contributedo making us review our traditional routines in open surgery.

Immediately recognizable limitations of LCR include aearning phase, prolonged operating time, and new com-plications. It has been estimated that 3550 procedures arenecessary before the learning curve flattens [23]. Further-more, it has been shown that the learning curve is in mostcases steep [5], although it may depend on the type of bowelesection [17]. A prolonged operating time at any phase ofhe learning period may in fact point out the limits of currentnstruments. Decreasing operating time must be achieved

without an increase in complication rates. Data from a largeprospective study [11] have shown that overall morbidityfollowing LCR is not increased when compared with open

urgery. However, the definition of morbidity may vary [17]and the use of one classification is certainly desirable [22].New complications such as resection of the wrong colonegment and port site hernias [17] may be overcome by a

more widespread use of intraoperative colonoscopy andoutine surgical closure of port wounds regardless of theirize.

Early claims on increased cost-effectiveness of LCR13] have been disconfirmed by convincing evidence show-ng that increased operating-room costs often offset possible

gains from shorter hospital stay [5, 16]. Direct costs of acompletely intracorporeal approach may differ markedlyamong institutions and should not be analyzed as isolateddata [19]. A judicious use of reusable laparoscopic equip-ment may help contain these costs. Early return to work isunlikely to lead to economic benefit since most patientswith colorectal diseases are retired [19]. Although it mightbe very difficult to provide evidence of increased cost-effectiveness of LCR, a cost-utility analysis should be mostappropriate because it would measure quality of life follow-ng LCR.

No immediately recognizable advantages followingLCR can be surmised from the present study. Still-unprovenfavorable physiologic effects (decreased cell-mediated im-munosuppression and blood loss) [2] and still-unknown

long-term benefits (reduced adhesion formation and de-creased incidence of small-bowel obstruction) [21] mightmagnify the cost-effectiveness of the celioscopic approach.

References

1. Bergamaschi R, Arnaud JP (1997) Intracorporeal colorectal anastomo-sis following laparoscopic left colon resection. Surg Endosc 11:800801

2. Bessler M, Whelan RL, Halverson A. Treat MR, Nowygrod R (1994)Is immune function better preserved after laparoscopic versus opencolon resection? Surg Endosc 8: 881883

3. Binderow SR, Cohen SM, Wexner SD, Nogueras JJ (1994) Must earlypostoperative oral intake be limited to laparoscopy? Dis Colon Rectum37: 584589

4. Corbitt JD (1992) Preliminary experience with laparoscopic-guidedcolectomy. Surg Laparosc Endosc 2: 7981

5. Falk PM, Beart RW Jr, Wexner SD, Thorson AG, Jagelman DG,Lavery IC, Johansen OB, Fitzgibbons RJ Jr (1993) Laparoscopic col-ectomy. A critical appraisal. Dis Colon Rectum 36: 2834

6. Fowler DL, White SA (1991) Laparoscopic assisted sigmoid resection.Surg Laparosc Endosc 1: 183188

7. Franklin ME, Rosenthal D, Norem RF (1995) Prospective evaluationof laparoscopic colon resection versus open colon resection for adeno-

carcinoma. Surg Endosc 9: 8118168. Herfarth C, Schumpelick V, Siewert JR (1994) Pitfalls of minimallyinvasive surgery. Surg Endosc 8: 847

9. Hotokezaka M, Dix J, Mentis EP, Minasi JS, Schirmer BD (1996)Gastrointestinal recovery following laparoscopic vs open colon sur-gery. Surg Endosc 10: 485489

10. Jacobs M, Verdeja JC, Goldstein HS (1991) Minimally invasive colonresection (laparoscopic colectomy). Surg Laparosc Endosc 1: 144150

11. Lumley JW, Fielding GA, Rhodes M, Nathanson LK, Siu S, Stitz RW(1996) Laparoscopic-assisted colorectal surgery. Lessons learned from240 consecutive patients. Dis Colon Rectum 39: 155159

12. Milsom JW, Lavery IC, Church JM, Stolfi VM, Fazio VW (1994) Useof laparoscopic techniques in colorectal surgery. Dis Colon Rectum37: 215218

13. Musser DJ, Boorse RC, Madera F. Reed JF (1994) Laparoscopic col-

ectomy: at what cost? Surg Laparosc Endosc 4: 1514. Ortega A, Beart R, Anthone G, Schlinker R (1994) Laparoscopicbowel resection and consecutive series (abstract). Dis Colon Rectum37: 22

15. Peters WR, Bartels TL (1993) Minimally invasive colectomy: are thepotential benefits realized? Dis Colon Rectum 36: 751756

16. Pfeifer J, Wexner SD, Reissman P, Bernstein M, Nogueras JJ, Singh S,Weiss E. (1995) Laparoscopic vs open colon surgery. Cost and out-come. Surg Endosc 9: 13221326

17. Reissman P, Cohen S, Weiss EG, Wexner SD (1996) Laparoscopiccolorectal surgery: ascending the learning curve. World J Surg 20:277282

18. Schlinkert RT (1991) Laparoscopic-assisted right hemicolectomy. DisColon Rectum 34: 10301031

19. Scott HJ, Spencer J (1995) Colectomy: the role of laparoscopy. Surg

Laparosc Endosc 5: 38238620. Slim K, Pezet D, Riff Y, Clark E, Chipponi J (1995) High morbidity

rate after converted laparoscopic colorectal surgery. Br J Surg 82:14061408

21. Thompson, JN, Whawell SA (1995) Pathogenesis and prevention ofadhesion formation. Br J Surg 82: 35

22. Troidl H, Spangenberger W, Dietrich A, Neugebauer E (1991) Lapa-roskopische Cholecystectomie. Erste Erfahrungen and Ergebnisse bei300 Operationen: eine prospektive Beobachtungsstudie. Chirurg 62:257265

23. Wishner JD, Baker JW Jr, Hoffman GC, Hubbard GWII, Gould RJ,Wohlgemuth SD, Ruffin WR, Melick CF (1995) Laparoscopic-assisted colectomy. The learning curve. Surg Endosc 9: 11791183

24. Zucker KA, Pitcher DE, Martin DT, Ford RS (1994) Laparoscopic-assisted colon resection. Surg Endosc 8: 1218

Table 3. Variables compareda: laparoscopic colon resection (LCR) vs openolectomy (OC)

LCR(n 94)

OC(n 90) p

Operating time (min) 180 10.3 116 9.7


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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 1.42

657 EA EindhovenThe Netherlandsor: P.O. Box 335

500 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 for

his non-profit collaboration between the Nicaraguan Ministry of Health,

he National Autonomous University of Nicaragua, and Medical

Training Worldwide. The program consists of tutoring general surgeons

who have already undergone a basic laparoscopic cholecystectomy

ourse. Medical Training Worldwide will provide donated equipment

nd supplies when needed.

