Proceedings on Minimally Invasive Surgery
Summary: Nach Erstbeschreibung der laparoskopischen Fundoplikation als wirksame chirurgische Behandlung der gastroösophageale Refluxerkranklung um 1995 und einem steilen Anstieg der durchgeführten Operationen weltweit, hat die Fundoplikation in den letzten Jahren durch Beschreibungen teilweise sehr hohe Nebenwirkungsraten als auch der Etablierung einer medikamentösen Alternative (Lotus-Trial) einen ebenso steilen Rückgang erlebt. Veröffentlichte Langzeitnebenwirkungen der medikamentösen Therapie, bis zu 30% hohe Wirkungslosigkeit (Regurgitation) als auch die fehlende Präventivwirkung vor Komplikationen (Barrett, Adenokarzinom) der PPI-Therapie, haben die operative Refluxchirurgie in den letzten Jahren wieder in den Fokus gerückt. Die Etablierung „neuer“, alternativer operativer Anti-Refluxmethoden (Sphinkteraugmentationen) versprechen gleiche Wirksamkeit bei geringeren Nebenwirkunsraten und öffnen die Tür zu einer individualisierten Refluxchirurgie. Es soll der Auf- und Abstieg, als auch die Renaissance der operativen Refluxchirurgie dargestellt werden und auf neue, alternative Sphinkteraugemntationsverfahren (endoskopische, magnetische, elektrischen Sphinkteraugmentation) eingegangen werden.
Copyright (c) 2020 Proceedings on Minimally Invasive Surgery https://creativecommons.org/licenses/by/4.0/
Robotic-TAPP as Teaching Procedure - Robotic-TAPP als Lehreingriff
Summary: Irgendwo zwischen Möglichkeit und Notwendigkeit ist der Raum, in dem sich über Jahrhunderte die grossen und kleinen Fortschritte der Chirurgie im Alltag etabliert haben. Jede Generation steht vor der Herausforderung, Neues zu prüfen und das Gute zu behalten. Die roboterassistierte minimalinvasive Chirurgie bietet bisher nicht dagewesene Möglichkeiten der Präzision und der Ergonomie. Der sinnvolle Einsatz eines Operationsroboters bedingt komplexe interdisziplinäre und interprofessionelle Abläufe; um diese in einem guten Rahmen zu fördern, sind kleinere Eingriffe wie zum Beispiel die TAPP, von besonderer Bedeutung. Im aktuellen Vortrag wird ein Stufenkonzept vorgestellt: ausgehend von einem TAPP-Operationsmodell und dem Roboter-Operationssimulator, werden junge Oberärzte/-innen (Fachärzte/-innen) schrittweise in die Durchführung der TAPP unter optimalen Arbeitsbedingungen (Ergonomie, Immersionsblick, Bildstabilität und -qualität sowie einem strukturierten Operationsablauf) eigewiesen. Dabei erlernen sie alle wesentlichen Fertigkeiten im Umgang mit der optimalen Positionierung der Trokare, des Andockens, der Ausrichtung der Roboter-Arme zum reibungslosen und harmonischen Führung der Wrist-Instrumente und nicht zuletzt die dynamische Anpassung aller Komponenten nach den individuellen Bedürfnissen des Eingriffes. Im Kantonsspital Olten üben alle Oberärzte/-innen am Simulator und werden im normalen Tagesablauf in die Roboter-Chirurgie integriert und individuell trainiert. Die Arbeitsteilung mit dem Leitenden Arzt mittels Teachingkonsole hilft dabei, den OP-Verlauf in den Grenzen der geplanten OP-Zeiten zu halten. Es werden im Rahmen des Vortrages einige Beispiele als Videosequenzen präsentiert. Wie bereits die Laparoskopie in der Vergangenheit, wird auch die Roboterchirurgie die Hürde der Kostenkalkulation überwinden und sich fest etablieren. Die junge Generation kann schon jetzt auf diese Zukunft vorbereitet werden.
Summary: This presentation will cover the progress of new advanced single port robotic technologies and how they might impact and improve surgical applications. The strategy for these new technologies is to evolve the platform and instrument portfolio to meet the clinical needs of surgeons and increase efficiency, precision and surgeon autonomy while enabling complex procedures with single port technology.
Robotics from the bench: Research for ultrasound automation with augmented reality visualization
Summary: Ultrasound imaging commonly used for diagnostics may also be used for radiation-free catheter and needle navigation. Due to the considerable skill and expertise it requires, ultrasound image acquisition and diagnostics are difficult to be done. Automated ultrasound image acquisition could potentially overcome this operator dependency. For the automation and standardization of the diagnostic ultrasound imaging process as well as for the operator-free automated catheter and needle navigation, we are currently developing a medical robotic device platform. A prototype of this robot-supported ultrasound platform was produced, on which various medical examination procedures can be developed. Three core technologies were applied therefor: A force-sensitive 7-DoF robot arm (KUKA LBR iiwa), which can position both automatically and manually over a certain target area on the body surface. The arm has collision avoidance and ensures the dynamic force-controlled posture of the transducer to the patient. 3D ultrasound is realized by a matrix probe and appropriate calculation algorithms on a modified ultrasound station (GE Vivid 7). It enables recording of large areas at high frame rates. Thus the target, its surrounding areas and nearby navigation points can be recorded simultaneously. 3D ultrasound data streaming from ultrasound system to Microsoft HoloLens glasses and visualization at a certain distance from the ultrasound probe by tracking augmented reality markers. The functionality was verified using an ultrasound phantom (BluePhantom FAST Trauma). The result is a 4D volume data set for the physician-assisted diagnostic evaluation. The process delivered reproducible real-time visualization results on a workstation where the volumes were simultaneously visualized and stored. Ultrasound volume data of the training model (matrix size 103x74x134) were sent from the ultrasound system to HoloLens in order to display them, showing a latency of 259 ± 86 ms. Automated ultrasound diagnostics and navigation should help to reduce the binding of clinical resources in the future, thereby enabling better reproducibility of imaging and reducing side effects from radiation exposure. The device platform will serve as the basis for further automated ultrasound diagnostics and therapy procedures.
