Laparoscopic Gastrointestinal and Gallbladder Surgery: Will the Promise be Fulfilled? A. JANSEN Dept. of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Jansen A. Laparoscopic gastrointestinal and gallbladder surgery: will the promise be fulfilled? Scand J Gastroenterol 1992;27 Suppl 194:41-46. The results of the first 181 consecutive patients who underwent laparoscopic choiecystectomy and 12 patients who underwent laparoscopic colon resection in our hospital are described. Our results show that laparoscopic cholecystectomy has proved to be the standard surgical procedure for treating gallbladder disease. The place of laparoscopic surgery in the treatment of other abdominal diseases is less clear. Our results in laparoscopic colon surgery indicate that a laparoscopic approach in segmental colon resection is feasible. The operation time is long, however, expressing the long learning curve for the operating team, as well as the technical difficulties encountered with this minimal invasive method. On the other hand, it has been proved that large abdominal operations can be performed via the laparoscope. By improving the laparoscopic instruments and increasing the laparoscopic surgeon’s experience, further application of this method in gastrointestinal surgery may be expected. Surgeons should, however, be aware of the long learning curve involved in advanced laparoscopic surgery. Key words: Cholecystectomy; colon resection; laparoscopic surgery A . Jansen, M.D . , Ph. D . , Dept. of Surgery, St. Antonius Hospital Nieuwegein, P.O. Box 2500, NL-3430 EM Nieuwegein, The Netherlands
After the first successful laparoscopic cholecystectomy in 1987 by Philippe Mouret in Lyon, a real revolution took place in traditional surgery. By combining modern optical instruments with small video camera systems, laparoscopic general surgery through the use of minimal incisions became a reality (1,2). An early postoperative recovery, a shortened hospitalization, and a shortened convalescence period are the key words associated with minimal invasive surgery. Whereas in open surgery adequate access is essential, in laparoscopic surgery this axiom is superfluous. The eye of the surgeon is replaced by the laparoscope, which can be brought directly towards the object, providing clear vision even in difficult accessible areas by way of magnification. The limited damage to the abdominal wall is thought to facilitate the patient’s postoperative recovery. In The Netherlands the first laparoscopic cholecystectomies were done in 1990. After the first enthusiastic reports were presented by pioneer surgeons, an increasing number of surgeons expressed interest in learning this new technique. This led to the establishment of laparoscopic training courses, the first of which took place in Maastricht in September 1990. After that period, the technique spread very quickly throughout The Netherlands. In our hospital the first laparoscopic cholecystectomy was done in June 1990. Since then nearly 300 laparoscopic cholecystectomies have been performed. After this laparoscopic experience had been gained, the first laparoscopic colon resection was carried out in October 1991.
We would here like to report our experience in laparoscopic gallbladder surgery and our early experiences in laparoscopic colon resection and discuss the present status of laparoscopic surgery and future expectations. ESSENTIALS OF THE LAPAROSCOPIC TECHNIQUE Laparoscopic cholecystectomy Laparoscopic cholecystectomy is performed using a fourtrocar puncture technique. After establishment of a pneumoperitoneum with carbon dioxide via a Veress needle, four trocars are inserted into the abdomen. The laparascope is introduced via the umbilical trocar opening. Two 5-mm trocars at the right hypochondrium are used to insert the forceps for suspension of the gallbladder. The fourth epigastric trocar site is used for the dissecting, clipping, cutting, and coagulation instruments. As in classical gallbladder surgery, at first the cystic duct and artery are identified, freed, and transected. The gallbladder is then removed from the liver bed using electro-coagulation. After hemostasis is achieved, the gallbladder is grasped and removed through one of the trocar sites, preferably the umbilical site. Peroperative cholangiography is done selectively. Laparoscopic colectomy Laparoscopic colectomy is performed using a four- or five-trocar puncture technique. After establishment of a pneumoperitoneum, the laparoscope is introduced at the umbilical site. Two trocars are inserted at the site opposite
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Fig. 1A. After laparoscopic mobilization of the right colon and transection of the ileum with the EndoGIA, the proximal ileum and the right colon are brought outside via a mini-incision in the right upper quadrant. 1B.The colon is resected using a TA-stapling instrument. 1C. A side-to-side anastomosis is made between the small bowel and the transverse colon. 1D.After closing of the remaining opening with a stapling instrument a functional end-to-end anastomosis is created.