For further information, please contact:

Medical Training Worldwide

Ramon Berguer, MD, Chairman

Tel: 707-423-5192

Fax: 707-423-7578

-mail: [email protected]

Fellowship in Minimally Invasive SurgeryGeorge Washington Medical Center

Washington, DC USA

A one-year fellowship is being offered at the George WashingtonUniversity Medical Center. Interested candidates will be exposed to abroad range of endosurgical Education and Research Center. Activeparticipation in clinical and basic science research projects is also

ncouraged.


Carole Smith202-994-8425

or, send curriculum vitae to:

Dr. Jonathan M. Sackier

Director of Endosurgical Education and ResearchGeorge Washington University Medical CenterDepartment of Surgery2150 Pennsylvania Avenue, N.W.6B-417Washington, DC 20037, USA

Fellowships in Minimally Invasive Surgery

The University of Pittsburgh Medical Center

Pittsburgh, PA, USA

One year fellowships in advanced minimally invasive surgery in both

general and thoracic surgery are being offered at the University of

Pittsburgh Medical Center beginning on July 1, 1997. Requirements

include completion of residency training programs in the desired area.

The fellowships include a competitive salary and travel allowance.

Interested candidates should send a letter of inquiry with curriculum vi-

tae to:

Philip R. Schauer, MD (General Surgery) orJames Luketich, MD (Thoracic Surgery)

The University of Pittsburgh Medical Center

3471 Fifth Avenue

Suite 300

Pittsburgh, PA 15213-3221

Fellowships in Laparoscopic Surgery

Staten Island University Hospital

Staten Island, NY USA

A one year fellowship, to start July 1, 1997, in advanced laparoscopic

surgery is being offered at Staten Island University Hospital. The

selected fellow will be exposed to many advanced general laparoscopic

surgeries including: hiatal hernia repair, splenectomy, adrenalectomy,

bowel resection, and others. Participation in research projects will be

encouraged.


Barbara Coleman

Coordinator, Surgical residency program

Tel: 718-226-9508

Essentials of Laparoscopic Surgery

Surgical Skills Unit

University of Dundee

Scotland, 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. Thisintensely practical program develops the necessary operating skills,emphasizes safe practice, and highlights the common pitfalls anddifficulties encountered when starting out. Each workshop has amaximum of 18 participants who will learn both camera and

instrument-manipulation skills in a purpose-built skills laboratory.During the course there is a live demonstration of a laparoscopiccholecystectomy. The unit has a large library of operative videos editedby Professor Cuschieri, and the latest books on endoscopic surgery areon display in our Resource area. Course fee including lunch and coursematerials is $860.

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For further details and a brochure please contact:

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

Advanced Endoscopic Skills

Surgical Skills Unit

University of Dundee

Scotland, UK

Each month Professor Cuschieri Surgical Skills Unit offers a 412 dayourse in Advanced Endoscopic Skills. The course is intensely practical

with hands on experience on a range of simulated models. The programs designed for experienced endoscopic surgeons and covers advanced

dissection techniques, extracorporeal knotting techniques, needle control,uturing, internal tying technique, stapling, and anastomotic technique.ndividual workstations and a maximum course number of 10 participantsllows for personal tuition. The unit offers an extensive collection of sur-

gical videos and the latest books and publications on endoscopic surgery.n addition, participating surgeons will have the opportunity to see livedvanced laparoscopic and/or thoracoscopic procedures conducted by Pro-essor Cuschieri and his team. The course is endorsed by SAGES. Courseee 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 experiencedaparoscopists wishing to include fundoplication in their practice. Theourse covers the technical details of total and partial fundoplication usingmall group format and personal tuition on detailed simulated models.

There will be an opportunity to observe one of these procedures live duringhe course. Maximum course number is six. Course fee including lunch is

$1850.



Courses at George Washington University EndosurgicalEducational and Research Center

George Washington University Endosurgical Educational and ResearchCenter is proud to offer a wide range of surgical endoscopy courses. These

ourses include advanced laparoscopic skills such as Nissen fundoplica-ion, colon resection, common bile duct exploration, suturing, as well asubspecialty courses. Individual surgeons needs can be met with privateuition. The Washington D.C. area is a marvelous destination to visit for

recreational pursuits which can be arranged by the facility to suit yourpersonal agenda.

For further details please contact:

Carole Smith:Department of Surgery2150 Pennsylvania Avenue NW6BWashington, DC 20037, USATel: (202) 994-8425

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 2040 credit hours in Cat-egory 1 of the Physicians Recognition Award of the American Medical

Association. 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 the

following courses:

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Laparoscopic antireflux and hiatal hernia surgery (July 1415, 1997); Lap-

roscopic management of the common bile duct and difficult cholecystec-

omy (May 1516, August 1112, November 1011, 1997); Laparoscopic

olon and rectal surgery (June 2021, September 1516, December 45,

997). Also, courses for operating room nurses and technicians will be run

on a monthly basis and personal instruction and preceptorship is available.

For further information, please call:

Carole Smith

Washington Institute of Surgical Endoscopy2150 Pennsylvania Avenue, N.W.

Washington, DC 20037

Tel: 202-994-9425

Call for AbstractsSociety of American Gastrointestinal EndoscopicSurgeons (SAGES) 1998 Annual MeetingApril 14, 1998Seattle, WA, USA

Abstract deadlines: Oral and Poster abstracts: September 12, 1997

Video Submissions: September 18, 1997

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

SAGES Program Committee

Society of American Gastrointestinal Endoscopic Surgeons

Suite #3000

2716 Ocean Park Boulevard

Los Angeles, CA 90405

Tel: (310) 314-2404

Fax: (310) 314-2585

-mail: [email protected]

European Course on Laparoscopic Surgery

English language) November 1821, 1997Brussels, Belgium

Course director: G.B. Cadiere


Administrative Secretariat

Conference Services s.a.

