Laparoscopic-assisted Bowel Resection Research Articles

Nonvisualized palpable bowel endometriotic satellites.

STUDY QUESTIONWhat is the prevalence of laparoscopically nonvisualized palpable satellite bowel nodules at or near the planned stapler site in women undergoing segmental bowel resection for endometriosis?SUMMARY ANSWEROverall, 13 (25.5%) of 51 patients who underwent resection had nonvisualized palpable satellite lesions as small as 2 mm, including seven (14%) who had nonvisualized palpable lesions at or beyond the planned stapler site.WHAT IS KNOWN ALREADYBoth laparoscopy and laparotomy for bowel resection are standard of care in Europe and the USA. Reoperation rates after laparoscopic bowel procedures are 1–16%. Endometriotic lesions at the stapler margin of bowel resections are associated with increased repeat surgery. Nodules of 0.1 mm to 1 cm in size were not recognized during laparoscopic bowel surgery but were recognized on histological examination. Up to 20 nodules not visualized at laparoscopy have been recognized and excised at laparotomy. Tenderness is found at up to 27 mm from a recognized lesion. The size of a lesion does not always predict its symptoms or behavior.STUDY DESIGN, SIZE, DURATIONThis single-arm, observational study focused on the presence of nonvisualized palpable satellite lesions of the bowel. Fifty-one patients scheduled for laparoscopic-assisted bowel resection for deep infiltrating endometriosis with suprapubic incision for placement of the stapler’s anvil and removal of the specimen in the course of routine clinical care were included. There were no additional inclusion or exclusion criteria.PARTICIPANTS/MATERIALS, SETTING, METHODSLaparoscopic-assisted segmental bowel resection for endometriosis was performed in a private referral center on women aged 24–49 years.MAIN RESULTS AND THE ROLE OF CHANCEForty-nine (96.1%) of the 51 patients underwent segmental resection of the sigmoid or rectum, and 14 (27.5%) underwent segmental resection of the ileum for large nodule(s) recognized on MRI. Twelve patients underwent both procedures. Eleven (22.4%) of the 49 patients with recognized sigmoid or rectal lesions and 5 (35.7%) of the 14 patients with recognized ileal lesions had nonvisualized, palpable, satellite lesions. All the large lesions and none of the satellite lesions had been recognized preoperatively on MRI. Five (10%) of 49 patients with lesions of the large bowel and 4 (28.6%) of the 14 patients with lesions of the ileum had nonvisualized palpable satellite lesions at or beyond the planned stapler site. Lesions as small as 2 mm were palpable.LIMITATIONS, REASONS FOR CAUTIONThis is an observational study. It is not known if the small lesions of this study contributed to the symptoms or were progressive, stable or regressive. This study analyzed lesions in the bowel segment proximal to the primary large bowel lesion, but not in the distal segment as that would have required a change in standard of care surgical technique. This study protocol did not include shaving or disk resection or patients in whom no lesions were visualized. The use of additional techniques for recognition, such as hand-assisted laparoscopy or rectal probes, was not investigated.WIDER IMPLICATIONS OF THE FINDINGSThis study confirms that some nonvisualized satellite lesions as small as 2 mm are palpable and that an increased length of resection can be used to remove lesions recognized by palpation and to avoid lesions at and beyond the stapler site. This may decrease recurrent surgery in 1–16% of the women undergoing surgery for bowel endometriosis. Knowledge of the occurrence of these small lesions may also be particularly useful in plans for repeat surgery or for women with clinically significant bowel symptoms and no visible lesions at laparoscopy. Moreover, small lesions are considered to be important as there is no current technique to determine whether a large primary lesion, smaller lesions, an associated adjacent tissue reaction or a combination of those cause symptoms.STUDY FUNDING/COMPETING INTEREST(S)This CIRENDO cohort was supported by the G4 Group (the University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE association. No specific funding was received for the study. H.R. reports receiving personal fees from Plasma Surgical Inc., Ethicon Endosurgery, Olympus and Nordic Pharma for presentations related to his experience with endometriosis surgery. D.C.M. reports being given access to Lumenis Surgical CO2 Lasers’ lab at a meeting. None of the other authors have conflicts of interest to disclose.TRIAL REGISTRATION NUMBERN/A

Palpation to Identify Non-Visualized Bowel Endometriosis during Laparoscopic-Assisted Rectal or Sigmoid Segmental Resection