Laparoscopic left hemihepatectoy applying intraoperative ICG counter perfusion method for visualization
Summary: Intraoperative Indocyanine green (ICG) fluorescence detection by the “counter perfusion method” is a useful tool to identify hepatic segments and intersegmental planes during anatomic liver resection. We report of a 54-year old patient with recurrent cholangitis due to Caroli disease, who underwent a laparoscopic hemihepatectomy. To determine the resection line and resection plane, we injected ICG intravenously after clamping/ligating the left hepatic artery and left portal vein. Before and during resection the liver was observed under visible light and under near-infrared (NIR) light. This method allowed for precise anatomical resection of non-perfused liver segments 2,3 and 4. ICG Visualisation is useful tool in laparoscopic liver resection.
Middle hepatic vein - landmark structure for safe anatomic laparoscopic liver resection
Background: The middle hepatic vein (MHV) represents the landmark structure for the anatomic hemihepatectomy. Intraoperative visualization and exposure of the MHV and it’s branches during laparoscopic liver resection is key to anticipate potential bleeding hotspots and allows for delicate bloodless vessel sealing and dissection. Material Methods: On the basis of a representative right and left laparoscopic hemihepatectomy-video, we demonstrate the importance of the intraparenchymal identification of the MHV for anatomic major liver resection. Technique: In standrdized french position hilar vessels are exposed first and the inflow ins controlled. Parenchymal transection is performed along the demarcation line (Seg 4 and 5+8, Cantli line) using ultrasonic shears and the laparoscopic CUSA. Intraparenchymal identification of the MHV is facilitated by intraoperative ultrasound. Clips or ligatures are used for vessel sealing. The hilar plate is transected with a laparoscopic stapler. The MHV is exposed and preserved in demonstrated videos. The left hepatic or right hepatic vein is again sealed using a laparoscopic stapler. Conclusions: Guidance and navigation according to the anatomy of the MHV helps to anticipate inflowing major branches thus possible major hotspots of bleeding. This might help to prevent injury to the future liver remnant and facilitates laparoscopic major liver resection at a good pace. Intraoperative Indocyanine green (ICG) fluorescence detection by the “counter perfusion method” is a useful tool to identify hepatic segments and intersegmental planes during anatomic liver resection. We report of a 54-year old patient with recurrent cholangitis due to Caroli disease, who underwent a laparoscopic hemihepatectomy. To determine the resection line and resection plane, we injected ICG intravenously after clamping/ligating the left hepatic artery and left portal vein. Before and during resection the liver was observed under visible light and under near-infrared (NIR) light. This method allowed for precise anatomical resection of non-perfused liver segments 2,3 and 4. ICG Visualisation is useful tool in laparoscopic liver resection.
Ultrasound-guided quadratus lumborum block versus caudal block for perioperative analgesia in children after minimal invasive surgery
Background: Ultrasound (US)-guided Quadratus Lumborum (QLB) block is an effective technique in providing analgesia for abdominal surgery. This study was designed to evaluate the efficacy of a US-guided QLB compare it with a caudal block in undergoing major abdominal surgery in children. Patients and Methods. 128 ASA 1-2, 1-14-year-old children scheduled for elective acute diseases of the abdominal cavity were studied. All patients received general anesthesia; sevoflurane was used for induction and maintenance of anesthesia and laryngeal mask airway (LMA) was used to secure the airway. After securing an intravenous cannula, patients were randomized to a US-guided QLB (n = 64) (group Q) using 0.5 ml/kg 0.25% bupivacaine, injected on the same side of surgery, and group C received a caudal block using 1 ml/kg 0.2% bupivacaine (n = 64). Surgery was allowed 15 min after administration the block. Block failure was considered in case of gross movement or more than 20% change in heart rate and/or ABP persisting more than 1 min after skin incision. Any adverse events were recorded. After surgery, patients remained for 4 h in the recovery room. Postoperative analgesia was evaluated using Children and Infants Postoperative Pain Scale (CHIPPS). An anesthesiologist, who was not part of the study team, evaluated the need for rescue analgesia in the intraoperative and postoperative period and a recovery nurse collected the data. If the CHIPPS score was greater than 4, a rescue analgesia of 20 mg/kg acetaminophen was administered. Results: No difference was found in hemodynamics in both groups. Also, intraoperative fentanyl consumption was not different and no rescue analgesia was required in the postanesthesia care unit. Conclusion: A US-guided QLB is as effective as a caudal block in providing immediate postoperative analgesia in acute diseases of the abdominal cavity.
