Incidence Of Intraoperative Complications Research Articles

Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients.

Three-column resection osteotomies (3COs) are commonly performed for sagittal deformity but have high rates of reported complications. Authors of this study aimed to examine the incidence of and intercenter variability in major intraoperative complications (IOCs), major postoperative complications (POCs) up to 6 weeks postsurgery, and overall complications (that is, both IOCs and POCs). They also aimed to investigate the incidence of and intercenter variability in blood loss during 3CO procedures. The incidence of IOCs, POCs, and overall complications associated with 3COs were retrospectively determined for the study population and for each of 8 participating surgical centers. The incidence of major blood loss (MBL) over 4 L and the percentage of total blood volume lost were also determined for the study population and each surgical center. Complication rates and blood loss were compared between patients with one and those with two osteotomies, as well as between patients with one thoracic osteotomy (ThO) and those with one lumbar or sacral osteotomy (LSO). Risk factors for developing complications were determined. Retrospective review of prospectively acquired data for 423 consecutive patients who had undergone 3CO at 8 surgical centers was performed. The incidence of major IOCs, POCs, and overall complications was 7%, 39%, and 42%, respectively, for the study population overall. The most common IOC was spinal cord deficit (2.6%) and the most common POC was unplanned return to the operating room (19.4%). Patients with two osteotomies had more POCs (56% vs 38%, p = 0.04) than the patients with one osteotomy. Those with ThO had more IOCs (16% vs 6%, p = 0.03), POCs (58% vs 34%, p < 0.01), and overall complications (67% vs 37%, p < 0.01) than the patients with LSO. There was significant variation in the incidence of IOCs, POCs, and overall complications among the 8 sites (p < 0.01). The incidence of MBL was 24% for the study population, which varied significantly between sites (p < 0.01). Patients with MBL had a higher risk of IOCs, POCs, and overall complications (OR 2.15, 1.76, and 2.01, respectively). The average percentage of total blood volume lost was 55% for the study population, which also varied among sites (p < 0.01). Given the complexity of 3COs for spinal deformity, it is important for spine surgeons to understand the risk factors and complication rates associated with these procedures. In this study, the overall incidence of major complications following 3CO procedures was 42%. Risks for developing complications included an older age (> 60 years), two osteotomies, ThO, and MBL.

Complications and Intercenter Variability of Three-Column Resection Osteotomies for Spinal Deformity Surgery: A Retrospective Review of 423 Patients

