Biomedical subjects

D Lomanto

Publications and source records attributed to D Lomanto.

At least 19 recordsLinked to original sources

PubMed2001

Robotic-assisted laparoscopic cholecystectomy.

We report a case of laparoscopic cholecystectomy that was performed using a robotic surgical system. A 70-year-old woman underwent laparoscopic robotic cholecystectomy ZEUS, the robotic system used in our study, has three interactive robotic arms fixed to the side of the operating table. The arms are controlled by the surgeon, who sits at a remote computer console. The surgeon's movements can be scaled down, and tremor is filtered out. The robotic-assisted laparoscopic cholecystectomy was completed in 42 min. The time to set up the robot was 22 mins. All of the surgically reproducible robotic maneuvers were performed without any particular difficulty. The robotic movements were stable, accurate, and reliable, as well as easy to control with precision. Our preliminary experience indicates that robotic laparoscopic cholecystectomy is safe and can be as fast as conventional laparoscopic cholecystectomy. However, further clinical applications of robotic surgery are needed to confirm this observation.

Aged↗

PubMed2001

Thoracolaparoscopic repair of traumatic diaphragmatic rupture.

Diaphragmatic rupture may occur after blunt or penetration trauma caused by the application of a powerful external force. Diaphragmatic rupture usually is repaired via laporotomy and/or thoracotomy, depending on the associated organ injury. The case of a 49-year-old man with traumatic rupture of the left hemidiaphragm is presented. Preoperatively, diaphragmatic rupture with herniation of the stomach into the left thoracic cavity was confirmed by computed tomography scan of the thorax. Under thoracoscopic guidance, the stomach, spleen, and omentum were repositioned in the abdominal cavity, and the rupture site (10 cm) was closed by nonabsorbable suture. A subsequent laparoscopy was performed to assess the efficacy of the repair and the absence of any abdominal organ injury. The patient was discharged from hospital without any respiratory or abdominal symptoms. Our report confirms that in the case of a patient with penetration injuries to the lower chest and upper abdomen, a combined thoracoscopic and laparoscopic approach may offer both diagnostic and therapeutic benefits with reduced surgical trauma. We conclude that thoracoscopic repair of traumatic diaphragmatic rupture can be used safely when no abdominal organ injuries are found.

Hernia, Diaphragmatic, Traumatic↗

PubMed2001

Robotically assisted laparoscopic cholecystectomy: a pilot study.

HYPOTHESIS: Since the advent of laparoscopic surgery in 1987 and the introduction of robotics into medicine in 1991, medical technology has advanced to robotic applications in performing surgery. In our study, we investigated the feasibility of performing simple laparoscopic maneuvers and laparoscopic cholecystectomy using a robotic surgical system. DESIGN: The study used a ZEUS robotic system (Computer Motion Inc, Goleta, Calif), consisting of 3 interactive robotic arms fixed at the operating table and remotely controlled by the surgeon. After initial training, using a bench model and 3 isolated porcine livers to perform cholecystectomy, 7 female pigs underwent robotically assisted laparoscopic cholecystectomy. The surgeon, seated at the console, manipulated the 3-mm laparoscopic instruments and performed the surgery. RESULTS: Robotically assisted laparoscopic cholecystectomy was accomplished in all 7 pigs, with a mean operative time of 46 minutes (range, 30-62 minutes). There were no complications. The mean time to setup of the robotic system decreased from 30 minutes to 14 minutes. All the robotic maneuvers were performed without any particular difficulties, and the movements were stable, accurate, and reliable, with good control. CONCLUSIONS: Our preliminary experimental study showed that robotically reproduced laparoscopic maneuvers, such as tying, suturing, dissection, clipping, and cautery, seemed to be as accurate and as fast as maneuvers made without robotics. We conclude that our initial experimental and animal study confirmed the feasibility of robotically assisted laparoscopic cholecystectomy. Further reports are needed to show that robotics can be used for clinical applications in surgery.

Animals↗

PubMed2001

Two-trocar laparoscopic cholecystectomy: a reproducible technique.

