Needle and trocar injury during laparoscopic surgery in Japan.
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Abdominal Injuries↗
Biomedical subjects
H J Bonjer
Publications and source records attributed to H J Bonjer.
Comparison of one-lung ventilation and high-frequency ventilation in thoracoscopic surgery.
OBJECTIVE: To report our experience of the use of high frequency ventilation (HFV) in thoracoscopic surgery. DESIGN: Retrospective study. SETTING: University Hospital Rotterdam, The Netherlands. SUBJECTS: 31 patients (18 men and 13 women, mean age 42 years, range 26-67 years) who underwent 46 thoracoscopic procedures between January 1992 and December 1997. INTERVENTIONS: Until October 1994 patients had conventional mechanical ventilation with a double-lumen tube. Since then HFV has been used. MAIN OUTCOME MEASURES: Duration of induction, oxygen saturation, and end-tidal carbon dioxide tension. RESULTS: 25 procedures were done with a double-lumen endotracheal tube for one-lung ventilation and in 21 HFV was used. Induction of anaesthesia took significantly less time in the HFV group (median 14 minutes) compared with one-lung ventilation group (median 31 minutes) (p < 0.05). There were no significant differences between the groups in either SaO2 or end-tidal CO2. CONCLUSION: HFV is both safe and simple for use in thoracoscopic surgery.
Adult↗
Endoscopic palliative treatment of advanced pancreatic cancer: thoracoscopic splanchnicectomy and laparoscopic gastrojejunostomy.
DESIGN: Evaluation of thoracoscopic splanchnicectomy and laparoscopic gastrojejunostomy as endoscopic palliative treatment of advanced pancreatic cancer. PATIENTS AND METHODS: Between November 1993 and September 1998 we performed 16 thoracoscopic splanchnicectomies and 6 laparoscopic gastrojejunostomies in patients with an advanced pancreatic cancer admitted to the Department of Surgery of University Hospital Rotterdam-Dijkzigt. These patients either did not achieve adequate pain control with medication or presented serious problems of gastric outlet obstruction, or both. RESULTS: There were fourteen patients (9 men and 5 women) with mean age of 51.8 years (range 28-83), mean BMI of 21.1 (range 17.2-27.2), ASA score I in 2, II in 11, III in 1. We performed 2 left, 2 right and 4 bilateral thoracoscopic splanchnicectomies, 4 laparoscopic gastrojejunostomies and 2 combined endoscopic procedures (bilateral thoracoscopic splanchnicectomy and laparoscopic gastrojejunostomy). The overall average operation ("skin to skin") time was 86 minutes (range 75-100) for bilateral thoracoscopic splanchnicectomies, 63 minutes (range 60-65) for unilateral splanchnicectomies, 88 minutes (range 65-115) for laparoscopic gastrojejunostomies and 190 minutes (range 180-200) for the combined procedure. Blood loss was insignificant with a median of 50 ml (range 30-150). The conversion's rate to open surgery was 4.5%. There were no intraoperative complications. The overall average postoperative mobilization was in 1.9 days (range 1-4) and the overall median postoperative hospital stay was 7 days (range 2-24). There was no mortality at 30 days after endoscopic procedures and the morbidity rate was 21.4%. The postoperative analgesic requirement was considerably reduced with a successful rate was 83.3%. The resolution of gastric outlet obstruction has been complete in all laparoscopic gastrojejunostomies. CONCLUSIONS: Our results show the feasibility and safety of these minimally invasive approaches such as endoscopic palliative treatment of complications of advanced pancreatic cancer.
Adult↗
Prognostic value of RET proto-oncogene point mutations in malignant and benign, sporadic phaeochromocytomas.
