Randomized controlled trial comparing the effects of usual gas release, active aspiration, and passive-valve release on abdominal distension in patients who have undergone laparoscopic cholecystectomy

Abstract

Introduction

Residual, intra-abdominal CO₂ contributes to abdominal distension and pain after laparoscopic surgery. The study was designed to assess recovery after gas release in patients who have undergone laparoscopic cholecystectomy (LC).

Methods

A total of 142 patients undergoing laparoscopic cholecystectomy were randomly divided into three groups: (i) group 1 (control group), gas release from the surgical wound without port release (n = 47); (ii) group 2, active gas aspiration via a subdiaphragmatic port (n = 48); and (iii) group 3, passive-valve release via a subdiaphragmatic port valve opening (n = 47). Abdominal distension and shoulder pain levels were assessed postoperatively.

Results

The active aspiration group had significantly reduced postoperative abdominal distensions at 30 min, 4, and 24 h compared with the control group (50.0% vs 80.9%, 43.8% vs 76.6%, 33.3% vs 57.4%, respectively; P < 0.05). Similarly, the passive-valve release group had significantly reduced postoperative abdominal distensions at 4 and 24 h compared with the control group (51.1% vs 76.6%, 57.4% vs 36.2%; P < 0.05). Both intervention groups had significantly reduced postoperative shoulder pain at 4 and 24 h compared with the control group (P < 0.001). In addition, the postoperative ambulation times for the active aspiration group were significantly shorter than those for the control and passive-valve release groups (P < 0.001).

Conclusion

Releasing residual CO₂ from the intra-abdominal cavity at the end of laparoscopic cholecystectomy by either the active aspiration or passive-valve release technique is an effective way to reduce postoperative abdominal distension and shoulder pain.

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Pediatric femoral hernia in the laparoscopic era

Abstract

Introduction

Femoral hernia is a rare and often misdiagnosed condition in childhood. The aim of our study was to demonstrate that the laparoscopic approach improves diagnostic accuracy and offers a safe and effective treatment.

Methods

A retrospective study of 687 pediatric patients who underwent laparoscopic inguinal hernia repair from January 2000 to December 2015 was performed.

Results

Femoral hernias were identified in 16 patients (2.3%). The right side was affected in 10 cases (62.5%), the left side in 5 (31.2%), and 1 case was bilateral (6.2%). The mean age of patients was 8.00 ± 3.81 years, and there was a male predominance. Preoperative diagnosis was femoral hernia in eight cases (50%) and indirect inguinal hernia in the remaining eight (50%). Seven children (43.8%) presented with hernia recurrence after having undergone an open ipsilateral indirect hernia repair. A modified laparoscopic McVay technique was performed in 12 cases (70.6%). An epigastric artery injury by trocar occurred in one patient. All operations were completed laparoscopically. The mean surgical time was 45.6 ± 22.9 min for unilateral cases and 110 ± 10.0 min for bilateral cases. No immediate postoperative complications were noted. The mean postoperative hospital stay was 0.6 ± 0.4 days. No recurrence was observed after a median follow-up of 11 years (range, 4–16 years).

Conclusion

Femoral hernia is a rare pathology in pediatric patients that is often difficult to diagnose. The laparoscopic approach is effective in the diagnosing and treating these hernias, and it allows for the simultaneous repair of multiple groin defects.

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Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System

Abstract

Introduction

The PINPOINT® Endoscopic Fluorescence Imaging System (Novadaq, Mississauga, Canada) allows surgeons to visualize the bile ducts during laparoscopic cholecystectomy. Surgeons can continue operation while confirming the bile ducts' fluorescence with a bright-field/color image. However, strong fluorescence of the liver can interfere with the surgery. Here, we investigated the optimal timing of indocyanine green administration to allow fluorescent cholangiography to be performed without interference from the liver fluorescence.

Methods

A total of 72 patients who underwent laparoscopic cholecystectomy were included in this study. The timing of indocyanine green administration was set immediately before surgery and at 3, 6, 9, 12, 15, 18, and 24 h before surgery. The luminance intensity ratios of gallbladder/liver, cystic duct/liver, and common bile duct/liver were measured using the ImageJ software (National Institutes of Health, Bethesda, USA). Visibility of the gallbladder and bile ducts was classified into three categories (grades A, B, and C) based on the degree of visibility in contrast to the liver.

Results

The luminance intensity ratio for the gallbladder/liver, cystic duct/liver, and common bile duct/liver was ≥1 in the 15-, 18-, and 24-h groups. The proportion of cases in which evaluators classified the visibility of the gallbladder and bile ducts as grade A (best visibility) reached a peak in the 15-h group and decreased thereafter.

Conclusions

In the present study, the optimal timing of indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT Endoscopic Fluorescence Imaging System was 15 h before surgery.

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Laparoscopic anterior resection for rectal cancer in a patient with a ventriculoperitoneal shunt

Abstract

Laparoscopic surgery has been relatively contraindicated in patients with ventriculoperitoneal shunts (VPS) because of concerns about the effect of the pneumoperitoneum on shunt function. However, there have been recent reports of laparoscopic surgery on the gallbladder and cecum. This is the first report of laparoscopic high anterior resection for rectal cancer without manipulation of the VPS catheter in a patient with VPS. We made a diagnosis of advanced rectal cancer in a 77-year-old man who had a VPS to treat hydrocephalus after a subarachnoid hemorrhage. We performed the procedure with the patient in a 15° head-down tilt and with 10-mmHg pneumoperitoneum pressure. There were no postoperative complications. We concluded that laparoscopic surgery for rectal cancer can be safely performed in patients with VPS.

