Laparoscopy: Historic, Present and Emerging TrendsPresentation Transcript
Laparoscopy: Historic, Present and Emerging Trends
Dr. George S Ferzli MD FACS
Professor of Surgery - State University of New York (Downstate)
Chairman of Surgery - Lutheran Medical Center, New York, USA
History of Laparoscopy
A three bladed speculum was found in the ruins
*A roman town buried by a volcano eruption
near modern Naples, Italy - 79 AD).
The first description dates to Hippocrates in Greece, for use of a speculum to visualize the rectum (460–375 BC).
History of Laparoscopy
1806: Philip Bozzini developed an instrument called a Lichtleiter (light-guiding instrument)
1853: Antoine Jean Desormeaux used Bozzini ’ s Lichtleiter
1867: Desormeaux used an open tube to examine the genitourinary tract
History of Laparoscopy
Maximilian Nitze (1848 – 1906)
invented the first cystoscope ( Nitze-Leiter cystoscope) using an electrically heated platinum wire for illumination .
In 1887, he modified Edison`s light bulb and created the first electrical light bulb for use during urological procedures.
Original carbon-filament bulb- Thomas Edison
History of Laparoscopy
1901: George Kelling, Dresden, Saxony (Germany) performed the 1st experimental laparoscopy, calling it ‘Celioscopy’.
Kelling insufflated the abdomen of a dog with filtered air and used a Nitze cystoscope to look inside.
Hans Christian Jacobaeus (1879 – 1937)
1910: Swedish internist; first thoracoscopic diagnosis with a cystoscope in a human subject.
Treatment of a patient with tubercular intra-thoracic adhesions.
The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Münchner Medizinischen Wochenschrift, 1911
1911 : First laparoscopy at Johns Hopkins
12mm proctoscope into epigastric incision on one of Halstead’s patients to stage pancreatic cancer
Bernheim called his procedure ‘organoscopy’
Findings confirmed on laparotomy
History of Laparoscopy
1920: Zollikofer discovered the benefit of CO 2 gas for insufflation
1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum.
After World War II, the development of fiberoptics represented an important step forward for endoscopy
1966: Hopkins rod lens scope & cold light
1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.
Kurt Semm (1927-2003)
Once, while making a slide presentation on ovarian cysts; suddenly the projector was unplugged - with the explanation that “such unethical surgery should not be presented”
In 1970, after becoming the chairman of Ob/Gyn at the University of Kiel, his co-workers demanded that he undergo a brain scan because, they said, “only a person with brain damage would perform laparoscopic surgery”
German Engineer and Gynecologist. Introduced automatic insufflator, thermocoagulation ,loop knots, irrigation device in 1983, performed endoscopic appendectomy as part of A gynecologic procedure.
History of Laparoscopy
1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany) performed the first successful laparoscopic cholecystectomy in a human. However, this was not well publicized until years later. The German Surgical Society rejected Mühe in 1986 after he reported that he had performed the first laparoscopic cholecystectomy.
Laparoscopy Takes Off
1988: 1st Lap cholecystectomy in the USA, Surgiport 1st available
1989: US TV picks up on “Key Hole” surgery EndoClip™ released
1990: Cuschieri (Aberdeen) warns on the explosion of endoscopy
1991: ‘Lap Chole’ is accepted and routine procedure
1992: The National Institutes of Health Consensus Conference concludes that laparoscopic cholecystectomy is now the preferred alternative to open cholecystectomy
1938 - Janos Veress , of Hungary, developed the spring-loaded needle. to perform therapeutic pneumothorax (TB).
Made of surgical stainless steel with a single trap valve. 2mm diameter x 80mm length
It consists of an outer cannula with a beveled needle point for cutting through tissues.
Controlled pressure insufflation of the peritoneal cavity is used to achieve the necessary work space for laparoscopic surgery.
Automatic insufflators allow the surgeon to preset the insufflating pressure, and the device supplies gas until the required intra-abdominal pressure is reached.
The trocar has a blade with a shaft and body.
The body includes a pointed tip which makes the initial incision in the abdominal wall of the patient.
(Trocar diameters range from 2mm-30 mm)
There are three important structural differences in telescope available
1. 6 to 18 rod lens system telescopes are available
2. 0 to 120 degree telescopes are available
3. 1.5 mm to 15 mm of telescopes are available
These cables are made up of a bundle of optical fibers glass thread swaged at both ends.
The fiber size used is usually between 10 to 25 mm in diameter.
