Laparoscopy Today

CONFERENCE REPORT: Single Port Access (SPA) Bilateral Oopherectomy and Hysterectomy

FROM THE ASIANAMERICAN MULTISPECIALTY SUMMIT III, FEBRUARY 6–9, 2008

STEPHANIE A. KING, MD, ATA ATOGHO, MD, ERICA PODOLSKY MD, PAUL G. CURCILLO II, MD

INTRODUCTION

Laparoscopic techniques have been widely accepted in gynecologic surgery since the 1960's facilitating easier dissection and visualization in the confines of the pelvis. A variety of procedures have become the standard of care making sometimes difficult open procedures safer and quicker. In the 1970's, the single arm operative scope was employed for tubal ligations. This scope required a single abdominal port of entry and allowed one rigid functional instrument to be inserted alongside the scope. Its use was limited in other procedures by the rigidity of the instruments. A single port access (SPA) surgical technique has been developed at our institution. Using one umbilical incision with articulating instrumentation, this technique reduces surgical scarring while broadening the variety of procedures to be performed through a single incision.

METHODS

Five SPA bilateral salpingoophorectomies were performed at our institution. A transverse umbilical incision following the medial fold was used as the portal of entry for all five procedures. A 5 mm trocar was inserted at the midline for a 5 mm scope. Skin flaps were raised laterally allowing for two 5 mm accessory trocars to be inserted inferior and lateral to the initial trocar. Using the accessory trocars the round ligament and infundibulopelvic ligaments were transected. The suspensory ligament, fallopian tube, and mesosalpinx were then dissected. The ovary was removed through the umbilicus. The same procedure was repeated on the opposite side. The fascia was closed using 0 Vicryl and the skin with a running 4 Vicryl subcuticular stitch.

RESULTS

All five women tolerated the procedure well. Operative time and length of stay were comparable to the traditional multiple port procedures. Postoperative recovery was uneventful. No complications were encountered. Cosmetic results were excellent with scars being hidden in the umbilicus.

DISCUSSION

Gynecologic surgery was among the first surgical specialties to adopt minimally invasive surgery. Improved visualization allows for easier dissection of the tight pelvic anatomy. Laparoscopy also allows for reduction of surgical scarring.

In the 1970's the single arm operative scope further reduced operative scarring by utilizing a single incision at the umbilicus. This technique was limited because only one instrument could be inserted alongside the scope. A single eyepiece was used for visualization restricting this procedure to single operator.

Single port access (SPA) surgery uses the umbilicus for a single portal of entry into the abdominal cavity. In more difficult dissection, articulating instruments allowed us to maintain the procedure as a single port technique. The technique of dissection is the same as being done in standard pelvic minimally invasive surgeries. Although the articulating instruments were not necessary for all procedures their availability facilitated difficult dissections.

JOURNAL WATCH: JSLS Transplantation

Laparoscopy in Transplantation. Krajewski E et al. 2006;10:426-431 • This report reviews the use of laparoscopic intervention in a variety of disease states following solid organ transplantation.

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JOURNAL WATCH: Gynecological Surgery Adnexal Masses in Adolescent Females

Laparoscopic Management of Adnexal Masses in Adolescent Females: a Multidisciplinary Approach. Woo YL et al. 2005;2:227-230 • Woo et al present 3 cases in which adolescent females were treated laparoscopically for adnexal masses. They point out that while adolescents should not be treated as children, their management poses a different set of problems from that of adults. Within the adolescent age group pathology (ovarian malignancy vs cysts and benign tumors) varies; type of malignancy varies; patients may require different tests (transvaginal ultrasound may not be an option due to an intact hymen and additional tumor markers may need to be requested). The authors have found that a multidisciplinary approach including the adolescent gynecologist and the gynecology oncologist works well for managing adnexal masses.