Study Type Retrospective review of a prospectively collected multicenter database. Introduction Three-column resection osteotomies (3CO), including pedicle subtraction osteotomies and vertebral column resections are performed for correction of sagittal deformity; however, they have high rates of reported complications. This study examined the incidence and intercenter variability of major intraoperative complications (IOC), postoperative complications (POC), and overall complications (IOC + POC) up to 6 weeks postoperation. Objective The aim of the study is to examine the incidence and intercenter variability of major complications associated with 3CO. Patients and Methods A retrospective review of patients with 3CO from eight different sites was performed. The incidence and types of complications were determined for the study population (N = 423). The analysis compared patients with one (n = 391) and two (n = 32) osteotomies, as well as patients with a thoracic osteotomy (ThO) (n = 72) versus a lumbosacral osteotomy (LSO) (n = 319) of the spine. Subsequent analysis was performed to compare sites with low-osteotomy volumes (< 50 patients) to sites with large osteotomy volumes (more than 50 patients). Major blood loss (MBL) was defined as more than 4L. Results Of the 423 patients, the incidence of major IOC, POC, and overall complications was 28, 45, and 58%, respectively (Table 1). The most common major IOC was MBL (24%) and the most common POC was unplanned return to the operating room (OR) (19%). Other IOC included cord deficit (2.6%), pneumothorax (1.5%), large vessel injury (1.7%), nerve root injury (1.4%), and cardiac arrest (0.2%). Other POC included motor deficit (12.1%), deep infection (7.6%), acute respiratory distress/failure (4.7%), deep venous thrombosis (3.1%), pulmonary embolism (2.8%), arrhythmia (1.2%), reintubation and sepsis (0.7%), cauda equine syndrome, myocardial infarction, visual deficit, stroke (0.5%), and death (0.2%). Patients with one 3CO had significantly less POC (43 vs. 69%, p < 0.01) and overall complications (57 vs. 75%, p < 0.01) than patients with two 3CO (Fig. 1). IOC, MBL, and return to the OR were not significantly different between groups. Patients with ThO had significantly more POC (66 vs. 39%, p < 0.01) and overall complications (76 vs. 53%, p < 0.001) than patients with LSO. Patients with LSO had more MBL (25 vs. 14%, p = 0.04). Patients with ThO had more unplanned return to OR (41 vs. 14%, p < 0.001) (Fig. 2). The incidence of IOC was greater for the low-volume sites than high-volume sites (46 vs. 23%, p < 0.001). Low-volume sites had a higher frequency of patients with MBL than high-volume sites (45 vs. 18%, p < 0.001) (Fig. 3). Patients who experienced MBL had a significantly longer operating time (p < 0.001) and a higher risk of developing other IOC, POC, and overall complications (OR = 2.18, 1.51, 1.63, respectively) than patients who did not experience substantial blood loss. Conclusions The overall incidence of complications was 58% following 3CO surgery. There was significant variation in incidence of complications depending on the number, location, and experience of performing osteotomies. Risks for developing complications included having two osteotomies, ThO, surgery at a low-volume center, and blood loss more than 4 L. With a better understanding of 3CO complications and risk factors, physicians may be more informed in the decision-making process of sagittal plane deformity correction.

Gravity line strategy may reduce risks of intraoperative injury during laparoscopic surgery

"Tilt" of surgical view was commonly shown on the monitor due to unintentional rotation of camera along its long axis by camera driver. Surgeons may be influenced on identification of anatomical structures by the tilt vision. We aimed to analyze the surgical records and videos of laparoscopic surgery, and to reveal the correlation between intraoperative complications and tilt view. A series of 425 consecutive patients who received laparoscopic low anterior resection and abdominoperineal resection were studied, and 398 surgery videos were reviewed. Still pictures showing intraoperative injury were selected. A method was established to measure tilt angle in the still pictures according to the reference line based on several anatomic landmarks. The patients were grouped with two methods according to different study purposes. Incidence of intraoperative complication and tilt angle were calculated, and statistical analysis was performed. The incidence of intraoperative complications was 8.3%. Tilt of the surgical field at different degrees (<15°, 15°-30° and >30°) was found in a relatively high rate in these surgery videos (31.4%). Compared with controls, comparatively bigger tilt angles were found in all cases of complication group. It is interesting to note that intraoperative complications happened more often when the tilt angle was in the range of 15°-30° (72.7%) than >30° (18.2%). We also noted a high incidence of complication (72.7%), while tilt angle was over 15° (26%) in the first 100 cases; comparatively a steady declining low rate of complication occurrence (5-7%) and also tilt angle over 15° (9-11%) were noted in the later 298 cases. Rotation of camera is common during laparoscopic procedures. The tilt view increased the risk of laparoscopic procedures. Tilt angle at 15-30° is the most dangerous rotation for laparoscopic surgeries. Therefore, we propose the "Gravity Line Strategy" principle as one of the basic operating criteria to correct the tilt angle.