Laparoscopic pylorus-preserving pancreaticoduodenectomy with duct-to-mucosa pancreaticojejunoanastomosis without stenting
Summary: Laparoscopic pylorus-preserving pancreaticoduodenectomy (LPD) is a complex procedure that is becoming increasingly popular among surgeons in last decades. Despite of many modern techniques there is still a high risk of anastomotic leakage following duct-to-mucosa pancreaticojejunostomy. Therefore, pancreaticojejunostomy is generally performed with stenting of the pancreatic duct. However, laparoscopic pancreaticojejunostomy with a duct-to-mucosa anastomosis does not always require a stent tube even in patients with a normal soft pancreas. The aim of our study was to compare the results obtained with LPD without stenting technique and those obtained with open pancreaticoduodenectomy (PD). The objective of this technique is to maintain adequate patency of the anastomosis using a laparoscopic approach. The pancreas, including the pancreatic duct, is transected with a monopolar cautery. The end-to-side anastomosis between the pancreas and jejunum consists of two layers of sutures. The outer layer, composed of the capsular parenchyma of the pancreas and the jejunal seromuscularis is performed using 4/0 monofilament suture material. The inner layer, composed of the pancreatic duct and the whole jejunal wall is performed using 5/0 absorbable suture material. Since September 2015 to September 2018, 18 patients underwent LPD . An equivalent cohort of open PD patients with and without stenting was obtained by matching sex, ASA, pancreas consistency and main pancreatic duct diameter. Severe complications and length of stay were signi?cantly lesser in LPD group without stenting of the anastomosis. No differences in posoperative pancreatic fistula formation was detected. In this case-matched study, LPD without stenting shows superior results than open PD with stenting of the anastomosis in terms of less severe postoperative complications and pancreatic fistula formation. Therefor laparoscopic pancreaticojejuno­stomy using duct-to-mucosa anastomosis does not require a stent tube. This nonstented method can be considered one of the basic procedures for laparoscopic pancreaticojejuno­stomy because of its safety and reliability. Randomized control trials arerequired to con?rm these results.
Copyright (c) 2019 Infinite Science Publishing https://creativecommons.org/licenses/by/4.0/
Perioperative and short-term outcomes of robotic assisted living kidney donation
Background: Robotic assisted kidney donor surgery represents one of the most advanced surgical techniques for living kidney donation. Material and Methods: We present our initial experience with 37 consecutive patients who underwent robotic assisted living kidney donation from September 2013 to May 2018. Results: Within the last 5 years the amount of robotic assisted living kidney donation almost quintupled. A total of 19 left (51%) and 18 (49%) right kidneys were used for transplantation. Mean donor age was 53 (range: 35-70). The average total operative time was 151+-27 minutes with no difference between patients with single 153+-27 or multiple (n=8; 22%) 144+-29 renal arteries or veins. Interestingly, right donor nephrectomy (139+-22) was significantly faster than left (163+-27) nephrectomy. Postoperative blood transfusions were necessary in n=1 (2,7%) patient. No conversion to open surgery was performed. Clavien Dindo Grade <IIIb complication occurred in (n=4) 10,8%. Grade IV and V complications did not occur. Mortality was 0%. 10 kidneys (27%) were transplanted across the AB0 barrier, requiring therapeutic apheresis as well as T and B cell directed immunosuppressive therapy. One year graft survival was 97%. Discussion and Conclusion: Robotic assisted living kidney donation is an emerging minimally invasive surgical technique which facilitates excellent perioperative and short-term outcomes.
Biliary reflux after one anastomosis gastric bypass
Introduction: One-anastomosis gastric bypass is one of the most popular bariatric procedure in the world. Nevertheless, there is ?ontroversy remains regarding biliary reflux after mini-gastric bypass/one-anastomosis gastric bypass (MGB/OAGB). The aim of this study was to analyze biliary reflux and its potential long-term consequences on esofagogastric mucosae in OAGB operated patients. Methods: Immediate and long-term outcomes (up to 30 months, mean 12 month) in a cohort of 70 patients undergoing surgery between 2014 and 2017 were analyzed. Patients were divided into two clinical groups, depending on the technique of gastroenteroanastomosis. A standard five-port laparoscopic technique was used. The first group included 32 patients who underwent MGB in a modified way in our clinic with the making of hand-sewn gastroenteroanastomosis. 38 patients were used the traditional technique with the making of anastomosis with using a linear stapler with a 45 mm blue cartridge. Then, mean 12 months after MGB, all patients was filled out a reflux symptom questionnaire. A gastroscopy with biopsies was done for all patients with a bile-reflux positive symptoms. Results: The number of patients who underwent surgery were 70 (mean body mass index 46 kg/m2). Mean percent excess weight loss (%EWL) at 12 months was 74.3%. Comorbidity resolution, determined by medication use, showed a reduction in diabetes (71.8% to 15.6%), hypertension (37.2% to 21.4%) and hypercholesterolaemia (40.4% to 13.4%). The absence of enterogastric biliary reflux was observed in 81.2% of patients in the study group, the absence of an ulcer of the gastroenteroanastomosis was observed in 97% of the study group, respectively. There was one death unrelated to surgery. Conclusions: Modified MGBP appears to be a safe and effective operation for the morbidly obese. It is durable, with good weight loss at up to 12 months post-surgery. The proposed technique for the formation of hand-sewn gastroenteroanastomosis allows decreasing the postoperative bile reflux up to 8,8%.