Laparoscopic cholecystectomy is usually performed with a four-trocar technique. From December 1998 to March 1999, 25 of 42 admitted patients underwent a two-trocar laparoscopic cholecystectomy. In our technique, after establishing umbilical carbon dioxide pneumoperitoneum, a 30 degree scope was inserted, and a second 5-mm trocar was positioned below and to the left of the xiphoid process. Then two stitches with nonabsorbable sutures were passed: one at the fundus to pull up the gallbladder, and the second through the neck of the gallbladder to expose the structure of the Calot triangle. Intraoperative cholangiography was performed with a percutaneous catheter in 15 patients. Retrograde cholecystectomy was performed and the gallbladder was extracted through the umbilical port. Scars were closed with glue, and bupivacaine was injected to reduce pain. The technique was feasible in approximately 84% (25 of 30) of patients. The mean operative time was 42 minutes, and the mean hospital stay was 1.6 days. We conclude that this method is similar to four-port laparoscopic cholecystectomy in terms of safety and operation time. This technique seems to be well reproducible and offers better results in terms of postoperative pain, hospital stay without considering better cosmetic results, and cost-effectiveness.

Adult↗

PubMed2001

Early experience with laparoscopic radical gastrectomy for advanced gastric cancer.

Use of the laparoscopic approach for the management of gastric cancer is still in the developmental phase. The authors present their experience with laparoscopic radical gastrectomy for advanced gastric cancer. Between September 1997 and August 1999, four laparoscopic gastrectomies for gastric carcinoma were performed on two male and two female patients (mean age, 61.5 years). One D2 total radical gastrectomy and three D2 subtotal distal gastrectomies were performed, using a totally laparoscopic approach. Mean operative time was 210 minutes. There were no intraoperative complications. All four patients recovered uneventfully from surgery and began oral feeding on the third postoperative day. Median postoperative stay was 7 days (range, 6-9). All patients were alive 8 months to 3 years after the operation, with no cancer recurrences. This series shows that laparoscopic radical gastrectomy for moderately advanced cancers can produce good results in terms of safety and oncologic adequacy.

Adenocarcinoma↗

PubMed2000

Impaired human gallbladder lipid absorption in cholesterol gallstone disease and its effect on cholesterol solubility in bile.

BACKGROUND & AIMS: The role of the gallbladder in gallstone pathogenesis is still unclear. We examined the effects of gallbladder mucosal lipid absorption on lipid composition and cholesterol crystallization in bile. METHODS: The in vitro-isolated, intra-arterially perfused gallbladder model was used (1) to compare the absorption rates of lipids from standard bile by gallbladders obtained from 7 patients with cholesterol gallstones and 6 controls; and (2) to measure the microscopic cholesterol crystal detection time in cholesterol-enriched pig bile before and after lipid absorption by the pig gallbladder. RESULTS: Control gallbladders, but not cholesterol gallstone gallbladders, significantly reduced cholesterol (P < 0.02) and phospholipid (P < 0.01) and increased bile salt (P < 0.01) molar percentages in bile over a 5-hour period by efficient and selective cholesterol and phospholipid absorption. A histomorphometric study of the epithelial cells showed significantly higher values for nuclear density (P < 0.01) and nuclear (P < 0.05) and cytoplasmic (P < 0.05) areas in the cholesterol gallstone than the control group. Sequential microscopy of cholesterol-enriched pig bile showed significantly shorter cholesterol filament (P < 0.01) and typical cholesterol plate (P < 0. 02) detection times before than after exposure of bile to the gallbladder lipid absorption. CONCLUSIONS: In cholesterol gallstone disease, the human gallbladder epithelium loses its capacity to selectively and efficiently absorb cholesterol and phospholipids from bile, even if it is hyperplastic and hypertrophic. This epithelial dysfunction eliminates the positive effect that the normal gallbladder exerts on cholesterol solubility in bile and might be a pathogenetic cofactor for cholesterol gallstone formation.

Absorption↗

PubMed2000

Effector Th-1 cells with cytotoxic function in the intestinal lamina propria of patients with Crohn's disease.