Robot Versus Laparoscopic Nerve-Sparing Radical Hysterectomy for Cervical Cancer

The aim of the study was to compare the initial surgical outcomes and learning curve of nerve-sparing robotic radical hysterectomy (RRH) with nerve-sparing total laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in the first 50 cases. Between January 2008 and March 2012, 50 consecutive patients underwent nerve-sparing RRH. These patients were compared with a historic cohort of the first 50 consecutive patients who underwent nerve-sparing TLRH. Both groups were similar with respect to patients and tumor characteristics. The mean operating time in the RRH group was significantly longer than that in the TLRH group (230.1 ± 35.8 vs 211.2 ± 46.7 minutes; P = 0.025). The mean blood loss for the robotic group was significantly lower compared with the laparoscopic group (54.9 ± 31.5 vs 201.9 ± 148.4 mL; P < 0.001). There was no significant difference in the mean pelvic lymph nodes between the 2 groups (25.0 ± 9.9 vs 23.1 ± 10.4; P = 0.361). The mean days to normal residual urine were 9.6 ± 6.4 in RRH and 11.0 ± 6.2 in TLRH (P = 0.291). The incidence of intraoperative complication was profoundly lower in RRH compared with that of TLRH (0% vs 8%; P = 0.041). Moreover, no intraoperative transfusion was required in RRH, whereas 4 (8%) were required in TLRH (P = 0.041). In both groups, we found no evidence of a learning effect during the first 50 cases. During the first 50 cases, surgical outcomes and complication rates of nerve-sparing RRH were found to be comparable to those of nerve-sparing TLRH. Moreover, the mean blood loss and intraoperative complication rate in the robotic group were significantly lower than those in the laparoscopic group. Surgical skills for nerve-sparing TLRH easily and safely translated to nerve-sparing RRH in case of experienced laparoscopic surgeon.

Supra-umbilical vertical midline abdominal incision in morbidly obese gynaecological oncology patients

The prevalence of obesity is rapidly increasing globally. Female malignancies linked to obesity comprise approximately 51% of newly diagnosed cancers. Endometrial, breast, ovarian and cervical cancers have been associated with obesity. Obesity presents problems with laparotomy incision placement and closure. Access to the pelvis can be challenging and there is a higher incidence of intraoperative complications. We review the outcome of seven patients where a supra-umbilical midline vertical laparotomy incision has been used in an attempt to minimise the surgical morbidity.

Peroral Endoscopic Myotomy (POEM) Is Safe and Effective in the Setting of Prior Endoscopic Intervention

ObjectiveWe aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions. PatientsThis study involves 40 consecutive patients undergoing POEM. InterventionPOEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm. Main Outcome MeasuresOutcome measures include length of procedure (LOP), intraoperative complications, and dysphagia relief. ResultsForty patients, with a mean age of 54 ± 19 years, underwent POEM. The pre-POEM intervention group consisted of 12 patients (nine achalasia, two nutcracker with nonrelaxing LES, and one diffuse esophageal spasm) who also had previous endoscopic treatment, while the pre-POEM non-intervention group consisted of 28 patients (22 achalasia, 3 hypertensive LES, 2 nutcracker with nonrelaxing LES, and 1 diffuse esophageal spasm). Ten patients had botox injections and two patients had large caliber balloon dilations prior to POEM. The median preoperative Eckardt score was 5 in the pre-POEM intervention group vs 6 in the pre-POEM non-intervention group (p value = 0.4). There was no statistical difference in the mean LOP (134 ± 43 vs 131 ± 41, p = 0.8) or the incidence of intraoperative complications (17 vs 3 %, p = 0.2) between the two groups. There was also no difference in the 6-month postoperative median Eckardt scores between the two groups (1 vs 1, p = 0.4). ConclusionPOEM is safe and effective even following preoperative endoscopic large caliber balloon dilations or botox injection. These interventions do not seem to contribute to increased adverse intraoperative or postoperative clinical outcomes.

Categorization of intraoperative ureteroscopy complications using modified Satava classification system