Laparoscopic mesh repair of large hiatal hernia and upside-down stomach with intraoperative treatment of an esophageal lesion
Purpose: Upside-down stomach (UDS) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. UDS is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. Surgical repair is the only curative treatment option and therefore recommended for these patients. Standard procedure includes a hiatoplasty followed by an anti-reflux procedure. In a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences. Methods: A 78-year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. She reported a weight loss of 14 kg in the last 6 months. CT scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately 10 cm, with intrathoracic UDS. Results: We performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (Tutomesh™) augmentation. Finally, a Toupet fundoplication was performed to recreate the anti-reflux valve. In consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. The esophageal mucosa was unaffected. We treated the lesion laparoscopically with a simple interrupted suture (Vicryl™ 3-0). An intraoperative Patent Blue V leak test did not identify any leaks. The recovery was uneventful. The patient was discharged on day 12 after surgery and was free of symptoms in her follow-ups. Conclusion: Patients with large hiatal hernias and UDS can be treated successfully and effectively with laparoscopic mesh repair. Intraoperative complications can be handled laparoscopically in a safe manner.
Die laparoskopische Narbenhernienreparation in IPOM-Technik - Ergebnisse nach 11 Jahren
Ziel: Die Reparation von Narbenhernien ohne Verwendung eines Netzes führt zu hohen Rezidivraten in bis zu 50 % der Fälle. Aber auch bei Verwendung konventioneller Netzplastiken werden kumulative Rezidivraten zwischen 20 und 36 % beschrieben. Im Gegensatz dazu sind beim minimal invasiven Narbenhernienrepair (lap. IPOM-Technik) Rezidivraten von unter 5 % dokumentiert. Methode: Von April 2007 bis April 2018 wurden 312 Patienten (167 Männer, 145 Frauen) mit einer Narbenhernie in der lap.-IPOM-Technik versorgt. Der BMI lag bei 30,4 kg/ m2, die durchschnittlich implantierte Netzgröße bei 428,4 cm2. Die lokalen Komplikationen wurden während des stationären Aufenthaltes dokumentiert. Zur Evaluierung erfolgten regelmäßig ambulante Kontrollen sowie die schriftliche Erhebung der follow up-Daten im Rahmen der Herniamed-Qualitätssicherung. Ergebnisse: Im gesamten Beobachtungszeitraum entwickelten 10 Patienten (3,2 %) ein Rezidiv. Alle innerhalb der ersten 2 Jahre p.o.. Bei den Revisionen konnten 5 Patienten (1,6 %) erneut mit einem Mesh in lap.-IPOM-Technik versorgt werden (Rezidivbruch am Netzrand lokalisiert). Ein Patient lehnte einen erneuten Eingriff ab. 4 Patienten (1,3 %) wurden offen nach Ramirez (2 Fälle) oder in sublay-Technik (2 Fälle) versorgt. In 4 Fällen (1,3 %) beobachteten wir postoperativ Hämatome, welche konservativ ausbehandelt werden konnten. 12 Patienten (3,8 %) entwickelten postoperativ Serome (sonographisch). In 4 Fällen (1,3 %) fiel ein Spätserom auf, welches ambulant punktiert wurde. Es kam zur kompletten Ausheilung. Fistelbildungen konnten wir nicht dokumentieren. Während der Operation kam es im Rahmen der Adhäsiolyse in 3 Fällen (1 %) zu einer Dünndarmläsion. In einem Fall konnte die suffiziente Versorgung in lap. Technik erfolgen. In 2 Fällen konvertierten wir und führten die Narbenhernienversorgung offen durch. Die Läsionen heilten folgenlos aus. Tiefe Wundinfektionen mit Revisionen oder Netzexplantationen traten gar nicht auf. Zusammenfassung: Nach 11 Jahren standardisierter Versorgung von Narbenhernien in lap.-IPOM-Technik zeigt sich eine konstant geringe Rezidivrate bei deutlich weniger Mesh- und Wundinfektionen. Die Technik ist komplikationsarm durch einen erfahrenen, minimal invasiv tätigen Chirurgen durchführbar und zeigt sehr gute Langzeitergebnisse.
Dynamic control strategies for cable-driven master-slave robots
Abstract: Controlling cable driven master slave robots is a challenging task. Fast and precise motion planning requires stabilizing struts which are disruptive elements in robot-assisted surgeries. In this work, we study parallel kinematics with an active deceleration mechanism that does not require any hindering struts for stabilization. Reinforcement learning is used to learn control gains and model parameters which allow for fast and precise robot motions without overshooting. The developed mechanical design as well as the controller optimization framework through learning can improve the motion and tracking performance of many widely used cable-driven master slave robots in surgical robotics.
