Open Versus Laparoscopic Surgery What is A Myth and What is Not!

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Open Versus Laparoscopic Surgery What is A Myth and What is Not!

  1. 1. Open Versus Laparoscopic Surgery What Is A Myth And What Is Not ! George Ferzli, MD, FACS
  2. 2. Open Versus Laparoscopic Surgery <ul><li>Esophageal </li></ul><ul><li>Gastric </li></ul><ul><li>Liver </li></ul><ul><li>Biliary </li></ul><ul><li>Pancreatic </li></ul><ul><li>Adrenal </li></ul><ul><li>Splenic </li></ul><ul><li>Bowel </li></ul><ul><li>Prostate </li></ul><ul><li>Hernia </li></ul>
  3. 3. Laparoscopic Esophageal Surgery <ul><li>Esophagectomy </li></ul><ul><li>Esophagomyotomy </li></ul><ul><li>Paraesophageal Hernia Repair </li></ul><ul><li>Nissen Fundoplication </li></ul>
  4. 4. Minimally Invasive Esophagectomy <ul><li>Is it safe and does it have any advantages over the open techniques? </li></ul>Nguyen NT et al, Arch Surg. 2000;135:920-925
  5. 5. Study Design <ul><li>Retrospective comparison of 3 methods of esophagectomy: combined thoracoscopic and laparoscopic (TM/LE), transthoracic (TT), and blunt transhiatal (THE) </li></ul><ul><li>Setting: University Medical Center </li></ul><ul><li>Patients: </li></ul><ul><li>TM/LE: 18 consecutive patients (10/9/98 to 1/19/00); data collected prospectively </li></ul><ul><li>TT and THE: 16 and 20 patients respectively (6/1/93 to 8/5/98); data collected from a retrospective chart review </li></ul>
  6. 6. Esophagectomy * P<.05, compared with TT and THE groups,Mann-Whitney Test Nguyen NT et al, Arch Surg. 2000;135:920-925 6.9 + 5.4 6.3 + 6.0 10.8 + 8.4 No. of nodes removed 22.3 + 16.1 23.0 + 22.3 11.3 + 14.2 * Hospital stay, days 11.1 + 15.7 9.9 + 16.3 6.1 + 11.3 * ICU stay, days 2.9 + 3.1 1.8 + 2.2 0.3 + 0.7 * Intraop. transfusion, U 1142 + 785 1046 + 792 297 + 233 * Blood loss, mL 391 + 144 437 + 65 364 + 73 * Operative time, min THE (n=20) TT (n=16) TM/LE (n=18)
  7. 7. Esophagectomy Nguyen NT et al, Arch Surg. 2000;135:920-925 0 0 1 (6) Tracheal-gastric fistula 0 1 (6) 0 Intra-abdominal abscess 4 (20) 0 0 Hoarseness 1 (5) 0 0 Chylous ascites 0 0 1 (6) Delayed gastric emptying 3 (15) 3 (19) 2 (11) Respiratory failure 1 (5) 0 1 (6) Pulmonary embolism 0 1 (6) 0 Gastric conduit ischemia 2 (10) 2 (12) 2 (11) Anastomotic leak 0 1 (6) 0 GI bleeding THE (n=20) TT (n=16) TM/LE (n=18) Complication
  8. 8. Minimally Invasive Esophagectomy Summary <ul><li>It is safe as the complication rate is comparable to open surgery </li></ul><ul><li>It is effective as the lymph node yield is comparable to open surgery </li></ul><ul><li>It has advantages over the open techniques as there is significantly less blood loss, and transfusion rate, and shorter operative time,ICU stay, and hospital length of stay </li></ul>
  9. 9. Minimally Invasive Esophagomyotomy <ul><li>How does the morbidity and outcome compare to the open technique? </li></ul>Dempsey et al, Surg Endosc (1999) 13: 747-750
  10. 10. Minimally Invasive Esophagomyotomy Study Design <ul><li>Retrospective analysis </li></ul><ul><li>Open myotomy: 10 patients from a pool of 20 (10 lost to follow-up) operated upon between Aug.1988 and Jan.1996 </li></ul><ul><li>Laparoscopic esophagomyotomy and Dor anterior fundoplication: 12 patients </li></ul><ul><li>Mean follow-up: 60 months in open group and 16 months in laparoscopic group </li></ul>Dempsey et al, Surg Endosc (1999) 13: 747-750
  11. 11. Esophagomyotomy * P<.05 Dempsey et al, Surg Endosc (1999) 13: 747-750 85 + 60 19 + 16 * Days off work post-op 40% 25% Post-op GERD 80% 84% Overall satisfaction 90% 92% Improved dysphagia 8.8 2.7 * Hospital stay, days 39 + 7 18 + 2 * Parenteral narcotic, mg 5.3 + 1.4 2.1 + 1.0 * Parenteral narcotic, days 2/10 2/12 Mucosal perforation 220 + 156 50 + 26 * Blood loss, mL 122 + 32 137 + 25 Operating time, min Open (n=10) Laparoscopic (n=12)
  12. 12. Minimally Invasive Esophagomyotomy Summary <ul><li>Symptomatic improvement and high patient satisfaction comparable to the open procedure </li></ul><ul><li>Significantly less morbidity: less intra-op blood loss, post-op pain and parenteral narcotic use, shorter hospital stay and fewer days off from work </li></ul>