To review our experience with ureteroscopy (URS) in the treatment of ureteral calculi and stratify intraoperative complications of URS according to the modified Satava classification system. We performed a retrospective analysis of 1,208 patients (672 males and 536 females), with a mean age of 43.1 years (range 1-78), who underwent ureteroscopic procedures for removal of ureteral stones. Intraoperative complications were recorded according to modified Satava classification system. Grade 1 complications included incidents without consequences for the patient; grade 2 complications, which are treated intraoperatively with endoscopic surgery (grade 2a) or required endoscopic re-treatment (grade 2b); and grade 3 complications included incidents requiring open or laparoscopic surgery. The stones were completely removed in 1,067 (88.3%) patients after primary procedure by either simple extraction or after fragmentation. The overall incidence of intraoperative complications was 12.6%. The most common complications were proximal stone migration (3.9%), mucosal injury (2.8%), bleeding (1.9%), inability to reach stone (1.8%), malfunctioning or breakage of instruments (0.8%), ureteral perforation (0.8%) and ureteral avulsion (0.16%). According to modified Satava classification system, there were 4.5% grade 1; 4.4% grade 2a; 3.2% grade 2b; and 0.57% grade 3 complications. We think that modified Satava classification is a quick and simple system for describing the severity of intraoperative URS complications and this grading system will facilitate a better comparison for the surgical outcomes obtained from different centers.

Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

The advantages of laparoscopic hernia repair on reducing postoperative pain and an earlier return to normal activities with similar recurrence rate have been confirmed by various studies. The objective of this study was to assess the effectiveness of laparoscopic totally extraperitoneal repair. Patients who underwent laparoscopic inguinal hernia repair between December 2000 and December 2010 were enrolled retrospectively. Patient demographics, operative and postoperative course, and outpatient follow-ups were studied. Of the 1371 cases in 1178 patients, 1328 cases (96.8%) were laparoscopic totally extraperitoneal repair and 43 cases (3.2%) represented other laparoscopic procedures--intraperitoneal onlay mesh or transabdominal preperitoneal techniques. There was only 1 conversion from a laparoscopic procedure to open surgery. The number of recurrent hernias was 129 (11.0%). Most of the recurrent hernias were secondary to open hernia repair. The mean operative time was 26 ± 18 minutes for unilateral hernias and 39 ± 29 minutes for bilateral hernias. The incidence of intraoperative complications was 3.8%. The overall postoperative morbidity rate was 15.3%, mainly representing seroma and pain. The recurrence rate was 0.5%. If performed by experienced laparoscopic surgeons, laparoscopic totally extraperitoneal repair is an excellent mode of hernia repair for most types of inguinal hernias.

An audit of indications and complications associated with elective hysterectomy at a public service hospital in South Africa

Objective To assess relationships between clinical indication for hysterectomy and postoperative histologic findings, and to audit complications of hysterectomy at the gynecologic surgical unit of a public-service hospital in South Africa. Methods Surgical indications and details, histologic findings, and postoperative course were reviewed and analyzed for 335 patients who underwent hysterectomy at Groote Schuur Hospital, Cape Town, South Africa, in 2007. Results Hysterectomy was performed abdominally in 265 patients (79.1%) and vaginally in 70 (20.9%) patients (5 of these procedures were laparoscopically assisted). The most common indication was fibroid-related menorrhagia (23%), followed by abnormal uterine bleeding (14.9%). The incidence of intraoperative complications was 6-fold greater among patients with malignant disease than among those with a benign condition ( P = 0.001). The incidence of postoperative complications was greater following abdominal rather than vaginal surgery, whether traditional or laparoscopic ( P = 0.02). Conclusion Most hysterectomies were carried out abdominally rather than vaginally, in part because many patients presented with advanced cancer or other condition that warranted this approach. Because of resource constraints, patients with benign conditions were more likely to be offered surgery if they had a clearly defined condition.

Influence of preoperative chemotherapy for advanced thoracic oesophageal squamous cell carcinoma on perioperative complications