Somatic mutations in the RET proto-oncogene are involved in the pathogenesis of an important subset (40-60%) of sporadic medullary thyroid carcinomas (MTCs) and less frequently (0-31%) in benign, sporadic phaeochromocytomas. Since limited data exist regarding the significance of somatic RET mutations in malignant phaeochromocytomas, we analysed a multicentre series of proven malignant (i.e., metastasised) phaeochromocytomas. Analogous with MTCs, where RET mutations lead to an aggressive behaviour, we hypothesised that somatic mutations would occur more frequently in malignant than in benign phaeochromocytomas. Paraffin-embedded tissue was available from 29 malignant and 27 benign phaeochromocytomas. Exons 10, 11 and 16 were analysed by non-radioactive single-strand conformation polymorphism, heteroduplex gel electrophoresis, restriction enzyme digestion and aberrant band patterns by non-isotopic sequencing. In only 1 of 29 malignant phaeochromocytomas was a mis-sense mutation found (at codon 634 of exon 11), whereas in 15% (4/27) of the benign tumours a point mutation was detected (in 3 tumours in exon 16 at codon 918 and in 1 tumour in exon 10 at codon 618). Absence of these mutations in non-tumourous DNA proved their somatic origin. Contrary to what has been reported for MTCs, oncogenic RET mutations are not associated with an aggressive tumour behaviour in sporadic phaeochromocytomas.
Adolescent↗
Germline mutations in the vhl gene in patients presenting with phaeochromocytomas.
It has been shown that an appreciable percentage of patients presenting with primary, apparently sporadic phaeochromocytomas may in fact have von-Hippel-Lindau (VHL) disease. In order to investigate this, we retrospectively screened 68 patients, who had been operated on for phaeochromocytomas, for the presence of germline mutations in the vhl gene. DNA was isolated from peripheral-blood leukocytes and used to screen the entire coding sequence and the intron-exon boundaries of the vhl gene for mutations, using a PCR-based SSCP strategy. When an abnormal pattern was found in the SSCP analysis, sequence analysis was carried out. We found SSC variants in the vhl gene in 8 of the 68 patients. Of 6 patients, 2 turned out to be related (an uncle and his nephew), and they carried the same mis-sense mutation: R64P. In 4 other patients, mis-sense mutations, P25L, L63P, G144Q and I147T, were also identified. None of these mutations has been described, and 3 of them (P25L, L63P and R64P) are located closer to the N terminus of the vhl protein than any reported vhl mutation. In the remaining 2 cases, the mutations were localized not in the coding sequence but in the intronic sequence (but not within splice-sites), adjacent to the exon, so they were probably not related to the disease. Our results show that a relatively high proportion (6/68, or 8.8%), though not as high as the 20% reported earlier, of patients with apparently sporadic phaeochromocytomas may carry germline mutations in the vhl gene.
Adrenal Gland Neoplasms↗
[Right-sided diverticulitis masquerading as acute appendicitis].
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Appendicitis↗
[Right-sided diverticulitis mimicking acute appendicitis].
The probability diagnosis in two patients, women aged 43 and 41 years, who for the last few days had had pain in the right lower abdomen, without nausea or vomiting, was acute appendicitis; a third patient, a woman aged 49 with the same symptoms, had undergone appendectomy in the past. Peroperative findings and, in two patients, microscopy of the resected specimen showed diverticulitis in the caecum or ascending colon. This is an uncommon disease, which mimicks acute appendicitis. Treatment depends on the severity of the inflammation. In the absence of perforation or abscess, conservative treatment suffices. Otherwise, resection of the colon is necessary.
Acute Disease↗
Effects of carbon dioxide pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy on body weight and tumor growth.