They have a very high quality of optical transmission, but are fragile.
Dissecting & Grasping Forceps
Atraumatic, with hollow jaws
MANGESHIKAR Grasping Forceps, serrated
Reusable three-piece design
Available in 2 mm, 3 mm, 3.5mm, 5 mm and 10 mm sizes, with lengths of 20 cm, 30 cm, 36 cm and 43 cm.
Choice of handle styles.
Fully rotating 360° sheath.
No hidden spaces that can trap operative blood and tissue debris.
HOOK SCISSORS, single action jaws
METZENBAUM SCISSORS, curved, length of blades 12-17 mm, widely used as an instrument for mechanical dissection in laparoscopic surgery.
STRAIGHT SCISSOR can give controlled depth of cutting because it has only one moving jaw.
TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x
Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.
tro-car - [Fr., troisis , three + carre, side] noun a sharp-pointed surgical instrument fitted with a cannula and used especially to insert the cannula into a body cavity cannula - [L., dim of canna, reed] noun a tube that is inserted into a cavity by means of a trocar filling it’s lumen
Avoid competing for the same space: Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect)
No obstacle between trocar entry and target To avoid iatrogenic injuries.
Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182
(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Anatomic distribution of nerves across anterior abdominal wall Iliohypogastric nerve Ilioinguinal nerve
(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Iliohypogastric n. Ilioinguinal n. Incision line/trocar sites vs. nerve distribution Epigastric a. Trocar site Pfannenstiel incision
Be aware of bladder location for suprapubic trocar
Avoid areas of prior surgery
Trocar distance from the target organ depends upon the size of the patient. Individual trocars can be moved closer to the target along an axis line. Additional trocars can be added along the semicircular line.
Gold Standard Laparoscopic Procedures Today
Laparoscopic RYGB for obesity
* 600,000 cholecystectomies annually in the U.S., 8%-20% have CBD stones, no consensus on optimal management. ** “No single clinical indicator is completely accurate in predicting CBD stones prior to cholecystectomy.” * Liu, TH et al. Ann Surg 234(1), July, 2001. **Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996
Liu TH et al: Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy. Ann Surg 234: 33-40, 2001
Laparoscopic US as a good alternative to intraoperative cholangiography (IOC) during laparoscopic cholecystectomy: results of prospective study.
685 IOC (35 cannot canulate cystic duct)
269 LUS (2 steatosis)
IOC detected 4.5% common bile duct stones; LUS 6%
IOC sensitivity 96.9%, specificity 99.2%
LUS sensitivity 100%, specificity 99.6%
In this prospective study, LUS has been certainly as effective as IOC as
a primary imaging technique for bile duct. It permitted to detect CBDS
with a high specificity and sensitivity , and was not followed by an
increase in CBDI.
Hublet A et al Laparoscopic US as a good alternative to intraoperative cholangiography during lap chole: results of prospective study Acta Chir Belg . 2009 May-Jun Belgique.
Indocyanine Green (ICG) Injection:
Shows the confluence between right and left hepatic
ducts during hepatectomy.
Enables identification of the cystic duct and CBD
before dissection of Calot’s triangle during
Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009; 208(1):e1-e4
Indocyanine Green Injection (ICG) Advantages
No need for dissection of Calot’s triangle
No need for insertion of trans-cystic tube
No exposure to radiation
No space-occupying C-arm machine required
Simple and convenient procedure
Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;208(1): e1-e4
Combined Laparoscopy and ERCP: Single Step – Treatment
45 pts underwent lap chole with intra-op cholangiogram
33 pts had succesful intra-op ERCP with extraction of common bile duct stones
No post-op complications related to procedure (i.e. pancreatitis, bleeding, perforation)
Mean hospital stay: 2.55+0.89 days
No pts with signs or symptoms of retained CBD stones during mean post-op follow-up of 9+4.07 months
Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7(4):338-46
National Hospital Discharge Survey database 1979 to 2001:
Frequency of ERCP vs CBDE
Beginning of study: 47,000 CBDE’s per year
End of study: 7,000 CBDE vs 43,000 ERCP
Complication rates from CBDE
3.4% at beginning of study
17.4% at end of study
“ ERCP has replaced the need for most but not all CBDE”
“ Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CBDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CBDE experience”
Livingston EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433
Public Health Problem #1: Laparoscopy in Bariatric Surgery OBESITY
Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults
Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults
County-level Estimates of Obesity among Adults aged ≥ 20 years: United States
Trocars - placed high, close to
the costal margin.