The Japan Clinical Oncology Group (JCOG) 9907 trial has changed the standard of care for advanced thoracic oesophageal cancer in Japan from postoperative chemotherapy to preoperative chemotherapy. The impact of preoperative chemotherapy on the risk of developing postoperative complications remains controversial. This article reports the safety analysis of JCOG9907, focusing on risk factors for postoperative complications. Patients with potentially resectable advanced thoracic oesophageal squamous cell carcinoma were randomized to either postoperative or preoperative chemotherapy followed by transthoracic oesophagectomy with D2-3 lymphadenectomy. Chemotherapy consisted of two cycles of cisplatin and 5-fluorouracil. Clinical baseline data, intraoperative complications, postoperative complications and in-hospital mortality, collected on the case report forms in a predetermined format, were analysed. Univariable and multivariable analyses were used to explore the risk of postoperative complications in relation to treatment group, age, sex, tumour depth, nodal metastasis, stage and location. Of 330 patients randomized, 166 were assigned to receive postoperative chemotherapy and 164 preoperative chemotherapy; 162 and 154 patients respectively underwent surgery. The incidence of intraoperative complications, postoperative complications and in-hospital mortality was similarly low in both groups. Multivariable analysis showed that age, sex and tumour location were independently associated with an increase in postoperative complications, but preoperative chemotherapy was not. Preoperative chemotherapy does not increase the risk of complications or hospital mortality after surgery for advanced thoracic oesophageal cancer.

Perioperative complications and adverse events after lumbar spinal surgery: evaluation of 1012 operations at a single center

BackgroundLumbar surgery and associated complications are increasing as society is aging. However, definitions of complications after lumbar surgery have not been established and previous reports have varied in the definition of, and focus on, intraoperative or major postoperative complications. We analyzed the frequency and severity of perioperative complications and all minor adverse events in lumbar surgery at a single center. MethodsWe retrospectively reviewed all lumbar surgery, including decompression surgery with or without fusion, at Meijo Hospital over a 10-year period. Perioperative complications and all surgery-related adverse events until 1 month postoperatively were reviewed for 1012 operations on 918 patients (average age 54 years old). The incidence of intraoperative complications was compared between junior (<10 years experience of spine surgery) and senior (≥10 years experience) surgeons. ResultsPerioperative complications and adverse events occurred in 159 operations (15.7%) on 127 patients (13.8%). There were a variety of perioperative adverse events, including digestive problems. Of the 159 complications and events, 24 (2.4%) were intraoperative and 135 (13.3%) were postoperative. Incidence of intraoperative complications was not significantly higher for junior surgeons; however, the operations performed by senior surgeons were significantly more invasive. Complications were more frequent in elderly patients (p < 0.01) and in operations that were longer (p < 0.0001), had greater estimated blood loss (p < 0.0001), and involved use of spinal instrumentation (p < 0.0001). Psychotic symptoms occurred significantly more often in older patients (p < 0.001). ConclusionThe absence of a relationship between the experience of the surgeon and incidence of intraoperative complications may be because of the greater effect of invasive surgery. Although age and invasiveness were associated with more perioperative adverse events, we do not conclude that major surgery should be avoided for elderly patients. In contrast, careful focus on the surgical indication and procedure is required for these patients.

Laparoscopic versus open appendicectomy for the treatment of acute appendicitis in young patients

Background: Debate exists about the benefits of laparoscopic appendicectomy in acute appendicitis. In this study, we compare the safety and efficacy of laparoscopic appendicectomy with open appendicectomy in young patients with acute appendicitis. Methods: This study is a prospective randomized clinical trial conducted in Ain Shams University Hospitals during the period from January 2007 till January 2010. One hundred forty young patients who were diagnosed as having acute appendicitis were randomized into 2 groups: group I included 70 patients who underwent laparoscopic appendicectomy (LA) and group II included 70 patients who underwent open appendicectomy (OA). Results: The mean operative time was significantly longer in the LA group (60±25 mins) than the OA group (45±15 mins) (P<0.01). There was a need for conversion to OA in 3 patients of the LA group (4.29%) due to extensive adhesions. There was no significant difference in the incidence of intraoperative complications between both groups. There was a statistically significant lower incidence of wound infection and wound seroma in the LA group (2.86% and 1.43% respectively) than the OA group (14.29% and 10% respectively) (P 0.1). The hospital stay was significantly shorter in the LA group (1.5±0.5 days) than the OA group (2±1 days) (P<0.001). The average cost was significantly higher in the LA group (3300±400 LE) than the OA group (1500+200 LE) (P<0.001). Conclusion: LA is safe and effective for the treatment of acute appendicitis as there is no significant incidence of major intraabdominal complications, there is lower incidence of postoperative complications especially wound infection than OA, and there is significantly shorter hospital stay. However, the mean operative time is significantly longer in the LA group, and the cost of LA is significantly higher than OA. Also the incidence of postoperative intraabdominal collection is higher in LA than OA, yet non significant.

