Evaluating Current Laparoscopic Applications In Surgery

Evaluating CurrentLaparoscopic Applications

in Surgery

George S Ferzli, MDGeorge S Ferzli, MD

Armando E Castro, MDArmando E Castro, MD

Evidence-Based Medicine

Formulate answerable questions:Formulate answerable questions: Which is superior, open or laparoscopic Which is superior, open or laparoscopic

approach?approach? Is the laparoscopic approach safe?Is the laparoscopic approach safe? Is the laparoscopic approach feasible?Is the laparoscopic approach feasible? Are the outcomes of the laparoscopic Are the outcomes of the laparoscopic

approach acceptable?approach acceptable?


Utilizing available scientific data to develop Utilizing available scientific data to develop guidelines for medical practiceguidelines for medical practice

Used to evaluate and integrate emerging Used to evaluate and integrate emerging techniques and advances into practicetechniques and advances into practice

Laparoscopy lends itself to evaluation and practice Laparoscopy lends itself to evaluation and practice through evidence-based medicinethrough evidence-based medicine


What does the available and most current What does the available and most current data tell us regarding the practice of data tell us regarding the practice of laparoscopy in general surgery?laparoscopy in general surgery?

Laparoscopic Applications in Surgery

EsophagusEsophagus StomachStomach PancreasPancreas LiverLiver

ColonColon AppendixAppendix AdrenalAdrenal SpleenSpleen Groin herniaGroin hernia

Laparoscopic Applications - Esophagus

What are some of the current uses of What are some of the current uses of laparoscopy in esophageal surgery?laparoscopy in esophageal surgery?

Achalasia – Heller MyotomyAchalasia – Heller Myotomy Hiatal hernia/GERD – FundoplicationHiatal hernia/GERD – Fundoplication Epiphrenic DiverticulumEpiphrenic Diverticulum CancerCancer

Laparoscopic Applications - EsophagusAchalasia Surgical treatment of achalasia: current status and Surgical treatment of achalasia: current status and

controversiescontroversies Literature review of the current management of Literature review of the current management of

achalasiaachalasia Laparoscopic Heller myotomy is generally Laparoscopic Heller myotomy is generally

accepted as the operative procedure of choice accepted as the operative procedure of choice Less invasive, associated with less pain and Less invasive, associated with less pain and

postoperative disability, shorter hospital staypostoperative disability, shorter hospital stay

Abir F et al, Dig Surg 2004;21:165-176

Laparoscopic Applications - EsophagusAchalasia


•Studies of laparoscopic Heller myotomy

Laparoscopic Applications - EsophagusAchalasia

NN% symptom % symptom

improvementimprovement% post-op % post-op

GERDGERD

Open trans-Open trans-abdominalabdominal 26802680 8383 12.312.3

Open trans-Open trans-thoracicthoracic 13791379 8686 10.510.5

ThoracoscopicThoracoscopic 204204 7676 3535

LaparoscopicLaparoscopic 499499 9494 1313

Laparoscopic Applications - EsophagusAchalasia The laparoscopic approach has a good to The laparoscopic approach has a good to

excellent response rate compared to other excellent response rate compared to other surgical approaches surgical approaches

Lower incidence of postoperative GERD Lower incidence of postoperative GERD than open or thoracoscopic approachesthan open or thoracoscopic approaches

Based on current evidence, laparoscopic Based on current evidence, laparoscopic Heller myotomy is the operative procedure Heller myotomy is the operative procedure of choice for achalasiaof choice for achalasia


Laparoscopic Applications - EsophagusHiatal Hernia/GERD Laparoscopic Laparoscopic

antireflux surgery is a antireflux surgery is a well-established well-established treatment of moderate treatment of moderate to severe GERDto severe GERD

Indicated for Indicated for symptomatic pts who symptomatic pts who have not responded have not responded fully to medical fully to medical therapy therapy

Laparoscopic Applications - EsophagusHiatal Hernia/GERD Laparoscopic antireflux surgery Laparoscopic antireflux surgery

for gastroesophageal reflux for gastroesophageal reflux disease: experience with 688 disease: experience with 688 laparoscopic antireflux laparoscopic antireflux proceduresprocedures Review of author’s Review of author’s

experience with GERDexperience with GERD 24 pH monitoring, 24 pH monitoring,

esophageal manometry, and esophageal manometry, and analysis of failure analysis of failure prospectively reviewedprospectively reviewed

Granderath F et al, Int J Col Dis 2004 Jan;18(1):73-77


for gastroesophageal reflux for gastroesophageal reflux disease: experience with 688 disease: experience with 688 laparoscopic antireflux laparoscopic antireflux proceduresprocedures Overall complication 7.6%Overall complication 7.6% Mean f/u 4.8 years with Mean f/u 4.8 years with

normal 24-h pH and normal 24-h pH and esophageal manometry in esophageal manometry in 93% of pts93% of pts



for gastroesophageal reflux for gastroesophageal reflux disease: experience with 688 disease: experience with 688 laparoscopic antireflux laparoscopic antireflux proceduresprocedures Conclusions: Laparoscopic Conclusions: Laparoscopic

antireflux surgery is antireflux surgery is feasible and effective, with feasible and effective, with low morbidity and good to low morbidity and good to excellent functional and excellent functional and symptomatic resultssymptomatic results


Laparoscopic Applications - EsophagusHiatal Hernia/GERD Laparoscopic treatment of Laparoscopic treatment of

gastro-oesophageal reflux gastro-oesophageal reflux disease.disease. Reviewed 9 Reviewed 9

randomized trials randomized trials comparing open and comparing open and laparoscopic laparoscopic fundoplicationfundoplication

Combined results of Combined results of these trials confirms these trials confirms advantage of the advantage of the laparoscopic approachlaparoscopic approach

Watson D, Best Pract Res Clin Gastroenterol. 2004 Feb;18(1):19-35

Laparoscopic Applications - EsophagusHiatal Hernia/GERD Laparoscopic treatment of Laparoscopic treatment of

gastro-oesophageal reflux gastro-oesophageal reflux diseasedisease Laparoscopic Laparoscopic

fundoplication is now the fundoplication is now the “gold standard” for the “gold standard” for the management of pts with management of pts with severe GERDsevere GERD

New endoscopic treatments New endoscopic treatments will need to achieve similar will need to achieve similar outcomes before they are outcomes before they are accepted replacements for accepted replacements for laparoscopic approachlaparoscopic approach

Watson D, Best Pract Res Clin Gastroenterol. 2004 Feb;18(1):19-35

Laparoscopic Applications - EsophagusHiatal Hernia/GERD Evidence-based appraisal of antireflux Evidence-based appraisal of antireflux

fundoplicationfundoplication

Catarci M et al, Ann Surg. 2004 Mar;239(3):325-37

Laparoscopic Applications - EsophagusHiatal Hernia/GERD


Laparoscopic Applications - EsophagusHiatal Hernia/GERD Evidence-based appraisal of antireflux Evidence-based appraisal of antireflux

fundoplicationfundoplication No perioperative deaths were reported in any of the No perioperative deaths were reported in any of the

trialstrials Comparing laparoscopic versus open approach:Comparing laparoscopic versus open approach:

Lower operative morbidity rate, 10.3% vs 26.7%Lower operative morbidity rate, 10.3% vs 26.7% Shorter postoperative stay, 3.1 vs 5.2 daysShorter postoperative stay, 3.1 vs 5.2 days Shorter sick leave, 20.1 vs 35.8 daysShorter sick leave, 20.1 vs 35.8 days