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JOURNAL WATCH: Surg Endosc Impact of Resident's Seniority

The Impact of a Resident’s Seniority on Operative Time and Length of Hospital Stay for Laparoscopic Appendectomy • Shabati M, Rosin D, Zmora O, et al. 2004;18:1328-1330. Reviews patient records for 341 appendectomies by residents alone. Operating times, conversion rates, and lengths of stay for surgical teams lead by residents with 3 or fewer years were compared with those lead by residents with 3 or more years and with those consisting of two residents with 3 or fewer years.

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JOURNAL WATCH: J Am Coll Surg Psychologic Problems

Some Psychologic Problems Seen in Surgery • Blacher RS. J Am Coll Surg(2003)196:301-305. The author takes readers through the preoperative, intraoperative, and postoperative phases of surgery from a patient’s point of view, discusses patient coping mechanisms, and addresses special issues concerning transplantation and cardiac surgery.

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Evolving Techniques in Cardiac Surgery

LAPAROSCOPY UPDATE

FRANCIS J. PODBIELSKI, MD, FACS

The first successful “open heart” surgical procedures were those performed for congenital abnormalities. Blalock and Taussig described a palliative procedure bearing their name for the treatment of cyanotic heart disease in 1945 [1]. Dr. John Gibbon performed the first intracardiac operation with the aid of cardiopulmonary bypass in 1953 [2]. Coronary revascularization for ischemic heart disease was popularized in the late 1960s. Approaches to each of these types of procedures have changed drastically with the development of new technologies. Within the scope of this review we will discuss the most frequently performed cardiac operations in the United States today, namely adult coronary revascularization and valve replacement or repair.

The gold standard against which new operative techniques are judged is a procedure performed via a full median sternotomy with central cardiopulmonary bypass. After cooling the body and heart via the pump perfusate, the aorta is cross-clamped; and antegrade, hyperkalemic solution (cardioplegia) is used to arrest the heart. This is frequently supplemented with retrograde cardioplegia and topical cold solution to the outer surface of the myocardium. Saphenous vein and/or internal thoracic arterial conduits are used to shunt blood from the ascending aorta to vessel targets on the heart. Valve replacement is accomplished by aortotomy or atriotomy. Upon completion of the bypass, repair, or replacement, the heart and body are rewarmed, the hyperkalemic coronary perfusate washed out, and the heart allowed to slowly resume its function as a pump.

As coronary revascularization became more popular, variations on the sequence of events and cardioplegic components (ie, cross-clamp removal, proximal graft anastomosis, warm vs. cold cardioplegia, blood vs. crystalloid cardioplegia) were each championed by their advocates. With the advent of new pharmacologic agents and monitoring techniques, surgeons began to re-examine the role of cardiopulmonary bypass in performing open-heart operations. One of the first “minimally invasive” techniques to be introduced was minimally invasive direct coronary artery bypass (MIDCAB). In its infancy, MIDCAB entailed a left anterior thoracotomy (usually the 4th interspace), through which the internal thoracic artery could be mobilized from the undersurface of the chest wall. After the pericardium was opened and traction sutures were placed, the heart could be rolled in the field of view and the mid-portion of the left anterior descending artery visualized. Common hand-held instruments were used to stabilize the heart. Bradycardia or intermittent cardiac arrest was achieved pharmacologically and a standard hand-sewn anastomosis performed.

Various vessel occluders, suction devices, and gas delivery systems were tried to maintain a bloodless field during the anastomosis. Currently, there are several commercially available stabilization devices that focally stop virtually all movement of the heart. This coupled with a moisturized gas delivery system enables optimal results. Drawbacks of MIDCAB include a limited number and range of target vessels [3]. Some studies have actually shown increased pain, greater tissue destruction, and an increase in the rate of wound infections with this technique compared to off-pump coronary artery bypass (OPCAB) [4].