Avenue de lObservatoire, 3 bte 17

B-1180 Bruxelles

Tel: (32 2) 375 16 48

Fax: (32 2) 375 32 99

Courses Offered at the University of MinnesotaMinneapolis, Minnesota, USA

September 17, 1997: Fourth Annual Conference,Molecular Biology of Colorectal Cancer

September 17, 1997: Sixth Annual Conference,Endorectal Ultrasonography

September 1820, 1997: Sixtieth Annual Conference,Principles of Colon and Rectal Surgery


Continuing Medical Education

University of Minnesota615 Washington Avenue SE, Suite 107

Minneapolis, MN 55414

Tel: 800-776-8636

Fax: (612) 626-7766

9th International Meeting

Society for Minimally Invasive Therapy

July 1416, 1997

Kyoto, Japan

Scientific program to include: Plenary, Parallel, Poster, and Video sessions.

Host Chairman: Professor Osamu Yoshida, Department of Urology, Kyoto

University, 54 Shogoin Kawahara-sho, Sakyo, Kyoto 606, Japan. Phone: +81

75 751-3328, Fax: +81 75 751-3740. This meeting coincides with the Gion

Festival in Kyoto, one of the greatest festivals in Japan.


Secretariat of SMIT 9th Annual International Meeting

c/o Academic Conference Planning

383 Murakami-cho

Fushimika, Kyoto 612 Japan

Tel: +81 75 611-2008

Fax: +81 75 603-3816

Colorectal Disease in 1998February 1921, 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 and

genetics, inflammatory bowel disease; and pouch surgery. There will be a

review of both basic and advanced principles of diagnosis and management

of 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 Florida

Department of Education

2950 West Cypress Creek Road

Fort Lauderdale, FL 33309-1743

Tel: 800-359-6101, ext. 6066

Fax: 954-978-5539

6th World Congress of Endoscopy Surgery Roma 98

6th International Congress of European Association

for Endoscopic SurgeryJune 36, 1998

Rome, 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 on

therapeutic 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 new

technology in surgery.


Congress Secretariat: Studio EGAViale Tiziano, 19

00196 Rome, Italy

Tel: +39 6 322-1806

Fax: +39 6 324-0143

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Letters to the editor

Laparoscopic colectomy

We read with great interest the papers of the SAGES Post-graduate Course published in the December 1995 issue ofSurgical Endoscopy, and we find that we cannot agree with

ome statements made by D.M. Ota in his work, Laparo-copic colon resection for cancer.

The author describes the basic principles of colorectalcancer management in open and laparoscopic surgery. Wedo agree with Ota that the laparoscopic procedures shouldeproduce the principles of open surgery. Nevertheless, Otaays that it is not possible to accomplish a complete staging

of the disease through the laparoscopic approach and that,herefore, retroperitoneal and periportal adenopathy can be

missed.Ota also states that early ligation of regional blood

vessels is not feasible during laparoscopic colectomy andhat anterior resection is also not feasible because the lap-

aroscopic intestinal stapler is straight and the stapled sutureine can only be 1012 cm from the anal verge. We do not

want to discuss whether radical hemicolectomy is preferableo segmental colectomy for cancer treatment since this is an

open question and the assertions made by the author in thisespect are not arguable. But we would like to assert someechnical principles which totally differ from those affirmed

by Ota.1. The identification of metastatic disease is certainly

ime consuming but at the same time extremely precise byaparoscopy. As far as the periportal nodes are concerned,

during laparoscopic hepatectomy and laparoscopic D2 gas-rectomy it has been demonstrated that it is possible to vi-ualize and dissect the element of the hepatoduodenal liga-

ment, carrying out the dissection of the group of nodes #12

according to the JSCC classification [3]. As far as lumbarand aortic node dissection is concerned, it has been dem-onstrated that this is feasible in colorectal cancer, cancer ofhe testis, and cervical, endometrial, and ovarian cancer [2].n our experience (165 laparoscopic colorectal resections

out of 250 laparoscopic colectomies, 101 of which for can-cer), in 12 cases an extended lymphadenectomy, includingnfraaortic node dissection, iliac, hypogastric, and obtura-ory node dissection have been performed. Intraoperative

complications and postoperative morbidity and mortalitywere similar to those of open operations. In one case, aesion of the aorta occurred during the disection due to the

detachment of the left ovarian artery at its origin. The lesionwas immediately repaired without any need of conversion.

2. The early ligature of the inferior mesenteric vessels isa basic step and the key element of laparoscopic colorectalprocedures. Such a maneuver is not only doable (Fig. 1) butmakes even easier the accomplishment of the operationsince the preparation of the inferior mesenteric artery at itsorigin is carried out along an avascular plane and the dis-section of the mesentery without previous colonic mobili-zation allows a clear visualization of the gonadic vessels,the ureter, and the genitofemoral nerve [1]. In this way theprocedure is safer, quicker, and oncologically correct: Onlytwo ligatures are required! The high ligature (the ligatureand division of the artery are performed close to its originfrom the aorta) of the mesenteric vessels is performed by usas the first step of a colorectal resection; thus, a no-touchprocedure is accomplished. In our opinion this does notincrease patient survival, but it does allow a precise stagingof the disease, which is essential for postoperative adjuvantchemotherapy.

3. Very low anastomoses (Fig. 2), even coloanal or il-eoanal anastomoses, are performed using one of the follow-ing techniques:

a. Double linear endostapler application with instrumentloaded with the 30-mm- or 35-mm-long cartridges and in-serted through the cannula placed in the right inferior quad-rant, while the rectum is pulled toward the left and a pres-sure is applied on the perineum to push upward the elevator-muscles plane.

b. Application of a standard roticulator stapler through asuprapubic minilaparotomy, with the operation continuedwith a gasless technique.

Correspondence to: M. M. Lirici

Fig. 1. High division of inferior mesenteric artery is achieved after eitherligating or clipping (two large clips 12 mm long, each side) the vessel at itsorigin from the aorta.