the colon segment requiring resection and are used for bimanual operating by the surgeon. At the other site, one or two trocars are inserted for suspension of the bowel. Three or four 10-mm trocars and one 12-mm trocar are used. The 12-mm trocar is necessary for the introduction of the Endo-GIA (U.S.S.C., Norwalk, USA). The Endo-GIA allows stapling and cutting of tissue simultaneously and can be used for transection of the bowel and larger vessels. The dissection techniques for the peritoneal attachments and mesentery of the right and left colon are identical to those used in open surgery. Instead of ligating the base of the ileocolic or mesenteric inferior artery with sutures, the
Endo-GIA is used. Smaller vessels in the mesentery are clipped with the Endoclip (U.S.S.C.). After freeing the diseased colon segment totally, the bowel is transected at the desired level (the ileal or rectal resection site), using the Endo-GIA. A small (5-7 cm) transverse abdominal incision is made, and the specimen removed by applying traction with a grasping instrument at the transected bowel side. The other side of the bowel can then be transected at the surface of the abdomen with a T A or GIA stapling instrument (Figs. 1 and 2). After right laparoscopic hemicolectomy, anastomosis between the proximal ileum and the transverse colon is
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Fig. 2A. In left colon resection, first the rectum is transected with the Endo-GIA. After total mobilization inside, the sigmoid colon is brought exteriorly and the sigmoid resected. 28. The anvil of the PCEEA is brought into the proximal bowel. 2C. After reestablishment of the pneumoperitoneum, bowel anastomosis is performed by assembling the EEA instrument. The main part of the PCEEA instrument is introduced via the anus. After perforation of the rectum the anvil can be inserted and the instrument closed. 2D. By firing of the instrument the bowel is stapled together, while at the same time an internal opening is made.
Table I. Indications for laparoscopic cholecystectomy Svmutomatic cholelithiasis Acuie cholecvstitis Chronic cholecystitis Cholelithiasis and choledocholithiasis
136 oatients f74.3%1 14 batients (7.7%)’ 15 patients (8.2%) 18 patients (9.8%)
made extracorporeally, using stapling instruments, and the abdominal incision is closed. In case of rectosigmoidectomy, the anvil of the PCEEA stapler instrument is inserted into the proximal bowel after transection. The anvil is replaced in the abdomen, the abdomen closed, and the pneumo-
peritoneum reestablished. The anastomosis is then performed intracorporeally, using the double stapling techniaue. This techniaue involves anal introduction of the circular stapling instrument, perforation of the transected rectal stump, assembling the anvil with the stapling apparatus, and closure and firing of the instrument. A circular anastomosis is created between the descending colon and rectal stump. OPERATION RESULTS Lupuroscopic chofecysrectorny During the period from 1 June 1990 to 1 December 1991, laparoscopic cholecystectomy was performed on 183 patients
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(138 women, 45 men). The mean age was 48.7 years (range, 17-88 years). The operation indications are listed in Table I. There were no deaths. Conversion to open cholecystectomy was done in two cases (0.9%). The reason for conversion was bleeding in one patient and a common bile duct injury in the second patient. In this patient with acute cholecystitis a small injury in the common bile was made, which could be closed with a simple suture. The complications after laparoscopic cholecystectomy are listed in Table 11. Major complications after laparoscopic cholecystectomy were encountered in two patients (0.9%). Two patients had postoperative biliary leakage; in one case a relaparoscopy was performed. The cystic duct appeared to be only partially occluded by clips and was ligated with an endoloop, and intra-abdominal bile was removed with suction. In the other case a laparotomy was performed, and a lesion at the junction of the cystic duct and common bile duct was closed with an atraumatic resorbable suture. Both patients were discharged from the hospital in good condition. There was no further major morbidity. Our operation results showed no difference except for the duration of the operation between obese (quetelait index >0.30) and non-obese patients as well as between patients with inflamed and non-inflamed gallbladder disease. The mean operating time was 52 min (range, 26-150 min). The mean duration of hospitalization was 3.1 days (range, 0-20 days). The mean duration of convalescence was 13 days (range, 1-59 days). LAPAROSCOPIC COLON RESECTIONS In the period October 1991 to April 1992, 12 patients have undergone a laparoscopic colon resection, 6 women and 6 men. The mean age was 64.5 years (range, 43-72 years). In six patients a right hemicolectomy was done, and in six other patients a left rectosigmoidectomy was done. The indications for surgery are listed in Table 111. In all patients high ligation of the vascular pedicle with removal of the adjacent mesentery and bowel was performed laparoscopically, using the Endo-GIA. This typical oncologic manner of removing the pathologic specimen and mesentery by dividing the major vascular supply at its origin facilitates the mesenteric dissection because fewer vessels are encountered during the mesenteric skeletization. Peroperative colonoscopy was used in rectosigmoidectomy to mark the distal resection line before transection. The mean operation time was 270min (range, 200360 min). The mean blood loss was 95 ml (range, 30-300 ml). After laparoscopic mobilization and mesenteric dissection a Pfannenstiehl incision was necessary in a male patient with a large rectal adenoma, because an adequate distal resection margin could not be obtained with the laparoscopic technique. After open rectal mobilization adequate distal clearance was obtained.