No significant differences in rate of recurrence, No significant differences in rate of recurrence, dysphagia, bloating and reoperation for failuredysphagia, bloating and reoperation for failure


Laparoscopic Applications - Stomach

Bariatric surgeryBariatric surgery CancerCancer Perforated ulcerPerforated ulcer Gastric outlet Gastric outlet

obstruction/Pyloroplastyobstruction/Pyloroplasty GastrostomyGastrostomy

Roux-en-Y Gastric Bypass

Good long-term results, EWL Good long-term results, EWL 60-75%60-75%

Solid food well toleratedSolid food well tolerated

Complications:Complications: Early: anastomotic leak, Early: anastomotic leak,

acute gastric dilatation, acute gastric dilatation, Roux-en-Y obstruction, Roux-en-Y obstruction, atelectasis, DVT/PEatelectasis, DVT/PE

Late: stomal stricture, staple Late: stomal stricture, staple line failure, pouch dilatation, line failure, pouch dilatation, dumping, anemia, vit Bdumping, anemia, vit B1212 deficiency, Cadeficiency, Ca+2 +2

deficiency/osteoporosisdeficiency/osteoporosis

Vertical Banded Gastroplasty

Edward E. Mason (1982), Edward E. Mason (1982), University of IowaUniversity of Iowa

Restriction with polypropylene Restriction with polypropylene band, Marlex mesh, or silastic band, Marlex mesh, or silastic ring ring

Rules of eatingRules of eating

Soft calorie syndromeSoft calorie syndrome

Complications: Complications: LeakLeak Persistent vomitingPersistent vomiting

Laparoscopic Adjustable Gastric Banding

Kuzmak (1990), Lodz Medical Kuzmak (1990), Lodz Medical Academy,Poland Academy,Poland

Adjustable band connected to port Adjustable band connected to port implanted in subcutaneous tissueimplanted in subcutaneous tissue

Complications:Complications: OOperative: sperative: splenic and plenic and

esophageal esophageal injury, injury, conversion to open procedureconversion to open procedure

Late: bLate: band slippage, reservoir and slippage, reservoir deflation/leak, failure to lose deflation/leak, failure to lose weight, persistent vomiting, weight, persistent vomiting, acid refluxacid reflux

Laparoscopic Applications - StomachGastric bypass The laparoscopic The laparoscopic

gastric bypass is now gastric bypass is now the preferred surgical the preferred surgical treatment for morbid treatment for morbid obesityobesity

Laparoscopic Applications - StomachGastric bypass Laparoscopic versus open Laparoscopic versus open

gastric bypass to treat gastric bypass to treat morbid obesitymorbid obesity Presentation of Presentation of

selected series of Roux selected series of Roux en Y gastric bypassen Y gastric bypass

Brolin R, Ann Surg. 2004 Apr;239(4):438-440

Laparoscopic Applications - StomachGastric bypass

Comprehensive review of Comprehensive review of 18 published cohort studies 18 published cohort studies (10 laparoscopic, 8 open) (10 laparoscopic, 8 open) favored laparoscopyfavored laparoscopy

Shorter LOSShorter LOS Lower incidence of Lower incidence of

abdominal wall herniasabdominal wall hernias Mortality and wound Mortality and wound

infection rate in infection rate in combined cohort combined cohort studies also favors the studies also favors the laparosopic approach laparosopic approach versus openversus open


Laparoscopic Applications - StomachGastric bypass

In combined cohort In combined cohort studies the open studies the open approach had a approach had a significantly lower significantly lower incidence of late stomal incidence of late stomal stenosis and bowel stenosis and bowel obstructionobstruction


Laparoscopic Applications - StomachGastric bypass Laparoscopic versus open gastric bypass to treat Laparoscopic versus open gastric bypass to treat

morbid obesitymorbid obesity


Laparoscopic Applications - StomachCancer Comparison of laparoscopic and open gastrectomy Comparison of laparoscopic and open gastrectomy

for malignant diseasefor malignant disease Retrospective case-matched study comparing Retrospective case-matched study comparing

laparoscopic (n = 12) and open (n = 13) partial laparoscopic (n = 12) and open (n = 13) partial gastrectomies for cancergastrectomies for cancer

Stage, extent of lymphadenectomy, and 18 Stage, extent of lymphadenectomy, and 18 month survival were comparedmonth survival were compared

Weber KJ et al, Surg Endosc. 2003 Jun;17(6):968-71.


for malignant diseasefor malignant disease No statistical difference in stages between No statistical difference in stages between

groupsgroups Resection margins in laparoscopic group were Resection margins in laparoscopic group were

all free of tumorall free of tumor No difference in extent of lymphadenectomy No difference in extent of lymphadenectomy

between groupsbetween groups No difference in survival between groups at 18 No difference in survival between groups at 18

month follow-upmonth follow-upWeber KJ et al, Surg Endosc. 2003 Jun;17(6):968-71.


for malignant diseasefor malignant disease Conclusions: The laparoscopic approach to Conclusions: The laparoscopic approach to

gastric cancer allows for adequate margins and gastric cancer allows for adequate margins and can follow oncologic principles, and is this an can follow oncologic principles, and is this an viable alternative to open surgeryviable alternative to open surgery

There is no difference in short-term survival There is no difference in short-term survival between the two approachesbetween the two approaches

Weber KJ et al, Surg Endosc. 2003 Jun;17(6):968-71.

Laparoscopic Applications - StomachCancer Application of minimally invasive treatment for Application of minimally invasive treatment for

early gastric cancer.early gastric cancer. To propose indications for the application of To propose indications for the application of

minimally invasive therapy for EGCminimally invasive therapy for EGC Retrospective analysis of 566 pts who had Retrospective analysis of 566 pts who had

undergone gastrectomy with D2 or more undergone gastrectomy with D2 or more extended lymphadenectomyextended lymphadenectomy

Risk factors for lymph node metastasis were Risk factors for lymph node metastasis were identifiedidentified

Hyung WJ et al, J Surg Oncol. 2004 Mar 15;85(4):181-5.

Laparoscopic Applications - StomachCancer Application of minimally invasive treatment for Application of minimally invasive treatment for

early gastric cancer.early gastric cancer. Lymph node metastasis was associated with Lymph node metastasis was associated with

submucosal invasion, larger tumor size, submucosal invasion, larger tumor size, undifferentiated histology and presence of undifferentiated histology and presence of lymphatic or vascular invasion (LBVI)lymphatic or vascular invasion (LBVI)

Minimally invasive treatment can be possibly Minimally invasive treatment can be possibly applied for pts with EGC using these four applied for pts with EGC using these four independent risk factors for lymph node independent risk factors for lymph node metastasismetastasis

Hyung WJ et al, J Surg Oncol. 2004 Mar 15;85(4):181-5.

Laparoscopic Applications - StomachCancer Current status of laparoscopic gastrectomy for Current status of laparoscopic gastrectomy for

cancer in Japan.cancer in Japan. Review of current indications for and outcomes Review of current indications for and outcomes

of laparoscopic procedures for gastric cancerof laparoscopic procedures for gastric cancerLaparoscopic wedge resection (LWR)Laparoscopic wedge resection (LWR)Intragastric mucosal resection (IGMR)Intragastric mucosal resection (IGMR)Laparoscopy-assisted distal gastrectomy Laparoscopy-assisted distal gastrectomy

(LADG)(LADG)

Kitano S et al, Surg Endosc. 2004 Feb;18(2):182-5.