Study Objective To determine the prevalence of palpable non-visualized bowel endometriotic nodules in women having a laparoscopic-assisted segmental bowel resection for large endometriotic lesions and to compare the operative findings and early postoperative complications with and without palpable non-visualized lesions. Design Observational with follow-up of 2.8 months to 1.2 years. Setting Multispecialty center. Patients or Participants Forty-nine patients with large endometriotic lesions of the rectum or sigmoid colon who underwent segmental resection. Interventions The patients underwent laparoscopic dissection and placement of the distal stapling devise and then exteriorization of the specimen through a small suprapubic incision. The proximal stapler was applied after a modification of the standard procedure that consisted of palpation anticipating small palpable lesions and to include those in the specimen. Hand-assisted laparoscopy and using rectal probes for recognition were not studied. Measurements and Main Results Eleven (22.4%) of the 49 patients who underwent sigmoid or rectal resection were found to have palpable non-visualized lesions of 2 mm to 10 mm. The median length of the proximal resected segment increased by 10 mm (range 5-30 mm) compared to the group with no such lesions. The was no difference in the short-term complication rate between the two groups. Conclusion This suggests that palpation for recognition, diagnosis, and treatment is useful in 22.4% of women undergoing laparoscopic-assisted colon resection for stapler placement. The presence of palpable, non-visualized endometriotic lesions adds to the controversy about the type of surgery needed for symptomatic endometriosis of the rectum and sigmoid colon. Although only 1% to 5% of patients have repeat surgery for symptomatic recurrence, the use of focused palpation may lower that further. The use of hand-assisted laparoscopy or rectal probes for recognition also need investigation.

Laparoscopy and complicated meckel diverticulum in children.

Background and Objectives:Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy.Methods:A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum.Results:Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications.Conclusions:Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.

Using the E-PASS scoring system to estimate the risk of emergency abdominal surgery in patients with acute gastrointestinal disease

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, which quantifies a patient's reserve and surgical stress, is used to predict morbidity and mortality in patients before elective gastrointestinal surgery. We conducted this study to clarify whether the E-PASS scoring system is useful for assessing the risks of emergency abdominal surgery. The subjects of this retrospective study were 51 patients who underwent emergency gastrointestinal surgery at a public general hospital. The main outcomes were the E-PASS scores and the postoperative course, defined by mortality and morbidity. Postoperative complications developed in 15 of the 51 patients (29.4%). The E-PASS score was significantly higher in the patients with postoperative complications than in those without (0.61 ± 0.31 vs 0.20 ± 0.35, respectively; n = 36). The morbidity rates were significantly lower in the patients with a value less than 0.5 than in those with a value more than 0.5 (17.1% and 56.3%, respectively; P < 0.01). There were 7 operative deaths among the 16 patients with a high score, versus none among the 9 patients with a low score (P < 0.01). Three patients underwent laparoscopic-assisted bowel resection with a good postoperative course, with scores of less than 0.5. The E-PASS scoring system is useful for surgical decision making and evaluating whether patients will tolerate emergency gastrointestinal surgery. Minimally invasive therapy would assist in lowering the risk of complications.

Laparoscopic-assisted bowel resection with construction of a colonic reservoir for cavernous hemangioma of the rectum: report of two cases

Diffuse cavernous hemangioma of the rectum is an unusual benign vascular lesion, marked by delayed diagnosis and often presenting recurrent rectal bleeding and anemia. Colorectal resection with coloanal anastomosis and construction of a colonic reservoir is the preferred surgical treatment. We report two cases of patients, a 23-year-old man and a 27-year-old woman, with cavernous hemangioma of the rectum, diagnosed by colonoscopy and confirmed by magnetic resonance imaging. Arteriography demonstrated vascular tumors in the rectal wall. Use of the embolization technique was not successful, since no large caliber vessel was available for this procedure. The patients underwent anterior abdominal excision of the rectum with a laparoscopic approach+ colonic reservoir and hand sewn coloanal anastomosis. Ileostomy closure was performed in both patients at 3 months after surgery, and they demonstrated good early and late postoperative outcomes. In summary, laparoscopic-assisted bowel resection may be a good option for surgical management of diffuse cavernous hemangioma of the rectum.

