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Open Versus Laparoscopic Surgery
What Is A Myth And What Is Not !
George Ferzli, MD, FACS
Open Versus Laparoscopic Surgery
• Esophageal
• Gastric
• Liver
• Biliary
• Pancreatic
• Adrenal
• Splenic
• Bowel• Prostate• Hernia
Laparoscopic Esophageal Surgery
EsophagectomyEsophagomyotomyParaesophageal Hernia RepairNissen Fundoplication
Minimally Invasive Esophagectomy
• Is it safe and does it have any advantages over the open techniques?
Nguyen NT et al, Arch Surg. 2000;135:920-925
Study Design• Retrospective comparison of 3 methods of
esophagectomy: combined thoracoscopic and laparoscopic (TM/LE), transthoracic (TT), and blunt transhiatal (THE)
• Setting: University Medical Center• Patients: – TM/LE: 18 consecutive patients (10/9/98 to
1/19/00); data collected prospectively – TT and THE: 16 and 20 patients respectively
(6/1/93 to 8/5/98); data collected from a retrospective chart review
Esophagectomy
TM/LE
(n=18)
TT
(n=16)
THE
(n=20)
Operative time, min 364+73* 437+65 391+144
Blood loss, mL 297+233* 1046+792 1142+785
Intraop. transfusion, U 0.3+0.7* 1.8+2.2 2.9+3.1
ICU stay, days 6.1+11.3* 9.9+16.3 11.1+15.7
Hospital stay, days 11.3+14.2* 23.0+22.3 22.3+16.1
No. of nodes removed 10.8+8.4 6.3+6.0 6.9+5.4
* P<.05, compared with TT and THE groups,Mann-Whitney Test
Nguyen NT et al, Arch Surg. 2000;135:920-925
EsophagectomyComplication TM/LE (n=18) TT (n=16) THE (n=20)
GI bleeding 0 1 (6) 0
Anastomotic leak 2 (11) 2 (12) 2 (10)
Gastric conduit ischemia 0 1 (6) 0
Pulmonary embolism 1 (6) 0 1 (5)
Respiratory failure 2 (11) 3 (19) 3 (15)
Delayed gastric emptying 1 (6) 0 0
Chylous ascites 0 0 1 (5)
Hoarseness 0 0 4 (20)
Intra-abdominal abscess 0 1 (6) 0
Tracheal-gastric fistula 1 (6) 0 0
Nguyen NT et al, Arch Surg. 2000;135:920-925
Minimally Invasive EsophagectomySummary
• It is safe as the complication rate is comparable to open surgery
• It is effective as the lymph node yield is comparable to open surgery
• 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
Minimally Invasive Esophagomyotomy
•How does the morbidity and outcome compare to the open technique?
Dempsey et al, Surg Endosc (1999) 13: 747-750
Minimally Invasive EsophagomyotomyStudy Design
• Retrospective analysis• Open myotomy: 10 patients from a pool of
20 (10 lost to follow-up) operated upon between Aug.1988 and Jan.1996
• Laparoscopic esophagomyotomy and Dor anterior fundoplication: 12 patients
• Mean follow-up: 60 months in open group and 16 months in laparoscopic group
Dempsey et al, Surg Endosc (1999) 13: 747-750
Esophagomyotomy
Laparoscopic (n=12) Open (n=10)
Operating time, min 137+25 122+32
Blood loss, mL 50+26* 220+156
Mucosal perforation 2/12 2/10
Parenteral narcotic, days 2.1+1.0* 5.3+1.4
Parenteral narcotic, mg 18+2* 39+7
Hospital stay, days 2.7* 8.8
Improved dysphagia 92% 90%
Overall satisfaction 84% 80%
Post-op GERD 25% 40%
Days off work post-op 19+16* 85+60
*P<.05 Dempsey et al, Surg Endosc (1999) 13: 747-750
Minimally Invasive EsophagomyotomySummary
• Symptomatic improvement and high patient satisfaction comparable to the open procedure
• Significantly less morbidity: less intra-op blood loss, post-op pain and parenteral narcotic use, shorter hospital stay and fewer days off from work
Laparoscopic Paraesophageal Hernia Repair
•Is it associated with higher recurrence compared to open repair ?
•Should mesh be used ?
•How does symptomatic outcome compare to open repair ?