Laparoscopic Applications - StomachCancer Current status of laparoscopic gastrectomy for Current status of laparoscopic gastrectomy for

cancer in Japan.cancer in Japan. Laparoscopic procedures are useful in early gastric Laparoscopic procedures are useful in early gastric

cancer (EGC) because ofcancer (EGC) because of Minimal invasivenessMinimal invasiveness Decreased painDecreased pain Faster recoveryFaster recovery

Improved outcomes with laparoscopic approaches for Improved outcomes with laparoscopic approaches for EGC have led to the application of these approaches to EGC have led to the application of these approaches to more advanced gastric cancermore advanced gastric cancer


Laparoscopic Applications - StomachCancer


LaparoscopicLaparoscopic local resectionlocal resection

IGMRIGMR LWRLWR Lap GastrectomyLap Gastrectomy

Number of casesNumber of cases 260260 14281428 26002600

IndicationIndication Early gastric Early gastric cancer cancer withoutwithout risk risk of LN metsof LN mets

Early gastric Early gastric cancer cancer withwith risk of risk of LN metsLN mets

Complication rateComplication rate

IntraoperativeIntraoperative 4.24.2 2.12.1 1.41.4

PostoperativePostoperative 6.56.5 4.64.6 9.79.7

•Laparoscopic surgery for gastric cancer in Japan

Laparoscopic Applications - StomachCancer Current status of laparoscopic gastrectomy for cancer in Current status of laparoscopic gastrectomy for cancer in

Japan.Japan. Conclusions:Conclusions:

Indication for LWR and IGMR is cancer Indication for LWR and IGMR is cancer without risk of lymph node metastasis, without risk of lymph node metastasis,

Indication for LADG is early gastric cancer Indication for LADG is early gastric cancer with risk of perigastric (n1) lymph node with risk of perigastric (n1) lymph node metastasismetastasis

Multicenter randomized control studies of Multicenter randomized control studies of long-term outcome are necessarylong-term outcome are necessary


Laparoscopic Applications - Pancreas

What are some of the current uses of What are some of the current uses of laparoscopy in pancreatic surgery?laparoscopy in pancreatic surgery?

DiagnosticDiagnostic TherapeuticTherapeutic

Laparoscopic Applications - PancreasDiagnostic Pancreatic surgery in the laparoscopic eraPancreatic surgery in the laparoscopic era

Diagnostic laparoscopy has been used to detect Diagnostic laparoscopy has been used to detect peritoneal metastases and obtain biopsies since peritoneal metastases and obtain biopsies since 1960’s1960’s

Staging laparoscopy avoids unnecessary Staging laparoscopy avoids unnecessary laparotomy in one-fifth of patients with laparotomy in one-fifth of patients with pancreatic cancerpancreatic cancer

The addition of laparoscopic ultrasound may The addition of laparoscopic ultrasound may also be beneficial in detection of intrahepatic also be beneficial in detection of intrahepatic metastases and vascular involvementmetastases and vascular involvement

Ammori B, J Pancreas 2003;4(6):187-192

Laparoscopic Applications - PancreasTherapeutic Pancreatic resectionPancreatic resection

Laparoscopic Applications - PancreasTherapeutic Laparoscopic Laparoscopic

pancreatic surgery. pancreatic surgery. Current indications Current indications and surgical resultsand surgical results Evaluated the Evaluated the

outcomes and outcomes and feasibility of feasibility of laparoscopic laparoscopic pancreatic surgerypancreatic surgery

Shimizu S et al, Surg Endosc 2004 Mar; 18(3):402-6

Laparoscopic Applications - PancreasTherapeutic

Fifteen patients (8M, Fifteen patients (8M, 7F)7F)

Distal pancreatectomy Distal pancreatectomy (DP) for solid tumor (DP) for solid tumor (n=4)(n=4)

DP for cystic lesion DP for cystic lesion (n=3)(n=3)

DP for chronic DP for chronic pancreatitis (n=2)pancreatitis (n=2)

Cystgastrostomy (CG) Cystgastrostomy (CG) for pseudocyst (n=4)for pseudocyst (n=4)

Enucleation of Enucleation of insulinoma (n=2)insulinoma (n=2)


Laparoscopic Applications - PancreasTherapeutic Laparoscopic Laparoscopic

pancreatic surgery. pancreatic surgery. Current indications Current indications and surgical resultsand surgical results Mean OR time was Mean OR time was

249+/-70 min249+/-70 min DP DP ~5 hrs, CG and ~5 hrs, CG and

enucleation ~3hrsenucleation ~3hrs Mean blood loss Mean blood loss

was 138+/-184gwas 138+/-184g



2 DP were 2 DP were converted to open converted to open

No related mortalityNo related mortality 2 pancreatic fistula 2 pancreatic fistula

(1 DP, 1 (1 DP, 1 enucleation) both enucleation) both treated non-treated non-operativelyoperatively


Laparoscopic Applications - PancreasTherapeutic Laparoscopic pancreatic Laparoscopic pancreatic

surgery. Current surgery. Current indications and surgical indications and surgical resultsresults

ConclusionsConclusions Laparoscopic pancreatic Laparoscopic pancreatic

surgery (LPS) is safe and surgery (LPS) is safe and feasible for patients with feasible for patients with benign tumors and cystic benign tumors and cystic lesionslesions



Although some Although some retrospective studies retrospective studies have shown that LPS have shown that LPS results in faster post-op results in faster post-op recovery and morbidity recovery and morbidity rates comparable to rates comparable to open surgery, no open surgery, no randomized controlled randomized controlled study confirming study confirming reduced invasiveness reduced invasiveness or superiority has been or superiority has been presentedpresented


Laparoscopic Applications - PancreasTherapeutic Laparoscopic resection of Laparoscopic resection of

the pancreas. A feasibility the pancreas. A feasibility study of the short-term study of the short-term outcomeoutcome 32 patients with pancreatic 32 patients with pancreatic

disease were evaluateddisease were evaluated Neuroendocrine tumors Neuroendocrine tumors

(n=13)(n=13) Unspecified tumors Unspecified tumors

(n=11)(n=11)

Edwin B et al, Surg Endosc 2004 Mar; 18(3):407-411


Cysts (n=2)Cysts (n=2) ITP with ectopic ITP with ectopic

spleen (n=2)spleen (n=2) Annular pancreas Annular pancreas

(n=1)(n=1) Trauma (n=1)Trauma (n=1) Splenic artery Splenic artery

aneurysm (n=)aneurysm (n=) Adenocarcinoma Adenocarcinoma

(n=1)(n=1)


Laparoscopic Applications - PancreasTherapeutic Laparoscopic resection Laparoscopic resection

of the pancreas. A of the pancreas. A feasibility study of the feasibility study of the short-term outcomeshort-term outcome Enucleations (n=6)Enucleations (n=6) Distal Distal

pancreatectomy pancreatectomy (DP) with (DP) with splenectomy (n=12)splenectomy (n=12)



DP without DP without splenectomy (n=5)splenectomy (n=5)

Laparoscopic Laparoscopic exploration only (n=3)exploration only (n=3)

Five procedures (13%) Five procedures (13%) converted to openconverted to open

One resection One resection converted to hand-converted to hand-assisted assisted


Laparoscopic Applications - PancreasTherapeutic Laparoscopic resection of the Laparoscopic resection of the

pancreas. A feasibility study of pancreas. A feasibility study of the short-term outcomethe short-term outcome Mortality rate for Mortality rate for

laparoscopic resection 8.2% laparoscopic resection 8.2% (2/24)(2/24)

Complications occurred Complications occurred after resection in 38% after resection in 38% (9/24)(9/24)

