Laparoscopic Bowel Surgery Research Articles

The Impact of Nociception Monitor-Guided Multimodal General Anesthesia on Postoperative Outcomes in Patients Undergoing Laparoscopic Bowel Surgery: A Randomized Controlled Trial.

Excess surgical stress responses, caused by heightened nociception, can lead to elevated levels of postoperative inflammation, resulting in an increased incidence of complications after surgery. We hypothesized that utilizing nociception monitor-guided multimodal general anesthesia would exert effects on postoperative outcomes (e.g., serum concentrations of C-reactive protein (CRP) after surgery, postoperative complications). This single-center, double-blinded, randomized trial enrolled ASA class I/II adult patients with normal preoperative CRP levels, scheduled for laparoscopic bowel surgery. Patients were randomized to receive either standard care (control group) or nociception monitor-guided multimodal general anesthesia using the nociceptive response (NR) index (NR group), where NR index was kept below 0.85 as possible. The co-primary endpoint was serum concentrations of CRP after surgery or rates of 30-day postoperative complications (defined as Clavien-Dindo grades ≥ II). One hundred and four patients (control group, n = 52; NR group, n = 52) were enrolled for analysis. The serum CRP level on postoperative day (POD) 1 was significantly lower in the NR group (2.70 mg·dL-1 [95% confidence interval (CI), 2.19-3.20]) than in the control group (3.66 mg·dL-1 [95% CI, 2.98-4.34], p = 0.024). The postoperative complication rate was also significantly lower in the NR group (11.5% [95% CI, 5.4-23.0]) than in the control group (38.5% [95% CI, 26.5-52.0], p = 0.002). Nociception monitor-guided multimodal general anesthesia, which suppressed intraoperative nociception, mitigated serum concentrations of CRP level, and decreased postoperative complications after laparoscopic bowel surgery.

FTP6.8 Impact of frailty on patients undergoing emergency surgeries under general anaesthesia in a district general hospital

Abstract Aims To assess the impact of frailty on the outcome of elderly patients underwent emergency surgical procedures in a district general hospital. Methods All patients above 65 years who underwent moderate/ major risk emergency surgical procedures from 1st of January 2022 to 31st of Dec 2022 were included in retrospective study. Data was collected from on call hand over and hospital electronic patients record system. Their ASA (American society of anaesthesiologist physical status classification) and P-POSSUM (Portsmouth- Physiological and operative severity score for the enumeration of mortality and morbidity) was calculated. Results Eighty-five patients (males:47, females:38) underwent emergency procedures in one year period. Age range was 65 to 90 years with mean age was 80.6 years. We performed 57 laparotomies, seven had laparoscopic bowel surgery. Other procedures were incarcerated hernias repair, appendectomies, lap/ open cholecystectomy/ cholecystostomy, debridement of necrotising fasciitis. Twenty-eight patients were frail (CFS 5-7) with mean ASA 3.4 and mean P-POSSUM mortality was 14.89. Fifty-seven patients were non frail with mean ASA 2.59 and P-POSSUM mortality was 16.12. Length of hospital stay was from 1 to 106 days, average being 13.7 days. Average length of stay for frail patients was 15.8 days and for non-frail was 12.9 days. Twelve patients died within 30 days of surgery or during the same admission, among them 54% were frail. Seventy five percent of mortalities were after bowel surgeries, mainly after stoma formation (both open and laparoscopic approach). Conclusions Clinical frailty scale is one of the predictors of prognosis along with other parameters and must be calculated at the time of admission.

Laparoscopy in high-risk emergency general surgery reduces intensive care stay, length of stay and mortality.