Primary Small Bowel Tumour Presenting as Bowel Obstruction in a Patient with a Virgin Abdomen

Primary malignancies of the small bowel are rare and usually present with vague, non-specific symptoms. This leads to diagnostic difficulties for both physician and radiologists alike. We present a case of a 54-year-old lady with a virgin abdomen who initially presented to hospital with vague abdominal symptoms suggestive of gastroenteritis. She responded partially to conservative treatment but represented to hospital 3 weeks later with obstructive symptoms. Contrast CT was inconclusive with regards to diagnosis. A diagnostic laparoscopy was performed, revealing an infiltrative growth. Consequently, she underwent segmental laparoscopic-assisted small bowel resection and recovered well post-operatively. After further histological and endoscopic investigations, a final diagnosis of primary small bowel adenocarcinoma was given. As the prognosis of small bowel malignancy is stage-dependent, this case demonstrates a high index of suspicion is necessary to reach early diagnosis, especially for symptoms non-responsive to conventional treatment. Diagnostic laparoscopy should be considered early as a definitive diagnostic tool.

Laparoscopic Resection of Metastatic Mucosal Melanoma Causing Jejunal Intussusception

A 47-year-old female was seen in an outpatient surgical setting for intermittent obstructive symptoms and abdominal pain. Computed tomography scan and upper GI series showed typical findings of intussusception. Laparoscopic-assisted small bowel resection was carried out. Histologic diagnosis revealed malignant melanoma. The patient had a history of right maxillary sinus melanoma greater than 12 years before presentation. We report the first case of a jejunojejunal intussusception caused by metastatic sinonasal melanoma, and its subsequent laparoscopic-assisted resection.

Mantle cell lymphoma of the gastrointestinal tract presenting with multiple intussusceptions – case report and review of literature

BackgroundMantle cell lymphoma (MCL) is an aggressive type of B-cell non-Hodgkin's lymphoma that originates from small to medium sized lymphocytes located in the mantle zone of the lymph node. Extra nodal involvement is present in the majority of cases, with a peculiar tendency to invade the gastro-intestinal tract in the form of multiple lymphomatous polyposis. MCL can be accurately diagnosed with the use of the highly specific marker Cyclin D1. Few cases of mantle cell lymphoma presenting with intussuception have been reported. Here we present a rare case of multiple intussusceptions caused by mantle cell lymphoma and review the literature of this disease.Case presentationA 68-year-old male presented with pain, tenderness in the right lower abdomen, associated with nausea and non-bilious vomiting. CT scan of abdomen revealed ileo-colic intussusception. Laparoscopy confirmed multiple intussusceptions involving ileo-colic and ileo-ileal segments of gastrointestinal tract. A laparoscopically assisted right hemicolectomy and extended ileal resection was performed. Postoperative recovery was uneventful. The histology and immuno-histochemistry of the excised small and large bowel revealed mantle cell lymphoma with multiple lymphomatous polyposis and positivity to Cyclin D1 marker. The patient was successfully treated with Rituximab-CHOP chemotherapy and remains in complete remission at one-year follow-up.ConclusionThis is a rare case of intestinal lymphomatous polyposis due to mantle cell lymphoma presenting with multiple small bowel intussusceptions. Our case highlights laparoscopic-assisted bowel resection as a potential and feasible option in the multi-disciplinary treatment of mantle cell lymphoma.

Laparoscopic repair of traumatic bowel injury in children

Purpose The aim of this study was to evaluate the laparoscopic repair of isolated intestinal injuries in children who sustain focal abdominal trauma. Methods A retrospective review was conducted of all patients 16 years and younger who required surgery for traumatic bowel injuries during a 5-year period at 2 university children's hospitals. The study population was composed of hemodynamically stable patients who sustained focal energy transfer to the abdomen and were diagnosed preoperatively with intestinal injury. Children sustaining multisystem injuries and gunshot wounds or who were hemodynamically unstable were excluded. Results Fifty hemodynamically stable children were explored for preoperatively documented intestinal injury sustained after focal abdominal trauma. Laparoscopy was used to repair intracorporeally gastrointestinal injuries in 8 children. Mean operating time, time to diet, and time to discharge after laparoscopic bowel repair compared favorably with patients managed by laparotomy. An additional 6 patients had a laparoscopic-assisted bowel resection or repair after exteriorization only of the ruptured intestine through a short extension of the nearest port site. No early (missed injury, wound infection, bleeding) or late (obstruction) complications resulted after laparoscopic repair. Conclusions Laparoscopic primary or assisted repair of injured bowel is an appropriate surgical option in hemodynamically stable children who sustain focal abdominal trauma and may be associated with a more prompt return of intestinal function and shorter hospital stay.

Laparoscopic-assisted bowel resection in pediatric/adolescent inflammatory bowel disease: laparoscopic bowel resection in children.