Table 11. Complications after laparoscopic cholecystectomy ( n = 183) ~
Biliary leakage from the cystic bile duct Abdominal wall hematoma Umbilical trocar site infection
~
~
2 patients (0.9%) 2 patients (0.9%) 2 patients (0.9%)
Postoperative complications were limited to a wound infection in one patient. Postoperative anastomotic leakage did not occur in this series. The pathology reports reflected good clearance of the resection sites in all patients. The mean postoperative hospitalization time was 7.1 days (range, 5-15 days). DISCUSSION It is evident that laparoscopic cholecystectomy has become the standard treatment of patients with cholelithiasis (1,2). Our results demonstrate that the operation can be performed safely. Except for biliary leakage, no serious complications were encountered. The management problem of the enlarged or edematous cystic duct has been solved by using endoloops instead of clips. Serious complications have, however, been reported after laparoscopic cholecystectomy (3). Major complications are arterial or venous injury to the larger abdominal vessels after trocar insertion, undetected postoperative bleeding from the cystic artery leading to exsanguination, and major injuries to the biliary tree, including right hepatic duct transection and common bile duct transection. As shown in our series, the incidence of bile duct injury should not be overestimated. In a recent inquiry (4) in 97 Dutch hospitals, bile duct injury was reported in 0.9% in a series of 2553 laparoscopic cholecystectomies in 1991. In the same period, the incidence of bile duct injury after classical gallbladder surgery was 0.5% (32 cases in 6338 procedures). These figures demonstrate that in 1991 the experience with the laparoscopic technique was still limited to a small number of Dutch hospitals. In our series common bile duct injury occurred only in 1 out of 183 patients (0.5%). This reflects that with increasing experience the number of complications will diminish. Laparoscopic treatment in complicated gallbladder disease such as acute cholecystitis, after previous abdominal surgery, or in patients with common bile duct stones is not yet widely advocated, although excellent results are reported
(5). Our own experience with laparoscopic treatment of patients with cholecystitis compared with patients with noncomplicated gallbladder disease did not show any difference in the outcome of surgery except for the longer duration of the operation. Moreover, previous surgery proved not to be a contraindication for laparoscopic cholecystectomy. The optimal management of patients with common bile
Laparoscopic GI and Gallbladder Surgery Table 111. The indication for surgery in 12 patients with laparoscopic colon resection Diverticular disease Colon adenoma Colon carcinoma
1 patient 2 patients 9 patients
duct stones is at the present moment not clarified. There are several therapeutic options, which include the use of pre- or post-operative endoscopic retrograde cholangiopancreatograPhY (ERCP) and endoScoPic PaPillotomY, laParoscoPic transcystic choledocholithotomY (6) Or the classical open approach. We have used Preoperative ERCPandendoScoPic PaPillotomY fo~~Owed within 2 days by laParoScoPic chokCYstectomY in this group of Patients. This method Proved to be very effective. However, complications like pancreatitis and cholangitis induced by the endoscopic Procedure, as well as the unknown long-term side effects on the Sphincter Of Oddi in younger patients are the disadvantages to this treatment modality. Good results with laparoscopic transcystic cho~edocholithotom~ are reported. New data are therefore required for the development of the optimal strategy in choledocholithiasis. For the patients, the benefits Of minimal surgery are vast. There are only minimal scars, the abdominal wall remains intact, and intra-abdominal trauma is reduced. The socioeconomic advantages are also enormous. Hospitalization and convalescence are shortened significantly. It is therefore not surprising that worldwide the tendency is to use minimal access surgery in other abdominal and thoracic procedures. One should consider, however, that cholecystectomy is ideal for a laparoscopic approach since it has only a small target area, whereas previously a large incision was required for removal. In laparoscopic appendectomy these advantages are less impressive, because of the already small abdominal incisions used with the classical approach. Nevertheless, because of good results with this method (7) further introduction of the laparoscopic approach may be expected. Surgery of the stomach and colon are, theoretically, less suitable for minimal access surgery with the present technology, First, the target area is larger, which implies that more overview is needed during the procedure. Second, with the larger dissection area, more vessels are encountered, increasing the risk of perioperative bleeding. Intra-abdominal anastomosis is feasible but depends largely on stapling instruments which are still in the developmental stage; these procedures therefore require that the surgeon has great technical skill. The first series of laparoscopic vagotomy (8,9) and laparoscopic Nissen fundoplication by expert surgeons are reported (10). Their results are favorable and justify further application of the laparoscopic technique; however, the longterm effects of these operations in randomized studies are