Median hospital stay 5.5 Median hospital stay 5.5 daysdays

Post-op opioids for median Post-op opioids for median of 2 daysof 2 days


Laparoscopic Applications - PancreasTherapeutic Laparoscopic resection of Laparoscopic resection of

the pancreas. A feasibility the pancreas. A feasibility study of the short-term study of the short-term outcomeoutcome

ConclusionConclusion Laparoscopic approach Laparoscopic approach

to pancreatic resections to pancreatic resections is feasible in selected is feasible in selected patientspatients



Offers benefits to Offers benefits to patients similar to patients similar to those provided by those provided by minimally invasive minimally invasive procedures for other procedures for other diseasesdiseases

Prospective Prospective randomized trials randomized trials needed to confirm needed to confirm potential benefitspotential benefits


Laparoscopic Applications - PancreasTherapeutic Pancreatic pseudocystPancreatic pseudocyst

Laparoscopic Applications - PancreasPseudocyst Minimally invasive Minimally invasive

approaches to the approaches to the management of management of pancreatic pseudocystspancreatic pseudocysts Endogastric, Endogastric,

transgastric and transgastric and extragastric extragastric techniques techniques describeddescribed

Bhattacharya D et al, Surg Laparosc Endosc Percutan Tech 2003 Jun;13(3):141-148

Laparoscopic Applications - PancreasPseudocyst

Approximately 40 Approximately 40 cases described cases described

Median post-op stay 4 Median post-op stay 4 daysdays

89% success rate89% success rate No recurrences at No recurrences at

median f/u 6-32 median f/u 6-32 monthsmonths

Complications in 2 Complications in 2 patients (7%)patients (7%)


Laparoscopic Applications - PancreasPseudocyst Minimally invasive approaches to the Minimally invasive approaches to the

management of pancreatic pseudocystsmanagement of pancreatic pseudocysts


Laparoscopic Applications - Liver

What are some of the What are some of the uses of laparoscopy in uses of laparoscopy in liver surgery?liver surgery? Liver resectionLiver resection


Laparoscopic liver Laparoscopic liver surgery: analyze the surgery: analyze the experience on 36 casesexperience on 36 cases Laparoscopic Laparoscopic

fenestration and fenestration and drainage were used in drainage were used in 7 patients with 7 patients with nonparasitic liver cystsnonparasitic liver cysts

Popescu I et al, Chirurgia. 2003 Jul-Aug;98(4):307-17


Nine patients had hydatid Nine patients had hydatid cystscysts

7/9 partial 7/9 partial pericystectomy after pericystectomy after inactivation and inactivation and evacuationevacuation

2/9 ideal 2/9 ideal pericystectomy in pericystectomy in segments II and IIIsegments II and III

Only in the case of Only in the case of metastasis was a left lateral metastasis was a left lateral sectorectomy performed sectorectomy performed (all other resections were (all other resections were non-anatomical)non-anatomical)



Laparoscopic liver Laparoscopic liver surgery: analyze the surgery: analyze the experience on 36 casesexperience on 36 cases No mortalityNo mortality 11.11% morbidity11.11% morbidity Mean f/u 18 monthsMean f/u 18 months

All patients All patients asymptomaticasymptomatic



Benefits are those Benefits are those of minimally-of minimally-invasive surgeryinvasive surgery

LessLess abdominal abdominal wall trauma, early wall trauma, early mobilization, mobilization, shorter LOS, shorter LOS, aestheticsaesthetics



Laparoscopic liver Laparoscopic liver resection: benefits and resection: benefits and controversiescontroversies Comparative studies often Comparative studies often

favor laparoscopic over favor laparoscopic over open approachopen approach

Decreased analgesic Decreased analgesic requirementrequirement

Shorter delay to oral Shorter delay to oral intakeintake

Decreased hospital stayDecreased hospital stay Quicker improvement Quicker improvement

in transaminase levelsin transaminase levels

Gagner M et al, Surg Clin North Am. 2004 Apr;84(2):451-62


These advantages are These advantages are most commonly seen most commonly seen in patients undergoing in patients undergoing cyst or benign tumor cyst or benign tumor resectionsresections



Laparoscopic liver Laparoscopic liver resection: benefits and resection: benefits and controversiescontroversies Comparison of Comparison of

survival of patients survival of patients after laparoscopic after laparoscopic malignant tumor malignant tumor resection to open resection to open approach is not approach is not establishedestablished



Bleeding and bile Bleeding and bile leakage are the most leakage are the most common perioperative common perioperative complicationscomplications

Difficult to control Difficult to control laparoscopicallylaparoscopically

Often lead to Often lead to conversion to open conversion to open approachapproach



Laparoscopic liver Laparoscopic liver resection: benefits and resection: benefits and controversiescontroversies

Literature review Literature review revealed the revealed the following:following: 709 patients have 709 patients have

undergone undergone laparoscopic liver laparoscopic liver surgerysurgery



Benign lesions 490 Benign lesions 490 (69%)(69%)

Malignant lesions Malignant lesions 195 (27.5%)195 (27.5%)

Complications 99 Complications 99 (14%)(14%)

Conversion to open Conversion to open surgery 36 (5%)surgery 36 (5%)



ProcedureProcedure NN %%

Cyst fenestration/unroofingCyst fenestration/unroofing 245245 3333

Non-anatomical resectionsNon-anatomical resections 225225 30.530.5

Anatomical resectionsAnatomical resections 152152 2020

Laparoscopic cryoablationLaparoscopic cryoablation 3838 5.55.5

Laparoscopic RFALaparoscopic RFA 3434 4.54.5

Gasless laparoscopyGasless laparoscopy 2525 3.33.3

PericystectomyPericystectomy 1010 1.51.5

Hand-assisted laparoscopic hepatectomyHand-assisted laparoscopic hepatectomy 1010 1.51.5

Laparoscopic donor hepatectomyLaparoscopic donor hepatectomy 22 0.20.2

TotalTotal 741741 100100


•Laparoscopic procedures for liver lesions



•Perioperative and postoperative complications

ComplicationComplication NN %%

AscitesAscites 1212 1.71.7

Pleural effusionPleural effusion 99 1.21.2

HemorrhageHemorrhage 88 1.11.1

Bile LeakBile Leak 55 0.70.7

Hepatic failureHepatic failure 55 0.70.7

InfectionsInfections 55 0.70.7

Incisional herniaIncisional hernia 44 0.60.6

Bowel obstructionBowel obstruction 33 0.40.4

Bowel injury not requiring conversionBowel injury not requiring conversion 33 0.30.3

ColitisColitis 11 0.10.1

PhlebitisPhlebitis 11 0.10.1

Pyoderma gangrenosumPyoderma gangrenosum 11 0.10.1

TotalTotal 5656 100100



•Conversions to open hepatectomy

ConversionConversion NN %%

HemorrhageHemorrhage 1919 2.72.7

Insufficient tumor excisionInsufficient tumor excision 99 1.31.3

AdhesionsAdhesions 44 0.50.5

Insufficient resection (positive margins)Insufficient resection (positive margins) 22 0.30.3

Gas embolusGas embolus 22 0.30.3

Severe cirrhosisSevere cirrhosis 11 0.10.1

Instrument malfunctionInstrument malfunction 11 0.10.1

TotalTotal 3636 5.35.3


Laparoscopic liver resection: benefits and Laparoscopic liver resection: benefits and controversiescontroversies