  13. 13. Laparoscopic Paraesophageal Hernia Repair <ul><li>Is it associated with higher recurrence compared to open repair ? </li></ul><ul><li>Should mesh be used ? </li></ul><ul><li>How does symptomatic outcome compare to open repair ? </li></ul>Hashemi et al, J Am Coll Surg 2000;190:553-561 Frantzides CT et al, Surg Endosc (1999) 13: 906-908
  14. 14. Paraesophageal Hernia Repair Study Design <ul><li>Retrospective review of 54 patients who underwent repair of large type III hiatal hernia between 1985 and 1998 </li></ul><ul><li>Laparotomy – 13, Thoracotomy – 14, Laparoscopy – 27 </li></ul><ul><li>Follow-up: Symptomatic outcomes at median 24 months, integrity of repair using video esophagogram at median 27 months </li></ul>Hashemi et al, J Am Coll Surg 2000;190:553-561
  15. 15. Paraesophageal Hernia Repair Technique and Recurrence <ul><li>Open Surgery </li></ul><ul><li>Reduction of hernia </li></ul><ul><li>Complete excision of sac </li></ul><ul><li>Primary closure of crura </li></ul><ul><li>Antireflux procedure </li></ul><ul><li>Laparoscopic Surgery </li></ul><ul><li>Reduction of sac </li></ul><ul><li>No excision of sac </li></ul><ul><li>Primary closure of crura </li></ul><ul><li>No mesh or gastropexy </li></ul>Hashemi et al, J Am Coll Surg 2000;190:553-561 P<.001
  16. 16. Paraesophageal Hernia Repair Symptomatic Outcomes Hashemi et al, J Am Coll Surg 2000;190:553-561
  17. 17. Paraesophageal Hernia Repair Technique and Recurrence <ul><li>Mesh vs. No Mesh </li></ul><ul><li>Prospective randomized trial </li></ul><ul><li>Hiatal defect >8cm diameter </li></ul><ul><li>Excision of sac, primary closure of crura, Nissen fundoplication in all cases </li></ul><ul><li>Randomized intra-op to mesh vs. no mesh </li></ul><ul><li>Follow-up for 6 months </li></ul>Frantzides CT et al, Surg Endosc (1999) 13: 906-908 16% 0%
  18. 18. Paraesophageal Hernia Repair Summary <ul><li>Symptomatic outcomes: Similar in both groups. Excellent or good in 76% patients after laparoscopic and 88% after open repair </li></ul><ul><li>Hernia recurrence: Significantly higher in laparoscopic group (42%, 9 of 21) compared to open group (15%, 3 of 20) </li></ul><ul><li>Use of mesh reduces paraesophageal hernia recurrence significantly </li></ul>
  19. 19. Laparoscopic Nissen Fundoplication <ul><li>Is there a higher incidence of complications ? </li></ul><ul><li>How are the functional results ? </li></ul>Laine S et al, Surg Endosc (1997) 11: 441-444 Bais JE et al, Lancet 2000; 355: 170-74
  20. 20. Laparoscopic Nissen Fundoplication Study Design <ul><li>Prospective randomized trial </li></ul><ul><li>110 consecutive patients with prolonged symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic and 55 to open repair </li></ul><ul><li>Follow-up: Post-op recovery, complications and outcome at 3- and 12-months were compared </li></ul>Laine S et al, Surg Endosc (1997) 11: 441-444
  21. 21. Nissen Fundoplication Complications Laine S et al, Surg Endosc (1997) 11: 441-444 3 0 Wound infection 1 0 Subphrenic abscess 1 0 Pneumonia 2 0 Splenic bleeding and splenectomy 0 1 Intraoperative bleeding 0 2 Esophageal perforation Open Lap. Complication
  22. 22. Nissen Fundoplication Proportion of Time (%) Mean pH<4 Laine S et al, Surg Endosc (1997) 11: 441-444
  23. 23. Nissen Fundoplication Mean LES Pressure Laine S et al, Surg Endosc (1997) 11: 441-444
  24. 24. Nissen Fundoplication Symptoms 3 Months After the Operation Laine S et al, Surg Endosc (1997) 11: 441-444 53% 16% 22% 2% 4% 2% 56% 18% 22% 4% (n=55) (n=55)
  25. 25. Nissen Fundoplication Symptoms 12 Months After the Operation Laine S et al, Surg Endosc (1997) 11: 441-444 70% 83% 17% 13% 3% 7% 7% (n=55) (n=55)
  26. 26. Laparoscopic Nissen Fundoplication Study Design <ul><li>Interim analysis of a prospective randomized trial comparing open and laparoscopic Nissen fundoplication </li></ul><ul><li>46 patients in open group and 57 in laparoscopic group operated before interim analysis </li></ul><ul><li>Follow-up: 3 months </li></ul><ul><li>Primary endpoints: Dysphagia, recurrent GERD, and intrathoracic hernia </li></ul><ul><li>Technical observation: No bougie used in either group </li></ul>Bais JE et al, Lancet 2000; 355: 170-74