Emergency general surgery patients undergoing laparoscopic surgery are at reduced risk of mortality and may require reduced length of critical care stay. This study investigated the effect of laparoscopy on high-risk patients' post-operative care requirements. Data were retrieved for all patients entered into the NELA database between 2013 and 2018. Only high-risk surgical patients (P-POSSUM predicted mortality risk of ≥ 5%) were included. Patients undergoing laparoscopic and open emergency general surgical procedures were compared using a propensity score weighting approach. Outcome measures included total length of critical care (level 3) stay, overall length of stay and inpatient mortality. A total of 66,517 high-risk patients received emergency major abdominal surgery. A laparoscopic procedure was attempted in 6998 (10.5%); of these, the procedure was competed laparoscopically in 3492 (49.9%) and converted to open in 3506 (50.1%). Following inverse probability treatment weighting adjustment for patient disease and treatment characteristics, high-risk patients undergoing laparoscopic surgery had a shorter median ICU stay (1day vs 2days p < 0.001), overall hospital length of stay (11days vs 14days p < 0.001) and a lower inpatient mortality (16.0% vs 18.8%, p < 0.001). They were also less likely to have a prolonged ICU stay with an OR of 0.78 (95% CI 0.74-0.83, p < 0.001). The results of this study suggest that in patients at high risk of post-operative mortality, laparoscopic emergency bowel surgery leads to a reduced length of critical care stay, overall length of stay and inpatient mortality compared to traditional laparotomy.

Implementation of the repeated, laparoscopic-vision-controlled "transversus-abdominis-plane" block (L-TAP) using bupivacaine in laparoscopic bowel resections – A prospective observational study

Objectives: The aim of the study was to monitor the implementation of a new ERAS-standard of pain management for elective laparoscopic bowel surgery. For this purpose, the prior standard of a single L-TAP block was optimized to reduce pain and morphine consumption postoperatively.

Effects of an open lung ventilatory strategy on lung gas exchange during laparoscopic surgery.

In general anaesthesia, early collapse of poorly ventilated lung segments with low alveolar ventilation-perfusion ratios occurs and may lead to postoperative pulmonary complications after abdominal surgery. An 'open lung' ventilation strategy involves lung recruitment followed by 'individualised' positive end-expiratory pressure titrated to maintain recruitment of low alveolar ventilation-perfusion ratio lung segments. There are limited data in laparoscopic surgery on the effects of this on pulmonary gas exchange. Forty laparoscopic bowel surgery patients were randomly assigned to standard ventilation or an 'open lung' ventilation intervention, with end-tidal target sevoflurane of 1% supplemented by propofol infusion. After peritoneal insufflation, stepped lung recruitment was performed in the intervention group followed by maintenance positive end-expiratory pressure of 12-15 cmH2O adjusted to maintain dynamic lung compliance at post-recruitment levels. Baseline gas and blood samples were taken and repeated after a minimum of 30 minutes for oxygen and carbon dioxide and for sevoflurane partial pressures using headspace equilibration. The sevoflurane arterial/alveolar partial pressure ratio and alveolar deadspace fraction were unchanged from baseline and remained similar between groups (mean (standard deviation) control group = 0.754 (0.086) versus intervention group = 0.785 (0.099), P = 0.319), while the arterial oxygen partial pressure/fractional inspired oxygen concentration ratio was significantly higher in the intervention group at the second timepoint (control group median (interquartile range) 288 (234-372) versus 376 (297-470) mmHg in the intervention group, P = 0.011). There was no difference between groups in the sevoflurane consumption rate. The efficiency of sevoflurane uptake is not improved by open lung ventilation in laparoscopy, despite improved arterial oxygenation associated with effective and sustained recruitment of low alveolar ventilation-perfusion ratio lung segments.

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

Dexamethasone on postoperative gastrointestinal motility: A placebo-controlled, double-blinded, randomized controlled trial.

Following abdominal surgery, patients usually experience a transient episode of impaired gastrointestinal motility. This study aimed to determine whether a single preoperative dose of dexamethasone can promote the recovery of gastrointestinal function in patients following elective gastrointestinal surgery. In this single-center, two-arm, parallel, randomized controlled trial, we studied 126 patients (aged 18-80years) who underwent elective open or laparoscopic bowel surgery for malignant or benign pathology. At the induction of anesthesia, a treatment group (n=64) received a single dose of 8-mg intravenous dexamethasone, and a control group (n=62) received normal saline. Intravenous administration of 8-mg dexamethasone significantly decreased the time to return of flatus by an average of approximately 8h (P<0.05). Abdominal distension was significantly reduced on the third day after surgery in the dexamethasone group (P<0.05), and the time to tolerance of a liquid diet was shorter in the dexamethasone group (P<0.01). There were no significant differences in other secondary outcomes, including postoperative pain, complication rates, length of hospital stay, or time to first defecation, between the two groups. A single intravenous dose of 8-mg dexamethasone at induction of anesthesia significantly decreases the time to return of flatus, improves abdominal distension at 72h, and promotes tolerance of a liquid diet. Although further studies are required to confirm our results, we recommend that dexamethasone should be used more widely in gastrointestinal surgery.