Endovenous radiofrequency ablation and varicose veins of the lower limbs with active venous ulcer
Purpose: To investigate the effectiveness of outpatient minimally invasive procedure application in patients with the varicose disease of the lower limbs with active venous ulcer. Can endovenous radiofrequency ablation (RFA) become the main method of treatment of superficial and perforating vein incompetence in patients with associated venous ulcers? Materials and methods. RFA saphenous vein of the lower limbs was performed in 17 patients with varicose vein disease with clinical disease class of C6 according to the CEAP classification. “Medtronic” apparatus with “VNUS Closure Fast” technology was used for the RFA. Results: Venous ulcers localized on the right limbs in 10 and on the left limbs in 7 patients. The number of trophic ulcers was within the range from 1 to 12, nine out of which were solitary ulcers. 8 patients showed 2 and more ulcers. The sizes of ulcers were from 5 mm along the minimal longitudinal axis and up to 90 mm along its maximal one, making up an average of 20,06±1,78 mm and 52,74±25,47 mm accordingly, and reaching the maximum size of 90 mm by 55 mm. The duration of ulcers existence was from 6 to 72 months, which average constituted 33,76±6,47 months. The mean diameter of a great saphenous vein (GSV) was 12,82±1,03 mm. The mean diameter of a small saphenous vein (SSV) was 3,94±0,57 mm. RFA of solely GSV was performed in 12 patients, of both vein (GSV and SSV) was performed in 4 patients and of solely SSV was performed in 1 patient. The duration of RFA was 33,82±2,07 minutes on average. The number of cycles of RFA was from 10 to 22, with its average of 17,47±0,80 for one patient. Trophic ulcers cured in all patients within the timeframe from 14 to 60 days. Conclusions: 1. Endovenous Radiofrequency Ablation is a highly effective means of treatment of superficial and perforating vein incompetence in patients with associated active venous ulcers. 2. Endovenous Radiofrequency Ablation can be used in an outpatient situation as a monosurgical method of active venous ulcers treatment.
Minimally invasive surgery for chronic pancreatitis as main and auxiliary options?
Purpose: Explore the possibilities of minimally invasive surgery for chronic pancreatitis (CP). What is the role of endoscopy, interventional sonography and laparoscopic surgery. Can these procedures be main or auxiliary? Materials and methods: We analyzed the results of surgical treatment of 258 patients with CP. Of these, minimally invasive surgery, was realized in 108 patients. Endoscopic transpap?llary procedure were made in 22 (20,4%) patients. The indications for their implementation was biliary and pancreatic hypertension, and external pancreatic fistulas. Endoscopic transmural procedures performed in 10 (9,2%) patients. Interventional sonography techniques were used in 70 (64,8%) patients with enormous pancreatic pseudocysts. Laparoscopic surgery was performed in 5 (4,6%) patients, including two successful total laparoscopic longitudinal pancreatojejunostomy. Results: Endoscopic transpapillary procedures with sufficient selection of patients eliminate the biliary and pancreatic hypertension, but does not have long-term effects and serve as the first stage of surgery. Endoscopic transmural anastomoses with the clear indications are effective. Interventional sonography techniques play an important but supporting role, breaking surgery on the steps and eliminate the main complications of the disease. With four attempts, the total laparoscopic longitudinal pancreatojejunostomy was performed in 2 patients. In 2 patients, a conversion was made. The average operation time was 207 minutes. The post-operative stay was an average of 9 days, and the average follow-up observation period was 13 months. There were no pancreatic fistulas and fatal cases. All patients in the long-term outcome noticed pain disappearance and weight gain. According to the questionnaires SF-36 and EORTC BCH there was a significant improvement on functional scales. Conclusions: Endoscopic transpapillary procedures and transmural anastomosis with clear indications are sufficiently effective but give a short-term effect, and government cases have auxiliary value. Methods of interventional sonography in the treatment of complications of chronic pancreatitis play an auxiliary therapeutic role, breaking surgical treatment at stages, eliminating the main complications of the disease or surgery Laparoscopic surgery, especially laparoscopic longitudinal pancreatojejunostomy for patients with «early chronic pancreatitis» with pancreatic hypertension without enlarging the head of pancreas, are technically possible and attractive.
Copyright (c) 2020 Proceedings on Minimally Invasive Surgery
Multimodal programme of enhanced recovery following pancreaticoduodenectomy
Background: Mortality after pancreaticoduodenectomy (PD) decreased from 25% to 1–3% in recent decades. However, the number of early postoperative complications varies from 29.5% to 70%. Therefore, there is a need for new methods of perioperative management of patients after PD to improve the immediate results. The aim of the study was to analyze the effectiveness of different perioperative treatment regimen in patients after PD. Materials and methods: This prospective-retrospective study included 78 patients after PD from 2003 to 2017. For comparative analysis, the patients were divided into 2 groups: group I included 39 patients recruited from January 2015 to December 2017. In them the perioperative treatment was carried out in accordance with the enhanced recovery programme, group II consisted of 39 patients recruited from January 2003 to December 2014, in whom the perioperative care was conducted traditionally. We studied the time to restoration of oral nutrition, postoperative complications, and duration of hospital stay. Results: There were no mortality in groups. The overall incidence of Clavien – Dindo complications in group I was significantly lower than in group II (10 (25.6%) vs 18 (46.1%) corr., p=0.029). The incidence of delayed gastric emptying in group I was lower compared to group II (15.4% (6 patients) vs 35.9% (14 patients), p=0.009). The incidence of pancreatic fistula (PF) in groups I and II did not differ significantly – 10.2% (4 patients) and 12.8% (5 patients), respectively (p=0.36). The incidence of infectious complications in group I was reduced in comparison with group II (5.1% (2 patients) vs 17.9% (7 patients), p=0.031). The mean duration of hospital stay in I was significantly less compared with group II (14 days 95% CI: [13, 17] vs. 18 days 95% CI: [16, 18], p=0.012). Conclusions. Implementation of the ERAS program in PD reduces postoperative morbidity and duration of hospital stay, demonstrating its feasibility in clinical practice.