Hashemi et al, J Am Coll Surg 2000;190:553-561Frantzides CT et al, Surg Endosc (1999) 13: 906-908
Paraesophageal Hernia RepairStudy Design
• Retrospective review of 54 patients who underwent repair of large type III hiatal hernia between 1985 and 1998
• Laparotomy – 13, Thoracotomy – 14, Laparoscopy – 27
• Follow-up: Symptomatic outcomes at median 24 months, integrity of repair using video esophagogram at median 27 months
Hashemi et al, J Am Coll Surg 2000;190:553-561
Paraesophageal Hernia RepairTechnique and Recurrence
Open Surgery•Reduction of hernia
•Complete excision of sac
•Primary closure of crura
•Antireflux procedure
Laparoscopic Surgery•Reduction of sac
•No excision of sac
•Primary closure of crura
•No mesh or gastropexy0
10
20
30
40
50
% R
ecur
renc
e
Laparoscopic Repair (n=21) Open Repair(n=20)
Hashemi et al, J Am Coll Surg 2000;190:553-561
P<.001
Paraesophageal Hernia RepairSymptomatic Outcomes
0
20
40
60
80
100
Excellent/Good Fair/Poor Satisfied
% p
atie
nts
Laparoscopic (n=26) Open (n=25)
Hashemi et al, J Am Coll Surg 2000;190:553-561
Paraesophageal Hernia RepairTechnique and Recurrence
0
5
10
15
20
% R
ecur
renc
e
PTFE mesh (n=17) No mesh (n=18)
Mesh vs. No Mesh
•Prospective randomized trial
•Hiatal defect >8cm diameter
•Excision of sac, primary closure of crura, Nissen fundoplication in all cases
•Randomized intra-op to mesh vs. no mesh
•Follow-up for 6 months
Frantzides CT et al, Surg Endosc (1999) 13: 906-908
16%
0%
Paraesophageal Hernia RepairSummary
• Symptomatic outcomes: Similar in both groups. Excellent or good in 76% patients after laparoscopic and 88% after open repair
• Hernia recurrence: Significantly higher in laparoscopic group (42%, 9 of 21) compared to open group (15%, 3 of 20)
• Use of mesh reduces paraesophageal hernia recurrence significantly
Laparoscopic Nissen Fundoplication
• Is there a higher incidence of complications ?
• How are the functional results ?
Laine S et al, Surg Endosc (1997) 11: 441-444Bais JE et al, Lancet 2000; 355: 170-74
Laparoscopic Nissen FundoplicationStudy Design
• Prospective randomized trial• 110 consecutive patients with prolonged
symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic and 55 to open repair
• Follow-up: Post-op recovery, complications and outcome at 3- and 12-months were compared
Laine S et al, Surg Endosc (1997) 11: 441-444
Nissen FundoplicationComplications
Complication Lap. Open
Esophageal perforation 2 0
Intraoperative bleeding 1 0
Splenic bleeding and splenectomy 0 2
Pneumonia 0 1
Subphrenic abscess 0 1
Wound infection 0 3
Laine S et al, Surg Endosc (1997) 11: 441-444
0
5
10
15
20
25
Open Lap
% ti
me
mea
n p
H<
4
Pre-op 3 mo post-op 1 yr post-op
Nissen FundoplicationProportion of Time (%) Mean pH<4
Laine S et al, Surg Endosc (1997) 11: 441-444
Nissen FundoplicationMean LES Pressure
Laine S et al, Surg Endosc (1997) 11: 441-444
0
5
10
15
20
25
30
Open Lap
Mea
n LE
S p
ress
ure
Pre-op 3 mo post-op 1 yr post-op
Nissen FundoplicationSymptoms 3 Months After the Operation
Open
No symptoms Bloating wound painHeartburn Upper abd. Pain Dysphagia
Laparoscopic
No symptoms Bloating wound painHeartburn Upper abd. Pain Dysphagia
Laine S et al, Surg Endosc (1997) 11: 441-444
53%16%
22%
2%
4%
2%56%
18%
22%
4%
(n=55) (n=55)
Nissen FundoplicationSymptoms 12 Months After the Operation
Open
No symptoms Bloating HeartburnUpper abd. Pain Dysphagia
Laparoscopic
No symptoms Bloating HeartburnUpper abd. Pain Dysphagia
Laine S et al, Surg Endosc (1997) 11: 441-444
70% 83%
17%13%3%
7%
7%
(n=55) (n=55)
Laparoscopic Nissen FundoplicationStudy Design
• Interim analysis of a prospective randomized trial comparing open and laparoscopic Nissen fundoplication
• 46 patients in open group and 57 in laparoscopic group operated before interim analysis
• Follow-up: 3 months• Primary endpoints: Dysphagia, recurrent GERD, and
intrathoracic hernia• Technical observation: No bougie used in either group
Bais JE et al, Lancet 2000; 355: 170-74
Laparoscopic Nissen FundoplicationResults
Laparoscopy
(n=57)
Laparotomy
(n=46)
Persistent dysphagia* (>3 months)
7 0
Recurrent GERD at 3 months
2 1
Intrathoracic herniation 2 0
Total** 11 1
*p=0.016, **p=0.011 (Fisher’s exact test)
Bais JE et al, Lancet 2000; 355: 170-74
Laparoscopic Nissen FundoplicationSummary
• Safe and feasible procedure• Complications are few and functional results
(post-op pH, LES pressure, symptoms) are good if not better than open surgery
• 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
Laparoscopic Gastric Surgery
Billroth I Gastrectomy Surgery for Perforated Peptic Ulcer Bariatric Surgery
Laparoscopy-Assisted Billroth I Gastrectomy
•Is it safe ?
