Laparoscopic nephrectomy.

Since the first clinical operation in June 1990 laparoscopic nephrectomy for benign renal disease has become widely accepted. Although the laparoscopic operation takes much longer than open surgery, there are considerable reductions in the length of postoperative hospital stay and the time taken to return to normal activities and to full recovery. Major complications were relatively common in early operations, but with more experience morbidity has been reduced. Laparoscopic nephrectomy for malignant renal disease is still controversial, largely because of the fear of release of malignant tissue into the abdominal cavity during the morcellation and retrieval of the diseased kidney. To prevent this, the kidney is removed intact through a 5-7 cm incision. Long term follow up is needed, however, before we will know whether the laparoscopic procedure is effective in preventing recurrence of cancer. New developments have improved various technical aspects of the operation, but stringent assessment of new techniques is necessary so that the medical community can decide which procedures should become routine practice.     

Laparoscopic and percutaneous ablative techniques in the treatment of renal cell carcinoma

Widespread use of computed tomography, ultrasound, and magnetic resonance imaging has led to an increase in detection of relatively small renal masses, and approaches to managing them have evolved in the last two decades. Indications for nephron-sparing surgery have expanded, and minimally invasive procedures, which can confer advantages over open surgery, are now available. Ablative techniques offer a combination of nephron-sparing and minimally invasive approaches. Ablative techniques include cryoablation, radiofrequency ablation (RFA), and high-intensity focused ultrasound (HIFU). Cryoablation and RFA have been relatively safe. HIFU has been associated with serious side effects in animal models, and is not yet acceptable for use in humans. Ablative techniques require long-term studies to confirm lasting efficacy. The best modality for tumor targeting, monitoring of therapy, and follow-up is still under investigation. Debate exists regarding the best method for ensuring adequate intraoperative tumor cryoablation. For minimally invasive ablative measures to gain a place as nephron-sparing approaches, they should show both equivalent efficacy and reduced morbidity relative to those of open partial nephrectomy. These techniques should currently be reserved for selected patients and should be compared to the evolving modality of laparoscopic partial nephrectomy.     

Arthroscopy.

Arthroscopy has reduced the morbidity and period of hospitalisation associated with orthopaedic surgery and has increased the range of procedures that may be performed. From early operations on the knee it has expanded to include procedures for the shoulder, elbow, wrist, hip, ankle, and foot. For some joints the indications for surgery are clear, for others the clinical advantages are still being assessed. This expansion has also led to the recognition of complications, though the incidence is low. Specialist instrumentation has allowed a wide variety of operations previously needing open surgery to be carried out arthroscopically. The repertoire of arthroscopic procedures will undoubtedly continue to expand, and controlled studies are required to validate their efficacy, particularly in the management of degenerative joint diseases.     

Secondary abdominal contour surgery: a review of early and late reoperative surgery

A retrospective chart review of 400 abdominal contour operations produced a series of 24 patients who underwent both their primary and then their secondary abdominal contour surgeries with the senior author (Matarasso). The majority of patients were classified and treated according to the abdominoplasty classification system previously described; however, a subgroup could not be categorized according to this system. In this study, the authors identified the secondary abdominal contour surgical experience of one surgeon. A comparison was made between two groups of patients treated for both primary and secondary operations: group I, considered early, less than 18 months after the previous operation; and group II, considered late, 18 or more months after the previous operation. There was a significant difference between groups I and II (chi2 = 4.12, p = 0.05); most patients had their surgical procedures before 18 months. For patients who underwent either a miniabdominoplasty or a full primary abdominoplasty, there was a statistically significant difference between the number of patients treated in group I and the number in group II (Fisher's exact test, D = 0, p = 0.05). Next, the nature of the secondary procedure was determined to be either a revisional procedure or a completely new reoperative procedure. The majority of patients underwent revision or "touch-ups," accomplished with either liposuction alone or in combination with scar revision. There was no significant difference between types of primary and secondary procedures performed in group I or group II. Secondary abdominal contour surgery accounted for 6 percent (24 of 400) of all abdominal contour procedures performed by one surgeon. Complete secondary surgery, performing an additional open procedure, occurred in 21 percent of cases (five of 24). Revision surgery (scar revision or removal of dog-ears) was performed in 29 percent of all cases (seven of 24). There was a 4 percent (one of 24) complication rate requiring operative intervention. This rate is consistent with that reported in the literature for primary abdominal contour surgery. With the overall acceptance of aesthetic surgery increasing, the number of patients undergoing abdominoplasty increasing, an aging population, and the safety of secondary abdominal contour surgery suggested from this review, it is likely that plastic surgeons will see more patients requesting secondary abdominal contour surgery in the future.     