OPCAB encompasses a variety of approaches to coronary bypass grafting with one central feature – no cardiopulmonary bypass. In addition to its well-known deleterious effects on blood components and end organ function (ie, liver, pancreas), cardiopulmonary bypass has also been shown to cause long-term cognitive changes. Some investigators have actually shown cardiopulmonary bypass to be an independent risk factor for higher morbidity or mortality [5,6]. Full sternotomy OPCAB procedures offer virtually the same range of exposure as their on-pump counterparts in light of left main coronary artery disease [7] and poor preoperative left ventricular function [8]. Off-pump techniques are equal in success and safety even in patients requiring emergent procedures [9] and those undergoing concomitant carotid endarterectomy [10].

Partial sternotomy and lateral thoracotomy approaches have been described with equal success. Thoracoscopic coronary anastomosis has been proven feasible, but tremor amplification via a long instrument made this technique difficult and time-consuming– until the introduction of robotics. Mechanical dampening (if not complete) ablation of human tremor and added degrees of freedom in motion have been a major breakthrough in the development of totally endoscopic coronary revascularization.

A technique developed in parallel to the surge in robotic technology has been peripheral cardiopulmonary bypass with intraaortic balloon occlusion. Using femoral vascular access, venous and arterial lines are placed. Employing special catheters and cannulae, antegrade cardioplegia can be delivered and cardiac arrest achieved. While occlusion balloon migration and aortic dissection plagued initial procedures performed with this technique, refinement of the technology and improved patient selection have overcome these issues. The hybrid technique of peripheral cardiopulmonary bypass (if needed) and robotic assistance in performing coronary anastomoses has arrived and awaits acceptance into the mainstream. Centers developing this technique usually begin with isolated left anterior descending (LAD) coronary artery to left internal thoracic artery (LITA) anastomoses with robotic assistance via a median sternotomy [11] until they progress to a total endoscopic operation.

Minimally invasive approaches to aortic or mitral valve operations and other procedures are varied. Total endoscopic atrial septal defect closure is now a reality [12] with excellent results. A popular approach to isolated aortic valve replacement is manubriotomy (upper sternotomy) and standard aortic and atrial cannulation. The entire procedure is performed through the smallest possible incision. Similarly, mitral valve repair or replacement (again with standard cardiopulmonary bypass techniques) can be performed through a small anterior or lateral right thoracotomy. Application of thoracoscopy (and now robotics) to this procedure has increased the level of repair complexity that can be performed. In one of the larger series, over 75% of coronary artery bypass graft (CABG) and mitral valve repair or replacement patients underwent an entirely endoscopic operation with results comparable to standard procedures [13].

In summary, the tools and technology are in place to inaugurate a new era in cardiac surgery. Acknowledging that no one operation is right for every patient, it remains the responsibility and duty of the surgeon to learn these new techniques so his or her patients can benefit from what others have so long labored to bring to fruition. Forward-thinking, proactive surgeons need to ensure that no subspecialty is left behind in the technology revolution.

This article is a synopsis of Dr Podbielski’s presentation at Endo Expo 2002.

Address reprint requests to: Francis J. Podbielski, MD, FACS, 67 Belmont St, Worcester, MA 01605-2657, Telephone: 508 334 8996, Fax: 508 334 6296, E-mail: Podbielf@ummhc.org

Francis J. Podbielski, MD, completed a general surgery residency at Columbus Hospital in Chicago and a cardiothoracic surgery fellowship at the University of Illinois at Chicago. Dr Podbielski is currently an assistant professor of thoracic surgery at the University of Massachusetts Medical Center in Worcester. He is a Fellow of the American College of Chest Physicians and serves as the Chair of the SLS Cardiac Surgery subcommittee. The application of minimally invasive techniques to general and thoracic surgery and the physiologic effects of lung volume reduction surgery on cardiac performance are Dr Podbielski’s primary research interests.

References

1.    Blalock A, Taussig H. The surgical treatment of malformation of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA. 1945;128:189.