•Is it useful for patients with early gastric cancer ?
•Does it have advantages over open surgery ?
Adachi Y et al, Arch Surg. 2000;135:806-810
Billroth I GastrectomyStudy Design
• Retrospective review of operative data, blood analyses and post-op clinical course
• Setting: University hospital in Japan
• 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 Adachi Y et al, Arch Surg. 2000;135:806-810
Billroth I GastrectomyLaparoscopic (n=49) Open (n=53)
Blood loss, mL 158 302
Leukocyte count, day1 9.42 11.14
Leukocyte count, day 3 6.99 8.22
Granulocyte count, day1 7.28 8.9
C-reactive protein, day 7, mg% 2.91 5.19
Interleukin-6, day 3, U/mL 4.2 26
Serum albumin, day 7 35.6 33.9
Analgesics, times given 3.3 6.2
Time to liquid diet, days 5.0 5.7
Post-op hospital stay, days 17.6 22.5
Weight loss on day 14 5.5% 7.7%
Time to first flatus, days 3.9 4.5P<.05, all features Adachi Y et al, Arch Surg. 2000;135:806-810
Billroth I Gastrectomy
Laparoscopic
(n=49)
Open
(n=53)
Operation time, min 246 228
Proximal margin, cm 6.2 6.0
No. of lymph nodes 18.4 22.1
Complication rate 8% 21%
P=NS, all features Adachi Y et al, Arch Surg. 2000;135:806-810
Laparoscopy-Assisted Billroth I Gastrectomy
Summary
• It is a safe procedure• 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)
• Prospective-randomized trial with long-term follow-up required
Perforated Peptic Ulcer
Perforated Peptic UlcerTechniques
• Simple closure Memon MA et al, Br. Med. J. 86:106-107, 1993
• Omental patchSo JB et al, Surg Endosc, 10:1060-63, 1996
• Fibrin glue Mouret P et al, Br J Surg, 77:1006,1990
• Placement of oxidized cellulose gauzeTate JJT et al, Br J Surg, 80:35, 1993
• Falciform ligament patchMunro WS et al, Ann R Coll Surg, 78:390-1, 1996
• Ligamentum teres patchCastalab G et al, Surg Endosc, 6:677-9, 1995
Perforated Duodenal UlcerLaparoscopic vs. Open Repair
• Decreased perioperative analgesic requirements in laparoscopic group
• No benefit in length of hospital stay, time to resume normal diet or return to normal activity
• Increased operative time and cost
Miserey M et al, Surg Endosc. 10:831-6, 1996So JB et al, Surg Endosc. 10:1060-63, 1996Lau WY et al, Ann Surg. 224: 131-38, 1996Lau WY et al, Br J Surg. 82:814-6, 1995
Laparoscopic Bariatric Surgery
•Is it safe ?
•Does it reduce post-op morbidity ?
•How does the outcome and cost compare to open surgery ?
Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001de Wit LT et al, Annals of Surgery, 230(6);800-807, Dec. 1999
Roux-en-Y Gastric BypassStudy Design
• Prospective randomized trial• Setting: University of California, Davis• 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
• Outcome, quality of life and cost was compared
Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001
Roux-en-Y Gastric BypassPerioperative Outcomes
Results Laparoscopic GBP (n=79)
Open GBP (n=76)
P Value
Operative time, min 225+40 195+41 <.001
Blood loss, mL 137+79 395+284 <.001
ICU stay, No. of Pts. 6 (7.6%) 16 (21.1%) .03
Median hospital LOS, days 3 (IQR 1) 4 (IQR 2) <.001
Reoperation, No. of Pts. 6 (7.6%) 5 (6.6%) NS
Return to daily activity, days 8.4+8.6 17.7+19.1 <.001
Return to work, days 32.2+19.8 46.1+20.6 .02
Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001
Roux-en-Y Gastric BypassMean % of Excess Body Weight loss
0
20
40
60
80
100
0 5 10 15
Time (months)
Exc
ess
Bo
dy
Wei
gh
t L
oss
(%
)
Open GBP Laparoscopic GBP
*
*
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
Roux-en-Y Gastric BypassMajor Complications
Complication Laparoscopic GBP (n=79) Open GBP (n=76)
Gastrointestinal
Anastomotic leak 1 1
Gastric pouch outlet obstruction 0 1
Hypopharyngeal perforation 1 0
Jejunojejunostomy obstruction 3 0
Pulmonary
Pulmonary embolism 0 1
Respiratory failure 0 1
Gastrointestinal bleeding 1 0
Wound infection 0 2
Retained laparotomy sponge 0 1
Total 6 (7.6%) 7 (9.2%)*
*P=0.78 Nguyen NT et al, Annals of Surgery, 234(3):279-91, Sept. 2001
Adjustable Silicon Gastric BandingStudy Design
• Prospective randomized trial
• Fifty patients with morbid obesity of >5 years’ duration and a BMI > 40 kg/m2 were randomized to undergo laparoscopic or open ASGB
• Complications, hospital stay, readmissions, and weight loss were compared
de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999
Adjustable Silicon Gastric Banding
Parameter Laparoscopic ASGB (n=25)
Open ASGB (n=24)
P Value
Surgical time, min 150+48 76+20 <0.05
Days in hospital, mean (range)
5.9 (4-10) 7.2 (5-13) <0.05
Difficulty of procedure (1-10)(range)
4.7+2.1
(3-10)
3.8+1.1
(3-7)
<0.05
Total readmissions 6 15 <0.05
Overall hospital stay, days 7.8+6 11.8+10.5 <0.05
de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999
Adjustable Silicon Gastric Banding
Laparoscopic ASGB (n=25)
Open ASGB (n=24)
P Value
Weight before surgery (kg)
152.2+31.4 146.4+19.9 NS
Weight 52 weeks after surgery (kg)
117.2+25.2 112.0+19.1 NS
Weight loss (kg) 35 34.4
BMI before surgery (kg/m2)
51.3+10.4 49.7+5.6 NS
BMI 52 weeks after surgery (kg/m2)
39.7+8.7 39.1+8.2 NS
All values are expressed as mean+SDP value difference before and 52 weeks after is < 0.05
de Wit LT et al, Annals of Surgery, 230(6);800-807, December 1999
Laparoscopic Bariatric SurgerySummary
• Compared to open surgery, laparoscopic Roux-en-Y gastric bypass is associated with: 1) Significantly decreased blood loss, ICU stay, and hospital stay,
2) Earlier return to daily activity and work, 3) Longer operative time, 4) Fewer complications, and 5) Equivalent weight loss at 1 year.
Laparoscopic Bariatric SurgerySummary
• Compared to open surgery, laparoscopic adjustable silicon gastric banding is associated with:
1) Significantly decreased length of hospital stay and readmission rate,
2) Increased OR time, and
3) Equivalent weight loss at 52 weeks.
Laparoscopic Liver Resection
Liver Resection
Laparoscopic (n=17)
Conventional (n=17)
p value
(Mann-Whitney U Test)
Age (years) 48.0+9.8 46.8+13.9 NS
Parenchymal hepatic resection rate (%)
11.6+6.1 10.8+4.6 NS
Operation time (min) 183.5+55.1 128.2+37.0 <0.05
Blood loss (mL) 457.6+343.7 555.9+385.8 NS
Post-op hospital stay (days)
7.8+8.2 11.6+12.8 <0.05
Rau HG et al, Hepato-Gastroenterology 1998; 45:2333-2338
Liver ResectionSummary
• Data on laparoscopic liver resection scarce
• At present laparoscopy appears to have a role in laparoscopic ultrasound and radiofrequency ablation and cryoablation of liver tumors
Laparoscopic Common Bile Duct Exploration
PREOPPREOP INTRAOINTRAOPP
POSTOPOSTOPP
ERCPERCP Lap Lap transcystictranscysticLap CBDLap CBDOpen CBDOpen CBDExpectantExpectant
ERCPERCP
Management Options
Laparoscopic CBD Exploration
Study No. of patients
No. of cholangio.
No. of pts with CBD
stones
Trans-
cystic
Choledo-
chotomy
Comment
Shuchleib et al
50 - 50 13 37 8% conversion. 92% success. 1 death. LOS 4.3d
Berci et al 226 99.5% 94% 83%, 5% conversion
17%, 19% conversion
2 duct injuries. 1 death. 7% morbidity 2.6% retained stones.