Early results of totally laparoscopic liver resections: analysis of first 42 cases
Objectives: Laparoscopic approach for liver surgery has become popular for some groups of patient because of its priority in terms of morbidity and oncological safety. Despite lots of advantages it remains technically demanded and require a long learning curve. Our centre has started laparoscopic liver surgery program in 2016. Present study is aimed to evaluate early results of this program. Materials and methods: From December 2016 to October 2018 42 patients with malignant and benign lesions where planned for elective laparoscopic liver resection. The indication were as follows: giant symptomous hemangioma in 10 patients (23.8%); liver adenoma in 12 patients (28.5%), cystadenoma in 3 patients (4.7%); hydatid cyst, resistant to conservative treatment in 7 patients (16.7%); small hepatocellular carcinoma in 7 patients (16.7%); colorectal liver metastasis in 1 patient (2.3%) and other liver metastasis in 2 patients (4.7%). Intention malignant to benign in this series was 10/32. Median of lesion size was 63.2 mm (from 10 to 110 mm). Four patients had previous open abdominal surgery – two had colon resections, one had urgent laparotomy in local hospital due to bleeding from tumor rapture and one patient had trisectionectomy due to huge fibrolamellar HCC and was operated laparoscopically due to tumor recurrence in remnant liver. Results: The procedures included 9 (22.5%) major hepatectomies, including 8 left lobectomies and 1 right posterior sectionectomy, and 33 (77.4%) minor resections. By IWATE classification of difficulty there were 3 (7.1%) low-complexity, 21 (50%) intermediate-complexity and 18 (42.8%) high-complexity procedures. IWATE complexity score ranged from 2 to 8 points. There was one conversion to hybrid procedure due to absence of progression in liver transection (conversion rate 2,3%). Mean blood loss was 326 ml (range 0–1500 ml). Mean operative time was 265 min (range 167–400 min). No major complications were observed. Among minor complication were observed wound infection in 4 patients and abdominal liquor collection, treated conservatively in 3 patients. Overall morbidity was 16.7%. There were no deaths and no reoperations. Mean of hospital stay was 7.8 days (range 5 – 11 days). Conclusion: Laparoscopic approach is accessible option for advanced HPB centres, experienced in liver surgery, which shows good early results. Small liver lesion in anterior segments is optimal for beginning of laparoscopic liver surgery program. Laparoscopic hepatectomies became feasible with growing experience.
Minimally invasive interventions on the pancreas: early recovery program use
Introduction: Implementation of early recovery program in combination with minimally invasive technique can provide better results. Materials and Methods: In the department of surgery, on the basis of GKB ?1 named by Pirogov N.I. In the period from 2016 to 2017, 32 laparoscopic operations on the pancreas were performed. 12 laparoscopic pancreaticoduodenectomy for malignant neoplasms, 16 laparoscopic distal resections, 2 laparoscopic enucleation of insulinoma, 2 Frey resection. In the perioperative period, patients who underwent laparoscopic Whipple procedure were performed in accordance with Fast Track protocol. The main components of the preoperative preparation are: prevention of thromboembolic complications - low molecular weight heparin in prophylactic doses, liquid carbohydrate mixtures with low glycemic index are allowed 2 hours before the operation, refusal of mechanical bowel preparation. Intraoperative: epidural analgesia, goal directed infusion therapy, one Jackson-Pratt drainage, refusal of prolonged artificial ventilation. In the postoperative period: the day after the operation patient is transferred to the surgical department, the urinary catheter is removed, multimodal analgesia, early activation, enteral feeding with liquid protein-carbohydrate mixtures. On the third day all patients undergo computer tomography with intravenous and oral contrast, the drainage is removed - with an amylase level less than 200 U / l. Solid food is allowed. The intensity of the pain is monitored on the 3rd day and on the 5th day after the removal of the epidural catheter on a visually analog scale. On the 5th day, the overall pshyco-emotional state of the patients is assessed according to the quality of life questionnaires EORTC and GSRS. Clavien-Dindo I - 3 patients, Clavien-Dindo II in 2 patients. One patient died from sepsis. The average bed-day was 8-9 days. Two patients after distal resection for cystic mucinous neoplasia developed pancreatic fistula type B. The average bed-day was 10-11 days. Conclusions: The use of laparoscopic methods in combination with Fast Track protocol can give promising results.