Identifying Preoperative Factors Associated with Nonresponders in Women Undergoing Comprehensive Surgical Treatment for Endometriosis

Study ObjectiveTo examine whether existing quality of health outcome measures can be used to predict or have an association with nonresponse surgery for endometriosis. DesignRetrospective cohort study. SettingsSingle endometriosis referral center. PatientsWomen (n = 198) undergoing surgery for endometriosis. InterventionsValidated health questionnaires and visual analogue scales. Measurements and Main ResultsPatients were given validated health questionnaires, including Endometriosis Health Profile 30, Gastrointestinal Quality of Life Index, EuroQol-5, Hospital Anxiety and Depression Scale, preoperatively and at 12 months after full surgical excision of endometriosis. Visual analogue scales were also used that measured dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain. Surgical management was dependent on severity of disease. Superficial disease was treated by laparoscopic peritoneal excision or laser ablation. Deep infiltrating disease involving the bowel was excised completely together with laparoscopic bowel surgery (shave, disc, or segmental resection) with/without concomitant total hysterectomy and bilateral salpingo-oophorectomy. Nonresponders were defined as women who failed to demonstrate an improvement in pain scores 12 months postoperatively. We examined preoperative and postoperative questionnaires, visual analogue scores, and other variables such as age at onset of symptoms, type of surgery, and the presence of postoperative complications comparing responder and nonresponder women to identify the factors associated with nonresponse. Of 102 women treated for superficial endometriosis, 25 (24.51%) were nonresponders. No factors were associated with nonresponse at 12 months. Of 96 women treated for severe endometriosis involving the bowel, 10 (10.41%) were nonresponders. Nonresponders had significantly less preoperative pain (p = .031) and feeling of control (p = .015) than responders. There was no association between nonresponders and women who underwent a hysterectomy with bilateral salpingo-oophorectomy or those with complications. Radical bowel surgery (resection) was associated with nonresponders. ConclusionMinimal preoperative factors are associated with nonresponse for women having surgery for endometriosis. The severity of pain experienced by women with endometriosis may be used to predict their response to surgery.

Gum chewing aids bowel function return and analgesic requirements after bowel surgery: a randomized controlled trial.

The aim was to compare the effectiveness of chewing sugar-free gum after bowel resection on bowel function and length of stay. This was a randomized controlled trial of patients undergoing elective open or laparoscopic bowel surgery, who were allocated into two groups: a chewing gum group (CG); or a nonchewing gum group (NG). Primary outcomes were time to discharge (length of hospital stay [LOS]), time to first flatus (TFF) and time to first bowel motion (TBM). Secondary outcomes were complication rates, pain and total morphine equivalent (TMEq) medication for 7days after the procedure. Between 2010 and 2013, 162 patients were randomized; four were excluded, leaving 158 in the study (82 in the CG and 76 in the NG). There was no difference in LOS between the CG (5.8days) and the NG (6.1days) (P=0.403) or in the median TFF between the CG (42.0h) and the NG (58.0h) (P=0.076). The median TBM was lower in the CG (40.0h) than in the NG (90.0h) (P=0.002). There was no difference in intra-operative complications between the CG (9%) and the NG (9%) (P=0.901) or in early postoperative complications (44% for CG and 55% for NG) (P=0.131). There was no difference in TMEq at 24h postprocedure, but the CG had reduced TMEq from days 2 to 7 post procedure and for the 7-day total. Pain was higher among patients in the NG on day 3. Chewing sugar-free gum resulted in an earlier return to bowel function and decreased analgesic requirements. There was no decrease in overall LOS or postoperative complications.