Differences in perioperative outcomes after laparoscopic management of benign and malignant adnexal masses

ObjectiveTo compare the feasibility and safety of the laparoscopic management of adnexal masses appearing preoperatively benign with those suspicious for malignancy.MethodsRetrospective study of 694 women that underwent laparoscopic management of an adnexal mass.ResultsLaparoscopic management of an adnexal mass was completed in 678 patients. Six hundred and thirty five patients had benign pathology (91.5%) and 53 (7.6%) had primary ovarian cancers. Sixteen patients (2.3%) were converted to laparotomy; there were 13 intraoperative (1.9%) and 16 postoperative complications (2.3%). Patients divided in 2 groups: benign and borderline/malignant tumors. Patients in the benign group had a higher incidence of ovarian cyst rupture (26% vs. 8.7%, p<0.05). Patients in the borderline/malignant group had a statistically significant higher conversion rate to laparotomy (0.9% vs. 16.9%, p<0.001), postoperative complications (1.9% vs. 12.2%, p<0.05), blood loss, operative time, and duration of hospital stay. The incidence of intraoperative complications was similar between the 2 groups.ConclusionLaparoscopic management of masses that are suspicious for malignancy or borderline pathology is associated with an increased risk in specific intra-operative and post-operative morbidities in comparison to benign masses. Surgeons should tailor the operative risks with their patients according to the preoperative likelihood of the mass being carcinoma or borderline malignancy.

The Incidence of Intraoperative Complications in Women Undergoing Surgery for ICS Stage 4 Prolapse Compared to ICS Stage 2 Prolapse

The Incidence of Intraoperative Complications in Women Undergoing Surgery for ICS Stage 4 Prolapse Compared to ICS Stage 2 Prolapse

Robotics Applied in Laparoscopic Kidney Surgery: The Yonsei University Experience of 127 Cases

We report our experience on 127 kidney surgeries with the da Vinci surgical system and show the feasibility of a robotics application in a variety of kidney surgeries by both a laparoscopically-trained and a laparoscopically-naïve surgeon. Clinical data of patients who underwent kidney surgery with the da Vinci surgical system from September 2006 to April 2009 were reviewed. Data acquired from medical records included patient demographics, operative time, estimated blood loss (EBL), incidence of intraoperative complication, duration of hospital stay, blood transfusion rate, oncological outcomes, and follow-up results. One-hundred twenty-seven kidney surgeries have been conducted with the da Vinci surgical system at our institution. Three urologists--1 with formal endourology training, 1 with laparoscopic experience, and 1 laparoscopically naïve--have used it for a variety of procedures involving the kidney. The cases include 65 partial nephrectomies (RPN), 38 radical nephrectomies (RRN), and 24 nephroureterectomies with bladder cuff (RNU). Results on operative time, EBL, incidence of intraoperative injury, duration of hospital stay, and blood transfusion rate are comparable with contemporary studies. Robotics application in kidney surgery is a viable option for various procedures. Our experience shows it can be safely and effectively conducted by both laparoscopically-trained and laparoscopically-naïve surgeons once they are accustomed to the robotics system.

How Many Cases Are Necessary to Develop Competence for Laparoscopic Radical Nephrectomy?