A large body of evidence points to a pivotal relationship between Th-1 cells and mucosal inflammation in Crohn's disease (CD). The aim of the present study was to assess whether CD is associated with specific functional activity of lamina propria T lymphocytes (LPT), particularly purified CD4, such as cytotoxic activity and specific cytokine-secreted profile. The results showed that CD4 LPT in patients displayed a chronically activated memory-like surface phenotype and, when compared to controls, had a significantly enhanced antibody-redirected cytotoxicity. Interestingly, the ratio of perforin expression in CD4 LPT was higher compared to controls, and a redirected lysis of human RBC mediated by a CD4 subset of intestinal lamina propria was evident, suggesting a cytolytic pore-forming mechanism. Moreover, a unique Th-1 cytokine profile pattern in the CD4 cells from CD was defined. These effector cells produced 12 times more IFN-gamma, two times more TNF-alpha, and three times less IL-4 than controls. In contrast, no increase in IL-2 was detected, while IL-5 was undetectable. Our studies suggest that these preexisting in vivo activated CD4 LPT may play an important role in the inflammatory process in CD, thus directly contributing to the intestinal lesions.

Antibody-Dependent Cell Cytotoxicity↗

PubMed1998

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair.

BACKGROUND: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). METHODS: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. RESULTS: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. CONCLUSIONS: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced.

Adolescent↗

PubMed1997

MR cholangiography (MRC) in the evaluation of CBD stones before laparoscopic cholecystectomy.

BACKGROUND: The aim of our work was to evaluate the predictive value of MR cholangiography (MRC) in detecting CBD stones before laparoscopic surgical treatment. METHODS: MRC was performed as a unique preoperative imaging modality in 45 selected patients (16 male; 29 female; age range: 28-72; mean age: 54.4) before laparoscopic cholecystectomy. MRC imaging was obtained with a 3D Turbo Spin-Echo sequence (TR = 3000 ms, TE = 700 ms, Echo Train Length--128) with an acquisition time of 5 min 48 s. Diagnostic confirmation was obtained in all the cases at i.o. cholangiography. When a stone was detected it was removed by transcystic or transcholedochal approach. RESULTS: Eighteen of the 45 patients (40%) had CBD stones. MRC correctly evaluated 16 out of 18 stones, with a resulting sensitivity of 88.9%, specificity 100%, positive predictive value 100%, negative predictive value 90%, and accuracy 95.6%. CONCLUSIONS: Despite the good results of MRC, it cannot be proposed as a screening technique to be performed in all patients submitted to laparoscopic cholecystectomy due to high cost and the limited amount of MR equipment. In conclusion, only selected patients should be submitted to MRC before laparoscopic cholecystectomy.

Adult↗

PubMed1997

Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases. PATIENTS AND METHODS: One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases. RESULTS: In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films. CONCLUSIONS: MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.

Adult↗

PubMed1997

[The role of surgery in the treatment of appendicular abscesses].

The management of appendiceal abscesses is still discussed and many different approaches are nowadays adopted. The aim of this study was to analyze retrospectively our experience with this disease to value the results of drainage of the abscess and appendectomy in one stage in presence of appendiceal abscesses. We studied 44 patients consecutively observed in our Department of General Surgery all submitted to drainage of the abscess and appendectomy for acute appendicitis with periappendiceal abscess. Preoperative ultrasonography showed an accuracy of 85.7% in detecting the presence of an abscess. Mean size of the abscesses were 5 cm (from a minimum of 3 cm to a maximum of 9 cm). The mean duration of surgical operation was 48 minutes (min 35'-max 95'), with a mean in-hospital stay of 6.2 days. Morbidity rate was 9% and was due in 75% of cases to wound infection and in 25% of cases to wound dehiscence. Neither major morbidity nor mortality were observed. In consideration of the results the authors conclude that even in presence of an appendiceal abscess, appendectomy with abscess drainage is not only a safe operation with a low morbidity rate but the procedure of choice allowing a significative reduction of hospitalization and health cost.

Abscess↗

PubMed1997

Cholecystoenteric fistula is not a contraindication for laparoscopic cholecystectomy: report of five cases treated by laparoscopic approach.