腹腔镜腹壁切口疝修补术的临床疗效分析

目的探讨腹腔镜腹壁切口疝修补术的临床疗效。方法选取2015年6月~2016年5月我院收治的腹壁切口疝患者89例,根据治疗方式的不同将患者分为开放组44例和腹腔镜组45例。开放组44例患者采用开放式腹壁切口疝修补术,腹腔镜组45例患者行腹腔镜腹壁切口疝修补术,并对两组患者的手术时间、术中出血量、术后疼痛评分、并发症及复发情况、住院时间进行比较。结果腹腔镜组患者的手术时间长于开放组(P0.05),而术中出血量、术后疼痛评分和住院时间均低于开放组(P0.05),并发症发生率和复发率低于开放组(P0.05)。结论腹腔镜腹壁切口疝修补术是一种安全、有效、可行的治疗手段,值得临床推广应用。     

Minimally invasive surgery in the field of gynecologic oncology

The aim of this paper was to present the results in minimal invasive surgery in the field of gynecologic oncology at General hospital Zabok, Croatia. 381 laparoscopic procedures were performed between 1994 and 1998. There were 263 operations of the benign adnexal masses, and 107 operations due to benign tumors of corpus uteri (there were 18 LAVH, 12 LH and 77 TLH). There were 11 laparoscopic operations due to carcinoma (1 ovary, 6 corpus and 4 cervix). Operations were: 3 LAVH (laparoscopically assisted vaginal hysterectomy), 5 TLH (total laparoscopic hysterectomy) with pelvic lymphadenectomy, 1 LAVH with pelvic lymphadenectomy, 1 coelio Shauta operation with laparoscopic pelvic lymphadenectomy and paraaortal lymphadenectomy, and 1 laparoscopic adnexectomy. Among laparoscopic procedures in 370 patients operations were successfully performed as planed, while in 11 patients it was necessary to switch to laprotomy. Among serious complications of laparscopic operations it is necessary to note 2 lesions of the ureter and 1 lesion of the bladder. Laparoscopic lymphadenectomies were performed successfully; there were no serious early or late postoperative complications. There was no operative mortality. Even though many authors claim that laparoscopic operations in the field of gynecologic oncology are safe and have the same results as in open surgery, patients benefit from shorter recovery and better quality of life during laparoscopic procedures.     

2. Newer aids in the diagnosis of blunt abdominal trauma.

The assessment of a case of blunt abdominal trauma can be complicated by many factors, and the resultant inaccurate or delayed diagnoses have contributed to the unacceptable mortality for this type of injury. Recently several useful diagnostic techniques have been developed that, if applied intelligently, may be instrumental in decreasing the high mortality among patients who present with ambiguous abdominal signs after sustaining blunt trauma. Although hematologic investigation and routine radiography have facilitated detection of intraperitoneal injury, peritoneal lavage has become the single most helpful aid. Scanning procedures are sometimes useful in recognizing splenic and hepatic defects especially; these may be confirmed or clarified by angiography. Although ultrasonography may be no more valuable than scintigraphy in outlining splenic and hepatic abnormalities, it is an important technique, especially in the diagnosis of retroperitoneal masses of traumatic origin. Laparoscopy also may be helpful in investigation if surgeons become more familiar with the procedure.     