Paganini et al
1975 1975 161 107 50 Major complications 3.8%. 1 death. 5% retained stones. 3.2% recurrent stones on f/u
Berthou et al
220 - 220 112, 68.8% success
137, 97.1% success
4 deaths. Morbidity 9.1%. 7 with residual stones.
Phillips et al
1231 99% 145 123, 91% success
10 1 death. Shorter LOS (3.4d), lesser morbidity (5%), fewer retained stones (5%) for transcystic.
Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001
Laparoscopic CBD ExplorationStudy No. of
patientsNo. of
cholangio.No. of pts with
CBD stonesTrans-
cystic
Choledo-
chotomy
Comment
Drouard et al
161 - 161 82,67% success
101, 96% success
No mortality. Morbidity 7.4%. LOS 7.6 days.
Cuschieri et al
133 132 109 56,80% success
55, 85% success
15.8% complication rate. 1 death. 13% conversion. LOS 6 days.
Giurgiu et al
217 - 217 217 0 No late retained stones or stricture.
Arvidsson et al
39 - 39 22 11 Overall success 82%. No mortality. Morbidity 10%
Gigot et al 92 - 92 63% success
93% success
12% conversion. 2 deaths. 15% complication rate.
Millat et al
247 - 247 116 92 Overall success 88%. 20 conversions. 22 major & 9 minor complications. 1 death.
Khoo et al 60 - 60 46 14 Overall success rate 75%
Stoker et al
700 - 80 33 27 Overall success rate 94%. Complication rate 10%
Fitzgibbons RJ, World J. Surg.25, 1317-1324, 2001
Laparoscopic Pancreatic Surgery
Diagnostic laparoscopy for staging of pancreatic cancer Laparoscopic ultrasound for staging of pancreatic cancer Pancreatic resection Palliative surgery for pancreatic cancer
“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
• Prospective study of 88 consecutive patients
• Pancreatic and periampullary adenocarcinoma
• Preoperative evaluation– CT scan with contrast 88 pts– MRI 20 pts– Laparoscopy 47 pts– Angiography 85 pts
Preoperative Staging and Assessment of Resectability of Pancreatic Cancer
Warshaw,A et al: Arch Surg 1990; 125:230-233
Results
• Overall resectability 33/88 (38%)
• Laparoscopy found metastatic disease when present in 22/23 patients (96%)
• Laparoscopy found no metastatic disease in 24/24 patients (100%)
Warshaw,A et al: Arch Surg 1990; 125:230-233
Conclusion
• Laparoscopy is particularly sensitive for detecting small metastases (96%)
• This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances
Warshaw,A et al: Arch Surg 1990; 125:230-233
The Value of Laparoscopy in the Staging of Patients with Potentially Resectable
Peripancreatic Malignancies
• 115 patients- radiologically resectable
• Extensive laparoscopy performed
– assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
Unresectability• Metastases
– hepatic, serosal, peritoneal• Extrapancreatic extension
– mesocolic involvement• Nodal involvement
– celiac or portal• Vascular invasion
– celiac axis or hepatic artery– portal vein, SMV, SMA
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
• Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient
• Positive predictive index of 100%
• Negative predictive index of 91%
• Accuracy of 94%
Results
Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
Laparoscopic Ultrasound in the Staging of Pancreatic Cancer
• Prospective evaluation of 90 patients
• All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography
• All patients had laparoscopy and laparoscopic ultrasound
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
CT LAP LAP SONO
ACTUAL
UNRESECTABLE 17
(19%)
41
(46%)
49
(54%)
50
(56%)
EQUIVOCAL 8
(9%)
13
(14%)
___ ___
Results
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
Laparoscopic Ultrasound
• Sensitivity 100%
• Specificity 98%
• Accuracy 98%
Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
Summary
• Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection
• The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer
Laparoscopic Pancreatic Resection
Laparoscopic Pancreatic ResectionAuthor (y) n Length
of stay (d)
OR time (h)
Total comp. (%)
Minor comp. (%)
Major comp. (%)
Panc. Fistula
(%)
30-day mortality
(%)
Laparoscopic
Patterson (2001) 19 7 4.3 26 10 16 16 0
Salky (2000) 7 4 3.7 28 28 0 0 0
Vezakis (1999) 6 34.5 5.0 33 0 33 33 0
Park (1999) 5 5 5.0 20 0 20 20 -
Gagner (1997) 13 - - 38 8 31 8 -
•Distal pancreatectomy
•Islet cell enucleation
9
4
5
4
4.5
3
-
-
-
-
-
-
-
-
-
-
Cuschieri (1996) 5 6 4.5 40 20 20 20 -
Open
Lillemoe (1999) 235 10 4.3 31 NR 31 5 0.9
Benoist (1999) 40 15 - 63 5 58 23 -
Broughan (1986) 84 - - - - 24 6 3.6
Patterson JE, J Am Coll Surg 2001;193:281-287
Laparoscopic Palliative Surgery for Unresectable Pancreatic
Cancer
Laparoscopic Gastro- and Hepaticojejunostomy
Case-Control Study 14 patients – open palliation10 patients – laparoscopic palliation4 patients – diagnostic laparoscopy
Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
Results
OPEN
(n=14)
LAP
(n=14)MORBIDITY 43% 7%
MORTALITY 29%
0%
HOSPITAL STAY
21 days
9 days
Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
p < 0.05
p < 0.05
p < 0.06
Summary
• Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer
• Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma
Laparoscopic Versus Open Adrenalectomy
Adrenalectomy
First author
Approach (n)
EBL (cc)
Operative time (min)
LOS (days)
OI (days)
Pain meds (mg)
Cost ($)
Brunt OA(25) 408 142 8.7 6.0 142 16,972
OP(17) 366 136 6.2 2.8 54 12,266
Lap(24) 104* 183* 3.2 * 1.6 * 15.9 * 13,184
Guazzoni Open(20) 450 145 9 2.8 320
Lap(20) 100 * 170 * 3.4 * 1.1 * 175 *
Prinz OA(11) 391 174 6.4 1002
OP(13) 288 139 * 5.5 801
Lap(10) 228 212 2.1 * 93 *
Korman OA(5) 200 141 6.2 3.4 3.6(days) 14,487
OP(5) 220 106 * 5.6 2.2 3.2(days) 11,193
Lap(10) 118 164 4.1 1.8 1.9(days) 8,188
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)
AdrenalectomyPosterior open
(n=50)Laparoscopic
(n=50)p Value
OR time (min) 127 167 0.0002
Blood transfusion (total group) None 2 units NS
MSO4 equivalents 48 28 0.002
Toradol doses 1.7 0.7 0.75
Antiemetic doses 5.7 3.1 0.50
Hospital stay (days) 5.7 3.1 0.0001
Early complications (%) 18 6 0.25
Late complications (%) 54 0 0.0001
Return to normal (weeks) 7 3.8 0.0001
Patient satisfaction (1-10) 7 9 0.0001
Adjusted hospital charges (median)
$6000 $7000 0.05
Thompson GB, Surgery 1997;122:1132-6
Adrenalectomy
Laparoscopic (n=40)
Open (n=40) P Value
Operating time (min)
•Skin to removal 147 79 <0.0001
•Skin to skin 180 127 <0.0001
Estimated blood loss (g) 40 162 <0.0001
Analgesic (times) 2.9 5.8 <0.0001
Hospital stay (days) 12 18 <0.0001
Hospital costs (dollars) $7000 $8000 NS
First solid food (days) 1.3 1.3 NS
Ambulatory (days) 1.3 1.5 NS
Imai T et al, Am J Surg. 1999;178:50-54
Laparoscopic AdrenalectomySummary
• It is a safe and feasible procedure• 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
• Significantly longer OR time• No difference in overall charges and early
complications
Laparoscopic Versus Open Splenectomy
Splenectomy
0
200
400
600
Donini et al, Jan 1999 Park et al, Nov 1999 Shimomatsuya et al,Feb 1999
Blo
od lo
ss (
mL)
LS OS
0
50
100
150
200
250
Donini et al, Jan 1999 Park et al, Nov 1999 Shimomatsuya et al,Feb 1999
Op
erat
ive
time
(min
)
LS OS
0
4
8
12
16
Donini et al, Jan 1999 Park et al, Nov 1999 Shimomatsuya et al,Feb 1999
Hos
pita
l sta
y (d
ays)
LS OS
*
*
* *
**
*p < 0.05
SplenectomyResults LS (n=44) OS (n=56) p