The authors present five cases (three female, two male, mean age 50.8) of cholecystoduodenal fistula incidentally discovered during laparoscopic cholecystectomy and treated by laparoscopic approach. The laparoscopic technique adopted is described and all patients recovered promptly with no immediate or long-term post-operative complications. Discharge from the hospital was after 4.5 days, and after 6 months follow-up all patients were in good clinical condition. These results indicate that when the surgeon is skilled in advanced laparoscopic operative techniques such as duodenal mobilization and intracorporeal suturing and knotting, cholecystoduodenal fistula can no longer be considered a contraindication for laparoscopic treatment.

Aged↗

PubMed1996

ESWL experience in the therapy of difficult bile duct stones.

In recent years, alternatives to surgery for difficult bile duct stones have been developed. Routine endoscopy fails in about 10% of patients. To verify the role of extracorporeal shock wave lithotripsy in residual CBD stones, we treated 32 patients by HM4 or MPL 9000 Dornier lithotripters. Ten (34.4%) patients needed two extracorporeal shock wave lithotripsy sessions, and 3 (10.3%) patients three. Complete clearance was achieved in 29 patients (90.6%) after one or more sessions either by endoscopic (20 pts) or percutaneous (9 pts) extraction of the debris; of the remaining 3 patients, in 2 a bilioduodenal stent was placed and in 1 electrohydraulic lithotripsy was performed. Eighteen and seven-tenths percent transient mild hemobilia, 12.5% microhematuria, and no mortality were observed. It is possible to state that in site- or size-related difficult biliary stones, extracorporeal shock wave lithotripsy is a rapid, safe, and highly effective treatment as an additional nonoperative option to resolve the failure of routine endoscopic measures.

Adult↗

PubMed1996

Laparoscopic treatment of gallbladder and common bile duct stones: a prospective study.

The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnoses at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed. Use of biliary drainage was liberal. A completion cholangiogram was obtained for all patients. Laparoscopic treatment of CBD stones was successful in 96 patients: after TC-CBDE in 63 and after D-CBDE in 33. Four operations were converted to open surgery (4%). Retained stones, observed in five patients, were treated by ES in two cases and by percutaneous endoscopic/fluoroscopic lithotripsy in three. Minor morbidity included biloma (n = 2), port site infection (n = 2), and subumbilical hematoma (n = 1). Major morbidity was bile leakage from the cystic duct stump in two cases due to clips or transcystic duct drainage displacement, respectively. One elderly, high risk patient died after being referred for several failed attempts of endoscopic clearance; she died from cardiogenic shock 3 days after successful laparoscopic treatment. Laparoscopic CBD exploration is feasible and safe in most patients, with short-term results that compare favorably with the results of sequential ES/LC reported in the literature.

Adolescent↗

PubMed1994

Technique and results of routine dynamic cholangiography during 528 consecutive laparoscopic cholecystectomies.

With the advent of laparoscopic cholecystectomy a trend toward more extensive preoperative diagnostic study of the biliary tree by intravenous cholangiography or ERCP has been observed. However, both exams have technical limitations and are not without risk. We report our experience with 500 consecutive routine dynamic intraoperative cholangiographies during laparoscopic cholecystectomy, 97% of which were successful. No lesions from cholangiography were observed. In ten patients clips on the cystic artery appeared on intraoperative cholangiogram to be too close to the hepatic duct and were removed. Anomalies of surgical importance were discovered in 11 patients (2.3%). Unsuspected stones were found in 18 cases (3.7%) and suspected stones confirmed in 12 (2.4%). In our experience routine dynamic intraoperative cholangiography provided important information in 51 cases out of 500 (10.2%). We conclude that routine dynamic intraoperative cholangiography is extremely useful for safer laparoscopic cholecystectomy and cost containment.

Cholangiography↗

PubMed1994

[The role of intraoperative echography in laparoscopic cholecystectomy].