Laparo-endoscopic cholecystolithotomy technology in the uncomplicated cases of cholecystolithiasis
Objectives: The high recurrence rate of cholecystolithiasis (20-40%) post cholecystolitho­tomy forced to delve into understanding of its causes. The use of endoscopic revision of the gallbladder (GB) cavity allowed to diagnose small immobile stones and polyps in the folds of the mucosa. A number of experts consider them to be factors for recurrence of cholecystolithiasis after the removal of mobile formed stones only. Purpose: to develop a technology of laparo-endoscopic cholecystolithotomy in the uncomplicated cases of cholecystolithiasis. Materials and methods: A retrospective analysis of the results of laparoscopic cholecystolithotomy in 46 patients for the period of 2007 to 2012 was performed. A prospective analysis of the results of laparoscopic endoscopically assisted cholecystolithotomy developed in 74 patients for the period of 2013 to 2018 was performed. There were 14 (18.9%) males and 60 (81.1%) females, ages 21-70 (36.4±4.2). The attention was focused on the establishment of the cause-and-effect factor in cholecystolithiasis development. The selection criterion included patients with uncomplicated symptomatic and asymptomatic cholecystolithiasis. The main selection criterion was sonography, with the definition of structure, signs of active inflammation and motility function of GB. Post-surgical rehabilitation program was used to prevent the recurrence of cholecystolithiasis. Results: According to the prospective analysis the number of removed gallstones ranged from 1 to 5. Their size ranged from 9-33 (18.7±3.5) mm. In 16 cases, after lithextraction, at the endoscopic examination of the GB cavity, small gallstones and mucus in the folds of the mucosa were diagnosed, which were removed by additional rinsing. In 8 cases, except for the lithextraction, GB polyps were removed, in the size of 3-6 mm. The surgical intervention lasted 55-130 (84.40±18.56) min. The recurrence of cholecystolithiasis with a retrospective analysis in terms of observation up to 10 years was diagnosed in 26.0%, and in a prospective analysis in terms of observation up to 5 years - in 4.1% cases. Conclusions: Laparo-endoscopic cholecystolithotomy technology is an optimal treatment modality for the uncomplicated cases of cholecystolithiasis which allows not only endoscopic control, but also the removal of muc?sa fixed concrements and polyps undiagnosed by ultrasound, which reduces cholecystolithiasis recurrence by 6.3 times (from 26.0% to 4.1%, p < 0.01).
Summary: In the 1880ies William S. Halsted, famous American surgeon, co-founder of Johns Hopkins Hospital, and father of “modern” surgical residency programs summed up surgical teaching in the sentence: “See one, do one, teach one”. Is this approach still valid in the area of minimal invasive surgery? How does a surgical resident acquire his minimal invasive skills? What are the tasks a laparoscopic native needs to learn before to be applied in patients? What is the best way to teach minimal invasive surgery? How can minimal invasive skills be evaluated? Does improvement in training models correlate with better clinical outcomes? What will the future of surgical education in minimal invasive techniques bring? These and other questions will be discussed in the talk “Teaching Minimal Invasive Surgery”.
Fluorescence imaging in colorectal surgery
Summary: Intraoperative fluorescent imaging has been improved during the last years and a lot of studies have been carried out on the use of Indocyanine Green Imaging (ICG) in the field of colorectal surgery. This talk will review the current literature available on current practice in ICG fluorescence in 3 fields of colorectal surgery. 1. Fluorescence angiography by ICG for the evaluation of tissue perfusion in acute setting of mesenteric ischemia. 2. ICG perfusion assessment for colorectal resections. 3. Lymph node assessment and new fields.
Summary: The management of rectal cancer has evolved over the years with several options available to physicians taking care of cancer patients, including refined neoadjuvant and adjuvant therapies and novel surgical techniques. Among the recently developed surgical approaches to rectal cancer, transanal total mesorectal excision (TaTME) proposes to address the anatomical limitations of the bony confines of the pelvis, bulky tumours, and fatty mesorectum through a new approach. Indeed, while taking advantage of the magnification of a laparoscope, performing a total mesorectal excision through the anus may confer a number of benefits. In particular, a different viewpoint with a facilitated excision of the lower third of the mesorectum, better visualization of the endangered structures during dissection, and potentially a safer anastomosis by avoiding the multiple stapler firings too often required in a conventional complete anterior approach. Following the first live case in 2009 and inspiring experience of the pioneers, dissemination of TaTME took place swiftly with many institutions having adopted this technique and published encouraging results. Yet, beyond the benefits of TaTME, surgeons did experience unknown intra-operative equipment and technical difficulties, with incorrect plane dissection, pelvic bleeding, unstable pneumopelvis and, more worryingly, major injuries such as urethral division which were not seen before embarking on TaTME procedures. This presentation will present the benefits and pitfalls of TaTME, report on own and international experience in TaTME, and suggest a training pathway to safely learn and implement TaTME.
Summary: Ever since the first laparoscopic liver resection (LLR) performed in the early 1990s, the scope of this surgical approach has been constantly expanding. Despite of some advantages of the LLR have been reported, there are still many situations in which LLR could not match the open surgery. Open liver resection remains the referent operation regarding the patient safety, maintenance of the liver function, oncological efficacy as well as surgeon’s comfort.