SummarySummary Laparoscopic liver resection is safe and feasibleLaparoscopic liver resection is safe and feasible Small tumors in left lateral segment are the Small tumors in left lateral segment are the

most amenable to laparoscopic approachmost amenable to laparoscopic approach Complication and conversion rates are Complication and conversion rates are

acceptableacceptable



Current status of the laparoscopic approach to Current status of the laparoscopic approach to liver resectionliver resection Over 700 reported laparoscopic liver Over 700 reported laparoscopic liver

procedures performed since 1991procedures performed since 1991 70% for benign lesions, 30% malignant tumors70% for benign lesions, 30% malignant tumors Cyst fenestration and unroofing most frequently Cyst fenestration and unroofing most frequently

performed procedure (245 patients)performed procedure (245 patients) Overall morbidity 12% (56 patients)Overall morbidity 12% (56 patients) Overall conversion rate 11% (36 patients)Overall conversion rate 11% (36 patients)

Rogula T et al, J Long Term Eff Med Implants. 2004;14(1):23-31


Current status of the laparoscopic approach to Current status of the laparoscopic approach to liver resectionliver resection

ConclusionConclusion Laparoscopic liver resection is safe and Laparoscopic liver resection is safe and

feasiblefeasible Acceptable morbidity and mortalityAcceptable morbidity and mortality Results should be confirmed with Results should be confirmed with

prospective studiesprospective studies

Rogula T et al, J Long Term Eff Med Implants. 2004;14(1):23-31

Laparoscopic Applications - Colon

Diverticular diseaseDiverticular disease Resection for malignancyResection for malignancy


Resection for Resection for diverticular diseasediverticular disease

Laparoscopic Applications - ColonDiverticular Disease Laparoscopic Laparoscopic

treatment of sigmoid treatment of sigmoid diverticulitisdiverticulitis Retrospective review Retrospective review

of 103 patients treated of 103 patients treated for Hinchey I-III for Hinchey I-III diverticulitisdiverticulitis

One-stage laparoscopic One-stage laparoscopic resection with primary resection with primary anastamosis planned anastamosis planned procedureprocedure

Pugliese R et al, Surg Endosc. 2004 Jun;18:1334-1348

Laparoscopic Applications - ColonDiverticular Disease

Hinchey IIa patients Hinchey IIa patients with abscesses were with abscesses were drained drained percutaneously pre-percutaneously pre-operativelyoperatively

Hinchey III patients Hinchey III patients underwent underwent emergency surgeryemergency surgery

Four-trocar approach Four-trocar approach with left iliac fossa with left iliac fossa minilaparotomy usedminilaparotomy used


Laparoscopic Applications - ColonDiverticular Disease Laparoscopic treatment of Laparoscopic treatment of

sigmoid diverticulitissigmoid diverticulitis Laparoscopic treatment Laparoscopic treatment

successfully completed in successfully completed in 100 patients100 patients

2.9% intra-operative 2.9% intra-operative complicationscomplications

1 uretheric injury in H31 uretheric injury in H3 2 anastamotic failure in 2 anastamotic failure in

H1 and H2aH1 and H2a 2 conversions due to 2 conversions due to

anatomic difficultiesanatomic difficulties



sigmoid diverticulitissigmoid diverticulitis 8% post-operative 8% post-operative

procedure related morbidityprocedure related morbidity 3 wound infection (2 in 3 wound infection (2 in

HI, 1 in H3)HI, 1 in H3) 2 anastamotic leak (1 in 2 anastamotic leak (1 in

HI, 1 in H2a)HI, 1 in H2a) 1 intestinal obstruction 1 intestinal obstruction

(HI)(HI)



1 anastamotic bleed 1 anastamotic bleed (HI)(HI)

1 intraperitoneal 1 intraperitoneal bleed (HI)bleed (HI)

2 pneumonia (H3)2 pneumonia (H3) No mortalityNo mortality Longer LOS for H2b Longer LOS for H2b

patients treated for patients treated for colovesical fistulacolovesical fistula



sigmoid diverticulitissigmoid diverticulitis There were no There were no

significant differences significant differences between classes of between classes of patients (HI-III) with patients (HI-III) with regard toregard to

Operating timeOperating time Nasogastgric tube Nasogastgric tube

daysdays



There were no There were no significant differences significant differences between classes of between classes of patients (HI-III) with patients (HI-III) with regard toregard to

Post-operative ileus Post-operative ileus daysdays

Days to oral intakeDays to oral intake LOSLOS


Laparoscopic Applications - ColonDiverticular Disease Laparoscopic Laparoscopic

treatment of sigmoid treatment of sigmoid diverticulitisdiverticulitis

ConclusionConclusion Laparoscopic resection Laparoscopic resection

for diverticulitis can be for diverticulitis can be performed without performed without additional morbidity in additional morbidity in

HIHI



Laparoscopic treatment Laparoscopic treatment of sigmoid of sigmoid diverticulitis can be a diverticulitis can be a safe and effective gold safe and effective gold standard procedure for standard procedure for HI-III patients in HI-III patients in experienced handsexperienced hands



Colectomy for colon Colectomy for colon cancercancer

Laparoscopic Applications - ColonResection for malignancy Laparoscopy-assisted Laparoscopy-assisted

colectomy versus open colectomy versus open colectomy for treatment of colectomy for treatment of non-metastatic colon non-metastatic colon cancer: a randomised trialcancer: a randomised trial Comparing the efficacy Comparing the efficacy

of laparoscopy-assisted of laparoscopy-assisted colectomy (LAC) and colectomy (LAC) and open colectomy (OC) open colectomy (OC) in terms of tumor in terms of tumor recurrence and survivalrecurrence and survival

Lacy AM et al, Lancet. 2003 Jun 29;359(9325):2224-9

Laparoscopic Applications - ColonResection for malignancy

219 patients 219 patients randomised to LAC or randomised to LAC or open colectomyopen colectomy


Laparoscopic Applications - ColonResection for malignancy Patients in the LAC group Patients in the LAC group

had decreased time to had decreased time to peristalsis and oral intake peristalsis and oral intake than OCthan OC

Patients with LAC had Patients with LAC had shorter LOS than open shorter LOS than open groupgroup

Morbidity was lower in Morbidity was lower in LAC than OCLAC than OC


Laparoscopic Applications - ColonResection for malignancy Probability of cancer-Probability of cancer-

related survival was related survival was higher in the LAC group higher in the LAC group than OCthan OC

In patients with stage III In patients with stage III tumors, LAC was tumors, LAC was independently associated independently associated with reduced risk of tumor with reduced risk of tumor relapse and death from relapse and death from cancer-related cause cancer-related cause compared to OCcompared to OC


Laparoscopic Applications - ColonResection for malignancy Conclusion:Conclusion:

LAC is more LAC is more effective then OC in the effective then OC in the treatment of colon cancer treatment of colon cancer in terms of morbidity, in terms of morbidity, LOS, tumor recurrence LOS, tumor recurrence and cancer-related and cancer-related survivalsurvival


Laparoscopic Applications - ColonResection for malignancy A comparison of A comparison of

laparoscopically assisted and laparoscopically assisted and open colectomy for colon open colectomy for colon cancercancer Prospective, randomized Prospective, randomized

trial 428 patients underwent trial 428 patients underwent open colectomy (OC), 435 open colectomy (OC), 435 patients underwent patients underwent laparoscopically assisted laparoscopically assisted colectomy (LAC)colectomy (LAC)

Primary endpoint was time Primary endpoint was time to tumor recurrenceto tumor recurrence

COST Study Group, NEJM. 2004 May;350:2050-9

Laparoscopic Applications - ColonResection for malignancy Surgery:Surgery:

Operating times longer for Operating times longer for LAC LAC

Extent of resection similar Extent of resection similar in both groupsin both groups

Margins <5cm in Margins <5cm in 6% OC vs 5% in 6% OC vs 5% in LACLAC

Median number of 12 Median number of 12 lymph nodes examined in lymph nodes examined in eacheach