Laparoscopic Surgery for Colorectal Endometriosis and its Impact upon Fertility: An Updated Australian Series of 307 Cases

Introduction Colorectal involvement occurs in up to 12% of cases of endometriosis. Various surgical options for its management have been described, including segmental resection and disc excision, with debate surrounding indications for surgery and the impact of such procedures. The current study aimed to describe the experiences of three Australian gynaecologists regarding laparoscopic bowel surgery for colorectal endometriosis. Methods The records of three gynaecological surgeons were analysed for patients who underwent surgical removal of colorectal endometriosis by way of appendicectomy, bowel disc excision and/or segmental resection, between 1999 and 2012. Results A total of 307 patients were identified. Sixteen (5.2%) underwent appendicectomy, 146 (47.6%) underwent disc excision, 126 (41.0%) underwent segmental resection and 19 (6.2%) underwent simultaneous procedures. The majority of procedures were performed laparoscopically (265 of 307; 86.3%). Nineteen procedures (6.2%) were planned laparotomies due to the known extent of disease. Twenty-three procedures were converted from laparoscopy to laparotomy (conversion rate of 7.5%). Complications occurred in 35 of the 307 cases (11.4%). Sixty-seven women amongst the 122 wishing to conceive post-operatively achieved at least one pregnancy (pregnancy rate of 54.9%). Of the 84 pregnancies achieved amongst the 67 women who conceived, 49 (58.3%) were achieved through assisted reproductive technologies, and 31 pregnancies (36.9%) were conceived spontaneously. This information was unavailable for 4 pregnancies (4.8%). Conclusions The current series demonstrates that laparoscopic surgery for severe disease is feasible in specialised centres. Furthermore, such surgery may have a positive impact upon post-operative fertility.

Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial)

Objectives To determine whether preoperative dexamethasone reduces postoperative vomiting in patients undergoing elective bowel surgery and whether it is associated with other measurable benefits during recovery from surgery, including quicker...

Lidocaine versus ropivacaine for postoperative continuous paravertebral nerve blocks in patients undergoing laparoscopic bowel surgery: a randomized, controlled, double-blinded, pilot study.

Background and objectivesLidocaine could provide many advantages in continuous regional anesthesia techniques, including faster onset, greater titratability, and lower cost than long-acting local anesthetics. This prospective, randomized, double-blinded, pilot study is therefore intended to compare lidocaine to ropivacaine in bilateral continuous paravertebral blocks using a multimodal approach for postoperative pain management following laparoscopic bowel surgery.MethodsThirty-five ASA I–III consecutive patients undergoing elective laparoscopic bowel surgery and bilateral thoracic paravertebral continuous blocks were analyzed: bilateral thoracic paravertebral infusions of ropivacaine 0.2% (Group Ropi, n=18) or lidocaine 0.25% (Group Lido, n=17) were started at 7 mL/h in the postanesthesia care unit. For each patient, we collected numerical rating scores (NRS) for pain at rest and during movement at baseline, at postanesthesia care unit discharge, at 24 hours and 48 hours after the end of surgery, as well as hydromorphone patient-controlled analgesia requirements, local anesthetic consumption, side effects, postoperative complications, and functional outcomes.ResultsNo effect of group distribution on NRS scores for pain at rest or at movement (P=0.823 and P=0.146), nor on hydromorphone (P=0.635) or local anesthetic consumption (P=0.063) was demonstrated at any analyzed time point. Hospital length of stay and spontaneous ambulation were comparable between groups (P=0.636 and P=0.148). In the context of a multimodal approach, the two drugs showed comparable safety profiles.DiscussionLidocaine 0.25% and ropivacaine 0.2% provided similar analgesic profiles after elective abdominal surgeries, without any difference in terms of functional outcomes. The easier titratability of lidocaine together with its lower cost induced our clinical practice to definitely switch from ropivacaine to lidocaine for postoperative bilateral paravertebral continuous infusions.

PD21-08 ADVANTAGES AND TECHNICAL CHALLENGES OF LIGHTED URETERAL STENTS DURING LAPAROSCOPIC BOWEL SURGERY.