Trocar A - liver retraction.
Trocar D - can be enlarged to
allow for placement of a port.
Trocar C - placed left of the
midline for correct view of
Angle of His.
LAP-BAND C D E B A
Multicenter, prospective, risk-adjusted data show that laparoscopic gastric bypass is safer than open gastric bypass, with respect to 30-day complication rate.
LRYGB has become the standard of care
Hutter et al. Ann Surg. May 2006
Massachusetts General Hospital, Boston .
National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health Statistics, 1979-1996.
Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140: 1198-202.
Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8.
Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12.
Popularity of Surgical Management Period or Decades Incidence of Surgery Reason for Change Late 1970’s Early 1980’s 25,000 procedures per year
Late 1980’s 1990’s 5,000 procedures per year
2000’s 80,000 to 110,000 procedures per year
Centers of Excellence
The first case of laparoscopic adrenalectomy was reported by Gagner in 1992.
Less blood loss
Less operative time!!
Less hospital stay
Less post operative pain
Tiberio et al.
Surg Endosc. Jun 2008
ACTH: adrenocorticotrophic hormone Indications for Adrenalectomy Unilateral adrenalectomy Bilateral adrenalectomy Hyperfunctioning tumors Aldosteronoma Cortisol-producing adenoma Virilizing tumors Pheochromocytoma Failed treatment of ACTH-dependent Cushing’s syndrome Nonfunctioning cortical adenoma a Cushing’s syndrome from primary adrenal hyperplasia Malignant tumors Adrenocortical carcinoma Malignant pheochromocytoma Adrenal metastasis (solitary without other metastatic disease) Bilateral pheochromocytoma symptomatic or enlarging adrenal myelolipomas, ganglioneuroma
a Relative contraindications Contraindications for Laparoscopic Adrenalectomy Local tumor invasiveness Regional lymph node involvement Large tumor size larger than 10 to 12 cm a Prior nephrectomy, splenectomy, or liver resection on the side of the adrenal lesion a
The Ebers Papyrus 1550 BC, Entitled “Beginning of the Secret of the Physician”
Heat application was one of the methods to reduce a strangulated hernia.
The mummy of Meren-Ptah (19th dynasty) shows a sign of an open wound resulting from surgical interference.
If thou examinst a swelling of the covering of his belly’s horns above his pudenda (sex organs) then thou shalt place thy finger on it and examine his belly and knock on the fingers (percuss) if thou examinst his that has come out and has arisen by his cough. Then thou shalt say concerning it: it is a swelling of the covering of his belly. It is a disease which I will treat”.
Hernia - Historic Perspective
Galen of Pergamum (AC 129-179) who was a surgeon to the gladiators practiced ligation of the sac and cord with amputation of the testicle.
Guy de Chauliac (AC 1300-1368) in his book Chirurgia Magna: laxatives, hang patient from his legs, bed rest for 50 days.
Totally Extraperitoneal (TEP) Additional trocar
INGUINAL HERNIA REPAIR
Inguinal Hernia Repair
What are indications for laparoscopic inguinal hernia repair?
Avoids scar tissue
Visualizes occult hernia
Earlier return to work
No difference in recurrence or complication
Obese / Athletic patients
Reduced infection in susceptible population
Patients with contralateral injury to vas deferens
Less chance to injure other vas
Are there contraindications to lap. inguinal hernia repair?
Patients for whom general anesthesia and pneumoperitoneum are risks (cardiac, pulmonary disease)
Prior pre-peritoneal surgery (prostate, hernia, vascular, kidney transplant)
Giant scrotal hernia
Anticipated bleeding (patients on anti-coagulation)
Management of recurrent inguinal hernias
Kamal MF Itani MD 1 , Robert Fitzgibbon Jr MD 2 , Samir S Awad MD 3 , Quan-Yang Duh MD 4 , George S. Ferzli MD5
1 Boston VA Health Care System and Boston University, Boston MA
2 Creighton University, Omaha NE
3 Michael E DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX
4 San Francisco VA Medical Center and University of California San Francisco, San Francisco CA
5 SUNY Downstate Medical Center and Lutheran Medical Center, Brooklyn NY
Role of the Patient in Recurrence
HEAD Score :
Hernia of the Adult
Attempt to individualize treatment based on 8 factors.