2.    Gibbon JH Jr. Application of a mechanical heart and lung apparatus in cardiac surgery. Minn Med. 1954;37:171.

3.    Gersbach P, Imsand C, von Segesser LK, et al. Beating heart coronary artery surgery: is sternotomy a suitable alternative to minimally invasive technique? Eur J Cardiothorac Surg. 2001;20:760-764.

4.    Detter C, Reichenspurner H, Boehm DH, et al. Single vessel revascularization with beating heart techniques– minithoracotomy or sternotomy? Eur J Cardiothorac Surg. 2001;19:464-470.

5.    Calafiore AM, Di Mauro M, Contini M, et al. Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome. Ann Thorac Surg. 2001;72:456-463.

6.    Hernandez F, Cohn WE, Baribeau YR, et al. In-hospital outcomes of off-pump versus on-pump coronary artery bypass procedures: A multicenter experience. Ann Thorac Surg. 2001;72:1528-1534.

7.    Dewey TM, Magee MJ, Edgerton JR, et al. Off-pump bypass grafting is safe in patients with left main coronary disease. Ann Thorac Surg. 2001;72:788-792.

8.    Arom KV, Emery RW, Flavin TF, et al. OPCAB surgery, a critical review of two different categories of preoperative ejection fraction. Eur J Cardiothorac Surg. 2001;20:533-537.

9.    Varghese D, Yacoub MH, Trimlett R, et al. Outcome of non-elective coronary artery bypass grafting without cardio-pulmonary bypass. Eur J Cardiothorac Surg. 2001;19:245-248.

10.    Youssuf AM, Karanam R, Prendergast T, et al. Combined off-pump myocardial revascularization and carotid endarterectomy: early experience. Ann Thorac Surg. 2001;72:1542-1545.

11.    Damiano RJ, Tabaie HA, Mack MJ, et al. Initial prospective multicenter clinical trial of robotically-assisted coronary artery bypass grafting. Ann Thorac Surg. 2001;72:1263-1269.

12.    Torracca L, Ismeno G, Alfieri O. Total endoscopic computer-enhanced atrial septal defect closure in six patients. Ann Thorac Surg. 2001;72:1354-1357.

13.    Mohr FW, Falk V, Diegeler A, et al. Computer-enhanced “robotic” cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg. 2001;121:842-853.

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The Status of Laparoscopic Surgery for Colon Cancer: 2002

LAPAROSCOPY UPDATE

ARTHUR P. FINE, MD, FACS

Over the past year, the percentage of colon surgeries performed laparoscopically has increased yet still remains a small fraction of all large bowel procedures performed. It has been estimated that last year 5% of all colon procedures were performed laparoscopically. This year, industry analysts estimate that 8% are accomplished laparoscopically and 7-9% by hand-assisted laparoscopic technique [1]. Despite an increasing body of literature suggesting an equivalency for cancer surgery, feasibility for resection of benign disease, and an improvement of recovery of physical and GI tract activity with a decreased length of hospital stay, most colon surgery is performed by open technique. The reasons may be multiple, including the technical difficulty of the procedure, the fact that most colon resections are performed for malignancy (and that the results of the large multi-institutional studies are pending), and the lack of demand by the public which, as much as any other factor, drove the rapid availability of laparoscopic cholecystectomy. It will be the eventual findings of the effectiveness of laparoscopic surgery for curative resection of colon cancer that will dictate its acceptance.

Multiple studies of laparoscopic colon cancer surgery have been released this year. Most have not been both randomized and prospective nor had sufficient numbers to reach statistical significance. The follow-up periods for these studies have varied between 3 and 5 years.