You have accessJournal of UrologyTechnology & Instruments: Laparoscopy and Robotics: Benign Disease1 Apr 2015PD21-08 ADVANTAGES AND TECHNICAL CHALLENGES OF LIGHTED URETERAL STENTS DURING LAPAROSCOPIC BOWEL SURGERY. Danny Huynh, Lucas Hockman, Jerry Trulson, and Mark Wakefield Danny HuynhDanny Huynh More articles by this author , Lucas HockmanLucas Hockman More articles by this author , Jerry TrulsonJerry Trulson More articles by this author , and Mark WakefieldMark Wakefield More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1437AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES With the increased use of laparoscopic colorectal surgery over the past 2 decades, iatrogenic ureteral injuries have become an increasing concern. Ureteral stent placement prior to laparoscopic surgery has assisted in the identification of the ureters but has not significantly decreased the number of ureteral injuries. Infrared-lighted ureteral stents (LUS) have been developed to improve ureteral identification but it is unclear whether this has translated to decreased ureteral injuries. We investigated the use of these LUS at our institution over a two-year period. METHODS A retrospective review was performed of all laparoscopic bowel resections done with the aid of LUS at the University of Missouri-Columbia from May 2006 to July 2008. Twenty patients were identified with a total of 29 LUS placement attempts. Each case was evaluated for success of ureteral identification and safety of LUS placement. In all cases the Stryker InfraVision Ureteral Kit was used. LUS were placed by one of four attending urologists. All LUS were removed prior to patient awakening. RESULTS The 20 identified surgeries included 7 low anterior resections, 5 colostomy reversals, 4 sigmoidectomies, 3 Hartman's procedures and 1 completion proctatectomy. Of the 29 placement attempts (unilateral or bilateral), 25 were successful. All illuminated and allowed for identification of the ureter except one, which was identified via palpation. No ureteral injuries were sustained during laparoscopic dissection. Of the four placement failures, 2 were secondary to ureteral narrowing requiring 5 fr catheters, one ureteral flap was created requiring ureteroscopy for indwelling stent placement and one ureteral perforated was encountered requiring indwelling stent placement. The overall complication rate was 13.8% (4/29) and ureteral injury rate was 6.9% (2/29). CONCLUSIONS Once placed, LUS do allow for identification of the ureter during laparoscopic bowel resection. However, due to technical difficulties with the stents themselves, complications were encountered during placement. The ureteral injury rate with the LUS was 6.9% which is higher than that reported for colorectal surgery alone (0.2-4.5%). Technical challenges with LUS placement limit its utility in laparoscopic bowel surgery and may lead to unnecessary risk. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e474 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Danny Huynh More articles by this author Lucas Hockman More articles by this author Jerry Trulson More articles by this author Mark Wakefield More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic Bowel Surgery for the Benign Gynecologist

Laparoscopic Bowel Surgery for the Benign Gynecologist

Crucial Controversies in Surgery

Crucial Controversies in Surgery

Short-term outcome following elective laparoscopic colorectal cancer resection in octogenarians and nonagenarians

The 30-day outcome after laparoscopic resection for cancer in patients over the age of 80 years was studied. An electronic database was used to identify patients over 80 years who underwent laparoscopic bowel resection between December 2000 and October 2009 at three UK laparoscopic colorectal training units. Patients who required abdominoperineal excision of the rectum were excluded. In all, 173 patients (80 men) of median age 84 (80-93) years were identified. American Society of Anesthesiologists (ASA) grades were ASA 1, 14; ASA 2, 87; ASA 3, 68; and ASA 4, 4. Median body mass index was 26 (14-45) kg/m(2). Thirteen (7.5%) patients were converted to open surgery. The major causes for conversion were bleeding and adhesions. Thirty-three major complications occurred in 21 (12%) patients. Ten (5.8%) required readmission after discharge for complications giving a total of 17.8% of patients with complications. The median hospital stay was 5 (1-37) days. Three (1.7%) patients died within 30 days of surgery. This study confirms that laparoscopic large bowel resection is safe and beneficial in a population over 80 years. It has low morbidity and mortality and a shortened hospital stay. Octogenarians should not be denied major laparoscopic bowel surgery based on age alone.

Laparoscopic treatment for IBD

Introduction: With the development of the technique of laparoscopic surgery laparoscopic bowel surgery gains wider acceptance. Patients suffering from IBD are usually young and potentially need more than one surgery during their life. Thus the use of minimally invasive surgery is justified.