  27. 27. Laparoscopic Nissen Fundoplication Results * p=0.016, ** p=0.011 (Fisher’s exact test) Bais JE et al, Lancet 2000; 355: 170-74 1 11 Total ** 0 2 Intrathoracic herniation 1 2 Recurrent GERD at 3 months 0 7 Persistent dysphagia * (>3 months) Laparotomy (n=46) Laparoscopy (n=57)
  28. 28. Laparoscopic Nissen Fundoplication Summary <ul><li>Safe and feasible procedure </li></ul><ul><li>Complications are few and functional results (post-op pH, LES pressure, symptoms) are good if not better than open surgery </li></ul><ul><li>High rate of post-op dysphagia in study by Bais et al may be a result of not using bougie which more important for laparoscopic surgery as there is no tactile sensation </li></ul>
  29. 29. Laparoscopic Gastric Surgery <ul><li>Billroth I Gastrectomy </li></ul><ul><li>Surgery for Perforated Peptic Ulcer </li></ul><ul><li>Bariatric Surgery </li></ul>
  30. 30. Laparoscopy-Assisted Billroth I Gastrectomy <ul><li>Is it safe ? </li></ul><ul><li>Is it useful for patients with early gastric cancer ? </li></ul><ul><li>Does it have advantages over open surgery ? </li></ul>Adachi Y et al, Arch Surg. 2000;135:806-810
  31. 31. Billroth I Gastrectomy Study Design <ul><li>Retrospective review of operative data, blood analyses and post-op clinical course </li></ul><ul><li>Setting: University hospital in Japan </li></ul><ul><li>Patients: 102 patients who underwent Billroth I gastrectomy for early-stage gastric cancer from 1/93 to 7/99. 49 laparoscopy-assisted and 53 open procedures </li></ul>Adachi Y et al, Arch Surg. 2000;135:806-810
  32. 32. Billroth I Gastrectomy P<.05, all features Adachi Y et al, Arch Surg. 2000;135:806-810 4.5 3.9 Time to first flatus, days 7.7% 5.5% Weight loss on day 14 22.5 17.6 Post-op hospital stay, days 5.7 5.0 Time to liquid diet, days 6.2 3.3 Analgesics, times given 33.9 35.6 Serum albumin, day 7 26 4.2 Interleukin-6, day 3, U/mL 5.19 2.91 C-reactive protein, day 7, mg% 8.9 7.28 Granulocyte count, day1 8.22 6.99 Leukocyte count, day 3 11.14 9.42 Leukocyte count, day1 302 158 Blood loss, mL Open (n=53) Laparoscopic (n=49)
  33. 33. Billroth I Gastrectomy P=NS, all features Adachi Y et al, Arch Surg. 2000;135:806-810 21% 8% Complication rate 22.1 18.4 No. of lymph nodes 6.0 6.2 Proximal margin, cm 228 246 Operation time, min Open (n=53) Laparoscopic (n=49)
  34. 34. Laparoscopy-Assisted Billroth I Gastrectomy Summary <ul><li>It is a safe procedure </li></ul><ul><li>It has several advantages over open surgery including less surgical trauma, less impaired nutrition, less pain, rapid return of GI function, shorter hospital stay and no decrease in operative curability (proximal margin, # of lymph nodes harvested) </li></ul><ul><li>Prospective-randomized trial with long-term follow-up required </li></ul>
  35. 35. Perforated Peptic Ulcer
  36. 36. Perforated Peptic Ulcer Techniques <ul><li>Simple closure </li></ul><ul><li>Memon MA et al, Br. Med. J. 86:106-107, 1993 </li></ul><ul><li>Omental patch </li></ul><ul><li>So JB et al, Surg Endosc, 10:1060-63, 1996 </li></ul><ul><li>Fibrin glue </li></ul><ul><li>Mouret P et al, Br J Surg, 77:1006,1990 </li></ul><ul><li>Placement of oxidized cellulose gauze </li></ul><ul><li>Tate JJT et al, Br J Surg, 80:35, 1993 </li></ul><ul><li>Falciform ligament patch </li></ul><ul><li>Munro WS et al, Ann R Coll Surg, 78:390-1, 1996 </li></ul><ul><li>Ligamentum teres patch </li></ul><ul><li>Castalab G et al, Surg Endosc, 6:677-9, 1995 </li></ul>
  37. 37. Perforated Duodenal Ulcer Laparoscopic vs. Open Repair <ul><li>Decreased perioperative analgesic requirements in laparoscopic group </li></ul><ul><li>No benefit in length of hospital stay, time to resume normal diet or return to normal activity </li></ul><ul><li>Increased operative time and cost </li></ul>Miserey M et al, Surg Endosc. 10:831-6, 1996 So JB et al, Surg Endosc. 10:1060-63, 1996 Lau WY et al, Ann Surg. 224: 131-38, 1996 Lau WY et al, Br J Surg. 82:814-6, 1995