Open laparoscopy. Commentary

Open laparoscopy has been receiving increased attention in the US and internationally. However, opinions differ on its appropriate role in laparoscopy services. In the US some surgeons remain comfortable using closed laparoscopy for all patients, including some who have had previous abdominal surgery. Some centers are using more open procedures, especially for training programs and for cases where open laparoscopy may be indicated, as described by Dr. Hasson in this "Bulletin." Others have converted to performing all laparoscopy by the open technique. The Planned Parenthood Federation of America encourages minilaparotomy and open laparoscopy for tubal occlusion n its facilities because of the greater inherent potential for patient safety with these approaches. AVS has not provided open laparoscopy equipment to international programs, although some projects have used an open technique. Neither the World Federation of Health Agencies for the Advancement of Voluntary Surgical Contraception nor the AVS Science Committee has addressed the role of open laparoscopy in international programs. This is due in part to insufficient worldwide experience in open laparoscopy. However, this does not preclude AVS from providing such equipment for open laparoscopy in the future. In the US approximately 300-500 Hasson cannulas have been commercially distributed annually for the past 4-5 years. About 2000 may be currently in use in the US. Therefore, among the 6915 hospitals registered with the American Hospital Association in 1982, a substantial proportion may now provide access to open laparoscopy equipment. Studies in the US are not yet available to fully assess the safety of open laparoscopy. However, general comparisons of complication rates for open and closed laparoscopy may not be appropriate since many surgeons reserve the more complicated cases for open laparoscopy.     

Teaching laparoscopic surgery: the need for guidelines.

There is a risk that minimally invasive surgery will fall into disrepute unless adequate steps are taken to reassure the public. Some form of accreditation after a recognised training scheme would go a long way towards allaying these fears. The cost of training surgeons must be addressed. Adequate training will probably pay dividends in reduced litigation. The royal colleges should be responsible for maintaining standards of teaching on recognised courses, setting criteria for accreditation, and supervising a national audit of all laparoscopic procedures.     

Thyroid cancer causing obstruction of the great veins in the neck

Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD) with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP) is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP) is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP) with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the abovementioned topics.     

Laparoscopic radical prostatectomy in obese patients: feasible or foolhardy?

More than 70% of men who are candidates for radical prostatectomy can be classified as either overweight or obese by body mass index. The role for laparoscopic radical prostatectomy (LRP) in treating these patients remains to be defined. A wealth of experience from bariatric surgery confirms that laparoscopic procedures can be performed successfully, even in the setting of morbid obesity, despite well-defined derangements in respiratory dynamics. Using the technical modifications outlined here, LRP can be performed safely and effectively in obese patients. Obesity raises the degree of difficulty for LRP, however, resulting in longer operative times and possibly a higher rate of open conversion. For this reason, surgeons early in their LRP experience are advised to avoid obese patients until they have become facile in the performance of LRP in normal-weight individuals.     

Open versus laparoscopic radical prostatectomy

Expert laparoscopic surgeons have demonstrated that laparoscopic radical prostatectomy with or without robotic assistance can be performed with excellent results. There is no evidence that laparoscopic radical prostatectomy with or without robotic assistance offers any clinically relevant advantage over open radical prostatectomy. Laparoscopic radical prostatectomy with or without robotic assistance requires a significant learning curve, is a longer surgical procedure, carries greater costs, and requires an expanded operating room team. The literature suggests that laparoscopic radical prostatectomy is associated with more intraoperative complications and higher positive surgical margins. The lesser amount of postoperative bleeding associated with laparoscopic radical prostatectomy is not clinically relevant. Laparoscopic radical prostatectomy is not associated with less pain and does not facilitate earlier urinary catheter removal. The best way to improve overall outcomes after radical prostatectomy is to direct patients to expert open or laparoscopic surgeons.     