A study by Franco-Osario [2] of 140 laparoscopic patients showed 3-year survivals for stages I, II, and III of 3.4%, 92.4% and 77.8% respectively. Bertolino [3] also evaluated 3-year survival for curative resection finding survivals of 100% for stage I and 87.7% and 76% for stage II and III. Feliciotti [4] compared 102 rectal cancer patients having both open and laparoscopic surgery. Survival probability for laparoscopic versus open procedures was 80.9% and 75.6% overall, 79% and 75% for stage II, and 69.2% and 66.7% for stage III. The same group [5] also compared 156 colon cancer patients who underwent either laparoscopic surgery or open procedures at 69 months. The cumulative survival probability was 89.7% for laparoscopic surgery and 86.1% open procedures. Lezoche [6] studied a group of 300 patents, still not enough to reach statistical significance; however, there was a trend toward a survival advantage for laparoscopic surgery (cumulative survival probability of 93.4% for laparoscopic versus 86% for open procedures). Lujon’s study [7] of 102 patients, however, compared their results with a benchmark. The results for laparoscopic versus open versus benchmark were 73%, 75%, 70% for stage I; 64%, 65%, 60% for stage II; 55%, 46%, 44% for stage III; and 0%, 11%, 7% for stage IV. While again not statistically significant, there was a trend for improved stage III survival for laparoscopic surgery. A study by Champault [8] also showed equivalence between the two procedures without reaching significance (cumulative survival probability of 63.1% for laparoscopic versus 59.1% for open procedures).

Lezoche’s data broken down by site seems to show a definite benefit for laparoscopic surgery (right colectomy: 86.5% for laparoscopic versus 81.8% for open and left colectomy: 97.1% for laparoscopic versus 88.7% for open). Even more interesting is when this group looked at their stage III survival. In a separate report of stage III patients, survival probability for right colectomy was 81.2% for laparoscopic surgery versus 66.7% for open procedures and was 95.0% for laparoscopic surgery versus 72.3% for open procedures for left colectomy.

The most significant paper of the past year was by Lacy [9]. It was a prospective, randomized study of 219 patients and did reach statistical significance at 43 months. The cancer related mortality for laparoscopic surgery was 9% and for open surgery 21% (p = 0.02). The statistical significance was entirely due to the improved stage III patient survival for laparoscopic patients.

The findings in Lacy’s paper are unique in this year’s significant studies in that they reached statistical significance; however, they are similar to the trends towards improved overall survival at 3-5 years for laparoscopic surgery primarily reflected in the stage III population. Is there significance for this?

Most patients who succumb to malignant disease do so because of metastatic tumor burden. There have been many studies on local or port site recurrences in laparoscopic colon cancer surgery which have as their most consistent finding that surgical technique is the greatest contributor to whether or not local disease recurrence is kept to a minimum. If local and port site recurrence is controlled, and that is painting with a rather broad brush, then these studies at least suggest that laparoscopic surgery may have a more favorable effect on the occult micrometastasis present in stage III malignancy than a comparable open procedure.

Rocca et al [10] evaluated levels of vascular endothelial growth factor (VEGF) in patients undergoing open colon cancer surgery. VEGF is a potent stimulator of tumor angiogenesis [11], without which micrometastasis cannot grow beyond several millimeters in size to become a clinically significant and detectable metastasis. Their data shows circulating levels of VEGF increasing from pre-op levels of 1.32 to 1.61 on postoperative day 2 and 2.43 on postoperative day 5.

A study by Fine (unpublished data) compared an unselected group of patients undergoing colon surgery either by laparoscopic or open technique and evaluated the data for a correlation between total incision length and pre- and postoperative levels of VEGF (The difference in the appearance of the data reflects Rocca’s dividing the VEGF level in pg/cc by the patient’s platelet count). In patients with a total incision length of 12 cm or greater, pre- and postoperative levels were 70 pg/cc and 625 pg/cc respectively. If less than 12 cm, the levels were 44 pg/cc and 90 pg/cc. Data in neither study had sufficient volume to teach statistical significance; however in Fine’s study, multivariate analysis revealed that in the subgroup of patients receiving perioperative blood transfusions, incision length alone accounted for 50% of the pre- and postoperative rise in VEGF.