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not yet known. our country, only small numbers of patients with ulcer disease and pathologic gastroesophageal reflux are referred to surgery; the learning curve of these technically difficult operations will therefore be long. Multicentered studies will be needed to demonstrate the efficacy on the long-term basis. Our first experiences with laparoscopic colon resection are encouraging. Laparoscopic colon resection is feasible and can be performed safely, as shown in our series. However, the place of laparoscopic colon resection as alternative treatment is not yet established (10, 11). Technically, it is still a difficult procedure which can only be performed by surgeons with a vast experience in colorectal surgery as well as a broad experience in laparoscopic surgery. The potential advantages of the procedure are clear. There is less damage to the abdomianl wall, so quick recovery, less wound infection, and fewer pulmonary comp~icationscan be expected. In our small series of patients we had the impression that postoperative recovery was remarkably fast in most of the laparoscopically operated patients. These results, however, are not examined in a study (ll). We have also observed that the whole operating procedure was performed quickly and in a routine fashion in the last operations than in the beginning of the series. The progress in the learning curve and the establishment of a routine order in the instrument handling during operation gives us the feeling that in selected this procedure will be superior to the classical operation. Moreover, one may expect further improvements in the laparoscopic instruments. On the other hand, there are still many problems to solve. First, inspection of the abdomen is less extensive than in classical surgery. Second, palpation cannot be done during endoscopic surgery. The question arises whether endoscopic ultrasonography may be of any help in this respect. In case of previous abdominal operations, cutting of adhesions may be very time-consuming. In patients with much intraabdominal fat, identification of structures and especially the dissection Of the mesentery may be With regard to colorectal carcinomas one should consider that surgery is still the best therapeutic option to cure the Patient. LaparoScopic resection, therefore, should in no way interfere with the principles of oncologic surgery. At present these include high ligation of the vascular pedicle, a free distal resection margin Of at least 2 Cm, and free lateral resection margins. Moreover, during the operation m d removal ofthe Specimen there should be no SPiIhe of tumor cells. Keeping these Principles in mind, laParoScoPic Colon resection can be an alternative form of treatment in carefully selected patients. Although minimal access surgery is attractive, the exact place of laparoscopic surgery has yet to be defined. Improvement of instruments as well as careful patient selection will lead to further applications of new minimal invasive techniques.
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REFERENCES 1. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:10738. 2. Larson GM, Vitale GC, Lasey J, et al. Multipractice analysis of laparoscopic cholecystomy in 1983 patients. Am J Surg 1992; 163:221-30. 3. Algie DG, Go PMNYH, Gouma DJ. Laparoscopic cholecystectomy: early results in The Netherlands. Ned Tijdschr Geneeskd 1992;136:974-7. 4. Gouma DJ, Go PMNYH. Inventarisation and treatment of common bile duct injuries after cholecystectomy [abstract]. Dutch Society of Surgery, Chirurgendagen 1992. 5. Reddick EJ, Olsen D, Spew A, et al. Safe performance of difficult laparoscopic cholecystectomy. Am J Surg 1991 ;161:37781. 6. Sachler JM, Berci G , Paz-Partlow M. Laparoscopic transcystic choledocholithotomy as an adjunct to laparoscopic cholecystectomy. Am J Surg 1991;57:3224.
7. Gotz F, Dier A, Bracher C. Modified laparoscopic appendectomy in surgery. A report on 388 operations. Surg Endosc 1990;4:6-9. 8. Kathouda N, Mouiel .I.A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. Am J Surg 1991;161:361-4. 9. Bailey RW, Flowers JL, Graham SM, Zucker KA. Combined laparoscopic cholecystectomy and selective vagotomy. Surg Laparosc Endosc 1991;1:45-9. 10. Cuschieri A, Shimi S, Nathanson LK. Laparoscopic reduction, crural repair, and fundoplication of large hiatal hernia. Am J Surg 1992;163:425-30. 11. Wexner S. Johansen OB, Jagelman DG, et al. Laparoscopic total abdominal colectomy. A prospective trial. Dis Colon Rectum 1992;35:651-5. 12. Jacobs M, Verdeja GD, Goldstein DS. Minimal invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1992;1 :144-50.