Incidence and pathophysiological relevance of postoperative endotoxemia

Abstract Patients who underwent surgical procedures usually develop elevated body temperature, changes of plasma levels of some proteins, and leucocytosis. These alterations are summarized as the postoperative acute-phase reaction. Also endotoxin can induce the described phenomena suggesting that endotoxin may play a role concerning the induction of the acute phase reaction. In order to test that hypothesis we determined endotoxin plasma levels preoperatively and daily postoperatively in patients who were operated on because of goiter ( n = 20), colonic, pancreatic and gastric diseases ( n = 58). A significant increase of endotoxin plasma levels was found at the first and third day after abdominal surgery whereas after goiter surgery the increase revealed to be only very slight. However, the decrease between the first and second postoperative day in the latter group was again statistically significant suggesting postoperative endotoxemia even after minor operations. Furthermore a correlation between the amount of circulating endotoxin and pulmonary or infectious complications could be established in patients after major operations even at the first postoperative day suggesting a pathogenetic relevance of postoperative endotoxemia.     

Laparoscopic colon surgery: our results

Formerly, the laparoscopic surgery was accepted as a method of choice for benign diseases, and for palliative operations in progressive stages of malignant diseases of the colon. Today, the laparoscopic surgery of the colon has been also adopted in treating malignant diseases. The first laparoscopic colon resection was performed in our Clinic on December 12, 2002, and 114 patients have been successfully operated until June 1, 2007. Among those 114 patients 56 were men and 57 were women with the average age 65 (ranging from 28-86) years. A series of various laparoscopic operations have been performed for malignant disease mainly (almost 80%). The pre-surgical treatment, preparation of patients and the types of the operations were identical to those applied in patients treated by open surgery. Patients with colon carcinoma have been operated on with the principles of oncologic radicality. In post-operative period we encountered eight complications (four minor and four major) with only one fatal outcome. According to our experience and the facts found in literature, the results of laparoscopic colon surgery are comparable with open surgery.     

Minimally invasive surgery. Future developments.

The rapid development of minimally invasive surgery means that there will be fundamental changes in interventional treatment. Technological advances will allow new minimally invasive procedures to be developed. Application of robotics will allow some procedures to be done automatically, and coupling of slave robotic instruments with virtual reality images will allow surgeons to perform operations by remote control. Miniature motors and instruments designed by microengineering could be introduced into body cavities to perform operations that are currently impossible. New materials will allow changes in instrument construction, such as use of memory metals to make heat activated scissors or forceps. With the reduced trauma associated with minimally invasive surgery, fewer operations will require long hospital stays. Traditional surgical wards will become largely redundant, and hospitals will need to cope with increased through-put of patients. Operating theatres will have to be equipped with complex high technology equipment, and hospital staff will need to be trained to manage it. Conventional nursing care will be carried out more in the community. Many traditional specialties will be merged, and surgical training will need fundamental revision to ensure that surgeons are competent to carry out the new procedures.     

腹腔镜胆囊手术和开腹胆囊手术对术后肠黏连的影响比较

目的:比较腹腔镜胆囊手术和开腹胆囊手术对于术后肠黏连的影响,对比两种手术的有效性和安全性。方法:回顾选取在我院接受胆囊手术治疗的196例病患,根据术式分成开腹组和腹腔组,每组均为98例患者,对比分析组间手术指标以及术后出现肠黏连的情况,同时观察手术前后患者消化道生存质量变化。结果:腹腔镜组手术耗时(123.57±4.65 min)长于开腹组,术中出血(27.52±5.69 mL)、胃肠功能恢复用时(18.03±3.51 h)、术后住院时间(4.51±1.03)、肠黏连发生率(10.20%)少于开腹组,(P0.05);两组术前GLQI评分相仿(P0.05),术后GLQI评分显著高于组内术前(P0.05),且腹腔镜组术后GLQI评分显著高于开腹组(P0.05)。结论:与开腹手术相比,腹腔镜胆囊手术不仅手术创伤小、术后恢复时间短,而且术后肠粘连发生率低,值得推广。     

Prospective controlled randomized trial on prevention of postoperative abdominal adhesions by Icodextrin 4% solution after laparotomic operation for small bowel obstruction caused by adherences [POPA study: Prevention of Postoperative Adhesions on behalf of the World Society of Emergency Surgery]

Background

In some randomized trials successful laparoscopic cholecystectomy for cholecystitis is associated with an earlier recovery and shorter hospital stay when compared with open cholecystectomy. Other studies did not confirm these results and showed that the potential advantages of laparoscopic cholecystectomy for cholecystitis can be offset by a high conversion rate to open surgery. Moreover in these studies a similar postoperative programme to optimize recovery comparing laparoscopic and open approaches was not standardized. These studies also do not report all eligible patients and are not double blinded.