Laparoscopic Applications - ColonResection for malignancy Recovery/Complications - No Recovery/Complications - No

significant difference in:significant difference in: Rate of intraoperative Rate of intraoperative

complicationscomplications 30-day postoperative 30-day postoperative

mortalitymortality Rate/severity of Rate/severity of

postoperative complications postoperative complications at dischargeat discharge

Rates of readmissionRates of readmission


Laparoscopic Applications - ColonResection for malignancy Survival and Recurrence Survival and Recurrence

at 4.4 years - No at 4.4 years - No significant difference in:significant difference in: Number of patients Number of patients

with recurrence in each with recurrence in each groupgroup

Cumulative incidence Cumulative incidence of recurrence between of recurrence between LAC and OC patientsLAC and OC patients



Overall survival rateOverall survival rate Disease-free survival Disease-free survival

raterate These were true for These were true for

any stageany stage


Laparoscopic Applications - ColonResection for malignancy ConclusionConclusion

This data suggests that This data suggests that LAC does not confer LAC does not confer additional risk for additional risk for cancer recurrencecancer recurrence

LAC is an acceptable LAC is an acceptable alternative to OC and alternative to OC and therefore it is safe to therefore it is safe to proceed with LAC in proceed with LAC in patients with colon patients with colon cancercancer


Laparoscopic Applications - ColonResection for malignancy Laparoscopic resection of Laparoscopic resection of

colon cancer Consensus colon cancer Consensus of the European of the European Association of Endoscopic Association of Endoscopic Surgery (E.A.E.S.)Surgery (E.A.E.S.) Review of the current Review of the current

literature to formulate literature to formulate evidence-based evidence-based recommendations on recommendations on the role of laparoscopy the role of laparoscopy in resection of colon in resection of colon cancercancer

Veldkamp R et al, Surg Endosc. 2004 Jun;18:1163-1185


colon cancercolon cancer Advanced age, obesity and Advanced age, obesity and

prior abdominal surgery are prior abdominal surgery are not absolute not absolute contraindications to contraindications to laparoscopic resection of laparoscopic resection of colon canercolon caner

Conversion is highest in Conversion is highest in presence of bulky or presence of bulky or invasive tumorsinvasive tumors



Operative time is longer for Operative time is longer for laparoscopic resection laparoscopic resection

Specimen size, extent of Specimen size, extent of resection and pathological resection and pathological examination is similar to examination is similar to open resectionopen resection


Laparoscopic Applications - ColonResection for malignancy Laparoscopic resection Laparoscopic resection

of colon cancerof colon cancer Immediate Immediate

postoperative postoperative morbidity and morbidity and mortality are mortality are comparable for open comparable for open and laparoscopic and laparoscopic resectionresection



Laparoscopic resection Laparoscopic resection results in results in

decreased paindecreased pain better-preserved better-preserved

pulmonary functionpulmonary function Earlier return of GI Earlier return of GI

functionfunction Decreased LOSDecreased LOS


Laparoscopic Applications - ColonResection for malignancy Laparoscopic resection Laparoscopic resection

of colon cancerof colon cancer The postoperative The postoperative

stress response is lower stress response is lower after laparoscopic after laparoscopic resectionresection

The incidence of port The incidence of port site metastasis is <1%site metastasis is <1%



Survival after Survival after laparoscopic resection laparoscopic resection appears to be equal to appears to be equal to that after open that after open resectionresection

The costs for The costs for laparoscopic resection laparoscopic resection is higher than for open is higher than for open resectionresection



colon cancercolon cancer Laparoscopic resection Laparoscopic resection

for colon cancer is safe for colon cancer is safe and feasible, with and feasible, with improved short-term improved short-term outcomesoutcomes

Results of studies of Results of studies of long-term survival will long-term survival will determine more determine more precisely its roleprecisely its role


Number of lymph nodes and extent of resection

Study No. of lymph nodes Resection margins (cm)

Laparoscopic Open P value Laparoscopic Openp value

Milsom 19a 25* — Clear in all Clear in all Delgaddo <70 yr 9.6 10.5 NS >70 yr 12.2 10.5 NS Cure 11 10 NS Length 26 25 —Stage 7 8 — Margins 4 4 Lacy 13 12.5 NS Lezoche RHC 14.2 13.8 NS Length 28.3 29.1 NS

LHC 9.1 8.6 NS Length 22.9 24.1 NS

LHC TFM 5.2 5.3 NS

Bouvet 8 10 NS Prox 10 10 NS

Dist 6 9 0.03

Hong 7 7 NS Dist 7.9 7.2 NS

Koehler 14 11 — Length 24.1 22.6 — Prox 13.2 10.1 — Dist 7.9 8.6 —Psaila 7.0 7.7 NS Khalili 12 16 — Lezoche 10.7 11 NS Length 26.8 29.4 NS

LHC TFM 5.2 5.3 NS

Marubashi LoD 1.7 2.25<0.01

Bokey 17 16 NS Prox 10.1 11.0 NS

Dist 10.0 13.4 0.03

Franklin NA NA NS NA NA NSSantoro Leung 9a 8a Dist 3a 3.5a


Morbidity

Study Laparoscopic (%) Open (%) p value

Lacy 11 29 0.001

Milsom 15 15 NSDelgado 10.9 25.6 0.001

<70 yr 11.4 20.3 NS

>70 yr 10.2 31.3 0.0038

Cure 1.5 5.28 NS

Stage 11 0 —

Lacy 8 30.8 0.04

Schwenk 7 27 0.08

Lezoche RHC 1.9 2.3 NS LHC 7.5 6.3 NS

Bouvet 24 25 NS

Hong Major 15.3 14.6 NS

Minor 11.2 21.5 0.029

Khalili 19 22 NS

Lezoche 13 14.3 NS

Minor 3.6 7.5 NS

Major 9.4 6.8 NS

Marubashi 27.5 25 —Bokey NA NA NS

Franklin Early 17 23.8 NA

Late 5.2 8.9

Santoro Early 28 28 —

Late 12 0

Leung 26 30 NS


Length of hospital stay

Study Laparoscopic Open p value

Week 5.6 ± 0.26 6.4 ± 0.23 <0.001

Hewitt 6 (57) 7 (4–9) —

Milsom 6.0 (3–37) 7.0 (524) NS

Delgado <70 yr 5 7 0.0001

>70 yr 6 7 0.0009

Curet 5.2 7.3 <0.05

Stage 5 (3–12) 8 (5–30) 0.01

Lacy 5.2 ± 1.2 8.1 ± 3.8 0.0012

Lezoche RHC 9.2 13.2 0.001

LHC 10.0 13.2 0.001

Bouvet 6 (2–35) 7 (4–52) <0.01

Hong 6.9 ± 5.4 10.9 ± 9.3 0.003

Koehler 8.1 (6–14) 15.3 (9–23) —

Psaila 10.7 ± 4.7 17.8 ± 9.5 0.001

Khalili 7.7 ± 0.5 8.2 ± 0.2 NS

Lezoche 10.5 13.3 0.027

Marubashi] 18.7 35.8 <0.0001

Franklin <50 yr 5.2 (2.0–9.2) 9.35 (517) —

>50 yr 7.84 (448) 12.85 (941)