The opinion and experience of surgeons with laparoscopic bowel grasper haptics

Background: In order to develop new and better laparoscopic bowel instruments, which reduces patient risks, the opinions and experience that surgeons have with current laparoscopic bowel grasper haptics is important. In this study we explored this by means of a questionnaire. Method: A total of 386 online- questionnaires, were sent to laparoscopic surgeons working in European hospitals. They were all members of the European Association of Endoscopic Surgery and perform laparoscopic obesities or bowel surgery. Surgeons where divided into different age and experience groups. Results: A total of 174 completely filled out forms were analyzed. In total, 16% of the surgeons cannot prevent damage when they pinch too hard, although they (10%) might have seen or felt it. Seven percent of the respondents were not able to see or feel tissue slippage. Whereas 31% can see or feel slippage they cannot do anything to prevent it. Overall, most of the respondents would appreciate technical changes in the laparoscopic bowel graspers to reduce tissue damage. Of all the respondents, 79% maintain that it is necessary to have a new laparoscopic grasper with augmented feedback. The majority of the respondents (77%) would like to have tactile feedback as an indication of the level of pinch force. There are not many differences in the opinions of surgeons at different skill levels. Conclusion: From the results of the questionnaire and the other comments made by respondents it is evident that research and developments in the field of new laparoscopic graspers should continue.

Significance of the localization of small tumors at laparoscopic large bowel resections

Introduction: The premalignant and malignant diseases of the colon could be identified earlier owing to the colonoscopic screening. Although large part of these small lesions could be removed by the new intraluminal techniques (endoscopic submucosal dissection), the other tumors needs minimal invasive surgical (laparoscopic large bowel resection) procedure. To find these small, T1-T2 tumors during the operation is usually very difficult, or impossible owing to the nature of the laparoscopic technique. The correct anatomical localization with the preoperative colonoscopy is false in about 15–20% of the cases, and the intraoperative colonoscopy is not considered to be an ideal solution for various reasons. Patients and method: 158 laparoscopic large bowel resections were performed because of malignant and benignant lesions of the colon between 1 Jan. 2005 and 31 Dec. 2008. The average age of the patients was 68,3 years. The size of the tumors was less than 3cm at 56 cases, and the histology detected lesions which not reached the serosa at 45 patients. Results: At 29/158 (18,4%) cases pre- or intraoperativ techniques had to be used for the localization. Preoperative endoscopic clip placement has been used at 5 cases. Intraoperative colonoscopy was performed at 4 cases owing to the difficulties of intraoperative localization, rectoscopy at 3 cases and rectal digital examination at 15 cases. Re-resection had to be made because of the missed blind resection at 2 cases. The average operation time of these small lesions was not shorter significantly to the large (T3-T4) tumors (168min. vs. 145min.). Conclusions: There is increasing claim for the preoperative (if it is possible at the time of the detection of the lesion) marking with the development of the laparoscopic large bowel surgery. The definition of the exact criteria's (when, where, how) needs consensus between gastroenterologists and surgeons. The present endoscopic tattooing did not live up to expectations, therefore development of such new inks is necessary, which could be detected easily during laparoscopic procedures.

Laparoscopy in Crohn's Disease

Crohn's disease represents a challenging operative dilemma. The nature of the disease increases the technical complexity of operations, their morbidity, and the likelihood of multiple operations. In this setting, the advantages of laparoscopic surgery, including shorter hospital stays, less adhesion formation, fewer wound complications, and faster recovery of bowel function, are particularly beneficial to the patient. Patients with Crohn's disease requiring operations in the elective and semi-elective setting can all be approached initially laparoscopically. The surgeon's skill set should include extensive experience in advanced laparoscopic bowel surgery as well as open management of Crohn's disease and its complications. Strict adherence to the basic tenet of bowel preservation is imperative. The operations most commonly performed for Crohn's disease include diagnostic laparoscopy, stricturoplasty, small bowel resection, ileocolic resection, colectomy, repair of fistulae, and gastrojejunostomy for bypass of gastric or duodenal disease. Postoperative management includes resumption of steroids, typically without the need for "stress-dosing," bowel rest for a short period, and pain control, which is also less than that experienced with a laparotomy.