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Jansen A. Laparoscopic gastrointestinal and gallbladder surgery: will the promise be fulfilled? Scand J Gastroenterol 1992;27 Suppl 194:41-46. The results of the first 181 consecutive patients who underwent laparoscopic choiecystectomy and 12 patients who underwent laparoscopic colon resection in our hospital are described. Our results show that laparoscopic cholecystectomy has proved to be the standard surgical procedure for treating gallbladder disease. The place of laparoscopic surgery in the treatment of other abdominal diseases is less clear. Our results in laparoscopic colon surgery indicate that a laparoscopic approach in segmental colon resection is feasible. The operation time is long, however, expressing the long learning curve for the operating team, as well as the technical difficulties encountered with this minimal invasive method. On the other hand, it has been proved that large abdominal operations can be performed via the laparoscope. By improving the laparoscopic instruments and increasing the laparoscopic surgeon’s experience, further application of this method in gastrointestinal surgery may be expected. Surgeons should, however, be aware of the long learning curve involved in advanced laparoscopic surgery. Key words: Cholecystectomy; colon resection; laparoscopic surgery A . Jansen, M.D . , Ph. D . , Dept. of Surgery, St. Antonius Hospital Nieuwegein, P.O. Box 2500, NL-3430 EM Nieuwegein, The Netherlands
After the first successful laparoscopic cholecystectomy in 1987 by Philippe Mouret in Lyon, a real revolution took place in traditional surgery. By combining modern optical instruments with small video camera systems, laparoscopic general surgery through the use of minimal incisions became a reality (1,2). An early postoperative recovery, a shortened hospitalization, and a shortened convalescence period are the key words associated with minimal invasive surgery. Whereas in open surgery adequate access is essential, in laparoscopic surgery this axiom is superfluous. The eye of the surgeon is replaced by the laparoscope, which can be brought directly towards the object, providing clear vision even in difficult accessible areas by way of magnification. The limited damage to the abdominal wall is thought to facilitate the patient’s postoperative recovery. In The Netherlands the first laparoscopic cholecystectomies were done in 1990. After the first enthusiastic reports were presented by pioneer surgeons, an increasing number of surgeons expressed interest in learning this new technique. This led to the establishment of laparoscopic training courses, the first of which took place in Maastricht in September 1990. After that period, the technique spread very quickly throughout The Netherlands. In our hospital the first laparoscopic cholecystectomy was done in June 1990. Since then nearly 300 laparoscopic cholecystectomies have been performed. After this laparoscopic experience had been gained, the first laparoscopic colon resection was carried out in October 1991.
We would here like to report our experience in laparoscopic gallbladder surgery and our early experiences in laparoscopic colon resection and discuss the present status of laparoscopic surgery and future expectations. ESSENTIALS OF THE LAPAROSCOPIC TECHNIQUE Laparoscopic cholecystectomy Laparoscopic cholecystectomy is performed using a fourtrocar puncture technique. After establishment of a pneumoperitoneum with carbon dioxide via a Veress needle, four trocars are inserted into the abdomen. The laparascope is introduced via the umbilical trocar opening. Two 5-mm trocars at the right hypochondrium are used to insert the forceps for suspension of the gallbladder. The fourth epigastric trocar site is used for the dissecting, clipping, cutting, and coagulation instruments. As in classical gallbladder surgery, at first the cystic duct and artery are identified, freed, and transected. The gallbladder is then removed from the liver bed using electro-coagulation. After hemostasis is achieved, the gallbladder is grasped and removed through one of the trocar sites, preferably the umbilical site. Peroperative cholangiography is done selectively. Laparoscopic colectomy Laparoscopic colectomy is performed using a four- or five-trocar puncture technique. After establishment of a pneumoperitoneum, the laparoscope is introduced at the umbilical site. Two trocars are inserted at the site opposite
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42
A. Jansen
Fig. 1A. After laparoscopic mobilization of the right colon and transection of the ileum with the EndoGIA, the proximal ileum and the right colon are brought outside via a mini-incision in the right upper quadrant. 1B.The colon is resected using a TA-stapling instrument. 1C. A side-to-side anastomosis is made between the small bowel and the transverse colon. 1D.After closing of the remaining opening with a stapling instrument a functional end-to-end anastomosis is created.