Leung 6 (3–22) 8 (3–28) <0.001


Overall survival rates

Study Follow-up Laparoscopic (%) Open (%) p value

Lacy 43 mo 82 74 NS

Leung 21.4 mo (median) 90.9 (n = 28) 55.6 (n = 56) NS

Leung 32.8 mo (median) 67.2 (n = 50) 64.1 (n = 50) NS

Khalili 19.6 mo 87.5 (n = 80) 85 (n = 90) NS

Santoro 5 yr 72.3 (n = 50) 68.8 (n = 50) NS

Hong Lap 30.6 mo NA (n = 98) NA (n = 219) NS

Open 21.6 mo

Delgado 42 mo AR 83, SR 87 (n = 31)

Cook Until patient

20 (n = 5)

Hoffman 2 yr Node–: 92 (n = 89)

Node +: 80%

Molenaar 3 yrAll: 59, by Dukes

Quattlebaum 8 mo 90 (n = 10)

Poulin Stage I–III: 24 mo 81

Stage IV: 9 mo


Disease-free survival rates

Study Follow-up Laparoscopic (%) Open (%) p value

Lacy 43 mo 91 79 0.03

Leung 5 yr 95.2 74.7 NS

Leung 4 yr 80.5 72.9 NS

Feliciotti 48.9 mo 86.5 86.7 NS

Lezoche 42.2 mo RHC 78.3 75.8 NS

42.3 mo LHC 94.1 86.8

Bouvet 26 mo 93 88 NS

Santoro NA 73.2 70.1 NS

Hong Lap 30.6 mo NA NA NS

Open 21.6 mo

Franklin 5 yr 87 80.9 NS

Delgado 42 mo AR: 78

SR: 70

Hoffmant 2 yr Node–: 96

Node +: 79


Port site metastasis

Study Design n Follow-up PSMLacy RCT 111 Median 43 1Milsom RCT 42 Median 18 0Lacy RCT 31 21.4 0Ballantyne Registry 498 NA 3Fleshman Registry 372 NA 4 (1.3%)Rosato Registry 1071 NA 10 (0.93%)Vukasin Registry 480 >12 5 (1.1%)Schledeck Registry 399 Mean 30 1 (0.25%)

Leung Prospective 217 Mean 19.8 1 (0.65%)Poulin Prospective 172 Mean 24 0Franklin Prospective 191 >30 0Bouvet Prospective 91 26 0Feliciottl Prospective 158 Mean 48.9 2Bokey Retrospective 66 Median 26 1 (0.6%)Fielding Retrospective 149 NA 2 (1.5%)Gellman Retrospective 58 NA 1 (1.7%)Hoffman Retrospective 39 24 0Huscher Retrospective 146 Mean 15 0Leung Retrospective 50 >32 1Khalili Retrospective 80 Mean 21 0Kwo Retrospective 83 NA 2 (2.5%)Leung Retrospective 179 Mean 19.8 1 (0.65%)Lord Retrospective 71 Mean 16.7 0Lumley Retrospective 103 NA 1 (1.0%)Khalili Retrospective 80 Mean 19.6 0Guillou Retrospective 59 NA 1 (1.7%)Larach Retrospective 108 Mean 12.6 0Croce Retrospective 134 NA 1 (0.9%)Kawamura Retrospective 67 (gasless) NA 0 5305

38 (0.72%)


Approved statement by American Society of Colon and Rectal Surgeons:

Laparoscopic Colectomy for Curable CanerLaparoscopic Colectomy for Curable Caner““Laparoscopic colectomy for curable cancer results in Laparoscopic colectomy for curable cancer results in

equivalent cancer related survival to open colectomy when equivalent cancer related survival to open colectomy when performed by experienced surgeons. Adherence to performed by experienced surgeons. Adherence to

standard cancer resection techniques including but not standard cancer resection techniques including but not limited to complete exploration of the abdomen, adequate limited to complete exploration of the abdomen, adequate proximal and disstal margins, ligation of the major vessels proximal and disstal margins, ligation of the major vessels at their respective origins, containment and careful tissue at their respective origins, containment and careful tissue

handling, and en bloc resection with negative tumor handling, and en bloc resection with negative tumor margins using the laparoscopic approach will result in margins using the laparoscopic approach will result in

acceptable outcomes.”acceptable outcomes.”

Laparoscopic Applications - Appendix

Laparoscopic vs open appendectomy. What is the Laparoscopic vs open appendectomy. What is the real difference? Results of a prospective real difference? Results of a prospective randomized double-blind trialrandomized double-blind trial 52 men randomized to open or laparoscopic 52 men randomized to open or laparoscopic

appendectomy (OA, LA)appendectomy (OA, LA) Operative time, LOS, lost work days, pain Operative time, LOS, lost work days, pain

scores and operative times were comparedscores and operative times were compared

Ignacio RC et al, Surg Endosc. 2004 Mar;18:334-337


Laparoscopic vs open appendectomy. What is the Laparoscopic vs open appendectomy. What is the real difference?real difference?

No statistically-different difference in:No statistically-different difference in: LOSLOS Post-operative pain days 1 and 7Post-operative pain days 1 and 7 Mean time to return to workMean time to return to work

Operative costs $600 higher for laparoscopic Operative costs $600 higher for laparoscopic groupgroup



Laparoscopic vs open appendectomy. What is the Laparoscopic vs open appendectomy. What is the real difference?real difference?

Conclusions:Conclusions: LA appears to confer no advantage over OA forLA appears to confer no advantage over OA for

LOSLOS Post-operative painPost-operative pain Lost work daysLost work days

Further studies may address possible advantages for Further studies may address possible advantages for specific patient populations (e.g. obese, women)specific patient populations (e.g. obese, women)


Laparoscopic Applications - Adrenal

Rationale for Rationale for Laparoscopic Laparoscopic AdrenalectomyAdrenalectomy Small size of most Small size of most

adrenal tumorsadrenal tumors Most adrenal tumors Most adrenal tumors

are benignare benign


Open adrenalectomy Open adrenalectomy requires a large requires a large incision for removal of incision for removal of a small tumora small tumor

Lap adrenalectomy Lap adrenalectomy associated with associated with reduced pain, a faster reduced pain, a faster recovery, and fewer recovery, and fewer complicationscomplications


Indications for Indications for Laparoscopic Laparoscopic AdrenalectomyAdrenalectomy AldosteronomaAldosteronoma Cushing’s syndromeCushing’s syndrome

Cortisol-producing Cortisol-producing adrenal adenomaadrenal adenoma

Primary adrenal Primary adrenal hyperplasiahyperplasia

Failed treatment of Failed treatment of ACTH-dependent ACTH-dependent Cushing’sCushing’s


Pheochromocytoma Pheochromocytoma (sporadic or familial)(sporadic or familial)

Nonfunctioning Nonfunctioning cortical adenoma cortical adenoma (selected cases)(selected cases)

Adrenal metastasesAdrenal metastases


Contraindications to Contraindications to Laparoscopic AdrenalectomyLaparoscopic Adrenalectomy Adrenocortical carcinoma Adrenocortical carcinoma Malignant Malignant

pheochromocytomapheochromocytoma Any tumor that appears Any tumor that appears

locally invasivelocally invasive Large adrenal masses (>8-Large adrenal masses (>8-

12cm)12cm) Contraindication to Contraindication to

laparoscopic surgerylaparoscopic surgery


Laparoscopic Laparoscopic Adrenalectomy: Difficult Adrenalectomy: Difficult CasesCases Large tumor sizeLarge tumor size Malignant or Malignant or

potentially malignant potentially malignant tumorstumors

Pheochromocytomas –Pheochromocytomas –especially large pheosespecially large pheos


Obese patients with Obese patients with Cushing’s syndromeCushing’s syndrome

Obese patientsObese patients Patients with extensive Patients with extensive

previous upper previous upper abdominal surgery abdominal surgery (consider RP approach)(consider RP approach)