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Robotic-assisted versus laparoscopic pancreaticoduodenectomy: oncological outcomes

Abstract

Background

Minimally invasive pancreaticoduodenectomy (MIPD) is being performed with increasing frequency for pancreatic cancer, but the most oncologically efficacious surgical platform, whether robotic or laparoscopic, is yet to be determined. Currently, there are no national studies comparing the oncological outcomes between robotic (RPD) and laparoscopic (LPD) pancreaticoduodenectomy.

Methods

This was a retrospective study using the National Cancer Database between 2010 and 2013. We compared the perioperative, pathological, and mid-term oncological outcomes between RPD and LPD.

Results

There were 1623 MIPD cases, of which 90% were LPD and 10% were RPD. Most LPD (63%) and RPD (51%) cases were performed at institutions with a volume of ≤ 5 MIPDs per year. There were no differences in patient- and tumor-related factors between the groups. The majority of treated tumors were adenocarcinoma (90.1% for RPD and 89.1% for LPD). RPDs were more likely to be performed at academic centers (89.1%) compared to LPDs (68.1%, P < 0.001) and at higher-volume centers (median MIPD/year of 4.7 for RPD vs 3.6 for LPD, P < 0.001). There was no difference in the median number of examined lymph nodes, margin status, median length of stay, 90-day mortality, or 30-day readmission between groups. There was no difference in median overall survival for pancreatic adenocarcinoma between LPD (20.7 months) and RPD (22.7 months; log-rank P = 0.445). The 1- and 3-year overall survival rates were 74 and 31% for LPD and 71 and 33% for RPD.

Conclusion

In this national cohort of patients, LPD and RPD were associated with equivalent perioperative, pathological, and mid-term oncological outcomes.

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Preoperative predictors of beyond endoscopic submucosal dissection indication or lymphovascular invasion in endoscopic resection for early gastric cancer

Abstract

Background

To successfully resect early gastric cancer (EGC), prediction of lymph node metastasis is essential. Beyond endoscopic submucosal dissection (ESD) indication or lymphovascular invasion (LVI) are known risk factors associated with lymph node metastasis. However, accurate prediction of tumor invasion depth or LVI is impossible before endoscopic resection even when endoscopic ultrasound is used. The aim of this study was to identify the predictive factors associated with beyond ESD indication or LVI after ESD for EGC.

Methods

Between Jan 2011 and Feb 2015, 532 lesions from 506 patients who received ESD for EGCs were included. We reviewed the data of patients diagnosed as EGCs without ulceration or those smaller than 3 cm with ulceration.

Results

The incidence of EGCs found to be beyond expanded ESD indications or present of LVI after ESD was 11.1% (59/532). On multivariable analysis, endoscopic features of SM invasion, surface color changes, and elevated lesions were associated with beyond ESD indication or LVI. In particular, submucosal (SM) invasive features such as SM tumor-like marginal elevation [odds ratio (OR) 17.2; 95% confidence interval (CI) 2.0–146.7], fusion of convergent folds (OR 12.9; 95% CI 3.9–42.1), irregular surface (OR 17.8; 95% CI 5.6–56.8), and discoloration of the tumor surface (OR 16.1; 95% CI 2.4–105.9) were significant risk factors for beyond ESD indication or LVI.

Conclusions

The decision to proceed with endoscopic resection for EGCs with endoscopic features of SM invasion, surface color changes, or elevated forms must be made cautiously.

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Safety and feasibility of the robotic platform in the management of surgical sequelae of chronic pancreatitis

Abstract

Background/Aim

The application of minimally invasive surgery to chronic pancreatitis (CP) procedures is uncommon. Our objective was to report the safety and feasibility of the robotic approach in the treatment of surgical sequelae of CP, and provide insights into the technique, tricks, and pitfalls associated with the application of robotics to this challenging disease entity.

Methods

A retrospective review of a prospectively maintained database of patients undergoing robotic-assisted resections and/or drainage procedures for CP at the University of Pittsburgh between May 2009 and January 2017 was performed. A video of a robotic Frey procedure is also shown.

Results

Of 812 robotic pancreatic resections and reconstructions 39 were for CP indications. These included 11 total pancreatectomies [with and without auto islet transplantation], 8 Puestow procedures, 4 Frey procedures, 6 pancreaticoduodenectomies, and 10 distal pancreatectomies. Median age was 49, and 41% of the patients were female. The most common etiology for CP was idiopathic pancreatitis (n = 16, 46%). Median operative time was 324 min with a median estimated blood loss of 250 ml. None of the patients required conversion to laparotomy. A Clavien III–IV complication rate was experienced by 5 (13%) patients, including one reoperation. Excluding the eleven patients who underwent TP, rate of clinically relevant postoperative pancreatic fistula was 7% (Grade B = 2, Grade C = 0). No 30 or 90 day mortalities were recorded. The median length of hospital stay was 7 days.

Conclusions

Use of the robotic platform is safe and feasible when tackling complex pancreatic resections for sequelae of chronic pancreatitis.

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