We evaluated the number of cases necessary to develop competence for performing laparoscopic radical nephrectomy (LRN) by chronologically analyzing the results of 150 cases. 150 patients were included in this study, each of whom had had pure transperitoneal LRNs between March 2003 and February 2008 performed by three surgeons who were all novices in laparoscopic surgery. Each surgeon performed 50 LRNs. These were divided into 10 groups chronologically, with five cases in each group (individual-group). Subsequently, we combined the data of the three surgeons, with 15 cases assigned to each group (combined-group). We identified the groups that demonstrated a statistically significant difference in operative time, compared with the most recent group. Based on this finding, we divided the cases into two groups: The novice group and the competent group. The complication rate, transfusion rate, and estimated blood loss were then compared between the two groups. The total average operative time was 187.6 +/- 46.56 minutes; from group 4 onward, there was no significant decrease in the operative time. Therefore, groups 1 to 3 were defined as the novice groups, and groups 4 to 10 as the competent groups. Incidence of intraoperative complications was six (13.3%) in the novice group and nine (8.6%) in the competent group. There were 14 cases with postoperative complications--4 (8.9%) in the novice group and 10 (9.5%) in the competent group. There were significant differences in the estimated blood loss and transfusion rate between the novice and competent groups (236.4 +/- 41.85 mL vs 191.5 +/- 21.9 mL, 17.8% vs 4.8%, respectively). Our results suggest that 15 cases are needed for a novice surgeon to achieve competence in LRN. Surgical outcomes and morbidity can be improved once this learning curve has been overcome.

Laparoscopic Radical Hysterectomy versus Open Radical Hysterectomy for Carcinoma Cervix Stage 1

The present review has considered good number of studies involving fair large number of patients operated with both modalities for carcinoma cervix stage 1. Minor differences in the operative techniques are ignored. Overall operation time for laparoscopic procedures was required more. Incidence of intraoperative complication was also higher in addition to inherent complications related to pneumoperitoneum. However, results in terms of disease free survival between the groups were comparable. Advantages pertaining to reduced hospital stay and better cosmesis with laparoscopic modality at present do not outweigh the higher incidence of intraoperative complication than that in open radical hysterectomy group.

Endoscopic Role for the Management of Postoperative Intraluminal Complications of Laparoscopic Assistant Gastrectomy

Background/Aims: Though laparoscopic assistant gastrectomy (LAG) of early gastric cancer (EGC) has become one of the most popular minimally invasive treatments of early gastric cancer, the frequency of postoperative complications did not decreased. The aim of this study is to find out the endoscopic role for the management of postoperative intraluminal complications of LAG. Methods: Clinical data of 392 patients who underwent LAG for EGC between Feb 2003 and Apr 2008 were enrolled and analyzed. Patient demographics, intraoperative complications, type of postoperative intraluminal complications, endoscopic treatment were examined. Statistical analysis were taken to find out the predictive factor for postoperative intraluminal complications. Results: Mean age of patients was 58 years and 250 (63.8%) were male. 352 (89.8%) had laparoscopic-assisted distal gastrectomy (LADG) and 40 (10.2%) underwent laparoscopic-assisted total gastrectomy (LATG). Anastomosis type were as follow; Roux-en-Y (52/13.3%), Billroth-I (213/54.3%), and Billroth-II (127/32.4%). 103 complications occurred in 69 patients (17.6%). The incidence of intraoperative complications, early (within 1 month), and late complication (after 1 month) were 4 (1%), 58 (14.8%), and 7 (1.8%), respectively. Endoscopic treatment was tried in 15 cases; intraluminal bleeding (11 cases), leakage (3 cases) and anastomotic stenosis (1 case). The endoscopic treatment was successful in 14 of 15 cases (93.3%) and failed in one case due to spurting Dieulafoy's ulcer bleeding. Intraluminal bleeding occurred frequently in older patients (p=0.031) and the risk of anastomosis leakage significantly increased in B-II (3.9%)/Roux-en-Y (5.5%), compared with B-I (0.5%) (p=0.013). Anastomosis stenosis occurred more frequently in LATG (7.1%) than in LADG (0.3%) (p=0.004) and also in Roux-en-Y (5.5%) than in B-I (0.5%)/B-II (0%) anastomosis (p=0.009). Conclusion: About 15% of postoperative complications of LAG is the indication that endoscopic treatment is needed. Intraluminal bleeding, anastomosis leakage, and stenosis after LAG of EGC could effectively be controlled with endoscopic treatment. The risk factors of these complications are LATG and Roux-en-Y anastomosis. So surgeons and endoscopists should pay attention to these conditions for prevention and management of postoperative intraluminal complications. Key word: laparoscopic gastrectomy, endoscopic treatment, intraluminal complications