On the basis of recent technological improvements, the laparoscopic approach has become the method of choice during cholecystectomy. This surgical procedure, however, needs that cholangiography be performed simultaneously to better define the anatomy of the biliary ducts and the possible presence of choledochus stones. The use of intraoperative US during cholecystectomy is nowadays advocated for the unquestionable advantages offered by this technique--i.e., its non-invasiveness, high spatial resolution and no need of contrast agent administration. In this study, we examined 30 patients with cholelithiasis who underwent laparoscopic cholecystectomy and were submitted to endolaparoscopic US besides routine intraoperative cholangiography. In all cases, both techniques allowed optimal visualization of the biliary tree, clearly demonstrating choledochus stones in 2 cases. Intraoperative US proved to be more accurate in two cases. In one case which was positive at intraoperative cholangiography, the method allowed the biliary duct filling defect to be referred to an artifact caused by the presence of an air bubble. In another case, the lack of opacification of the hepatic ducts at cholangiography was referred, after US, to extrinsic gallbladder compression. US also allowed the adjacent parenchymal organs, such as the liver and the head of pancreas, to be studied. A limitation of this technique was represented by the difficult assessment of the choledochus in the patients with anatomical abnormalities or adhesions of the intestinal loops of the upper abdomen. In conclusion, endolaparoscopic US proved to be a reliable technique in the intraoperative study of the biliary ducts and can be considered as a procedure complementary to intraoperative cholangiography.

Biliary Tract↗

PubMed1994

[Intraoperative digital cholangiography during laparoscopic cholecystectomy interventions].

In the last years, laparoscopic cholecystectomy has become the method of choice in the surgical treatment of gallbladder stones. Recently, the same laparoscopic approach has been used to remove choledochus stones. This surgical procedure needs the accurate intraoperative study of the biliary tree with diagnostic imaging modalities to better define the anatomy of the biliary ducts and the possible presence of choledochus stones. To this purpose, transcutaneous and endolaparoscopic US with dedicated probes and intraoperative cholangiography can be performed. In this study, we performed 30 laparoscopic cholecystectomies during which all the patients were submitted to intraoperative cholangiography with a digital fluoroscopic unit. The maneuvers for catheter insertion in the cystic duct and the examination as a whole took 3 to 5 minutes. Intraoperative cholangiography demonstrated choledochus stones in 3 patients, while preoperative US detected them in 2 patients only. In 8 cases the dynamic study, carried out with digital image acquisition, allowed to refer the biliary duct filling defects to artifacts caused by the presence of air bubbles. In conclusion, intraoperative cholangiography, also during endolaparoscopic cholecystectomy, plays a major role in the surgical assessment of the biliary tree. When the procedure was performed with a digital fluoroscopic unit, its diagnostic accuracy was higher and the images on the TV monitor were better visualized.

Cholangiography↗

PubMed1993

Role of magnetic resonance imaging (MRI) in detecting liver changes after gallstone extracorporeal shock wave lithotripsy (ESWL).

Recently published literature on biliary extracorporeal shock wave lithotripsy (ESWL) has shown that high-energy ESWL utilizing high kV is more effective than the low-energy ESWL and low kV used previously. Prior studies have not reported injury to the gallbladder or adjacent liver following ESWL. Our study evaluated 29 patients that were treated with high kV ESWL. Magnetic resonance imaging (MRI) was used to study the gallbladder and adjacent liver for possible injury resulting from the high-energy treatment. The patients, selected using the Dornier MPL-9000 United States protocol, underwent ESWL using 18-24 kV (average 21 kV). MRI was done both pre and post-ESWL in all 29 patients. Ten patients had a second treatment to reduce fragment size and, subsequently, had an additional MRI examination. Spin echo MRI images were obtained at the level of the gallbladder fossa using a 0.5-Tesla ESATOM RM 5000 (ESAOTE Biomedica, Genva, Italy.) superconductive unit. Both T1- and T2-weighted images were obtained. In 26 patients the hepatic parenchyma was normal post-ESWL. Two patients had a hyperintense region on T1-weighted images post-ESWL that was felt to be related to pericholecystic fat. A third patient had an abnormality detected on T2-weighted images that was thought to be due to hepatic edema or microhemorrhage. No significant changes were shown by laboratory or concurrent ultrasound examinations. Repeat MRI examinations in these three patients were normal. High-energy ESWL appears as safe as low-energy ESWL in the treatment of patients with symptomatic gallstones.

Adult↗