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In both cases the anastomosis is then accomplished ac-cording to the double stapling technique. In 20 cases of very

ow anastomoses performed through the laparoscopic ap-proach, we found no technical difference compared to open

urgery. On the contrary, the dissection of mesorectumeems to be more accurate by the laparoscopic route.

Laparoscopic colorectal procedures can really reproducehe techniques performed in open surgery: They should be

considered a surgical option for that reasonnot becauseadical operations have not shown real advantages com-

pared to segmental colonic resections.

References

. Buess G, Manncke K, Mehran J, Lirici MM (1993) State of the art oflaparoscopic colorectal surgery. End Surg 1: 312

2. Childers JM, Hatch KD, Surwit EA (1993) Laparoscopic paraortic

lymphadenectomy in gynecologic malignancies. Obstet Gynecol 82:741747

3. Huscher C, Chiodini S, Recher A, Battiston C, Tarantini M, Soccio M(1995) Laparoscopy-assisted gastrectomy for cancer: initial experience.Proceedings International Gastric Cancer Congress, Kyoto, pp 12151218

C. S. G. Huscher1

M. M. Lirici2

L. Angelini2

1Department of General SurgeryOspedale Vallecamonica25040 Esine (BS)Italy2

4th Department of SurgeryPoliclinico Umberto I University HospitalViale del Policlinico00161 RomeItaly

Fig. 2. Multiple applications of linear endostapler with the described technique allow a very low division of the rectum (the line of transection, below theperitoneal reflection, is brought down to the inferior third of the rectum) and performance of very low colorectal anastomoses and coloanal or ileoanal

nastomoses according to the double stapling procedure.

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Telementoring

A practical option in surgical training

J. C. Rosser,1 M. Wood,2 J. H. Payne,3 T. M. Fullum,4 G. B. Lisehora,5 L. E. Rosser,1 P. J. Barcia,5 R. S. Savalgi1

Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, USARiverview Hospital, Detroit, MI, USAKaiser Foundation Hospital, Honolulu, HI, USAProvidence Hospital, Washington DC, USA

Tripler Army Medical Center, Honolulu, HI, USA

Received: 17 May 1996/Accepted: 19 August 1996

AbstractBackground: Telemedicine offers significant advantages inbringing consulting support to distant colleagues. There is a

hortage of surgeons trained in performing advanced lapa-oscopic operations.

Aim: Our aim was to evaluate the role of telementoring inhe training of advanced laparoscopic surgical procedures.

Methods: Student surgeons received a uniform training for-mat to enhance their laparoscopic skills and intracorporealuturing techniques and specific procedural training in lap-

aroscopic colonic resections and Nissen fundoplication.Subsequently, operating rooms were equipped with threecameras. Telestrator (teleguidance device), instant replayto critique errors), and CD-ROM programs (to provide in-

formation of reference) were used as intraoperative educa-ional assistance tools. In phase I, four colonic resections

were performed with the mentor in the operating roomgroup A) and four colonic resections were performed withhe mentor on the hospital grounds, but not in the operating

oom (group B). The voice and video signals were receivedat the mentors location, using coaxial cable. In phase II,wo Nissen fundoplications were performed with the men-ors in the operating room (group C) and two Nissen fun-

doplications were performed with the mentors positionedfive miles away from the operating room (group D), usingcurrently existing land lines at the T-1 level.Results: There were no differences in the performances ofhe surgeons and outcome of the operations between groups

A & B and C & D. It was possible to tackle the intraopera-ive problems effectively.

Conclusions: The telementoring concept is potentially aafe and cost-effective option for advanced training in lap-

aroscopic operations. Further investigation is necessary be-fore routine transcontinental patient applications are at-tempted.

Key words: Telemedicine Telementoring Surgicaltraining Laparoscopic surgery

Telemedicine has previously been defined as live two-wayinteractive video communications between a physician anda patient and/or another physician, where all participants areable to see and hear one another much like a face to faceencounter. This basically constitutes the remote practiceof medicine. This concept has gained recent notoriety be-cause of the great advances in telecommunications and theincreasing cost-effectiveness associated with its utilization.If the subject is more closely reviewed, it will be revealedthat telemedicine is not a recent concept. Telemedicine be-gan in the 1950s during the early days of television. Fortyyears later, we now have a resurgence of the telemedicine

initiative. Most of the current applications are based onteleconferencing, utilizing interactive vocal communication,high-quality clinical still photographs, and video imageswhich are not of full-motion quality.

Telementoring is a telemedicine technique that involvesthe remote guidance of a treatment or investigational pro-cedure (Fig. 1), where the student has no or limited expe-rience with the featured technique. The multiple educationaland technological requirements place telementoring in amuch more sophisticated and higher-risk category than stan-dard telemedicine applications. These factors dictate that astandard training protocol be formulated so that quality as-

surance can be maintained.

Materials

The technology that makes telementoring possible may seem to be futur-istic and to require Star Wars technology, but in fact the technology is

Correspondence to: J. C. Rosser, Jr., Yale University School of Medicine,Department of Surgery, 40 Temple Street, Suite 3A, New Haven, CT06510, USA

Surg Endosc (1997) 11: 852855

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performed. Four of the cases were performed via the stan-dard mentoring process (group A). In this group the mentorwas in the OR with the student surgeon. The other fouraparoscopic colon cases were performed utilizing telemen-oring techniques (group B).

In group A (Table 1) the average OR time (mean SEM) was 231.0 36.4 min. The average blood loss was155.0 48.4 ml. The return to consumption of liquid and

olids was an average of 2.6 0.3 days and 4.0 0.4 days,espectively. The average length of stay in the hospital was

6.6 1.0 days and patients returned to normal activity in25.0 6.2 days.

In comparison with group A, the OR time in group Bwas slightly longer (318 79 min). All cases were success-fully completed laparoscopically without mentor interven-ion. In group B the blood loss was 263.0 122.5 ml and theeturn to consumption of liquid and solids was 2.3 0.3

days and 4.3 0.6 days, respectively. The average length oftay in the hospital was 6.3 1.2 days, and the return to

normal activity was 16.0 2.5 days. There were no com-plications in either group. Statistical parameters were very

imilar in both the groups and therefore the next phase ofhe mission was begun.