While the large multi-institutional studies have yet to report what will be regarded as the greatest body of evidence to judge the relative effectiveness of laparoscopic colon cancer surgery, this year, as in the past few years, studies have consistently shown a rough, albeit usually a not significant benefit for this procedure. The consistent finding of improved stage III survival raises the question of whether “wounding” is a factor in how quickly solid tumors and their metastasis recur and whether open surgery hastens the appearance of distant occult metastasis compared to laparoscopic surgery.

This article is a synopsis of Dr Fine’s presentation at Endo Expo 2002.

Address reprint requests to: Arthur P. Fine, MD, FACS, Jefferson Regional Medical Center, South Hills Medical Building, 575 Coal Valley Rd, Ste 372, Jefferson Hills, PA 15025, Telephone: 412 469 7035, Fax: 412 469 7037, E-mail: arthur_fine@msn.com

Arthur P. Fine, MD, trained in general surgery at McKeesport Hospital in Pennsylvania. Before entering private practice, Dr Fine joined the US Air Force where he served as Chief of Surgery at Laughlin Air Force Base until he was discharged, and he began his private practice. He first performed laparoscopic colon surgery in 1992. Since then he has continued clinical research and has reported on the results of laparoscopic surgery in a variety of clinical settings as well as the biochemical changes that may be responsible for the improvements demonstrable to the patient.

References

1.    IHS Health Group (Medical Data International). US Surgical Procedure Volumes: 2001. Englewood, Colo: IHS Health Group (Medical Data International); 2001.

2.    Franco-Osario JD, Garcia-Molina FJ, Dominguez-Adame E, Ortegon-Castellano B, Marquez-Platero R, Mateo-Vallejo F, Gonzalez-Ruiz M, Medina-Diez J. Surg Endosc. 2002;16(suppl):s529.

3.    Zorzi D, Bertolino F, Bima C, Calgaro M, Ribero D, Capussotti L. Curative resection for colorectal cancer: laparoscopy vs. open surgery; preliminary results of a prospective not randomized trial. Surg Endosc. 2002;16(suppl):s178.

4.    Feliciotti F, Guerrieri M, Raganini AM, De Sanctis A, Campagnacci R, Lezoche E. Long-term results of laparoscopic vs. open resection for rectal cancer. Surg Endosc. 2002;16(suppl):s181.

5.    Feliciotti F, Guerrieri M, Paganini AM, De Sanctis A, Campagnacci R, Lezoche E. Laparoscopic vs. open colonic resections for cancer: long-term results on 266 unselected patients. Surg Endosc. 2002;16(suppl):s195.

6.    Lezoche E, Feliciotti F, Paganini AM, Guerrieri M, De Sanctis A, Minervini S, Campagnacci R. Laparoscopic vs. open hemicolectomy for colon cancer. Surg Endosc. 2002;16(4):557-602.

7.    Lujan HJ, Plascencia G, Jacobs M, Viamonte M, Hartman RF. Long-term survival after laparoscopic colon resection for cancer. Dis Colon Rectum. 2002;45(4):291-500.

8.    Champault GG, Barrat C, Raselli R, Elizoldo A, Catheline J-M. Laparoscopic vs. open surgery for colorectal carcinoma. Surg Laparosc Endosc Percutan Tech. 2002;12(2):88-95.

9.    Lacy AM, Garcia-Valdecasa JC, Delgado S, Castelis A, Taura P, Pique JM, Visa J. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial. Lancet. 2002;359:2224-2229.

10.    Rocca A, Lucca F, Sandri MT, Zorzino L. Andrenoni B, de Braud F. Vascular endothelial growth factor: serum levels after surgery for colorectal cancer. Proc AACR. 2001;42.

11.    Retsky M, Demicheli R, Hrushesky W. Premenopausal status accelerates relapse in node positive breast cancer: hypothesis links angiogenesis, screening controversy. Breast Cancer Res and Treatment. 2001;65:217-224.

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