  38. 38. Laparoscopic Bariatric Surgery <ul><li>Is it safe ? </li></ul><ul><li>Does it reduce post-op morbidity ? </li></ul><ul><li>How does the outcome and cost compare to open surgery ? </li></ul>Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 de Wit LT et al, Annals of Surgery, 230(6);800-807, Dec. 1999
  39. 39. Roux-en-Y Gastric Bypass Study Design <ul><li>Prospective randomized trial </li></ul><ul><li>Setting: University of California, Davis </li></ul><ul><li>Patients: From 5/99 to 3/01, 155 patients with a BMI of 40-60 kg/m2 were randomly assigned to undergo laparoscopic (n=79) or open (n=76) GBP </li></ul><ul><li>Outcome, quality of life and cost was compared </li></ul>Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001
  40. 40. Roux-en-Y Gastric Bypass Perioperative Outcomes Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 .02 46.1 + 20.6 32.2 + 19.8 Return to work, days <.001 17.7 + 19.1 8.4 + 8.6 Return to daily activity, days NS 5 (6.6%) 6 (7.6%) Reoperation, No. of Pts. <.001 4 (IQR 2) 3 (IQR 1) Median hospital LOS, days .03 16 (21.1%) 6 (7.6%) ICU stay, No. of Pts. <.001 395 + 284 137 + 79 Blood loss, mL <.001 195 + 41 225+40 Operative time, min P Value Open GBP (n=76) Laparoscopic GBP (n=79) Results
  41. 41. Roux-en-Y Gastric Bypass Mean % of Excess Body Weight loss * * n=60 n=45 n=29 n=56 n=44 n=25 Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 * p<.05
  42. 42. Roux-en-Y Gastric Bypass Major Complications * P=0.78 Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001 7 (9.2%) * 6 (7.6%) Total 1 0 Retained laparotomy sponge 2 0 Wound infection 0 1 Gastrointestinal bleeding 1 0 Respiratory failure 1 0 Pulmonary embolism Pulmonary 0 3 Jejunojejunostomy obstruction 0 1 Hypopharyngeal perforation 1 0 Gastric pouch outlet obstruction 1 1 Anastomotic leak Gastrointestinal Open GBP (n=76) Laparoscopic GBP (n=79) Complication
  43. 43. Adjustable Silicon Gastric Banding Study Design <ul><li>Prospective randomized trial </li></ul><ul><li>Fifty patients with morbid obesity of >5 years’ duration and a BMI > 40 kg/m 2 were randomized to undergo laparoscopic or open ASGB </li></ul><ul><li>Complications, hospital stay, readmissions, and weight loss were compared </li></ul>de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999
  44. 44. Adjustable Silicon Gastric Banding de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999 <0.05 11.8 + 10.5 7.8 + 6 Overall hospital stay, days <0.05 15 6 Total readmissions <0.05 3.8 + 1.1 (3-7) 4.7 + 2.1 (3-10) Difficulty of procedure (1-10)(range) <0.05 7.2 (5-13) 5.9 (4-10) Days in hospital, mean (range) <0.05 76 + 20 150 + 48 Surgical time, min P Value Open ASGB (n=24) Laparoscopic ASGB (n=25) Parameter
  45. 45. Adjustable Silicon Gastric Banding All values are expressed as mean + SD P value difference before and 52 weeks after is < 0.05 de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999 NS 39.1 + 8.2 39.7 + 8.7 BMI 52 weeks after surgery (kg/m 2 ) NS 49.7 + 5.6 51.3 + 10.4 BMI before surgery (kg/m 2 ) 34.4 35 Weight loss (kg) NS 112.0 + 19.1 117.2 + 25.2 Weight 52 weeks after surgery (kg) NS 146.4 + 19.9 152.2 + 31.4 Weight before surgery (kg) P Value Open ASGB (n=24) Laparoscopic ASGB (n=25)
  46. 46. Laparoscopic Bariatric Surgery Summary <ul><li>Compared to open surgery, laparoscopic Roux-en-Y gastric bypass is associated with: 1) Significantly decreased blood loss, ICU stay, and hospital stay, </li></ul><ul><li>2) Earlier return to daily activity and work, </li></ul><ul><li>3) Longer operative time, </li></ul><ul><li>4) Fewer complications, and </li></ul><ul><li>5) Equivalent weight loss at 1 year. </li></ul>
  47. 47. Laparoscopic Bariatric Surgery Summary <ul><li>Compared to open surgery, laparoscopic adjustable silicon gastric banding is associated with: </li></ul><ul><li>1) Significantly decreased length of hospital stay and readmission rate, </li></ul><ul><li>2) Increased OR time, and </li></ul><ul><li>3) Equivalent weight loss at 52 weeks. </li></ul>
  48. 48. Laparoscopic Liver Resection