Average age (range) 40 (13-64) 39 (18-64) -
Splenic weight (g) 773+1,112 732+1,184 0.86
Blood loss (mL) 295+269 347+511 0.67
Transfusion (patients) 2 (5%) 15 (26%) 0.004
Operative time (min) 130+62 133+42 0.76
Accessory spleens (No. of pts) 4 (4) 7 (5) 0.70
Time to oral liquids (days) 1.7+0.8 3.6+0.8 <0.0001
Post-op stay (days) 5.1+2.7 7.2+2.1 0.0002
Post-op complications 3 (7%) 13 (23%) 0.03
Pain medication (No.of vials) 2.4 +1.7 4+2.8 <0.0001
Deaths 0 0 -
Donini A et al, Surg Endosc (1999) 13: 1220-1225
Laparoscopic SplenectomySummary
• It is a safe and feasible procedure• 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
• Significantly longer OR time
Laparoscopic Bowel Surgery
Diagnosis and treatment of small bowel obstruction Colectomy for benign and malignant disease
Small Bowel ObstructionDiagnostic and Therapeutic Laparoscopy
Author Total #
Diagnostic laparoscopy
Laparoscopic treatment
Converted to laparotomy
Iatrogenic bowel injury
Navez B, 1998 150 68 31 (46%) 31 (46%) 6 (9%)
Strickland P, 1999 40 40 24 (60%) 13 (32%) 4 (10%)
Agresta F, 2000 136 63 52 (82%) 11 (17.4%) 1 (1.5%)
Suter M, 2000 83 83 47 (57%) 36 (43%) 4 (8%)
Leon EL, 1998 40 40 14 (35%) 26 (65%) 3 (7.5%)
Al-Mulhim A, 2000 19 19 13 (68%) 6 (32%) 0 (0%)
Bailey IS, 1998 139 65 35 (54%) 30 (46%) 1 (1.5%)
Small Bowel ObstructionSummary
• Only 35-82% success rate in laparoscopic treatment of SBO
• Some studies report high incidence of iatrogenic small bowel injury
• No prospective randomized trial to address whether laparoscopic or open treatment of SBO is better
Laparoscopic Versus Open Colectomy for Cancer
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
0
10
20
30
40
RHC Trans AR Sig LAR APR Total
Ave
. # ly
mp
h no
des
0
5
10
15
20
25
RHC Trans AR Sig LAR APR
Ave
. spe
cim
en le
ngth
, cm
0
4
8
12
16
20
RHC Trans AR Sig LAR APR
Ave
. dis
tal m
arg
in, c
m
LCR OCR
0
7
14
21
28
35
RHC Trans AR Sig LAR APR
Ave
. pro
xim
al m
arg
in, c
m
LCR OCR
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
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
Laparoscopic
(n=192)
Open
(n=224)
Hospitalization, days 5.6 9
Blood loss, mL 150 450
Wound complications 0.5% 6%
Recurrence rates 12.2% 22%
Cumulative death and recurrence rates 5 years into the study (Stages I, II, and III)
13% 19.1%
Franklin ME et al, Dis Colon Rectum 1996;39:s35-s46
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
Lap (n=18) Open (n=18) Converted (n=7)
Operating room time (min) 210 138 242
Blood loss (mL) 284 407 683
ICU stay (days) 3 4 6
Clear liquids (days) 2.7 4.4 5
Regular diet (days) 4.1 5.8 7
Length of stay (days) 5.2 7.3 8
Complications (n, %) 1, 5% 5, 28% 8, 100%
Length of specimen (cm) 26 26 32
Number of lymph nodes 11 10 12
Late death from cancer (mean follow-up 4.9 years)
4 6 1
Recurrence 0 1 1
Curet MJ et al, Surg Endosc (2000) 14: 1062-1066
Colorectal ResectionLaparoscopic vs. open resection for carcinoma
Follow-up Lap. Open
No. of cases (n) 40 43
Overall metastases 8 (20%)
10 (23%)
Single site 3 5
Liver 2 4
Regional 1 1
Multiple sites 5 5
Liver+ Peritoneum 4 4
Liver+Peritoneum+
Trocar-site or scar
1 1
Five-year overall survival
020406080
100
0 12 24 36 48 60
Follow-up (months)
Sur
viva
l (%
)
Five-year disease-free survival
0
50
100
0 12 24 36 48 60
Follow-up (months)
Sur
viva
l (%
)
Lap OpenSantoro E et al, Hepato-Gastroenterology 1999; 46:900-904
Colorectal ResectionSummary
• 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
• Shorter ICU and hospital stay, less blood loss and wound complications