Courtesy of Dr. Christian Peiper
2. Do we have an answer for groin pain after hernia repair?
Nerves prone to injury anterior and posterior
Groin Pain Incidence * Groin pain or discomfort lasting more than 3 months after groin hernia repair. Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain . 1986; 3 (suppl): 1–226. Author # of Pts Pain * Pain Severe Outcome of Pain A. S. Poobalan 2001 226 30% > 3 mo Morten Bay-Nielsen 2001 1166 28.7% > year 3% S. Kumar 2002 454 30% >21 mo C. A. Courtney 2002 4062 > 3 mo 3% > 2.5 yrs 71% have pain Severe in 22% Mild in 45% Marcello Picchio 2004 593 25% > 1 yr 6%>1 yr A. M. Grant 2004 928 9.7%>1 yr 1.8% > 5 yrs Jrg Kninger 2004 208 36% (Shouldice) 31% (Lichtenstein) 15% (TAPP) > 52 mo Ulf Fränneby 2006 2456 31% >24 to 36 mo Sergio Alfieri 2006 973 9.7% > 6 mo 2.1 %> 6 mo Mild 4.1% > 1yr Severe 0.5% > 1yr E. K. Aasvang 2006 210 34.3% >1year Less pain 75.8% Same pain 16.7% More severe 7.5% > 6.5 years
Quality of Life Author Pts Pain affects the quality of life Morten Bay-Nielsen 2001 1166 16.6% S Kumar 2002 454 18.1% Jrg Kninger 2004 208 14% (Shouldice) 13% (Lichtenstein) 2.4% (TAPP) Ulf Fränneby 2006 2456 6% EK Aasvang 2006 210 Nb 24.8% 6% after 6.5 years Sergio Alfieri 2006 973 11.3% to 14.2%
Causes and Risk Factors of Groin Pain Anatomical Variation Innervation symmetry - 40.6% Normal distribution - 20.3% “ Normal” anatomic pattern - 56.3% Mesh repair No clear correlation between use of mesh and chronic pain Age Studies disagree on correlation between older age and post-herniorrhaphy pain Pre-operative pain Pain associated with hernia before repair is associated with post-operative pain BMI No correlation found between elevated BMI and post-operative pain Post-operative complications Postoperative complications linked to an increased risk for long term pain Recurrent hernia Day case surgery Open versus laparoscopic Recurrence associated with recurrent pain The probability of developing chronic pain is 2.5 times higher in day-case patients, controlling for age Open repair strongly correlated with post-operative pain compared to laparoscopic repair
What are recommendations for prevention
of chronic pain?
Material reduced meshes have some advantages with respect to longterm discomfort and foreign body sensation in open hernia repair (when only considering chronic pain).
Prophylactic resection of the ilioinguinal nerve does not reduce the risk of chronic pain after hernia surgery.
Identification of all inguinal nerves during open hernia surgery may reduce the risk of nerve damage and postoperative chronic groin pain.
Treatment of chronic pain
A multidisciplinary approach at a pain clinic is an option for the treatment of chronic post herniorrhaphy pain.
Surgical treatment of specific causes of chronic post herniorrhapy pain can be beneficial, such as resection of entrapped nerves, mesh removal in mesh-related pain, removal of endoscopic staples or fixating sutures.
European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients
Laparoscopic Ventral Hernia:Is the Abdomen a Weakness in the Human Race ?
Incidence of Ventral Hernias
Around 10% of all laparotomies will generate incisional hernias.
The bigger the incision, the higher the risk.
~77% are median hernias
~17% are lateral hernias
~6% are iliac hernias
Direct closure have a high recurrences incidence (50%). The rate
increases (58%) with repair of recurrent hernias.
Significant reduction in recurrences is achieved when meshes are used.
Luijendijk RW, et al. A Comparison of Suture Repair with Mesh Repair for Incisional
Hernia .NEJM 2000; 343:392-398
Factors Influencing Ventral Hernia Occurrence
The most important functions of the abdominal wall are protection,
compression and retention of the abdominal contents, flexion and rotation
of the trunk and forced expiration.
Endogen Exogene Others
Age > 45 Sutures Emergency
BMI > 25 Length of incision Intra-abdominal
Previous operation Contamination pressure
Shock Type of incision
Hypothesis: In midline incisions closed with a single layer running suture, the
rate of wound complications is lower when a suture length to wound length
ratio of at least 4 is accomplished with a short stitch length rather than with a
Surgical site infection occurred in 35 of 343 patients (10.2%) in the long stitch
group and in 17 of 326 (5.2%) in the short stitch group (P=0.2). I ncisional
hernia was present in 49 of 272 patients (18.0%) in the long stitch group and
in 14 of 250 (5.6%) in the short stitch group (P<.001).