  49. 49. Liver Resection Rau HG et al, Hepato-Gastroenterology 1998; 45:2333-2338 <0.05 11.6 + 12.8 7.8 + 8.2 Post-op hospital stay (days) NS 555.9 + 385.8 457.6 + 343.7 Blood loss (mL) <0.05 128.2 + 37.0 183.5 + 55.1 Operation time (min) NS 10.8 + 4.6 11.6 + 6.1 Parenchymal hepatic resection rate (%) NS 46.8 + 13.9 48.0 + 9.8 Age (years) p value (Mann-Whitney U Test) Conventional (n=17) Laparoscopic (n=17)
  50. 50. Liver Resection Summary <ul><li>Data on laparoscopic liver resection scarce </li></ul><ul><li>At present laparoscopy appears to have a role in laparoscopic ultrasound and radiofrequency ablation and cryoablation of liver tumors </li></ul>
  51. 51. Laparoscopic Common Bile Duct Exploration
  52. 52. PREOP INTRAOP POSTOP ERCP Lap transcystic Lap CBD Open CBD Expectant ERCP Management Options
  53. 53. Laparoscopic CBD Exploration Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001 1 death. Shorter LOS (3.4d), lesser morbidity (5%), fewer retained stones (5%) for transcystic. 10 123, 91% success 145 99% 1231 Phillips et al 4 deaths. Morbidity 9.1%. 7 with residual stones. 137, 97.1% success 112, 68.8% success 220 - 220 Berthou et al Major complications 3.8%. 1 death. 5% retained stones. 3.2% recurrent stones on f/u 50 107 161 1975 1975 Paganini et al 2 duct injuries. 1 death. 7% morbidity 2.6% retained stones. 17%, 19% conversion 83%, 5% conversion 94% 99.5% 226 Berci et al 8% conversion. 92% success. 1 death. LOS 4.3d 37 13 50 - 50 Shuchleib et al Comment Choledo- chotomy Trans- cystic No. of pts with CBD stones No. of cholangio. No. of patients Study
  54. 54. Laparoscopic CBD Exploration Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001 Overall success rate 94%. Complication rate 10% 27 33 80 - 700 Stoker et al Overall success rate 75% 14 46 60 - 60 Khoo et al Overall success 88%. 20 conversions. 22 major & 9 minor complications. 1 death. 92 116 247 - 247 Millat et al 12% conversion. 2 deaths. 15% complication rate. 93% success 63% success 92 - 92 Gigot et al Overall success 82%. No mortality. Morbidity 10% 11 22 39 - 39 Arvidsson et al No late retained stones or stricture. 0 217 217 - 217 Giurgiu et al 15.8% complication rate. 1 death. 13% conversion. LOS 6 days. 55, 85% success 56,80% success 109 132 133 Cuschieri et al No mortality. Morbidity 7.4%. LOS 7.6 days. 101, 96% success 82,67% success 161 - 161 Drouard et al Comment Choledo- chotomy Trans- cystic No. of pts with CBD stones No. of cholangio. No. of patients Study
  55. 55. Laparoscopic Pancreatic Surgery <ul><li>Diagnostic laparoscopy for staging of pancreatic cancer </li></ul><ul><li>Laparoscopic ultrasound for staging of pancreatic cancer </li></ul><ul><li>Pancreatic resection </li></ul><ul><li>Palliative surgery for pancreatic cancer </li></ul>
  56. 56. “ In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence”. 1911 Bernheim: First laparoscopy for pancreatic cancer in the U.S.A. Bernheim B. Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911
  57. 57. <ul><li>Prospective study of 88 consecutive patients </li></ul><ul><li>Pancreatic and periampullary adenocarcinoma </li></ul><ul><li>Preoperative evaluation </li></ul><ul><ul><li>CT scan with contrast 88 pts </li></ul></ul><ul><ul><li>MRI 20 pts </li></ul></ul><ul><ul><li>Laparoscopy 47 pts </li></ul></ul><ul><ul><li>Angiography 85 pts </li></ul></ul>Preoperative Staging and Assessment of Resectability of Pancreatic Cancer Warshaw,A et al: Arch Surg 1990; 125:230-233
  58. 58. Results <ul><li>Overall resectability 33/88 (38%) </li></ul><ul><li>Laparoscopy found metastatic disease when present in 22/23 patients (96%) </li></ul><ul><li>Laparoscopy found no metastatic disease in 24/24 patients (100%) </li></ul>Warshaw,A et al: Arch Surg 1990; 125:230-233
  59. 59. Conclusion <ul><li>Laparoscopy is particularly sensitive for detecting small metastases (96%) </li></ul><ul><li>This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances </li></ul>Warshaw,A et al: Arch Surg 1990; 125:230-233