Phase II was held in Honolulu, Hawaii (Fig. 4). Full

CODEC (coder/decoder)-mediated computer compressionechnology was utilized. There were a total of four cases;wo were performed with the mentor (group C) in the OR

and the other two cases were performed in the control cen-er, located approximately 5 miles from the hospital (Ta-

ble 2).The OR times for groups C and D were 278.0 10 and

280.0 10 min, respectively. The blood loss for both groupC (90.0 10 ml) and D (110.0 14.1 ml) was minimal. Forgroup C the consumption of liquid and solids began in 1 dayand 2 days, in comparison to group D, in 1 day and 4 days,espectively. In both groups all the patients stayed in the

hospital for 3 days. For group C and group D the mean timeequired before returning to normal activity was 10.0 2.0

days and 12.0 1.0 days, respectively. The results betweenboth groups showed no significant difference.

TID was found useful in many instances. These included

review of anomalous anatomical presentations (digitized il-lustrations); reviewing the correct method to achieve anoperative goal in the operation (digitized video clips); andreviewing suturing technique needed to achieve intracorpo-real suturing in certain areas of the abdomen.

Discussion

Telemedicine is not a recent innovation. It began in theUnited States at the University of Nebraska in the late1950s. In 1959, the University of Nebraska implemented atelemedicine network to support clinical continuing medicaleducation and training, and also research collaboration ap-plications in geographically remote areas of Nebraska. Themajority of the early experiments in telemedicine eventuallywere closed down. At the same time during the investigationof the remote delivery of health care, there was an increasein efforts to expand the health-care delivery system in theUS and telemedicine entered a period of stagnation.

The potential advantages of telemedicine were revisitedas a result of the health-care delivery crisis, ever-tighteningbudgetary concerns, and the impact of managed care. Tele-communications and other technological breakthroughs alsofueled renewed enthusiasm. Credible, financially sound pro-grams have now been established. In 1986, the Mayo Clinicimplemented a two-way satellite program between theirRochester, Minnesota, campus and remote clinics inScottsdale, Arizona, and Jacksonville, Florida. In 1991, theMedical College of Georgia established a telemedicine linkbetween its Augusta, Georgia, campus and Dodge CountyHospital in Eastman, Georgia, to provide consultation andcontinuing education to the 87-bed hospital [8].

Telementoring is an advanced application of telemedi-cine. It adds new dimensions to current educational andclinical practices. It involves the remote guidance of a pro-cedure where the student has no or limited experience. Thisarticle is a review of the results of phase I and phase II ofour telementoring project.

Others have also begun investigating this new applica-tion. Go et al. used videoconferencing applications to evalu-ate early technology [1]. Ranshaw et al. [3] teleproctored aGeorgian rural surgeon in more than 24 cases. All caseswere successfully completed laparoscopically without anycomplications. They utilized one-half and full T1 lines and

demonstrated that they can be used for telementoring.Moore et al. [2] developed an in-house telementoring sys-tem without the use of computer compression technology.These studies represent preliminary investigations. There isa need for further critical evaluation of this technology inclinical settings.

There are several impressions that have come from ourinitial experience. At this time, with current CODEC com-puter compression algorithms, one-half T-1 bandwidth isthe minimum required for maximal motion display capabil-ity with minimal delay. The two-way audio link is besthandled with individual headsets rather than relying on one

speaker and microphone for all parties in the remote OR.Well-established military and aviation communicationspeech patterns are crucial for prompt execution of com-mands. In addition to an annotator to target important land-marks, the use of instant replay with a VCR allows for

Fig. 4. Pictorial depiction of phase I and phase II of telementoring.

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he rapid review and critique of unsafe or unwanted opera-ive techniques. The use of a concept called Tactical Infor-mation Deployment (TID) provides the surgeon with rapidaccess to reference information in the operating suite. Mul-imedia Interactive CD-ROMs with digitized movie clips,llustrations, sound bits, and the latest academic review ofhe literature arm the surgeon with a database that estab-ishes an unprecedented clinical adaptive capability.

The laparoscopic and intracorporeal suturing skills ofhose to be mentored must be assessed (and thereby es-ablished) to maintain the safety of the patient. Adherence to

a uniform, step-by-step tactical operative protocol that is

part of the training regimen provides common ground fornstructor and student. This must be established before themission is undertaken. An animal laboratory practical [6]hat is conducted under telementoring guidance conditionss essential to prepare the students to utilize all that they

have learned while interfacing with technology.The results of our initial experience are very encourag-

ng. We feel that this concept, if properly established, cannot only impact the delivery of health care for areas that are

underserved but also accelerate the safe deployment of ad-vanced procedural capability worldwide.

References

1. Go PMNYH, Payne JH Jr, Satava RM, Rosser JC (1996) Teleconfer-encing bridges two oceans and shrinks the surgical world. Surg Endosc10: 105106

2. Moore RG, Adams JB, Partin AW, Docimo SG, Kavoussi LR (1996)Telementoring of laparoscopic procedures. Surg Endosc 10: 107110

3. Ranshaw B, Tucker J, Duncan T, Mason E, Lucas G (1996) Laparo-scopic herniorrhaphy: a review of 900 cases. Surg Endosc 10: 255

4. Rosser J, Rosser L, Savalgi R (1996) Computer based training inlaparoscopic surgery. Surg Endosc 10: 257

5. Rosser J, Rosser L, Savalgi R (1996) Objective evaluation in laparo-scopic surgical training and credentialling. Surg Endosc 10: 257

6. Rosser J, Rosser L, Savalgi R (1996) Incorporation of telementoring inthe surgical training of advanced laparoscopic operations. Program andAbstracts, 4th International Congress of The European Association forEndoscopic Surgeons, A49

7. Stix G (1995) Boot camp for surgeons. Sci Am 273: 24

8. Whitehead R (1995) The evolution of telemedicine: then, now, andwhat will be. Teleconference 14: 911

Table 1. Results from phase I involving both mentored (group A) and telementored (group B) groups featuring laparoscopic colon resection (CODECnot utilized)a

GroupOR time(minutes)

Blood loss(ml)

PO liquid(days)

PO solid(days)

Admn(days)

RTNA(days)

A (n 4) 231.0 36.4 155.0 48.4 2.6 0.3 4.0 0.4 6.6 1.0 25.0 6.2B (n 4) 318 79.7 263.0 122.5 2.3 0.3 4.33 0.6 6.3 1.2 16.0 2.5