Conclusion: In midline incisions closed with a running suture and having a
suture length to wound length ratio of at least 4, current recommendations of
placing stitches at least 10mm from the wound edge should be changed to
avoid patient suffering and costly wound complications.
Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study Daniel Millbourn, MD; Yucel Cengiz, MD, PhD; Leif A. Israelsson, MD, PhD Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com
Significant predictors of surgical site infection and incisional hernia a Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CI, confidence interval; OR odds ratio; SL, suture length; WL wound length A Results of logistic regression analysis. All recorded variables were included in the model and removed by a backward reduction strategy if nonsignificant. Predictor Regression Coefficient (SE) OR (95%CI) Surgical site infection Wound contamination 1.03 (0.48) 2.81 (1.09-7.25) Being diabetic 1.01 (0.38) 2.73 (1.30-5.72) Long stitch length 0.77 (0.31) 2.15 (1.17-3.96) Incisional hernia Male sex 0.76 (0.34) 2.14 (1.10-4.15) Higher BMI 0.05 (0.02) 1.05 (1.01-1.10) Longer operation time 0.005 (0.002) 1.01 (1.002-1.01) Surgical site infection 1.16 (0.40) 3.18 (1.44-7.02) SL to WL ratio <4 1.32 (0.52) 3.73 (1.36-10.26) Long stitch length 1.44 (0.34) 4.24 (2.19-8.23)
Prospective Clinical Trial of Factors Predicting the Early Development of Incisional Hernia after Midline Laparotomy
6 months analysis after operation of numerous demographic, clinical, treatment and outcomes-related peri-operative factors to determine statistical association with development of incisional hernia.
Four covariates independently predictive of incisional hernia were studied: Body mass index (BMI) > 24.4kg/m2 ; fascial suture to incision ratio (SIR) < 4.2 ; deep surgical site, deep space, or organ infection (SSI ); and time to suture removal or complete epithelialization >16 days (TIME).
Conclusion: The hernia risk scoring system equation [p(%) = 32(SIR) + 30(SSI) + 9(TIME) + 2(BMI)] provided accurate estimates of incisional hernia according to stratified risk groups based on total score: low (0 to 5 points), 1.0%; moderate (6 to 15 points), 9.7%; increased (16 to 50 points), 30.2%; and markedly increased (>50 points), 73.1%
Erosion of the prosthesis into the adjacent hollow viscous
Contraction of prosthesis
Processing of Biomaterials
Cadaveric, Bovine, Porcine, Equine: removal of all live cells and removal of all nuclear tissue to prevent rejection by the host .
Cross-linking: serve to form either an intermolecular or an intramolecular cross-link between two aminoacids along protein structure (HDMI and EDC are in common use) .
Crosslinked products are more resistant to collagenase degradation (more stable in infected fields where collagenases are secreted by bacteria). Rapid dissolution in the presence of enteric contents (fistulas) .
Must be placed in direct contact with healthy tissue, under no tension and should not be usedto bridge the defect.
Comparison of Biologic Grafts – Overview of Gaertner Study Alloderm Bulge Alloderm Translucency Gaertner, W et al. Experimental Evaluation of Four Biologic Prostheses for Ventral Hernia Repair. J Gastrointest Surg July 2007
Thickness at the defect area diminished significantly at 6 months with both Veritas and AlloDerm (P<0.05), so much so that they became translucent.
Permacol and Peri-Guard, the mean defect area and thickness were virtually identical to when they were originally installed 6months earlier.
Tensile strength of the material itself after 6 months was significantly reduced for the non-cross-linked prostheses (Veritas and AlloDerm) compared to the cross-linked prostheses (Peri-Guard and Permacol).
Stretching, bulging, and translucency were routine with AlloDerm.