The purpose of this study is to discuss indications, technical approach, and morbidity of laparoscopic approaches to major bowel resection in the pediatric/adolescent population with inflammatory bowel disease and familial polyposis. Retrospective review of laparoscopic-assisted bowel procedures between May 1991 and January 2002 was performed. Laparoscopic-assisted bowel resection is defined as complete intracorporeal mobilization and devascularization of a segment of colon or rectum. The indications for extracorporeal vs. intracorporeal anastomosis will be discussed. Clinically unstable, septic, or massively bleeding patients were not candidates for this technique. The decision to attempt the laparoscopic approach was based on the experience of the consulting surgeon. There were 31 patients, including 14 females. Five patients had undergone prior surgery. Twenty-nine patients had inflammatory bowel disease, one had familial polyposis, and one had a cavernous hemangioma. We included all pediatric/adolescent patients in our practice undergoing laparoscopic resection. Twenty-nine patients had 33 laparoscopic operations, including proctocolectomy with ileal pouch-anal anastomosis (n = 14), proctocolectomy with ileostomy (n = 3), ileocolectomy with ileocolic anastomosis (n = 13), and small-bowel obstruction (n = 1). Average operating time was 158 (range, 30-400) minutes, with average blood loss of 159 ml. Average wound length was 4.9 cm. The complication rate was 16 percent (n = 5), with one anastomotic leak. The rate of conversion to open operations was 5.8 percent. Liquid diet was begun on Day 3, and the average length of stay was 5.9 days. Major laparoscopic bowel surgery can be performed safely in the pediatric/adolescent population, with reasonable operative times, low conversion to open operations, and low morbidity.

Laparoscopic-assisted bowel resection offers advantages over open surgery for treatment of segmental Crohn’s disease in children

Background/purpose Minimally invasive approaches have been shown to decrease hospital length of stay (LOS), decrease postoperative pain, and speed return to normal activity for a number of intraabdominal procedures. In this study, laparoscopic (LAP)-assisted bowel resection is compared with an open technique for patients undergoing an initial bowel resection. Methods A retrospective review was conducted of 28 patients (12 LAP, 16 open) undergoing initial bowel resection for segmental Crohn’s disease. Results Patients in the LAP group had decrease LOS (5.5 days v 11.5 days) decreased days of parenteral narcotics (3 days v 5 days) and more rapid return to regular diet (3 days v 5 days). Conclusions The data suggest that the laparoscopic approach may offer advantages to pediatric patients undergoing an initial bowel resection for segmental Crohn’s disease.

The influence of adhesion prophylactic substances and taurolidine/heparin on local recurrence and intraperitoneal tumor growth after laparoscopic-assisted bowel resection of colon carcinoma in a rat model.

The goal of the study was to investigate the influence of adhesion prophylactic substances (Interceed/lntergel) as well as taurolidine/heparin on intraperitoneal tumor growth and the local recurrence rate after laparoscopic cecum resection in a rat tumor model. Sixty BDIX rats were randomized in three therapy groups and one control group. A laparoscopic-assisted cecum resection was performed via three-trocar method after intraperitoneal tumor cell application (10,000 cells) of a colon carcinoma cell line (DHD/K1/TRb) in all animals. According to the randomization, the cecum suture and a 1 x 1-cm peritoneal defect were either covered with Intergel/Interceed or 1 ml of 0.5% taurolidine 10 IU heparin. The control group underwent instillation of 1 ml 0.9% NaCl solution. After 4 weeks the animals were euthanized and intraperitoneal tumor growth, local recurrence rate, and the number of intraperitoneal adhesions were determined. The local recurrence rate was not significantly affected by any of the substances. Nevertheless, taurolidine/heparin significantly reduced the total number and weight of intraperitoneal metastases. The formation of adhesions was not significantly influenced by adhesion prophylaxis substances or by taurolidine/heparin. Taurolidine/heparin led to a significant reduction of intraperitoneal tumor growth after intraperitoneal application, whereas local tumor recurrence was not significantly influenced. This might be due to the number of injected tumor cells in this cell suspension model. Interceed and Intergel did not reduce intraperitoneal tumor growth. Furthermore, adhesion formation was not reduced by any of the substances.