BACKGROUND: The oncologic consequences of intraperitoneal carbon dioxide (CO2) insufflation during the laparoscopic resection of cancer are under debate. The effect of other insufflating gases or gasless laparoscopy on cancer requires study. OBJECTIVE: To study body weight and tumor growth in rats after CO2 pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy. METHODS: On day 1, an 8-mg bolus of ROS-1 tumor was placed under the renal capsule of both kidneys in rats. In experiment A, rats had either CO2 insufflation (n=10) or a gasless laparoscopic bowel resection (n=10) on day 3 and were humanely killed after 7 days. In experiment B, rats had either a laparoscopic bowel resection with CO2 insufflation (n=11) or insufflation with air (n=11) on day 3 and were killed after 7 days. In both experiments, postoperative weight loss and tumor growth were measured, and the differences were tested with an analysis of covariance. RESULTS: Renal subcapsular tumor growth in the group having gasless laparoscopy was less than that in the group having CO2 pneumoperitoneum (P=.04). Postoperative weight loss in these groups showed no differences (P=.55). No differences in tumor growth or weight loss were found between rats having insufflation with CO2 and those having insufflation with air (P=.61 and P=.68, respectively). CONCLUSIONS: The restoration of body weight after a laparoscopic surgical procedure was similar with CO2, air, or gasless laparoscopy. Gasless laparoscopy was associated with less renal subcapsular tumor growth than was insufflation with CO2. Therefore, the application of gasless techniques in laparoscopic oncologic surgical treatment demands further study.
Air↗
2-Methoxyisobutylisonitrile probe during parathyroid surgery: tool or gadget?
The success of parathyroid surgery is determined by the identification and removal of all parathyroid tumors. Parathyroid tumors accumulate and retain 2-methoxyisobutylisonitrile (MIBI) labeled with technetium-99m. Intravenous injection of this radiopharmacon prior to parathyroid surgery allows identification of parathyroid tumors with a hand-held gamma detector. To assess the value of this technique, a case-control study was performed with 62 patient having nuclear-guided parathyroidectomy and 60 patients having conventional parathyroid explorations. The sensitivity rates of the MIBI probe in single and multiple gland disease were 84.6% and 63.0%, respectively. Rates of success, temporary and permanent hypoparathyroidism, and injury of the recurrent laryngeal nerve were similar in patients who underwent probe-guided surgery and those who had conventional surgery. In conclusion, although the MIBI probe appears to be a valuable tool in parathyroid surgery, its use has not improved the outcome of such surgery at our institution.
Case-Control Studies↗
Retroperitoneal adrenalectomy: open or endoscopic?
Conventional adrenalectomy requires relatively large incisions. To assess the value of retroperitoneal endoscopic adrenalectomy, a case-control study was performed comparing the endoscopic technique to conventional posterior adrenalectomy. All patients had adrenal tumors less than 7 cm in diameter. Endoscopic retroperitoneal adrenalectomy required more operative time (90 vs. 60 minutes, p < 0.0001) than the open approach but was associated with less blood loss (20 vs. 125 ml, p < 0.0001). Endoscopic adrenalectomy caused less pain postoperatively (p = 0.0005) and was associated with fewer complications (p = 0.035). The hospital stay was shorter after endoscopic adrenalectomy than after open adrenalectomy (p < 0.0001). In conclusion, we advocate endoscopic retroperitoneal adrenalectomy in patients with small adrenal tumors.
Adenoma↗
Laparoscopic vs conventional bowel resection in the rat. Earlier restoration of serum insulin-like growth factor 1 levels.
BACKGROUND: The role of laparoscopic surgery in the treatment of colorectal disease is still controversial. To assess the metabolic consequences of laparoscopic and open bowel surgery, we studied serum levels of insulin-like growth factor 1 (IGF-1), an anabolic and mitogeneic peptide, in rats. MATERIALS AND METHODS: In experiment 1, the serum IGF-1 levels of 10 rats undergoing laparoscopic small bowel resections (group I) and 10 rats undergoing conventional small bowel resections (group II) were determined before surgery and on days 1, 2, and 7. Experiment 2 compared five rats that had CO2 pneumoperitoneum (group III), five rats that underwent laparotomy (group IV), and five rats that received anesthesia only (group V). Differences in IGF-1 levels were tested with analysis of covariance. RESULTS: In experiment 1, preoperative IGF-1 levels were similar in groups I and II (87.9 +/- 6.1 nmol/L versus 90.5 +/- 8.1 nmol/L). One day after surgery IGF-1 was 54.6 +/- 10.5 in group I versus 41.6 +/- 8.3 in group II (p = 0.006). Two days after surgery, IGF-1 was 79.4 +/- 9.2 in group I versus 59.0 +/- 10.5 in group II (p < 0.001). Seven days after both types of surgery, IGF-1 levels had returned to almost normal levels. In experiment 2, no significant differences were found between the rats with CO2 pneumoperitoneum (group III) and those with laparotomy only (group IV). Rats that had anaesthesia only showed a significant decrease in IGF-1 levels between days 0 and 1 (p < 0.018). CONCLUSION: Our study indicates that laparoscopic bowel surgery is associated with a better postoperative anabolic state (i.e., less catabolism) than conventional surgery. This finding reflects a potential benefit of laparoscopy in bowel surgery.