  60. 60. The Value of Laparoscopy in the Staging of Patients with Potentially Resectable Peripancreatic Malignancies <ul><li>115 patients- radiologically resectable </li></ul><ul><li>Extensive laparoscopy performed </li></ul><ul><ul><li>assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels </li></ul></ul>Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  61. 61. Unresectability <ul><li>Metastases </li></ul><ul><ul><li>hepatic, serosal, peritoneal </li></ul></ul><ul><li>Extrapancreatic extension </li></ul><ul><ul><li>mesocolic involvement </li></ul></ul><ul><li>Nodal involvement </li></ul><ul><ul><li>celiac or portal </li></ul></ul><ul><li>Vascular invasion </li></ul><ul><ul><li>celiac axis or hepatic artery </li></ul></ul><ul><ul><li>portal vein, SMV, SMA </li></ul></ul>Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  62. 62. <ul><li>Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient </li></ul><ul><li>Positive predictive index of 100% </li></ul><ul><li>Negative predictive index of 91% </li></ul><ul><li>Accuracy of 94% </li></ul>Results Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  63. 63. Laparoscopic Ultrasound in the Staging of Pancreatic Cancer <ul><li>Prospective evaluation of 90 patients </li></ul><ul><li>All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography </li></ul><ul><li>All patients had laparoscopy and laparoscopic ultrasound </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  64. 64. Results Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2) ___ ___ 13 (14%) 8 (9%) EQUIVOCAL 50 (56%) 49 (54%) 41 (46%) 17 (19%) UNRESECTABLE ACTUAL LAP SONO LAP CT
  65. 65. Laparoscopic Ultrasound <ul><li>Sensitivity 100% </li></ul><ul><li>Specificity 98% </li></ul><ul><li>Accuracy 98% </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  66. 66. Summary <ul><li>Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection </li></ul><ul><li>The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer </li></ul>
  67. 67. Laparoscopic Pancreatic Resection
  68. 68. Laparoscopic Pancreatic Resection Patterson JE, J Am Coll Surg 2001;193:281-287 3.6 6 24 - - - - 84 Broughan (1986) - 23 58 5 63 - 15 40 Benoist (1999) 0.9 5 31 NR 31 4.3 10 235 Lillemoe (1999) Open - 20 20 20 40 4.5 6 5 Cuschieri (1996) - - - - - - - - - - 4.5 3 5 4 9 4 <ul><li>Distal pancreatectomy </li></ul><ul><li>Islet cell enucleation </li></ul>- 8 31 8 38 - - 13 Gagner (1997) - 20 20 0 20 5.0 5 5 Park (1999) 0 33 33 0 33 5.0 34.5 6 Vezakis (1999) 0 0 0 28 28 3.7 4 7 Salky (2000) 0 16 16 10 26 4.3 7 19 Patterson (2001) Laparoscopic 30-day mortality (%) Panc. Fistula (%) Major comp. (%) Minor comp. (%) Total comp. (%) OR time (h) Length of stay (d) n Author (y)
  69. 69. Laparoscopic Palliative Surgery for Unresectable Pancreatic Cancer
  70. 70. Laparoscopic Gastro- and Hepaticojejunostomy <ul><li>Case-Control Study </li></ul><ul><li>14 patients – open palliation </li></ul><ul><li>10 patients – laparoscopic palliation </li></ul><ul><li>4 patients – diagnostic laparoscopy </li></ul>Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
  71. 71. Results Rothlin,M et al;Surg Endosc (1999) 13:1065-1069 p < 0.05 p < 0.05 p < 0.06 9 days 21 days HOSPITAL STAY 0% 29% MORTALITY 7% 43% MORBIDITY LAP (n=14) OPEN (n=14)
  72. 72. Summary <ul><li>Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer </li></ul><ul><li>Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma </li></ul>
  73. 73. Laparoscopic Versus Open Adrenalectomy
  74. 74. Adrenalectomy OA, open anterior; OP, open posterior; Lap, laparoscopic; EBL, estimated blood loss; LOS, length of stay; OI, oral intake * Significant outcome compared to other outcome measures in same series (p<0.05) 8,188 1.9(days) 1.8 4.1 164 118 Lap(10) 11,193 3.2(days) 2.2 5.6 106 * 220 OP(5) 14,487 3.6(days) 3.4 6.2 141 200 OA(5) Korman 93 * 2.1 * 212 228 Lap(10) 801 5.5 139 * 288 OP(13) 1002 6.4 174 391 OA(11) Prinz 175 * 1.1 * 3.4 * 170 * 100 * Lap(20) 320 2.8 9 145 450 Open(20) Guazzoni 13,184 15.9 * 1.6 * 3.2 * 183 * 104 * Lap(24) 12,266 54 2.8 6.2 136 366 OP(17) 16,972 142 6.0 8.7 142 408 OA(25) Brunt Cost ($) Pain meds (mg) OI (days) LOS (days) Operative time (min) EBL (cc) Approach (n) First author