A, Colon resection with mentor in OR; B, Colon resection with mentor not in OR; mean SEM

Table 2. Results from phase II involving both mentored (group C) and telementored (group D) groups featuring laparoscopic Nissen fundoplicationCODEC utilized)a

GroupOR time(minutes)

Blood loss(ml)

PO liquid(days)

PO solid(days)

Admn(days)

RTNA(days)

C (n 2) 278.0 10.0 90.0 10.0 1.0 0.0 2.0 0.0 3.0 0.0 10.0 2.0D (n 2) 280.0 10.0 110.0 14.1 1.0 0.0 2.0 0.0 3.0 0.0 12.0 1.0

C, Nissen fundoplication with mentor in OR; D, Nissen fundoplication with mentor not in OR; mean SEM

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Original articles

Intracorporeal colorectal anastomosis following laparoscopic leftcolon resection

R. Bergamaschi, J.-P. Arnaud

Department of Visceral Surgery, Angers University Hospital, 4 rue Larrey, 49033 Angers, France

Received: 26 March 1996/Accepted: 9 September 1996

AbstractBackground: The aim of this study was to assess the impactof an intracorporeal double-stapled colorectal anastomosisupon the outcome of laparoscopic left colon resection.Methods: Fifty-four selected patients underwent electiveaparoscopic left colon resection for benign disease. Onceesection was completed, a 33-mm suprapubic port allowednsertion of the anvil of a circular stapler into the colon,

which was closed by a handsewn purse-string suture usinghe T-needle technique. The circular stapler was passedransanally to perform a double-stapled anastomosis. Speci-

mens were delivered in a plastic bag via the suprapubic port.Results: There were no deaths. Minor intraoperative andpostoperative complications occurred in 3.7% and 9.2% ofhe patients, respectively. Median operating time was 125

min (range 80210 min). Complete proximal and distaldoughnuts were obtained in all patients and anastomoseswere all methylene blue tight. Median hospital stay was 4range 37) days.

Conclusions: Fashioning double-stapled colorectal anasto-moses intracorporeally is feasable and safe.

Key words: Laparoscopy Colectomy Surgical tech-

nique

Despite the lack of convincing statistical evidence in sup-port of laparoscopic colectomy as an approach which resultsn immediately recognizable benefits to the patient and cost-

effectiveness, it is a fact that an increasing number of sur-geons are attempting it to treat benign diseases of the large

bowel. Since resecting and anastomosing segments of colontotally within the abdomen may become the procedure ofchoice, we describe here an approach to intracorporeal co-lorectal anastomosis that uses the double-stapling technique[3].

Patients

Between January 1992 and November 1994, 54 selected patients (31 menand 23 women; mean age 51, range 3981 years) underwent elective lap-aroscopic left colon resection for diverticulitis (n 40), polyps (n 10),

ischemic colitis (n 3), and endometriosis (n 1). Patients with previousextensive abdominal surgery and previous and/or ongoing treatment formalignant disease were excluded.

Technique

A mechanical bowel preparation is achieved using 2 l of polyethyleneglycol ingested orally during 2 days before surgery. Broad-spectrum in-travenous antibiotics are given 1 h preoperatively. Patients are given peri-operative epidural analgesia and general endotracheal anesthesia and un-dergo placement of nasogastric tube and urinary catheter. Patients areplaced in the lithotomy position with the thighs unflexed. The surgeon,cameraman, and scrub nurse stand on the patients right side. The cam-

eraman and the scrub nurse stand on the surgeons left and right side,respectively. Pneumoperitoneum is induced using carbon dioxide insuf-flated to a pressure of 10 mmHg by placement of a trocar in the infraum-bilical skin using a cut-down technique. A 0 forward-viewing telescope isemployed. A 10-mm port and a 12-mm port are placed lateral to the rectusmuscle sheath in the right hypocondrium and iliac fossa, respectively.Patients are turned into a steep Trendelenburg tilt and right lateral decu-bitus after trocar introduction.

The sigmoid colon is retracted with a Babcock clamp and dissected freefrom the retroperitoneum using curved scissors with monopolar cautery.The left ureter is identified. Further proximal mobilization of the bowel andof the splenic flexure is performed in a similar way according to the extentof the resection in order to ensure a tension-free anastomosis. The visceralperitoneum of the mesentery of the intended specimen is incised. Theproximal and distal margins of the specimen are divided with intestinal

cartridges of an endoscopic 30-mm linear stapler. The mesentery is dividedusing diathermy, clips, and a linear stapler with vascular cartridges. Anadditional 33-mm trocar (Endopath, Ethicon, Somerville, NJ) is insertedsuprapubically once the surgeon has judged that conversion to an openprocedure is unlike to occur. When necessary, the large bowel may begrasped with a Babcock clamp introduced through the 33-mm cannula and

Presented at the 6th joint meeting of the International Gastro-Surgical Club

IGSC), Bangkok, Thailand, 36 December 1995, and at the 5th WorldCongress of the Society of American Gastrointestinal Endoscopic Sur-geons (SAGES), Philadelphia, Pennsylvania, USA, 1317 March 1996Correspondence to: R. Bergamaschi, Institute of Surgery, University ofBergen, Diakonissehjemmets University Hospital, N-5009 Bergen, Nor-way

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held by the scrub nurse, thus allowing the surgeon to use a two-handedechnique during dissection of the mesentery. A plastic bag introduced viahe 33-mm port allows temporary intraabdominal storage of the specimen.

The anvil of a 31-mm or 33-mm-diameter circular stapler is then in-erted through the suprapubic trocar and held into the proximal colon afteromplete excision of the staple line. A noncrushing bowel clamp passed viahe trocar in the right hypocondrium and held by the cameraman may be

placed over the proximal colon to avoid fecal spillage. The bowel lumen isgenerally not widened by dilators prior to anvil introduction, while intra-venous glucagon is given when necessary [6]. During the earlier part of our

xperience, hand-sutured purse strings were made with a ski-shaped needlend extracorporeal knotting. Following the development of the T-needleechnique (Endo-Stitch, USSC, Norwalk, CT) purse strings are made andied intracorporeally around the purse-string notch of the anvil (Fig. 1). Theectal stump is irrigated by luminal wash-out in order to verify that the

inear staple row is tight before introduction of the circular stapler. Adouble-stapled colorectal anastomosis is performed according to a previ-ously described technique [3]. The circular stapler is removed and bothissue doughnuts are inspected for completeness and thickness. The integ-ity of the anastomosis is checked by irrigation with methylene blue afterhe application of a noncrushing intestinal clamp just proximal to theircular staple line. In case of intraoperative leak, the anastomosis is rein-orced with sutures. The specimen in a plastic bag is delivered through the3-mm suprapubic port.