Level of Complexity Grade 1 Low risk of infection Low risk of complications Grade 2 Smoker Immunosuppressed Obese Diabetic Grade 4 Active infection Infected mesh Grade 3 Contamination risk Stoma present Violation of bowel wall Previous Wound infection Grade 5 Traumatic fascia loss Extensive fascia loss Percent Performed Open Patients with co-morbid conditions have up to 4x increase in wound-infection rates Open incisional hernias are 10x more likely to have infection than a clean surgical case Infected mesh commonly results in a 2 nd procedure for removal Synthetic Biologic
Massive Incisional Hernias
Material Functions for Soft Tissue Repair Synthetics Autografts
Good mechanical properties
High foreign body reaction
Infection up to 8% 1
Can cause pain
Good Mechanical Properties
Donor Site Morbidity
Many patients unqualified
Ease of handling
Ability to vascularize
Developed by Dr. Ramirez in the late 80’s
Employs the use of autologous myofascial tissue to effect abdominal wall closure
Bilateral relaxation incisions 2cm lateral to the external oblique from costal margin to level of symphasis pubis
Blunt separation of external oblique layer from underlying internal oblique layer taking care not to interrupt vascular/nerve supply
May employ undermining of one or both posterior rectus sheaths to achieve further medial advancement
**Provides dynamic support of the abdominal girdle**
Ventral Hernia: Anatomy
Grevious MA. Cohen M. Shah SR. Rodriguez P. Structural and functional anatomy of the abdominal wall. Clinics in Plastic Surgery. 33(2):169-79, v, 2006 Apr. External oblique Internal oblique Transversus abdominis Rectus abdominis Components Separation
Laparoscopic Appendectomy Endo-loop
Alternatively, an appendectomy can be
performed through a trocar in the
umbilicus and two trocars in the
suprapubic area medial to the epigastric vessels
for a superb cosmetic result (if an extended
right hemicolectomy is to be performed, the
hepatic flexure positioning is preferred.)
Laparoscopic Appendectomy Evidence-based Medicine
Clear advantage in children*
- Less wound infection, LOS, ileus
- More OR time, intra-abdominal abscess
Controversies in adults
- Cost, obese patients, severe appendicitis
*Aziz et al. Ann Surg 2006 - Prelude to NOTES
LAPAROSCOPIC PROCEDURES WITH CLEAR ADVANTAGES.
Laparoscopic Heller’s Cardiomyotomy
Short recovery time
Less overall complication rates
1945 to present
Multiple methods and techniques:
Hill gastropexy ….
Laparotomy vs laparoscopy
Thoracotomy vs thoracoscopy
Rudolph Nissen, MD INFLUENTIAL PEOPLE: Lortat-Jacob, MD AndreToupet, MD Jacques Dor, MD Ernst Heller, MD Rudolph Nissen MD Ivor Lewis, MD J. Leigh Collis, MD K. Alvin Merendino, MD Lucius Hill, MD Ronald Belsey, MD Alan Thal, MD
Nissen’s Fundoplication Technique
Esophageal Hiatus Liver Esophagus Left crus Right crus Aorta
Hiatal Defect Chest cavity Stomach Left crus
Polypropylene mesh Esophagus
Do not use metal tacks
Biologic mesh? dual mesh?
No mesh at all?
(remember original Toupet repair)
Mesh Wrap Circular mesh Fundoplication
Laparoscopic Surgery in Colorectal Diseases
Port Site Recurrence
If proximal divided end of colon can reach through
the skin there has been sufficient dissection of
splenic flexure providing a tension-free anastomosis.
HEPATIC FLEXURE COLON RESECTION
The ileum is more mobile than the
transverse colon, which can still be
delivered adequately at this level.
A B Tension-free anastomosis Trocar C is used for GIA division of distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis). C
Cochrane Systematic review of short term outcomes in 25 RCTs showed that laparoscopic colorectal surgery had:
Longer operative time
Less intraoperative blood loss
Less postoperative pain
less postoperative ileus
Better postoperative pulmonary function
Less total and local morbidity
Less postoperative hospital stay
Similar general morbidity and mortality
Better quality of life (within 30 days)
Schwenk et al. 2005 Jul 20;(3):Cochrane Database 003145
Cochrane Systematic review of long term outcomes showed:
Similar port-site metastases and wound recurrences
Similar cancer-related mortality at maximum follow-up
Similar tumor recurrence
Similar overall mortality
Kuhry et al. Cancer Treat Rev. Oct 2008
Consensus Review of Optimal Perioperative Care in Colorectal Surgery, Enhanced Recovery After Surgery (ERAS) Group Recommendations
No oral bowel preparation
Pre operative fasting of 2 hours for liquids and 6 hours for solids. Carbohydrate loading
Single dose antibiotic prophylaxis.
No routine use of nasogastric tubes.
Use of drains not advisable.
Oral diet at will after surgery.
Oral bowel preparation
Pre operative fasting of 6 hours
Prolonged antibiotic use.
Nasogastric tubes used routinely.
Drains routinely used.
Delayed oral intake.
