Advanced Laparoscopic Procedures Research Articles

How to avoid esophageal perforation while performing laparoscopic dissection of the hiatus.

An increasing number of surgeons attempt advanced laparoscopic procedures, involving the distal esophagus such as Nissen fundoplication, truncal vagotomy, and Heller's myotomy. At this time, there are probably as many techniques as there are surgeons. The authors have tried to provide a "ready to use" universal strategy that details how to approach the distal esophagus while avoiding the dangerous pitfalls of surgery in that area.

A pig model for advanced laparoscopic biliary procedures.

Advanced laparoscopic biliary procedures can be undertaken in a pig model, but the small size of the normal common bile duct makes learning difficult. We have developed a prepared pig model of common bile duct ligation on which to practice advanced laparoscopic biliary surgery. The pig's distal common bile duct was occluded using several different methods via a minilaparotomy. Laparoscopic biliary procedures were undertaken 6-21 days later. The common bile duct became dilated to between 2 and 3 cm in diameter in all cases, and this was well tolerated by the animals. All advanced laparoscopic biliary procedures were possible, including choledochoscopy, exploration of the bile duct, and cholecystojejunostomy. Short-term common bile duct ligation is well tolerated in pigs and can be used to create a model for practicing advanced laparoscopic biliary procedures.

Development of Advanced Laparoscopy

The development of advanced laparoscopic procedures will rely on operator creativity and flexibility. Larger, more complex procedures draw upon the experience gained from varied lesser procedures. The evolution of many laparoscopic techniques has resulted in circumvention of intense preliminary laboratory study. The honesty and integrity of the practicing surgeon and the manufacturers of laparoscopic equipment are critical in ensuring the safe and practical development of the discipline of laparoscopic surgery.

A new technique of fascial closure for laparoscopic incisions.

The objective was to develop a technique and instrumentation for closure of 10-mm and larger laparoscopic incisions with a single instrument under direct laparoscopic vision, ensuring complete fascial and peritoneal closure. The Carter-Thomason Needle-Point Suture Passer functions as both a needle and a grasper, allowing for performance of laparoscopic directed fascial and peritoneal closure. It uses a 2.7-mm diameter grasping tool with a single-action jaw. The device introduces the suture through the muscle, fascia, and peritoneal layers under direct laparoscopic vision, drops the suture, picks it up at the opposite side of the opening, and is withdrawn grasping the suture. The surgeon completes the mass closure of the layers by tying the suture below the skin. Pneumoperitoneum is maintained. The closed peritoneal layer is viewed through the laparoscope, and palpation of the closure ensures that the fascial layer is completely occluded. The Carter-Thomason Needle-Point Suture Passer has been used as a single instrument for closure of 10-mm and larger incision sites in over 200 advanced laparoscopic procedures since March 1993. No incisional hernias or complications of the incisional site have occurred. This instrument and the technique have been used for ligation to control hemorrhage from a lacerated inferior epigastric vessel, with successful ligation obtained in less than 5 min. It also was used to pass suture to allow ligation of the infundibulopelvic ligament. This device provides complete and secure closure of operative incisions of 10 mm or larger, thereby reducing the risk of herniation during the postoperative recovery period.

Surgical endoscopy fellowships

This study was conducted to evaluate the career impact of a formalized surgical endoscopy fellowship. Sixteen surgeons who have completed this training were surveyed via questionnaire. Twelve individuals were found to be in teaching settings, 10 had academic appointments, and 12 had published in the endoscopic and gastrointestinal literature. Gastrointestinal endoscopy constituted a mean of 28% of these surgeons' practices. Gastrointestinal surgery was the focus of a mean of 51% of their operative experience, and laparoscopic surgery constituted a mean of 40% of their surgical activity. Twelve of these individuals performed ERCP as part of their clinical practice, and 11 performed advanced laparoscopic surgical procedures. Relationships with nonsurgical endoscopic colleagues were considered positive for 5 surgeons, negative for 7, and neutral for 4. Professional relationships with nongastroenterologic physicians were uniformly positive or neutral. We conclude that formal surgical endoscopy fellowships facilitate subsequent academic and educational activity, foster surgical practices oriented toward gastrointestinal disease, and impact relationships with nonsurgical colleagues in a variable fashion.

Brachial plexus neuropathies after advanced laparoscopic surgery

A retrospective review of 3,200 advanced laparoscopic procedures demonstrated five brachial plexus injuries during a 5-month period in 1986 (0.16% incidence rate). Brachial plexus injury can occur during laparoscopic surgery using steep Trendelenburg's position with shoulder braces and the patient's arm extended at 90 degrees. Position modification can reduce the risk for upper extremity neuropathies.

Laparoscopic Vagotomy

The increasing applicability of advanced laparoscopic procedures has fueled the ongoing request for the perfect ulcer operation. Using the laparoscopic approach to selectively denervate the parietal cell mass has led investigators to evaluate laparoscopic right posterior truncal vagotomy with anterior seromyotomy. The history of this procedure and its appeal to the laparoscopist is discussed. The technical aspects of the operation are outlined. Laparoscopic vagotomy may play a central role in the surgical treatment of peptic ulcer disease.

Initiating advanced laparoscopic surgery in a medical college hospital with basic laparoscopic set up: Is it feasible and safe?

Laparoscopic surgery involves performing surgery through small incisions in abdominal wall to get access. Primary goal of this procedure is to achieve good cosmetic outcome, reduced post operative pain, early recovery and reduced hospital admission. The main objective of this study is to see the feasibility and benefit of performing advance laparoscopic surgery in a place where basic laparoscopic surgery is done and to share my experience while performing it. A retrospective study of case sheets and discharge summary from 1st May 2008 till 1st August 2009 was done. Altogether eight patients underwent different advanced laparoscopic procedure. Cases done for the fi rst time in the institute and those done by himself were only included. Technical feasibility, use of devices like harmonic scalpel, need for incision extension, operative time, blood product requirement, ambulation and enteral feed, post operative hospital stay and patients satisfaction regarding minimal scars were assessed. Total eight patients underwent advance laparoscopic surgery. There were two common bile duct (CBD) exploration of which one was transcystic exploration, one total laparoscopic abdominoperineal resection (APR) for rectal cancer, one laparoscopic assisted right hemicolectomy for carcinoma ceacum, one laparoscopic assisted sigmoid colectomy for recurrent sigmoid volvulus, two laparoscopic right nephrectomy for non functioning right kidney, one retroperitoneal pyelolithotomy and one laparoscopic assisted splenectomy for massive splenomegaly with haemolytic anaemia. All procedures were technically feasible with basic laparoscopic instruments. However harmonic scalpel was required for splenectomy due to difficult hilum dissection. Ureteroscope was used as a choledochoscope in CBD exploration. Blood transfusion was required only in patient with low preoperative haemoglobin. Early ambulation and enteral feed was done within 24 hours in all and within 48 hours in patients who had bowel anastomosis. Post operative hospital stay was 5-8 days. Cosmetic scar was appreciated by all. Although long term oncological outcome is yet to come in malignancy case, biopsy report of laparoscopic APR identified 13 nodes which shows complete nodal dissection on oncological principal basis. Advanced laparoscopy is feasible, safe and effective in the hand of surgeons performing basic laparoscopic surgeries with guidance from surgeons who have long experience on same procedures but by open method.