Design

The present study project is a prospective, randomized investigation. The study will be performed in the Department of General, Emergency and Transplant Surgery St Orsola-Malpighi University Hospital (Bologna, Italy), a large teaching institutions, with the participation of all surgeons who accept to be involved in (and together with other selected centers). The patients will be divided in two groups: in the first group the patient will be submitted to laparoscopic cholecystectomy within 72 hours after the diagnosis while in the second group will be submitted to laparotomic cholecystectomy within 72 hours after the diagnosis.

Trial Registration

TRIAL REGISTRATION NUMBER ISRCTN27929536 – The ACTIVE (Acute Cholecystitis Trial Invasive Versus Endoscopic) study. A multicentre randomised, double-blind, controlled trial of laparoscopic versus open surgery for acute cholecystitis in adults.     

The new era of cardiac surgery: hybrid therapy for cardiovascular disease

Surgical therapy for cardiovascular disease carries excellent long-term outcomes but it is relatively invasive. With the development of new devices and techniques, modern cardiovascular surgery is trending toward less invasive approaches, especially for patients at high risk for traditional open heart surgery. A hybrid strategy combines traditional surgical treatments performed in the operating room with treatments traditionally available only in the catheterization laboratory with the goal of offering patients the best available therapy for any set of cardiovascular diseases. Examples of hybrid procedures include hybrid coronary artery bypass grafting, hybrid valve surgery and percutaneous coronary intervention, hybrid endocardial and epicardial atrial fibrillation procedures, and hybrid coronary artery bypass grafting/carotid artery stenting. This multidisciplinary approach requires strong collaboration between cardiac surgeons, vascular surgeons, and interventional cardiologists to obtain optimal patient outcomes.     

Use of laparoscopy in pediatric urology

The goal of laparoscopy is to minimize patient morbidity while maintaining successful outcomes. The use of laparoscopy in urology has grown significantly over the past 30 years. Its use has been slower to gain acceptance in pediatrics than in the adult population. Laparoscopic orchidopexies and nephrectomies are commonly performed and have become widely accepted as alternatives to open surgery, if not the gold standard. The more technically demanding procedures, such as laparoscopic pyeloplasty, laparoscopic-assisted bladder reconstruction, and laparoscopic ureteral reimplantation, tend to be performed at selected centers and have yet to achieve widespread acceptance. As laparoscopy is applied more widely in pediatric urology, its potential benefits and drawbacks will be clarified.     

腹腔镜与开放输尿管切开取石术治疗输尿管结石的临床疗效分析

目的:比较腹腔镜与传统开放手术行输尿管切开取石术治疗输尿管结石的临床效果,评价腹腔镜手术的优势。方法:回顾性分析我院2011年9月~2013年2月45例行开放输尿管切开取石术(开放组)与33例行腹腔镜输尿管切开取石术(腹腔镜组)患者的临床资料并进行比较。结果:78例手术均取石成功,腹腔镜组2例分别因结石逃逸入肾盂和输尿管炎症水肿粘连明显改行开放手术。腹腔镜组在术中出血量、术后下床时间、肛门排气时间、术后引流总量、术后引流时间、住院天数方面均显著优于开放组,而手术时间及住院总费用显著高于开放组,差异均有统计学意义(P0.05)。两组患者术后均未出现尿瘘、伤口愈合不良、严重血尿等并发症。结论:两组术式治疗输尿管结石均能有效取石,腹腔镜术式在很多方面拥有一定优势,传统切开取石也有自己的特点。临床上应综合考虑患者意愿、病情特点、术者操作水平、患方经济条件等一系列因素决定最终手术方式。