Less frequent Laparoscopic procedures
First performed 1994 by Huscher et al
A safe procedure in experienced hands
Bipolar vessel sealing (Ligasure)
Laparoscopic left hemihepatectomy (resection of segments 2, 3, and 4). (A) Intraoperative view showing ischemic delineation of the left liver. Note the vascular endoscopic stapler encircling the left Glissonian pedicle. (B) Schematic view. The stapler is closed, and ischemic delineation of the left liver is obtained. (C) Intraoperative view. The stapler is fired, and the left main Glissonian pedicle is transected (arrows). (D) Schematic view. The stapler is fired
Pulitan ò C and Aldrighetti L Nat Clin Pract Gastroenterol Hepatol (2008) Outcomes of laparoscopic hepatectomy
Spleen-preserving total pancreatectomy
Spleen-preserving distal pancreatectomy
Procedures are technically challenging
Long learning curve
High volume center improves clinical outcome
DISTAL PANCREATECTOMY D E C B A
Trocars “A” and “B” divide gastrocolic ligament
GIA is introduced through “D”
Laparoscopic pancreatectomy Vs. open
Finan et al. Am Surg. Aug 2009 Laparoscopic and open distal pancreatectomy: a comparison of outcomes.
There was no significant difference in the incidence of postoperative morbidity or mortality
There was no significant difference in the rate of all pancreatic fistula formation or clinically significant leaks
Lparoscopic technique had decreased:
length of stay in the lap group.
Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers.
Laparoscopic Urologic procedures
Lymph node dissection
Bladder neck suspension
RT. KIDNEY RESECTION
Subxiphoid port (D) - liver retraction
Trocar A - parallel to vena cava
(perpendicular approach to rt. renal
vessels and rt. adrenal vein –
additional trocar E may be placed
more laterally and posterior to
trocar A if needed.)
B C D A E
PROSTATECTOMY A B C Trocars – added as needed along semicircular line. i.e., during a prostatectomy, another trocar is added between A and B. Another trocar may be added between B and C allowing the surgeon and assistant surgeon on the opposite side to each use both hands.
Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-37.
Sjostrom L, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351: 2683-93.
Long-term Weight Control Analysis Studies Type and Size Effect on Weight Effect on Comorbidities Buchwald et al. Meta-analysis n = 22,094 pts Mean excess weight loss: 61%
Sleep apnea: 86%
Swedish Obese Subject trial (SOS) Prospective matched cohort n = 4,047 pts
At 10 years:
Med: 1.6% gain
Surg: 16% loss
Improved by surgery:
Schauer et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003 Oct; 238 (4): 467-84
1160 patients underwent LRYGBP 5-year period
LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM
Fasting plasma glucose and HBA1C normalized (83%) or markedly improved (17%) in all patients
Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery
suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic
Rates of Remission of Diabetes Adjustable Gastric Banding Roux-en-Y Gastric Bypass Biliopancreatic Diversion >95% (Immediate) 48% (Slow) 84% (Immediate)
“ Gastric bypass and biliopancreatic diversion
seem to achieve control of diabetes as a primary and
independent effect, not secondary
to the treatment of overweight.”
Potential of Surgery for Curing Type 2 Diabetes Mellitus. Rubino, Francesco, MD; Gagner,
Michel MD, FACS, FRCSC Annals of Surgery; 236 (5): 554-559, November 2002
2002: Antidiabetic Effect of Bariatric Surgery: Direct or Indirect?
3 patients with poorly control DM
3-4 days after subtotal gastrectomy all 3 pateints showed an improvement in their DM
Occurred sooner than associated weight loss
Patients later regained their weight without an associated loss of glucose control or glycosuria
Mingrone 1977 : Case report
Young, non obese woman with DM who underwent BPD for chylomicronemia
Plasma insulin and blood glucose levels normalized within 3 months
Bittner –1981- subtotal gastrectomy and gastrointestinal reconstructions that excluded duodenal passage (B2 and RYGB
Lowered plasma glucose and insulin
Conclusion: Plasma glucose and insulin fall rapidly post-operatively
antidiabetic medications can be reduced or stopped shortly after gastrointestinal bypass interventions
Rubino F. Bariatric Surgery:effects on glucose homeostasis. Curr. Opin. Clin. Nutr. Metab. Care 9: 497-507
Bittner R. Homeostasis of glucose and gastric resection: the influence of food passage through the duodenum Z Gastroenterology 1981; 19: 698-707.