the colon segment requiring resection and are used for bimanual operating by the surgeon. At the other site, one or two trocars are inserted for suspension of the bowel. Three or four 10-mm trocars and one 12-mm trocar are used. The 12-mm trocar is necessary for the introduction of the Endo-GIA (U.S.S.C., Norwalk, USA). The Endo-GIA allows stapling and cutting of tissue simultaneously and can be used for transection of the bowel and larger vessels. The dissection techniques for the peritoneal attachments and mesentery of the right and left colon are identical to those used in open surgery. Instead of ligating the base of the ileocolic or mesenteric inferior artery with sutures, the
Endo-GIA is used. Smaller vessels in the mesentery are clipped with the Endoclip (U.S.S.C.). After freeing the diseased colon segment totally, the bowel is transected at the desired level (the ileal or rectal resection site), using the Endo-GIA. A small (5-7 cm) transverse abdominal incision is made, and the specimen removed by applying traction with a grasping instrument at the transected bowel side. The other side of the bowel can then be transected at the surface of the abdomen with a T A or GIA stapling instrument (Figs. 1 and 2). After right laparoscopic hemicolectomy, anastomosis between the proximal ileum and the transverse colon is
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Laparoscopic GI and Gallbladder Surgery
43
Fig. 2A. In left colon resection, first the rectum is transected with the Endo-GIA. After total mobilization inside, the sigmoid colon is brought exteriorly and the sigmoid resected. 28. The anvil of the PCEEA is brought into the proximal bowel. 2C. After reestablishment of the pneumoperitoneum, bowel anastomosis is performed by assembling the EEA instrument. The main part of the PCEEA instrument is introduced via the anus. After perforation of the rectum the anvil can be inserted and the instrument closed. 2D. By firing of the instrument the bowel is stapled together, while at the same time an internal opening is made.
Table I. Indications for laparoscopic cholecystectomy Svmutomatic cholelithiasis Acuie cholecvstitis Chronic cholecystitis Cholelithiasis and choledocholithiasis
136 oatients f74.3%1 14 batients (7.7%)’ 15 patients (8.2%) 18 patients (9.8%)
made extracorporeally, using stapling instruments, and the abdominal incision is closed. In case of rectosigmoidectomy, the anvil of the PCEEA stapler instrument is inserted into the proximal bowel after transection. The anvil is replaced in the abdomen, the abdomen closed, and the pneumo-
peritoneum reestablished. The anastomosis is then performed intracorporeally, using the double stapling techniaue. This techniaue involves anal introduction of the circular stapling instrument, perforation of the transected rectal stump, assembling the anvil with the stapling apparatus, and closure and firing of the instrument. A circular anastomosis is created between the descending colon and rectal stump. OPERATION RESULTS Lupuroscopic chofecysrectorny During the period from 1 June 1990 to 1 December 1991, laparoscopic cholecystectomy was performed on 183 patients
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44
A. Jansen
(138 women, 45 men). The mean age was 48.7 years (range, 17-88 years). The operation indications are listed in Table I. There were no deaths. Conversion to open cholecystectomy was done in two cases (0.9%). The reason for conversion was bleeding in one patient and a common bile duct injury in the second patient. In this patient with acute cholecystitis a small injury in the common bile was made, which could be closed with a simple suture. The complications after laparoscopic cholecystectomy are listed in Table 11. Major complications after laparoscopic cholecystectomy were encountered in two patients (0.9%). Two patients had postoperative biliary leakage; in one case a relaparoscopy was performed. The cystic duct appeared to be only partially occluded by clips and was ligated with an endoloop, and intra-abdominal bile was removed with suction. In the other case a laparotomy was performed, and a lesion at the junction of the cystic duct and common bile duct was closed with an atraumatic resorbable suture. Both patients were discharged from the hospital in good condition. There was no further major morbidity. Our operation results showed no difference except for the duration of the operation between obese (quetelait index >0.30) and non-obese patients as well as between patients with inflamed and non-inflamed gallbladder disease. The mean operating time was 52 min (range, 26-150 min). The mean duration of hospitalization was 3.1 days (range, 0-20 days). The mean duration of convalescence was 13 days (range, 1-59 days). LAPAROSCOPIC COLON RESECTIONS In the period October 1991 to April 1992, 12 patients have undergone a laparoscopic colon resection, 6 women and 6 men. The mean age was 64.5 years (range, 43-72 years). In six patients a right hemicolectomy was done, and in six other patients a left rectosigmoidectomy was done. The indications for surgery are listed in Table 111. In all patients high ligation of the vascular pedicle with removal of the adjacent mesentery and bowel was performed laparoscopically, using the Endo-GIA. This typical oncologic manner of removing the pathologic specimen and mesentery by dividing the major vascular supply at its origin facilitates the mesenteric dissection because fewer vessels are encountered during the mesenteric skeletization. Peroperative colonoscopy was used in rectosigmoidectomy to mark the distal resection line before transection. The mean operation time was 270min (range, 200360 min). The mean blood loss was 95 ml (range, 30-300 ml). After laparoscopic mobilization and mesenteric dissection a Pfannenstiehl incision was necessary in a male patient with a large rectal adenoma, because an adequate distal resection margin could not be obtained with the laparoscopic technique. After open rectal mobilization adequate distal clearance was obtained.