Laparoscopic vs. Open Adrenalectomy

Over 12 retrospective Over 12 retrospective studies, no prospective studies, no prospective trialstrials

Operating times are longer Operating times are longer with laparoscopic with laparoscopic adrenalectomy but blood adrenalectomy but blood loss is lessloss is less

Laparoscopic vs. Open Adrenalectomy

Laparoscopic Laparoscopic adrenalectomy associated adrenalectomy associated with decreased pain and with decreased pain and pain medication use, pain medication use, shorter postoperative shorter postoperative hospital stay, and a faster hospital stay, and a faster return to full activity and return to full activity and workwork

Meta-analysis of Complications of Laparoscopic vs Open Adrenalectomy

LA associated with significantly LA associated with significantly fewer complications than open fewer complications than open adrenalectomyadrenalectomy

Primary differences are in fewer Primary differences are in fewer wound, pulmonary, and wound, pulmonary, and infectious complications and a infectious complications and a lower rate of associated organ lower rate of associated organ injury (eg splenectomy)injury (eg splenectomy)

Bleeding is the #1 complication Bleeding is the #1 complication of lap adrenalectomyof lap adrenalectomy

10.9

25.2

0

5

10

15

20

25

30

%

Laparoscopic Series Open Series

Brunt LM Surg Endosc 2002;16:252-57Brunt LM Surg Endosc 2002;16:252-57


The case for laparoscopic adrenalectomyThe case for laparoscopic adrenalectomy Review of literature addressing the role of Review of literature addressing the role of

laparoscopy in adrenal disorderslaparoscopy in adrenal disorders Studies comparing open versus laparoscopic Studies comparing open versus laparoscopic

adrenalectomy were evaluatedadrenalectomy were evaluated

Gill IS, J Urol. 2001 Aug;166(2):429-36


Gill IS, J Urol. 2001 Aug;166(2):429-36


The case for laparoscopic adrenalectomyThe case for laparoscopic adrenalectomy Conclusions:Conclusions:

Data from available literature indicates that Data from available literature indicates that laparoscopic surgery is safe and efficacious forlaparoscopic surgery is safe and efficacious for

AldosteromaAldosteromaPheochromocytomaPheochromocytomaCushing’s diseaseCushing’s diseaseIncidentalomaIncidentaloma

Gill IS, J Urol. 2001 Aug;166(2):429-36


The case for laparoscopic adrenalectomyThe case for laparoscopic adrenalectomy Conclusions, cont’dConclusions, cont’d

Compared to open surgery, laparoscopic Compared to open surgery, laparoscopic adrenalectomy providesadrenalectomy providesEquivalent outcomesEquivalent outcomesDecreased morbidityDecreased morbidityFinancial benefitsFinancial benefits

The role of the laparoscopic approach to The role of the laparoscopic approach to adrenal cancer demands further studyadrenal cancer demands further studyGill IS, J Urol. 2001 Aug;166(2):429-36


The case for laparoscopic adrenalectomyThe case for laparoscopic adrenalectomy In the majority of patients with adrenal In the majority of patients with adrenal

disease, laparoscopy may now be disease, laparoscopy may now be considered the gold standard for surgical considered the gold standard for surgical treatmenttreatment

Gill IS, J Urol. 2001 Aug;166(2):429-36


LA is the preferred method of removal of the vast LA is the preferred method of removal of the vast majority of adrenal tumorsmajority of adrenal tumors

Complete biochemical work-up and localization pre-opComplete biochemical work-up and localization pre-op Keys to a successful outcome: patient selection, surgical Keys to a successful outcome: patient selection, surgical

approach, meticulous dissection and hemostasisapproach, meticulous dissection and hemostasis Avoid difficult cases during “learning curve”Avoid difficult cases during “learning curve” Lap ultrasound may be useful early in one’s experience Lap ultrasound may be useful early in one’s experience

and in difficult cases, esp. obese patients with difficult to and in difficult cases, esp. obese patients with difficult to find tumorsfind tumors

Laparoscopic Applications - Spleen

Laparoscopic Laparoscopic splenectomysplenectomy


Laparoscopic Laparoscopic splenectomy: evolution splenectomy: evolution and current statusand current status Review of literature Review of literature

addressing the role of addressing the role of laparoscopic laparoscopic splenectomy (LS)splenectomy (LS)

Klinger PJ et al, Surg Laparosc Endosc. 1999 Jan;9(1):1-8


Laparoscopic Laparoscopic splenectomy: splenectomy: evolution and current evolution and current statusstatus Compared to OS, LS Compared to OS, LS

results in:results in: Fewer perioperative Fewer perioperative

complicationscomplications Less morbidityLess morbidity Shorter LOSShorter LOS



LS has a limited role in LS has a limited role in hypersplenism and hypersplenism and traumatic splenic traumatic splenic injuryinjury

LS is the operation of LS is the operation of choice for spleens choice for spleens <20cm in diameter<20cm in diameter


Laparoscopic Applications - Hernia

Initial trocar Initial trocar placementplacement


Finger dissection of the Finger dissection of the preperitoneal spacepreperitoneal space


Insufflation of per-Insufflation of per-peritoneal spaceperitoneal space


Trocar placementTrocar placement


Dissection of hernia Dissection of hernia spacesspaces


Reduction of direct Reduction of direct hernia sachernia sac


Reduction of direct Reduction of direct hernia sachernia sac

• Easily identified Easily identified medial to the epigastric medial to the epigastric vesselsvessels

• Easily reduced away Easily reduced away from the thinned from the thinned transversalis fasciatransversalis fascia


Reduction of indirect Reduction of indirect hernia sachernia sac

In the presence of hernia:In the presence of hernia: The vas deferent is not The vas deferent is not

visiblevisible The sac is seen over The sac is seen over

the spermatic cordthe spermatic cord The sac has to be always The sac has to be always

separated from the cord separated from the cord structures prior to any structures prior to any attempt of reductionattempt of reduction


Placement of meshPlacement of mesh


Fixation of the meshFixation of the mesh Stapler Stapler Tacker Tacker Adhesive butyl-2-Adhesive butyl-2-

cyanoacrylatecyanoacrylate** Fibrin sealantFibrin sealant****

(fibrinogen plus thrombin)(fibrinogen plus thrombin) No fixationNo fixation

Laparoscopic Applications - SummaryLaparoscopic ApplicationLaparoscopic Application Is if safe?Is if safe? Feasible?Feasible? Gold Standard?Gold Standard?

Esophagus – AchalasiaEsophagus – Achalasia YesYes YesYes YesYes

Esophagus – GERDEsophagus – GERD YesYes YesYes YesYes

Stomach – Bariatrics (RNY)Stomach – Bariatrics (RNY) YesYes YesYes YesYes

Stomach – CancerStomach – Cancer YesYes YesYes NoNo

Pancreas – DiagnosticPancreas – Diagnostic YesYes YesYes NoNo

Pancreas – Therapeutic Pancreas – Therapeutic YesYes YesYes NoNo

Liver – ResectionLiver – Resection YesYes YesYes NoNo

Colon – Diverticular DiseaseColon – Diverticular Disease YesYes YesYes YesYes

Colon – MalignancyColon – Malignancy YesYes YesYes YesYes

AppendixAppendix YesYes YesYes NoNo

Adrenal Adrenal YesYes YesYes YesYes

SpleenSpleen YesYes YesYes YesYes

HerniaHernia YesYes YesYes NoNo

Evaluating Current Laparoscopic Applications In Surgery

Health & Medicine

Transcript of Evaluating Current Laparoscopic Applications In Surgery