• Low incidence of port site recurrence and no difference open scar site recurrence
Laparoscopic Prostatectomy
Laparoscopic Prostatectomy
Total Procedures 1-10
Procedures 50-79
Procedures 80-125
Operative time (mean), min 265 352 210 200
Conversion, % 0 0 0 0
Blood loss (mean), mL 185 250 140 145
Transfusion, % 2 20 0 0
Catheter time (mean), days 12 19 6.5 5.5
Hospital stay (mean), days 8 10 7 6.5
Turk I et al, Eur Urol 2001;40:46-53
Laparoscopic ProstatectomyTotal Procedures
1-50Procedures
51-100Procedures
101-240
Operative time (mean), min 232 278 240 206
Blood loss (mean), mL 370 280
Transfusion, % 15 6 1.4
Catheter time (mean), days 7.8 7 4.2
Hospital stay (mean), days 5.2
Complications• Rectal injury
• Peritonitis
• Ureteral injury
• Urinary leakage
• Obturator nerve injury
• Anastomotic stricture
3
1
1
1
1
1
Guillonneau B et al, Urologic Clinics of North America 28(1);189-202: Feb 2001
Laparoscopic ProstatectomySummary
• Laparoscopic prostatectomy is a safe procedure but has a steep learning curve
• OR time, blood loss and transfusion, catheter time and length of hospital stay decrease as the surgeon becomes more experienced with the procedure
• A prospective randomized trial comparing results of open and laparoscopic prostatectomy is required
Laparoscopic Inguinal Hernia Repair
Laparoscopic Inguinal Hernia RepairOutcomes Analyzed
Cost
Operative time
Complications
Recurrence
Return to work
Inguinal Hernia RepairCost
0
2000
4000
6000
8000
10000C
ost (
dolla
rs)
Joha
nsso
nW
ellw
ood
Zier
enLa
wre
nce
Kal
dF
arin
asB
arku
nS
toke
rLo
renz
O'D
wye
rLi
emP
ayne
Hei
kkin
en 1
997
Hei
kkin
en 1
998
Mill
iken
Author
Laparoscopic Open
Inguinal Hernia RepairOperative Time
0
20
40
60
80
100
120
140
Ope
rativ
e tim
e (m
inut
es)
Kho
ury
Mad
dern
Liem
Kon
inge
rS
chre
nkZi
eren
Joha
nsso
nLe
ibl
Hau
ters
Cha
mpa
ult
Hei
kkin
enK
ald
Law
renc
eA
itola
Pag
anin
iP
ayne
Sar
liJu
ulB
eets
Cha
mpa
ult
Dam
amm
eD
irks
enTa
nphi
phat
Tsch
udi
Fili
piK
ozol
Author
Laparoscopic Open
Inguinal Hernia RepairComplications
0
0.2
0.4
0.6
0.8
1
Com
plic
atio
n (f
ract
ion
of c
ases
)
Kal
dC
ham
pau
Sto
ker
Juul
Bes
sell
Wel
lwoo
dLa
wre
nce
Mill
iken
Pay
neLo
rnez
Tsc
hudi
Hei
kkin
eZ
iere
nB
arku
nW
right
Pic
chio
O'D
wye
rJo
hans
soM
adde
rnT
anph
iph
Bee
ts
Authors
Laparoscopic Open
Inguinal Hernia RepairRecurrence
0
0.1
0.2
0.3R
ecur
renc
e (fr
actio
n of
ca
ses)
Filip
iK
ald
Kon
inge
rLa
wre
nce
Tanp
hiph
atJo
hans
son
Kho
ury
Pay
neTs
chud
iH
aute
rs Juul
Liem
Sch
renk
Pag
anin
iM
adde
rnC
ham
paul
tD
irkse
nAi
tola
Bee
ts
Author
Laparoscopic Open
Inguinal Hernia RepairReturn to Work
0
10
20
30
40
50D
ays
Zie
ren
Sch
renk
Aito
laK
hour
yN
atha
nson
Mer
ello
Bee
tsJu
ulH
eikk
inen
Liem
Sar
liS
toke
rT
anip
hiph
atJo
hans
son
Pag
anin
iC
ham
paul
tM
adde
rnLe
ibl
Law
renc
eK
onin
ger
Dam
amm
eH
aute
rs
Author
Laparoscopic Open
Laparoscopic Inguinal Hernia RepairSummary
• Higher cost
• Longer OR time
• Fewer complications
• Low recurrence rate equivalent to open technique
• Faster return to work
Open Versus Laparoscopic SurgerySummary
Operation Yes No Needs additional trials
Esophagectomy X X
Esophagomyotomy X X
Paraesophageal hernia X
Nissen fundoplication X
Billroth II gastrectomy X X
Peptic ulcer disease X
Roux-en-Y GBP X
Adjustable silicon GB X
Hepatectomy X X
Open Versus Laparoscopic SurgerySummary
Operation Yes No Needs additional trials
CBDE X X
Diagnostic laparoscopy / Sono pancreatic ca.
X
Distal pancreatectomy X X
Palliative pancreatic ca. X
Adrenalectomy X
Splenectomy X
Small bowel obstruction X
Colectomy for cancer X X
Prostatectomy X X
Inguinal hernia repair X