  75. 75. Adrenalectomy Thompson GB, Surgery 1997;122:1132-6 0.05 $7000 $6000 Adjusted hospital charges (median) 0.0001 9 7 Patient satisfaction (1-10) 0.0001 3.8 7 Return to normal (weeks) 0.0001 0 54 Late complications (%) 0.25 6 18 Early complications (%) 0.0001 3.1 5.7 Hospital stay (days) 0.50 3.1 5.7 Antiemetic doses 0.75 0.7 1.7 Toradol doses 0.002 28 48 MSO 4 equivalents NS 2 units None Blood transfusion (total group) 0.0002 167 127 OR time (min) p Value Laparoscopic (n=50) Posterior open (n=50)
  76. 76. Adrenalectomy Imai T et al, Am J Surg. 1999;178:50-54 NS 1.5 1.3 Ambulatory (days) NS 1.3 1.3 First solid food (days) NS $8000 $7000 Hospital costs (dollars) <0.0001 18 12 Hospital stay (days) <0.0001 5.8 2.9 Analgesic (times) <0.0001 162 40 Estimated blood loss (g) <0.0001 127 180 <ul><li>Skin to skin </li></ul><0.0001 79 147 <ul><li>Skin to removal </li></ul>Operating time (min) P Value Open (n=40) Laparoscopic (n=40)
  77. 77. Laparoscopic Adrenalectomy Summary <ul><li>It is a safe and feasible procedure </li></ul><ul><li>Data suggests significantly decreased blood loss, hospital length of stay, time to oral intake, post-op analgesic use, and late complications and increased patient satisfaction compared to open surgery </li></ul><ul><li>Significantly longer OR time </li></ul><ul><li>No difference in overall charges and early complications </li></ul>
  78. 78. Laparoscopic Versus Open Splenectomy
  79. 79. Splenectomy * * * * * * * p < 0.05
  80. 80. Splenectomy Donini A et al, Surg Endosc (1999) 13: 1220-1225 - 0 0 Deaths <0.0001 4+2.8 2.4 +1.7 Pain medication (No.of vials) 0.03 13 (23%) 3 (7%) Post-op complications 0.0002 7.2+2.1 5.1+2.7 Post-op stay (days) <0.0001 3.6+0.8 1.7+0.8 Time to oral liquids (days) 0.70 7 (5) 4 (4) Accessory spleens (No. of pts) 0.76 133+42 130+62 Operative time (min) 0.004 15 (26%) 2 (5%) Transfusion (patients) 0.67 347+511 295+269 Blood loss (mL) 0.86 732+1,184 773+1,112 Splenic weight (g) - 39 (18-64) 40 (13-64) Average age (range) p OS (n=56) LS (n=44) Results
  81. 81. Laparoscopic Splenectomy Summary <ul><li>It is a safe and feasible procedure </li></ul><ul><li>Data suggests significantly decreased blood loss and transfusion rate, hospital length of stay, time to oral intake, post-op analgesic use, and complications compared to open surgery </li></ul><ul><li>Significantly longer OR time </li></ul>
  82. 82. Laparoscopic Bowel Surgery <ul><li>Diagnosis and treatment of small bowel obstruction </li></ul><ul><li>Colectomy for benign and malignant disease </li></ul>
  83. 83. Small Bowel Obstruction Diagnostic and Therapeutic Laparoscopy 1 (1.5%) 30 (46%) 35 (54%) 65 139 Bailey IS, 1998 0 (0%) 6 (32%) 13 (68%) 19 19 Al-Mulhim A, 2000 3 (7.5%) 26 (65%) 14 (35%) 40 40 Leon EL, 1998 4 (8%) 36 (43%) 47 (57%) 83 83 Suter M, 2000 1 (1.5%) 11 (17.4%) 52 (82%) 63 136 Agresta F, 2000 4 (10%) 13 (32%) 24 (60%) 40 40 Strickland P, 1999 6 (9%) 31 (46%) 31 (46%) 68 150 Navez B, 1998 Iatrogenic bowel injury Converted to laparotomy Laparoscopic treatment Diagnostic laparoscopy Total # Author
  84. 84. Small Bowel Obstruction Summary <ul><li>Only 35-82% success rate in laparoscopic treatment of SBO </li></ul><ul><li>Some studies report high incidence of iatrogenic small bowel injury </li></ul><ul><li>No prospective randomized trial to address whether laparoscopic or open treatment of SBO is better </li></ul>
  85. 85. Laparoscopic Versus Open Colectomy for Cancer
  86. 86. Colorectal Resection Laparoscopic vs. open resection for carcinoma RHC = Right hemicolectomy; Trans = Transverse; AR = Anterior resection; Sig = Sigmoid; LAR = Low anterior resection; APR = Abdominoperineal resection Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46
  87. 87. Colorectal Resection Laparoscopic vs. open resection for carcinoma Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46 19.1% 13% Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III) 22% 12.2% Recurrence rates 6% 0.5% Wound complications 450 150 Blood loss, mL 9 5.6 Hospitalization, days Open (n=224) Laparoscopic (n=192)