Table 11. Complications after laparoscopic cholecystectomy ( n = 183) ~
Biliary leakage from the cystic bile duct Abdominal wall hematoma Umbilical trocar site infection
~
~
2 patients (0.9%) 2 patients (0.9%) 2 patients (0.9%)
Postoperative complications were limited to a wound infection in one patient. Postoperative anastomotic leakage did not occur in this series. The pathology reports reflected good clearance of the resection sites in all patients. The mean postoperative hospitalization time was 7.1 days (range, 5-15 days). DISCUSSION It is evident that laparoscopic cholecystectomy has become the standard treatment of patients with cholelithiasis (1,2). Our results demonstrate that the operation can be performed safely. Except for biliary leakage, no serious complications were encountered. The management problem of the enlarged or edematous cystic duct has been solved by using endoloops instead of clips. Serious complications have, however, been reported after laparoscopic cholecystectomy (3). Major complications are arterial or venous injury to the larger abdominal vessels after trocar insertion, undetected postoperative bleeding from the cystic artery leading to exsanguination, and major injuries to the biliary tree, including right hepatic duct transection and common bile duct transection. As shown in our series, the incidence of bile duct injury should not be overestimated. In a recent inquiry (4) in 97 Dutch hospitals, bile duct injury was reported in 0.9% in a series of 2553 laparoscopic cholecystectomies in 1991. In the same period, the incidence of bile duct injury after classical gallbladder surgery was 0.5% (32 cases in 6338 procedures). These figures demonstrate that in 1991 the experience with the laparoscopic technique was still limited to a small number of Dutch hospitals. In our series common bile duct injury occurred only in 1 out of 183 patients (0.5%). This reflects that with increasing experience the number of complications will diminish. Laparoscopic treatment in complicated gallbladder disease such as acute cholecystitis, after previous abdominal surgery, or in patients with common bile duct stones is not yet widely advocated, although excellent results are reported
(5). Our own experience with laparoscopic treatment of patients with cholecystitis compared with patients with noncomplicated gallbladder disease did not show any difference in the outcome of surgery except for the longer duration of the operation. Moreover, previous surgery proved not to be a contraindication for laparoscopic cholecystectomy. The optimal management of patients with common bile
Laparoscopic GI and Gallbladder Surgery Table 111. The indication for surgery in 12 patients with laparoscopic colon resection Diverticular disease Colon adenoma Colon carcinoma
1 patient 2 patients 9 patients
duct stones is at the present moment not clarified. There are several therapeutic options, which include the use of pre- or post-operative endoscopic retrograde cholangiopancreatograPhY (ERCP) and endoScoPic PaPillotomY, laParoscoPic transcystic choledocholithotomY (6) Or the classical open approach. We have used Preoperative ERCPandendoScoPic PaPillotomY fo~~Owed within 2 days by laParoScoPic chokCYstectomY in this group of Patients. This method Proved to be very effective. However, complications like pancreatitis and cholangitis induced by the endoscopic Procedure, as well as the unknown long-term side effects on the Sphincter Of Oddi in younger patients are the disadvantages to this treatment modality. Good results with laparoscopic transcystic cho~edocholithotom~ are reported. New data are therefore required for the development of the optimal strategy in choledocholithiasis. For the patients, the benefits Of minimal surgery are vast. There are only minimal scars, the abdominal wall remains intact, and intra-abdominal trauma is reduced. The socioeconomic advantages are also enormous. Hospitalization and convalescence are shortened significantly. It is therefore not surprising that worldwide the tendency is to use minimal access surgery in other abdominal and thoracic procedures. One should consider, however, that cholecystectomy is ideal for a laparoscopic approach since it has only a small target area, whereas previously a large incision was required for removal. In laparoscopic appendectomy these advantages are less impressive, because of the already small abdominal incisions used with the classical approach. Nevertheless, because of good results with this method (7) further introduction of the laparoscopic approach may be expected. Surgery of the stomach and colon are, theoretically, less suitable for minimal access surgery with the present technology, First, the target area is larger, which implies that more overview is needed during the procedure. Second, with the larger dissection area, more vessels are encountered, increasing the risk of perioperative bleeding. Intra-abdominal anastomosis is feasible but depends largely on stapling instruments which are still in the developmental stage; these procedures therefore require that the surgeon has great technical skill. The first series of laparoscopic vagotomy (8,9) and laparoscopic Nissen fundoplication by expert surgeons are reported (10). Their results are favorable and justify further application of the laparoscopic technique; however, the longterm effects of these operations in randomized studies are