Friedman NM et al. The amelioration of diabetes mellitus following subtotal gastrectomy. Surg. Gynecol. Obstetr. 1955; 100:201-204
2004: Duodenal-Jejunal Exclusion - Foregut
Slides taken from: DIABETES IS NO LONGER A HOPELESS DISEASE The Guilty Gut Walter Pories, MD, FACS, Chief, Metabolic Institute East Carolina University Greenville, North Carolina 2006:
2004: “ Results of our study support the hypothesis that the bypass of duodenum and jejunum can directly control type 2 diabetes and not secondarily to weight loss or treatment of obesity.” Effect of Duodenal-Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes: A New Perspective for an Old Disease. Rubino, Francesco, MD; Marescaux, Jacques MD, FRCS Annals of Surgery; 239 (1): 1-11, January 2004
Double blind study: 16 patients assigned to LRYGBP and 16 Pts to LSG
Patients reevaluated on the 1st, 3rd, 6th, and 12th mos
No change in ghrelin levels after LRYGBP Significant decrease in ghrelin after LSG ( P < 0.0001)
Fasting PYY levels increased after either surgical procedure ( P <= 0.001)
Appetite decreased in both groups but to a greater extend after LSG
Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Karamanakos et al Ann Surg . 2008 Mar; 247(3): 401-7.
“ PYY levels increased similarly after either procedure.
The markedly reduced ghrelin levels in addition to increased
PYY levels after LSG, are associated with greater appetite
suppression and excess weight loss compared with LRYGBP”
March 2008: Weight loss, appetite suppression, and changes in fasting and postprandial
ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a
prospective, double blind study. Karamanakos et al Ann Surg. 2008 Mar; 247(3): 401-7.
2009: Ferzli et al
2009: Ferzli et al
2009: Ferzli et al. Results at 12 months
A ll subjects consistently felt relief from fatigue, pain and/or numbness in the extremities, polyuria, and polydypsia.
Clinical resolution was obtained for one patient, and the preoperative diabetic medication requirements decreased for most of the other patients.
The subjects demonstrated an overall improved HbA1c (from 9.4% to 8.5%) and fasting blood glucose level (from 209 to 154 mg/dl).
The Diabetes Surgery Summit Consensus Conference Rubino et al. Annals of Surgery. Vol 251, Number3,300-405, March 2010 45% of type 2 patients with diabetes world-wide demonstrate a BMI less than 30 ADA : “ Bariatric Surgery should be considered for adults with BMI > 35Kg/m2 And type 2 diabetes ,especially if the diabetes is difficult to control with lifestyle And pharmacologic therapy
The Surgeon and the Diabetologists
And it ought to be remembered that there is nothing more difficult than to take the lead in the introduction of a new order of things, because the innovator has for enemies, all those who have done well under the old conditions.
Nicolo Machiavelli (1469-1527), The Prince, 1513
Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007) Patient Duration of Type 2 Diabetes Pre-Operative Medication 1 Year Medication Requirement #1 19 Metformin 850mg One tablet daily Metformin 850 mg half tablet daily #2 10 30/10 Units Insulin 30/10 Units Insulin #3 12 40/20/20/20 Units Insulin 30 Units occasionally at night #4 12 2 Metformin 850mg daily; 40/20 Units Insulin 1 Metformin 850mg daily; 5 Units n occasionally #5 12 40/20 Units Insulin 5 Units Insulin three times per week #6 * 6 20/12 Units Insulin No Medication #7 4 Clormin 1000mg daily; 30/20 Units Insulin Diaformin 500mg daily; 30/20 Units Insulin
Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007)
The mean HBA1c at pre-op and 1 year was 9.371 and 8.500 respectively
FBG at pre-op and 1 year were 208 and 154 respectively for the seven patients (p=0.057)
Lipid profiles improved with lower total cholesterol levels and triglycerides 1 year
Mean (SEM) Pre vs post op Correlation P value* HBA1C Pre-op 9.371 (0.85) -0.040 0.933 HBA1C 1yr 8.500 (0.67) FBG Pre-op 208.86 (22.50 0.74 0.057 FBG 1YR 154.86 (39.9) Cholesterol preop 183.71 (11.5) 0.632 0.128 Cholesterol 1yr 186.00 (19.9) TG pre-op 112.43 (27.7) -0.245 0.596 TG 1yr 127.29 (25.3) Cpep pre-op 1.343 (0.29) -0.245 0.205 Cpep 3 months 1.200 (0.32)