Time course of differences in lymphocyte proliferation rates after laparotomy vs CO2 insufflation

Our laboratory has previously demonstrated that cell-mediated immune function is significantly more suppressed after both laparotomy and laparoscopic-assisted bowel resection than after peritoneal insufflation or open bowel resection, as assessed by delayed-type hypersensitivity (DTH) response. The purpose of this study was to further evaluate cell-mediated immunity by examining lymphocyte proliferation rates after laparotomy vs CO(2) insufflation. Female Balb/C mice (n = 75) were randomly divided into the following three groups: (a) anesthesia control (A/C), (b) CO(2) insufflation (INS), and (c) sham laparotomy (OPEN). The A/C group mice underwent no procedure. The INS group underwent insufflation with CO(2) gas at 4-6 mmHg for 20 min. The OPEN group underwent a midline incision from xiphoid to pubic symphysis, which was clipped closed after 20 min. Splenocytes were obtained via splenic harvest and lymphocyte isolation on postoperative days (POD) 1, 2, 3, 4, and 8. Lymphocyte proliferation was determined by a nonradioactive colorimetric MTS/PMS assay 72 h after concanavalin A stimulation. The laparotomy group's lymphocyte proliferation rates were significantly lower than both the control and the insufflation groups on POD 2, POD 3, and POD 4. On POD 1 and POD 8, there were no significant differences in lymphocyte proliferation among the three groups. No differences were found between the control and insufflation groups at any point. After stimulation, lymphocytes proliferate at a lower rate after laparotomy than after CO(2) insufflation. Significant differences in lymphocyte proliferation rates between groups persist at least through POD 4. By POD 8, the mean lymphocyte proliferation rate in the laparotomy group was back to the baseline level. Our results suggest greater immunosuppression after sham laparotomy than after CO(2) insufflation.

Colon adenocarcinoma and B-16 melanoma grow larger following laparotomy vs. pneumoperitoneum in a murine model.

Mouse mammary carcinoma tumors are established more easily and grow larger after sham laparotomy and open bowel resection than after CO2 pneumoperitoneum and laparoscopic-assisted bowel resection. The purpose of this study was to determine whether similar differences in tumor growth would be found when sham laparotomy and pneumoperitoneum were compared for the colon-26 mouse adenocarcinoma and B-16 mouse melanoma tumor lines. In all three studies, a high-dose injection of tumor cells was used, which resulted in tumors in almost all control mice. In Study 1, female BALB/C mice (n = 127) were injected intradermally in the dorsal skin with 10(6) colon-26 cells in a 0.1-ml volume before interventions. In Study 2, female C57 BL/6 mice (n = 140) were inoculated similarly with 10(6) B-16 melanoma cells. Study 2 consisted of three separate trials conducted on different days. Study 3 was performed because considerable differences in mean tumor size were observed in each of these trials. In Study 3, the B16 experiment was repeated with a larger n (n = 82) on a single day. In each study, after tumor cell injections, mice were randomly assigned to one of three groups: 1) anesthesia control (no procedure); 2) full laparotomy (4-cm midline incision x 20 minutes, staple closure); or 3) CO2 pneumoperitoneum (4-6 mmHg X 20 minutes). Tumors were excised and weighed on postoperative day 12. In Studies 1 and 3, mean tumor sizes of the laparotomy groups were significantly larger than both the control group and pneumoperitoneum group lesions (P values by Student's t-test). In Study 2, laparotomy group tumors, although significantly larger than control group lesions, were not significantly larger than pneumoperitoneum group tumors. For all three studies, there was no significant difference between mean tumor sizes of the pneumoperitoneum and control groups. Both colon-26 adenocarcinoma and B-16 melanoma tumors grow larger after laparotomy than after pneumoperitoneum in a murine model. The mechanism of these postoperative tumor growth differences remains to be elucidated.

Incisional hernias after advanced laparoscopic surgery

A retrospective case review was performed to determine the risk factors and frequency of incisional hernias after advanced operative laparoscopy. Ten incisional hernias occurred in nine women over 13 years, a frequency of about 0.1%. Omentum herniated in six women and bowel herniated in four. In one patient the bowel fat herniated through the peritoneum and not the fascia. The hernia occurred through a 5-mm cannula incision site in six patients. Since they all occurred on the left lower entry point, they were most likely related to the extensive manipulation of the suction-irrigation probe inserted through this cannula. Seven women required laparoscopic surgery to retract the entrapped omentum or bowel. In one, laparoscopic-assisted bowel resection was necessary. The underlying fascia and peritoneum should be closed not only when using cannulas of 10 mm and larger, but also when extensive manipulation is performed through a 5-mm cannula port.