Results

No perioperative deaths occurred. Median operating time

was 125 (range 80210) min. Median length of ileus was3.7 (range 25) days. Median hospital stay was 4 (range37) days. Intraoperative complications (3.7%) included

difficult extraction of circular stapler (n 1) and end-to-side anastomosis (n 1). Postoperative complications(9.2%) included wound hematoma (n 1), wound infec-tion (n 2), pleural effusion (n 1), and urinary retention(n 1). Median operating-room cost was $3,040 (range$2,7843,424).

ConclusionThe procedure described here is not by any means a newsurgical technique. In fact, only access to the double-stapling technique [3] has been changed. A variety of meth-ods have been described for fashioning intracorporeal colo-rectal anastomoses [1, 2, 4, 5]. All these procedures sharethe potential disadvantages of operating with an open rectalstump. Besides, a triple-stapled anastomosis [2, 4] appearsto unnecessarily complicate surgical technique. With regardto specimen delivery, a transanal route has been proposedeither in association with transanal endoscopic microsur-gery [4] or using a snare placed through a colonoscope [1].

Contradicting Darzi et al. [2], transanal specimen removalseems to us inappropiate regardless of the size of the lesionand particularly when operating on cancer. A 33-mm su-prapubic port allows safe specimen retrieval and construc-tion of a colorectal anastomosis with a closed rectal stump.

It has been claimed [7] that an intracorporeal anastomo-sis would entail a hardly justifiable increase in operatingtime and costs when compared to open surgery. The presentdata, which in part include the authors learning curve, donot appear to support these claims. In fact, a judicious use ofreusable laparoscopic equipment may help contain costs.No data are available in the literature comparing extracor-

poreal and intracorporeal anastomoses in terms of immedi-ately recognizable benefits to the patient and cost-effectiveness. In this respect, a costutility analysis wouldbe most appropiate because it measures quality of life.

Acknowledgment. The authors are grateful to Hans Knapp, South Tyrol, forhaving designed Figure 1.

References

1. Bleday R, Babineau T, Forse RA (1993) Laparoscopic surgery for colonand rectal cancer. Semin Surg Oncol 9: 5964

2. Darzi A, Super P, Guillou PJ, Monson JRT (1994) Laparoscopic sig-moid colectomy: total laparoscopic approach. Dis Colon Rectum 37:268271

3. Knight CD, Griffen FD (1980) An improved technique for low anteriorresection of the rectum using the EEA stapler. Surgery 88: 710714

4. Kokerling F, Gastinger I, Gall CW, Schneider B, Krause W, Gall FP(1992) Laparoskopische kolorektale Chirurgie: Kolon- und Rektu-manastomosen in triple-stapling-technique. Minimal Invasive Chir 1:4450

5. Mentges B, Bue G, Schafer D, Manncke K, Becker HD (1995) Trans-anal endoscopic microsurgery and combined operations. In: Moreno-Gonzalez E, Escart n P, Lygidakis NJ, Balibrea JL, Pajares JM, HidalgoPascual M (eds) Joint meeting of surgery, gastroenterology and endos-copy. Jarpyo, Madrid, pp 339345

6. Moseson MD, Hoexter B, Labow SB (1980) Glucagon, a useful adjunctin anastomosis with a stapling device. Dis Colon Rectum 23: 25

7. Scott HJ, Spencer J (1995) Colectomy: the role of laparoscopy. SurgLaparosc Endosc 5: 382386

Fig. 1. Fashioning hand-sewn purse strings intracorporeally.

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Laparoscopically assisted gastric surgery using DexterityPneumo Sleeve

T. Naitoh, M. Gagner

Department of General Surgery/A-80, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA

Received: 18 September 1996/Accepted: 26 December 1996

AbstractBackground: Laparoscopic surgery has been successfullyapplied to several gastrointestinal procedures. Although theotally laparoscopic gastrectomy is feasible, tactile sensa-ion and manipulation of the organ as well as the lesion are

decreased when compared to open surgery. The DexterityPneumo Sleeve is a new device which allows the surgeon tonsert a hand into the abdominal cavity while preserving the

pneumoperitoneum. This device was used for patients whounderwent laparoscopic gastric surgery.Methods: The first patient presented with a non-Hodgkins

ymphoma of the stomach. A laparoscopically assisted dis-al gastrectomy was performed with Roux-en-Y reconstruc-ion. The second patient had a 5-cm leiomyoma involvinghe greater curve of the stomach, and this device was used

for manipulation of the tumor. The last patient suffered frommorbid obesity with its associated medical complicationsand a ventral hernia. The Sleeve was applied at the hernia

ite and a laparoscopically assisted gastric bypass was per-formed.Results: The Pneumo Sleeve was useful in these cases foractile localization of the tumor and for retraction and ma-

nipulation of the stomach and surrounding upper abdominal

organs.Conclusions: The utilization of this device resulted in amore easily performed dissection, resection, and anastomo-

is and was felt to decrease operation time.

Key words: Gastric surgery Lymphoma Leiomyoma Morbid obesity Laparoscopic surgery Surgicaldevice

Laparoscopic surgery has been recently applied to several

gastrointestinal procedures to reduce pain and effect a fasterecovery and better cosmetic result. Gastric surgery is no

exception. Goh et al. reported two cases of totally intra-abdominal laparoscopic Billroth II gastrectomy in 1992 [5].Watson et al. described the technique of totally laparoscopicBillroth II gastrectomy for early gastric cancer in 1995 [14].

Although the totally laparoscopic gastrectomy for car-cinoma is feasible, there are still some concerns about de-tection of other lesions and surgical margins [3, 8]. A per-sistent problem with laparoscopic surgery is the inability ofthe surgeon to palpate the abdominal contents during theoperation. This lack of tactile sensation can lead to poorgeneral abdominal exploration, difficulty in extraction of

organs, or a relatively long operation time compared toconventional open procedures.