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not yet known. our country, only small numbers of patients with ulcer disease and pathologic gastroesophageal reflux are referred to surgery; the learning curve of these technically difficult operations will therefore be long. Multicentered studies will be needed to demonstrate the efficacy on the long-term basis. Our first experiences with laparoscopic colon resection are encouraging. Laparoscopic colon resection is feasible and can be performed safely, as shown in our series. However, the place of laparoscopic colon resection as alternative treatment is not yet established (10, 11). Technically, it is still a difficult procedure which can only be performed by surgeons with a vast experience in colorectal surgery as well as a broad experience in laparoscopic surgery. The potential advantages of the procedure are clear. There is less damage to the abdomianl wall, so quick recovery, less wound infection, and fewer pulmonary comp~icationscan be expected. In our small series of patients we had the impression that postoperative recovery was remarkably fast in most of the laparoscopically operated patients. These results, however, are not examined in a study (ll). We have also observed that the whole operating procedure was performed quickly and in a routine fashion in the last operations than in the beginning of the series. The progress in the learning curve and the establishment of a routine order in the instrument handling during operation gives us the feeling that in selected this procedure will be superior to the classical operation. Moreover, one may expect further improvements in the laparoscopic instruments. On the other hand, there are still many problems to solve. First, inspection of the abdomen is less extensive than in classical surgery. Second, palpation cannot be done during endoscopic surgery. The question arises whether endoscopic ultrasonography may be of any help in this respect. In case of previous abdominal operations, cutting of adhesions may be very time-consuming. In patients with much intraabdominal fat, identification of structures and especially the dissection Of the mesentery may be With regard to colorectal carcinomas one should consider that surgery is still the best therapeutic option to cure the Patient. LaparoScopic resection, therefore, should in no way interfere with the principles of oncologic surgery. At present these include high ligation of the vascular pedicle, a free distal resection margin Of at least 2 Cm, and free lateral resection margins. Moreover, during the operation m d removal ofthe Specimen there should be no SPiIhe of tumor cells. Keeping these Principles in mind, laParoScoPic Colon resection can be an alternative form of treatment in carefully selected patients. Although minimal access surgery is attractive, the exact place of laparoscopic surgery has yet to be defined. Improvement of instruments as well as careful patient selection will lead to further applications of new minimal invasive techniques.
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A. Jansen
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REFERENCES 1. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:10738. 2. Larson GM, Vitale GC, Lasey J, et al. Multipractice analysis of laparoscopic cholecystomy in 1983 patients. Am J Surg 1992; 163:221-30. 3. Algie DG, Go PMNYH, Gouma DJ. Laparoscopic cholecystectomy: early results in The Netherlands. Ned Tijdschr Geneeskd 1992;136:974-7. 4. Gouma DJ, Go PMNYH. Inventarisation and treatment of common bile duct injuries after cholecystectomy [abstract]. Dutch Society of Surgery, Chirurgendagen 1992. 5. Reddick EJ, Olsen D, Spew A, et al. Safe performance of difficult laparoscopic cholecystectomy. Am J Surg 1991 ;161:37781. 6. Sachler JM, Berci G , Paz-Partlow M. Laparoscopic transcystic choledocholithotomy as an adjunct to laparoscopic cholecystectomy. Am J Surg 1991;57:3224.
7. Gotz F, Dier A, Bracher C. Modified laparoscopic appendectomy in surgery. A report on 388 operations. Surg Endosc 1990;4:6-9. 8. Kathouda N, Mouiel .I.A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. Am J Surg 1991;161:361-4. 9. Bailey RW, Flowers JL, Graham SM, Zucker KA. Combined laparoscopic cholecystectomy and selective vagotomy. Surg Laparosc Endosc 1991;1:45-9. 10. Cuschieri A, Shimi S, Nathanson LK. Laparoscopic reduction, crural repair, and fundoplication of large hiatal hernia. Am J Surg 1992;163:425-30. 11. Wexner S. Johansen OB, Jagelman DG, et al. Laparoscopic total abdominal colectomy. A prospective trial. Dis Colon Rectum 1992;35:651-5. 12. Jacobs M, Verdeja GD, Goldstein DS. Minimal invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1992;1 :144-50.