Summary: Minimally invasive abdominal surgery became more advanced and widely applied during the last decades by technical development of modern equipment and increased laparoscopic skills and adequate training of the surgeons. Furthermore, formerly considered absolute contraindications of this procedure have changed to be only relative contraindications in benign as well as in malignant surgical diseases. This fact is also true for gastric surgery and the majority of operations in metabolic surgery, benign- or gastrointestinal stromal tumors resp. and perforation of peptic ulcer is performed with a laparoscopic approach. Surgery of gastric cancer must observe oncological principles as adequate lymphadenectomy and tumor-free resection margins. These requirements must be fulfilled also in minimally invasive surgery to be equivalent to an open procedure. Kitano reported the first distal gastrectomy with a laparoscopic approach for an early gastric cancer in 1994. After that several studies started for the treatment of stage I cancer in Asia and this procedure was recommended according to the Japanese guidelines. In the meantime the German guidelines recommended also this kind of treatment but only for early gastric carcinomas founded on the oncological outcome data. For more advanced cancer, there is currently no evidence to recommend a laparoscopic approach although similar results can be expected as those after minimally invasive surgery for early gastric cancer. Some studies are on the way but a final decision must be awaited because a Cochrane-analysis of a total of 2528 randomized patients undergoing laparoscopic or open gastrectomy resp. stated that the data are sparse with wide confidence intervals and significant benefits or harms of laparoscopic gastrectomy cannot be ruled out. Furthermore, evidence for minimally invasive surgery mainly based on Asian studies from Japan and Korea. Several differences exist between populations compared to Europe with patients having a higher BMI, much more advanced tumor stages, higher incidence of tumors in the upper third of the stomach or gastroesophageal junction and less high volume centers. The latter aspect might be the most important factor resulting in limited skills and experiences of the surgeon in complex oncological operations. Therefore, minimally invasive gastric surgery cannot be recommended in general above all not in advanced gastric tumor stages at the moment.
Robotic esophagectomy: Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer – a randomized controlled trial
Background: The standard curative treatment for patients with esophageal cancer is perioperative chemotherapy or preoperative chemoradiotherapy followed by open transthoracic esophagectomy (OTE). Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RAMIE) may reduce complications and improve functional recovery. Methods: A single center randomized controlled trial was conducted, assigning 112 patients with resectable intrathoracic esophageal cancer to either RAMIE or OTE. The composite primary endpoint was the occurrence of overall surgery-related postoperative complications (modified Clavien–Dindo classification (MCDC) grade 2-5). Results: Overall surgery-related postoperative complications occurred less frequently after RAMIE (59%) compared to OTE (80%) (risk ratio with RAMIE (RR) 0.74 (95% Confidence interval (CI), 0.57-0.96; P=0.02). RAMIE resulted in less median blood loss (400ml versus 568ml, P<0.001), a lower percentage of pulmonary complications (RR 0.54 (95%CI, 0.34-0.85; P=0.005) and cardiac complications (RR 0.47 (95%CI, 0.27-0.83; P=0.006)) and lower mean postoperative pain (visual analogue scale, 1.86 versus 2.62; p<0.001) compared to OTE. Functional recovery at postoperative day 14 was better in the RAMIE group (RR 1.48 (95%CI, 1.03–2.13; P=0.038)) with better quality of life score at discharge (mean difference quality of life score 13.4 (2.0-24.7, p=0.02) and 6 weeks post-discharge (mean difference 11.1 quality of life score (1.0-21.1; p=0.03)). Short and long-term oncological were comparable at a medium follow up of 40 months. Conclusions: RAMIE resulted in a lower percentage of overall, surgery-related and cardiopulmonary complications with lower postoperative pain, better short-term quality of life and a better short-term postoperative functional recovery compared to OTE. Oncological outcomes were equal and in concordance with the highest standards nowadays. This randomized controlled trial provides evidence for the use of RAMIE to improve postoperative outcome in patients with resectable esophageal cancer.
Summary: All minimally invasive pancreatic resections have been performed using conventional laparoscopic techniques. In purely resective procedures (e.g. distal pancreatectomy with en-bloc splenectomy) laparoscopy is enough in most patients, as witnessed also by the growing diffusion of this procedure. On the contrary, the intrinsic limitations of laparoscopy become evident when fine intracorporal dissections and multiple intracorporeal reconstructions are need, such as in pancreatoduodenectomy. Indeed, although feasible, laparoscopic pancreatoduoden­ectomy has not gained widespread popularity and has instead been associated with high morbity rates. Robotic surgery is a variation of laparoscopic surgery that employs an electromechanical actuator, the da Vinci Surgical System® to enhance surgical dexterity in minimally invasive procedures. As such, robotic surgery in pancreatic procedures is expected to be particularly rewarding in pancreatoduodenectomy, in central pancreatectomy and in distal pancreatectomy when preservation of the spleen along with the splenic vessels is anticipated to be difficult or troublesome. In my talk I will present the results of some 400 robotic pancreatectomies and will provide a sketch on how our program was developed and attained standardizaion for all types of pancreatic procedures, including those that may require resection and reconstruction of the superior mesenteric/portal vein.