Animals↗
General oncologic effects of the laparoscopic surgical approach. 1997 Frankfurt international meeting of animal laparoscopic researchers.
The results from the majority of the reviewed studies support the hypothesis that abdominal surgery, performed via either a large incision or CO2 pneumoperitoneum, systemically encourages tumor growth in the postoperative period. A full laparotomy incision appears to have a significantly greater effect than CO2 pneumoperitoneum on postoperative tumor growth. Whether the large tumor observed in the surgical groups are the result of increased tumor cell proliferation or diminished tumor cell death remains unclear. There is some evidence pointing to both mechanisms. The loss of the postoperative tumor growth differences between the open and pneumo animals in the athymic mouse experiment suggests that cell-mediated immune function plays a role in tumor containment. The proliferation study results, however, suggest that other stimulatory influence(s) are also at work. Clearly, much research needs to be done regarding the etiology of these tumor growth differences. Other tumor cell lines need to be studied, and investigations regarding tumor growth in an intra-abdominal location need be performed as well. This body of research suggests that the manner in which the surgeon gains access to the abdominal cavity may have an impact on the propensity of tumor cells to implant, survive, and grow in the period immediately after surgery. If true, this may be the most compelling justification for the use of minimally invasive techniques for the curative resection of malignancies. However, it remains to be proven that human tumors will demonstrate differences in tumor growth similar to those noted in some of these animals models. Furthermore, it is not all clear that slight differences in tumor growth postoperatively will translate into significant differences in long-term survival or recurrence rates. At first glance, the existence of port-site tumors would appear to contradict totally the conclusions of many studies discussed in this synopsis. If laparoscopic methods are associated with decreased rates of tumor growth and establishment, then why do port-site tumors form? This is a complex issue calling for discussion that goes far beyond the scope of this article. However, several brief comment on this topic follow. The etiology of port tumors is unknown, although traumatization of the tumor during mobilization, resection, or removal is likely to play a significant role in the liberation of tumor cells from the primary. A relatively small protective benefit, in terms of slower tumor growth rates in laparoscopic patients, will likely not be sufficient to prevent a large inoculum of viable tumor cells in an abdominal wound from establishing a metastasis. Furthermore, as suggested earlier, the systemic effects on tumor growth may be different from the local (i.e., intra-abdominal or abdominal wound) effects. Finally, the true incidence of port tumors remains unknown. It has not been definitively established that the laparoscopic wound tumor incidence is significantly higher than the open rate, although this is the assumption of most surgeons. Several relatively large recently published laparoscopic series have reported port tumor incidences of 0 to 1.2%, which is in the same "ballpark" as the 0.6 1.0% abdominal wound tumor incidences mentioned in several open colectomy series. Clearly, much more research in this area is needed to understand port tumors better and to reconcile the port tumor results with the systemic tumor growth benefits that may be associated with minimally invasive methods.
Animals↗
Peritonitis and adhesions in laparoscopic surgery. First workshop on experimental laparoscopic surgery, Frankfurt 1997.