The Dexterity Pneumo Sleeve (Dexterity, Research Tri-angle Park, NC) is a new device which allows the surgeonto insert a hand into the abdominal cavity through a rela-tively small incision while preserving the ability to workunder pneumoperitoneum [15]. The use of this product pro-vides the possibility of hand assistance during laparoscopicsurgery and tactile sensation of the lesion which might notbe apparent with the use of instrumentation alone. Thisproduct was recently approved for clinical use in the UnitedStates. During our early experience in this project, we had

three patients who underwent laparoscopically assisted gas-tric surgery using the Dexterity Pneumo Sleeve.

Description of Dexterity Pneumo Sleeve

The device has two main components: the Protector Retrac-tor and the Pneumo Sleeve (Fig. 1).

The Protector Retractor is an open-ended cylinder witha flexible ring at each end. One ring is inserted through theincision into the peritoneal cavity while the other remainsoutside of the incision. The retractor lines the wound andacts to keep the incision open and to protect against wound

contamination.The Pneumo Sleeve is approximately 34 inches long and

912 inches wide and is made of a biocompatible, sealablepolyolefin-type material. The distal side of the sleeve has afenestration and an adhesive flange for attaching to the pa-Correspondence to: M. Gagner

Surg Endosc (1997) 11: 830833

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ients abdomen. The proximal end of the sleeve has a cuffconstructed of Velcro or molded plastic) which is designedo secure the sleeve around the surgeons arm and preventeakage of pneumoperitoneum gas.

Generally, the length of the skin incision (in centime-ers) required to insert the surgeons hand is almost equal tohe surgeons glove size.

Surgical technique

The patients who underwent laparoscopic-assisted gastric surgery using the

Dexterity Pneumo Sleeve signed a specific informed consent which waspproved by the Institutional Review Board of the Cleveland Clinic Foun-

dation.

Case 1

The patient is 66-year-old female who weighed 119 kg and was 170 cmall. She presented with upper gastrointestinal bleeding due to ulceration of non-Hodgkins lymphoma of the stomach. The lymphoma was on theesser curvature of the gastric body starting at approximately 5 cm distal tohe gastroesophageal (GE) junction; the ulcer was approximately 7 cm in

diameter. She was scheduled to undergo laparoscopically assisted distalgastrectomy with Roux-en-Y gastroenterostomy.

Surgery was performed with the patient supine with legs in the splitposition. The surgeon stood between the legs and an assistant was on each

ide. An 8-cm skin incision was made in the lower midline and the Dex-erity set was applied to the skin surrounding the wound. A 10-mm trocar

was inserted in the left flank and pneumoperitoneum was created. A 10-mm and a 12-mm trocar were then inserted in the left subcostal region aswell as a 10-mm trocar in the right subcostal area.

The left hand of the surgeon was inserted into the abdominal cavityhrough the Pneumo Sleeve, and the tumor was easily palpable, as were its

margins. Using the Harmonic Scalpel (UltraCision Inc., Smithfield, RI),he gastrocolic ligament was taken down to mobilize the greater curvature

of the stomach. The right gastroepiploic artery was transected after apply-ng clips. Then the duodenum bulb was dissected and the first portion of the

duodenum was transected with an endoscopic linear stapler. While retract-ng the stomach inferiorly with the left hand, the lesser curvature was

dissected with the Harmonic Scalpel until a point just distal to the GEunction. The short gastric arteries were taken in a similar fashion. Clips

were utilized to control the larger vessels. Then, using the endoscopicinear stapler with several cartridges, the distal stomach was divided (Fig.

2). This specimen was taken out through the Sleeve and sent to pathology.Next, the jejunum was divided with an endoscopic linear stapler ap-

proximately 20 to 25 cm from the ligament of Treitz and the distal loop wasbrought up over the transverse colon. After putting a stay suture betweenthe stomach and jejunum, a small incision was made in the anterior wall ofthe stomach and antimesenteric side of the jejunum, respectively. Theendoscopic linear stapler was inserted through the hole and fired twice tocreate a 6-cm gastrojejunostomy. The remaining enterotomy was closedwith 3-0 running suture using the hand-assisted intracorporeal knot-tying

technique. Then a loop of more distal jejunum was selected and pulledthrough the skin incision of the Pneumo Sleeve; the jejunojejunostomy wascreated extracorporeally.

The abdominal cavity was irrigated and two drains were left next to theanastomosis. Trocars were all removed, and all fascial wounds were closedwith 0 Polyglactin 910 sutures and 4-0 sutures for subcutaneous.

Approximate blood loss was 150 ml and duration of operation was 360min. The patient started normal diet on 5th postoperative day and wasdischarged on postoperative day 8 without complications.

Case 2

A 78-year-old male who was otherwise in good health presented with a

history of gastrointestinal bleeding. The examination and subsequentworkup revealed a 5-cm submucosal tumor of the stomach which wasinvolving the anterior wall of the gastric body. Biopsies returned probableleiomyoma and computerized tomography demonstrated the lesion withoutany signs of malignancy or metastasis. A 1.5-cm gallstone was also seen inthe gallbladder.

After usual laparoscopic cholecystectomy, an 8-cm skin incision wasmade in the infraumbilical area. The Dexterity Pneumo Sleeve was appliedto the skin, and the left hand of the operator was inserted inside of theabdominal cavity. After insufflation of carbon dioxide gas up to 15 mmHg,a 10-mm trocar was inserted in the left subcostal area, and a 12-mm trocarfor the insertion of the endoscopic linear stapler was inserted in the leftparamedian area. Using 10-mm 30 angle laparoscope, the lesion was takenby the inserted hand and lifted up to the anterior abdomen. Confirming theadequate margins with manual palpation, a wedge resection of the stomach

was performed with four cartridges of the endoscopic linear stapler, 12 mmin diameter, 30 mm in length (Fig. 3). The specimen was retrieved throughthe Pneumo Sleeve and sent to pathology for immediate examination. Itwas confirmed to be leiomyoma with clear margins.

One stitch of 2-0 silk was applied with a laparoscopic needle holder,using intracorporeal knot tying technique, to the superior staple line tocontrol bleeding in that area. The Pneumo Sleeve and trocars were allremoved

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