Trocar Site Tumour Recurrence In Laparoscopic Surgery India

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  • Trocar Site Tumour Recurrence In Laparoscopic Surgery India

    1. 1. TROCAR SITE TUMOUR RECURRENCE IN LAPAROSCOPIC SURGERY SURGERY AUSTRALIA PETER HEWETT
    2. 4. TROCAR SITE RECURRENCE <ul><li>GALLBLADDER </li></ul><ul><li>PANCREAS </li></ul><ul><li>STOMACH </li></ul><ul><li>BOWEL </li></ul><ul><li>LIVER </li></ul><ul><li>OVARIAN </li></ul>
    3. 5. TROCAR SITE RECURRENCE <ul><li>INITIAL REPORTS OF UP TO 30% OF OPERATIVE CASES! </li></ul><ul><li>THEORIES WERE OF CELL DISSEMINATION BY CO2 INSUFFLATION OR MECHANICAL TRANSMISSION OF CELLS TO TROCAR SITES. </li></ul>
    4. 6. INCISIONAL RECURRENCE <ul><li>2,439 PATIENTS OVER A 30 YEAR PERIOD </li></ul><ul><li>1,603 CURATIVE RESECTION </li></ul><ul><li>11 (0.45%) ISOLATED RECURRENCE IN WOUND. </li></ul><ul><li>(HUGHES et al. Dis Colon Rectum. 1983) </li></ul>
    5. 7. INCISIONAL RECURRENCE <ul><li>21,500 cases from 58 Australian Surgeons. </li></ul><ul><li>Wound recurrence .186% </li></ul><ul><li>Wound drain site recurrence .048% </li></ul>
    6. 8. Wound recurrence 0 / 102 1/ 106 Lacy (median 3.6 yrs) 0 / 170 0 / 167 Leung (median 4.1 yrs) 1 / 428 (0.2%) 2 / 435 (0.5%) COST (median 4.4 yrs) Open Laparoscopic Trial
    7. 9. Overall cancer recurrence 28 / 102 18 / 106 Lacy (median 3.6 yrs) 30 / 170 37 / 167 Leung (median 4.1 yrs) 84 / 428 (20%) 76 / 435 (17%) COST (median 4.4 yrs) Open Laparoscopic Trial
    8. 10. TROCAR OR PORT SITE RECURRENCE <ul><li>BASIC EXPERIMENTS TO DETERMINE MECHANISMS </li></ul><ul><li>FILTERING OF EXHAUST CO 2 </li></ul><ul><li>EXAMINATION OF LAPAROSCOPIC INSTRUMENTS & TROCARS. </li></ul>
    9. 13. TROCAR OR PORT SITE RECURRENCE 0 minutes 30 minutes
    10. 14. LAP BABCOCK
    11. 15. LAP TROCAR
    12. 16. TROCAR SITE
    13. 17. EFFECT OF BLOOD <ul><li>RADIOLABELLED CELLS WERE COMBINED WITH BLOOD. </li></ul><ul><li>INSERTED INTO A PIG ABDOMEN. </li></ul><ul><li>CELLS TRAPPED IN A CLOT MATRIX. ALL TROCAR SITES AND INSTRUMENTS WERE CONTAMINATED WITH A DESUFFLATED ABDOMEN. </li></ul>
    14. 18. INSUFFLATION VOLUME* <ul><li>CELL MOVEMENT AROUND THE PERITONEAL CAVITY IS INCREASED AS THE VOLUME OF INSUFFLATION INCREASES BUT THIS HAS NO EFFECT ON TROCAR OR TROCAR SITE CONTAMINATION. </li></ul>
    15. 19. INSUFFLATION PRESSURE* <ul><li>INSUFFLATION PRESSURE HAD AN INVERSE RELATIONSHIP TO TROCAR & TROCAR SITE CONTAMINATION WITH MALIGNANT CELLS. </li></ul>
    16. 20. TIMING OF LAVAGE <ul><li>SIGNIFICANTLY GREATER NUMBER OF CELLS ON TISSUE RESECTED IN THE POSTOP LAVAGE GROUP. </li></ul><ul><li>SIGNIFICANTLY GREATER NUMBER OF CELLS IN THE PREOP LAVAGE FLUID. </li></ul><ul><li>CELL CONTAMINATION OF RESECTED TISSUES DECREASED BY PREOPERATIVE LAVAGE. </li></ul>
    17. 21. TROCAR COMPOSITION* <ul><li>IN VIVO & IN VITRO MODELS </li></ul><ul><li>TUMOUR CELLS ADHERE MORE TO METAL THAN PLASTIC TROCARS </li></ul><ul><li>SURFACE ELECTROSTATIC CHARGE OR IRREGULAR SURFACE </li></ul>
    18. 22. ELECTRON MICROSCOPY METAL
    19. 23. TROCAR COMPOSITION* <ul><li>TROCAR DISPLACEMENT LEADS TO AN INCREASED CELL NUMBER AT TROCAR SITES. </li></ul>
    20. 24. FACTORS IN TROCAR SITE CONTAMINATION. <ul><li>MAINTAIN INSUFFLATION PRESSURE </li></ul><ul><li>DECREASE PREOP TUMOUR LOAD </li></ul><ul><ul><li>PREOP CYTOCIDAL LAVAGE. </li></ul></ul><ul><ul><li>WASHING INSTRUMENTS & TROCARS DURING & AT END OF OP. </li></ul></ul><ul><li>MINIMIZE INTROPERATIVE BLEEDING </li></ul><ul><li>USE NON METAL TROCARS </li></ul>
    21. 25. Oncologic Principles <ul><li>Trocars sutured into position </li></ul><ul><li>Luminal cytocidal washout </li></ul><ul><li>Peritoneal washout </li></ul><ul><ul><li>?timing </li></ul></ul><ul><ul><li>500ml of 10% betadine </li></ul></ul><ul><li>Wound protector </li></ul><ul><li>Cytocidal to port sites </li></ul>

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