  88. 88. Colorectal Resection Laparoscopic vs. open resection for carcinoma Curet MJ et al, Surg Endosc (2000) 14: 1062-1066 1 6 4 Late death from cancer (mean follow-up 4.9 years) 12 10 11 Number of lymph nodes 32 26 26 Length of specimen (cm) 8, 100% 5, 28% 1, 5% Complications (n, %) 8 7.3 5.2 Length of stay (days) 7 5.8 4.1 Regular diet (days) 5 4.4 2.7 Clear liquids (days) 6 4 3 ICU stay (days) 683 407 284 Blood loss (mL) 242 138 210 Operating room time (min) Converted (n=7) Open (n=18) Lap (n=18) 1 1 0 Recurrence
  89. 89. Colorectal Resection Laparoscopic vs. open resection for carcinoma Santoro E et al, Hepato-Gastroenterology 1999; 46:900-904 1 1 Liver+Peritoneum+ Trocar-site or scar 4 4 Liver+ Peritoneum 5 5 Multiple sites 1 1 Regional 4 2 Liver 5 3 Single site 10 (23%) 8 (20%) Overall metastases 43 40 No. of cases (n) Open Lap. Follow-up
  90. 90. Colorectal Resection Summary <ul><li>No difference compared to open surgery in terms of average lymph node yield, specimen length, proximal margin, distal margin, 5-year disease free and overall survival </li></ul><ul><li>Shorter ICU and hospital stay, less blood loss and wound complications </li></ul><ul><li>Low incidence of port site recurrence and no difference open scar site recurrence </li></ul>
  91. 91. Laparoscopic Prostatectomy
  92. 92. Laparoscopic Prostatectomy Turk I et al, Eur Urol 2001;40:46-53 6.5 7 10 8 Hospital stay (mean), days 5.5 6.5 19 12 Catheter time (mean), days 0 0 20 2 Transfusion, % 145 140 250 185 Blood loss (mean), mL 0 0 0 0 Conversion, % 200 210 352 265 Operative time (mean), min Procedures 80-125 Procedures 50-79 Procedures 1-10 Total
  93. 93. Laparoscopic Prostatectomy Guillonneau B et al, Urologic Clinics of North America 28(1);189-202: Feb 2001 3 1 1 1 1 1 <ul><li>Complications </li></ul><ul><li>Rectal injury </li></ul><ul><li>Peritonitis </li></ul><ul><li>Ureteral injury </li></ul><ul><li>Urinary leakage </li></ul><ul><li>Obturator nerve injury </li></ul><ul><li>Anastomotic stricture </li></ul>5.2 Hospital stay (mean), days 4.2 7 7.8 Catheter time (mean), days 1.4 6 15 Transfusion, % 280 370 Blood loss (mean), mL 206 240 278 232 Operative time (mean), min Procedures 101-240 Procedures 51-100 Procedures 1-50 Total
  94. 94. Laparoscopic Prostatectomy Summary <ul><li>Laparoscopic prostatectomy is a safe procedure but has a steep learning curve </li></ul><ul><li>OR time, blood loss and transfusion, catheter time and length of hospital stay decrease as the surgeon becomes more experienced with the procedure </li></ul><ul><li>A prospective randomized trial comparing results of open and laparoscopic prostatectomy is required </li></ul>
  95. 95. Laparoscopic Inguinal Hernia Repair
  96. 96. Laparoscopic Inguinal Hernia Repair Outcomes Analyzed <ul><li>Cost </li></ul><ul><li>Operative time </li></ul><ul><li>Complications </li></ul><ul><li>Recurrence </li></ul><ul><li>Return to work </li></ul>
  97. 97. Inguinal Hernia Repair Cost
  98. 98. Inguinal Hernia Repair Operative Time
  99. 99. Inguinal Hernia Repair Complications
  100. 100. Inguinal Hernia Repair Recurrence
  101. 101. Inguinal Hernia Repair Return to Work
  102. 102. Laparoscopic Inguinal Hernia Repair Summary <ul><li>Higher cost </li></ul><ul><li>Longer OR time </li></ul><ul><li>Fewer complications </li></ul><ul><li>Low recurrence rate equivalent to open technique </li></ul><ul><li>Faster return to work </li></ul>
  103. 103. Open Versus Laparoscopic Surgery Summary X X Hepatectomy X Adjustable silicon GB X Roux-en-Y GBP X Peptic ulcer disease X X Billroth II gastrectomy X Nissen fundoplication X Paraesophageal hernia X X Esophagomyotomy X X Esophagectomy Needs additional trials No Yes Operation
  104. 104. Open Versus Laparoscopic Surgery Summary X Inguinal hernia repair X X Prostatectomy X X Colectomy for cancer X Small bowel obstruction X Splenectomy X Adrenalectomy X Palliative pancreatic ca. X X Distal pancreatectomy X Diagnostic laparoscopy / Sono pancreatic ca. X X CBDE Needs additional trials No Yes Operation

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