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Animals↗
Port site metastases in laparoscopic surgery. First workshop on experimental laparoscopic surgery, Frankfurt 1997.
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Animals↗
Can sonographic signs predict conversion of laparoscopic to open cholecystectomy?
BACKGROUND: The aim of this study was to determine whether sonographic signs can predict the risk for conversion of laparoscopic (LC) to open cholecystectomy (OC). METHODS: All 346 patients who underwent LC at our institution between January 1, 1993, and March 1, 1996, were studied retrospectively. Patients who had no sonographic examination during 6 months prior to surgery and patients treated by inexperienced surgeons were excluded from the study. Patient characteristics and sonographic parameters were evaluated by univariate and multivariate analysis, using conversion to OC as a dependent variable. RESULTS: In 23 of 134 patients (17.2%), LC was converted to OC. In the univariate analysis, gallbladder distention (>4.5 cm; relative risk [RR] 3.5; 95% confidence intervals [CI] 1.7-5.3), stone impaction (RR 2.4; 95% CI 1.1-5.1), thickened gallbladder wall (RR 2.4; 95% CI 1.2-5.1), and acute cholecystitis (RR 2.6; 95% CI 1.1-6.7) were able to predict the need for conversion. Logistic regression defined only the sonographic sign of distention of the gallbladder as a predictor of conversion. CONCLUSIONS: Gallbladder distention as a sonographic sign is associated with a high relative risk for conversion. The predictive value of sonographic signs for conversion requires further assessment in a prospective study.
Adolescent↗
Port-site metastases. Impact of local tissue trauma and gas leakage.
BACKGROUND: Port-site metastases after laparoscopic procedures in patients with digestive malignancies have evoked concern. The pathogenesis of port-site metastases remains unclear. Two experiments in rats were performed to determine the impact of both tissue trauma and leakage of CO2 along trocars (chimney effect) in the development of port-site metastases. METHODS: Experiment I: Ten WAG rats had four 5-mm incisions in all abdominal quadrants. The incisions on the right side were crushed to induce tissue trauma. After inserting 5-mm trocars in all incisions, a pneumoperitoneum was created, and CC-531 tumor cells were injected intraperitoneally. CO2 was insufflated for 20 min. Experiment II: Ten WAG rats had 5-mm incisions in the left and right abdominal upper quadrant. A 5-mm trocar was inserted in the incision in the left upper quadrant, and a 2-mm trocar was inserted in the incision in the right upper quadrant. After insufflating the abdomen, CC-531 tumor cells were injected intraperitoneally. Total leakage of CO2 along the trocar in the right quadrant was 10 liters. After 4 weeks, in both experiments, the tumor deposits at the trocar sites were assessed. Statistical analysis was performed by the Wilcoxon matched-pairs test. RESULTS: Experiment I: The median weight of tumor deposits at the trocar sites without induced tissue trauma was 22 mg. At the traumatic port sites, median weight of tumor deposits was 316 mg (p = 0.007). Experiment II: The median weight of tumor deposits at the leaking trocar sites was 478 mg and at the control sites 153 mg (p = 0.009). CONCLUSION: Tissue trauma at trocar sites and leakage of CO2 along a trocar appear to promote implantation and growth of tumor cells at port sites.
Abdominal Muscles↗
Vascular injuries during laparoscopy.
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Abdomen↗
[Abdominal wall metastasis following surgical removal of colorectal carcinomas].
Abdominal wall metastases after laparoscopic resection of colorectal cancer have been reported by various authors. It appeared that abdominal wall metastases occur more frequently after laparoscopic than after conventional, open resection of colorectal cancer. However, the frequency of abdominal wall metastases after laparoscopic surgery varies from only 0 to 1.9% in centres with sufficient relevant experience, whereas after conventional resections the frequency is 0.8-3.3%. A randomized clinical study comparing laparoscopic with conventional resection of colon cancer is necessary to assess the optimal surgical approach to colon cancer. Such a trial has been set up.
Abdominal Muscles↗