Effectiveness of a mucolythic agent as a local adjuvant in revision lumbar spine surgery

Aim of this prospective randomized trial was to analyze the effectiveness of MESNA in chemical dissection of peridural fibrosis in patients who underwent revision lumbar spine surgery. Between January 2003 and October 2006, 30 patients who underwent revision lumbar spine surgery were enrolled in the study. Patients were randomly assigned to one of two groups: a study group (A) and a control group (B). Once peridural fibrosis was exposed, MESNA (Uromixetan MESNA, 50 mg/ml) was intraoperatively applied on the fibrous tissue (Group A) to ease tissue dissection and enter the canal. In patients of Group B, saline solution was used. Surgical time, preoperative and 1 week postoperative hemoglobin (Hb), length of hospitalization (days), and incidence of perioperative complications were evaluated. The blinded surgeon assigned the surgeries to one of four categories as none, minimal, moderate, and severe basing on intraoperative difficulty in dissecting the fibrous tissue and intraoperative bleeding. Statistical analysis used chi-square analysis to evaluate the difference in surgery difficulty and the incidence of intraoperative complications between the two groups. The analysis of surgical time and hemoglobin levels was performed using a one-sample Wilcoxon test and Mann-Whitney U test. Patients in whom MESNA was used intraoperatively (Group A) presented better intraoperative and perioperative parameters with respect to the control group. Average surgical time and decrease in Hb postoperatively were more in the saline group (B) respect to MESNA (A) (P = 0.004 and P = 0.001, respectively), while no difference in average hospital stay was reported between the two groups. Surgeon-blinded intraoperative report on surgical difficulty showed a significant difference between the two groups (P < 0.05). Postoperatively, no complications directly attributable to the use of MESNA were experienced. The incidence of dural tears and intraoperative bleeding from epidural veins were significantly less in Group A with respect to the control group. MESNA contributed significantly to reduce the operative complications, with a diminution of the surgical time and the grade of difficult for the surgeon, confirming its ability as chemical dissector also for epidural fibrosis in revision lumbar spine surgery.

Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years

Two revolutions in inguinal hernia repair surgery have occurred during the last two decades. The first was the introduction of tension-free hernia repair by Liechtenstein in 1989 and the second was the application of laparoscopic surgery to the treatment of inguinal hernia in the early 1990s. The purposes of this study were to assess the safety and effectiveness of laparoscopic totally extraperitoneal (TEP) repair and to discuss the technical changes that we faced on the basis of our accumulative experience. Patients who underwent an elective inguinal hernia repair at the Department of Abdominal Surgery at the Institute of Laparoscopic Surgery (ILS), Bordeaux, between June 1990 and May 2005 were enrolled retrospectively in this study. Patient demographic data, operative and postoperative course, and outpatient follow-up were studied. A total of 3,100 hernia repairs were included in the study. The majority of the hernias were repaired by TEP technique; the repair was done by transabdominal preperitoneal (TAPP) repair in only 3%. Eleven percent of the hernias were recurrences after conventional repair. Mean operative time was 17 min in unilateral hernia and 24 min in bilateral hernia. There were 36 hernias (1.2%) that required conversion: 12 hernias were converted to open anterior Liechtenstein and 24 to laparoscopic TAPP technique. The incidence of intraoperative complications was low. Most of the patients were discharged at the second day of the surgery. The overall postoperative morbidity rate was 2.2%. The incidence of recurrence rate was 0.35%. The recurrence rate for the first 200 repairs was 2.5%, but it decreased to 0.47% for the subsequent 1,254 hernia repairs According to our experience, in the hands of experienced laparoscopic surgeons, laparoscopic hernia repair seems to be the favored approach for most types of inguinal hernias. TEP is preferred over TAPP as the peritoneum is not violated and there are fewer intra-abdominal complications.