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Biomedical subjects

M Gagner

Publications and source records attributed to M Gagner.

At least 55 records · Page 3Linked to original sources
PubMed2001

A biodegradeable membrane from porcine intestinal submucosa to reinforce the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: preliminary report.

BACKGROUND: A Silastic ring has been used to prevent dilation of the gastrojejunostomy in Roux-en-Y gastric bypass (RYGBP). The use of a bio-membrane may prevent dilation of the anastomosis without the risks associated with prostheses. The aim of this study was to evaluate the feasibility and safety of applying such a bio-membrane around the gastrojejunostomy in Laparoscopic RYGBP (LRYGBP). METHODS: We used a new bio-membrane, that is derived from porcine small intestinal submucosa (SIS) and acts as a scaffolding for the ingrowth of connective tissue. Over a 4-month period, 14 LRYGBP patients had their proximal anastomosis wrapped with 10 x 2.5 cm SIS by a single surgeon. We compared these patients to a control group of LRYGBP patients matched for BMI. RESULTS: The average age of the patients was 35.0 years (control group: 45.1 years). The patients had a mean initial BMI of 44.7 kg/m2 (+/- 5.9) standard error, and the control subjects had a mean initial BMI of 46.7 kg/m2 (+/- 6.5). SIS application took a mean time of 11 (+/- 3) minutes without any intraoperative complication. The median hospital stay was 3.5 days in the experimental group and 3.7 days in controls. Three patients developed a symptomatic stenosis at the gastrojejunostomy following surgery. In the control group there were two stenoses. At an average follow-up of 87 days (controls: 95 days), the mean reduction in BMI was 7.8 (+/- 0.8) kg/m2 [controls 8.6 kg/m2 (+/- 1.5)]. CONCLUSION: Application of SIS around the gastrojejunostomy in patients undergoing LRYGBP is feasible and safe. Further follow-up is required, however, to evaluate the effectiveness in preventing dilation of the anastomosis.

Adult↗
PubMed2001

Hand-assisted laparoscopic pancreatic resection.

The extent of reported laparoscopic pancreatic resections vary from enucleation to pancreaticoduodenectomy. Nevertheless, most patients with pancreatic disease who require resection are still treated with a traditional approach. Technological advancements in recent years may play an important role for the future diffusion of laparoscopic pancreatectomy. In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen through a small laparotomy while pneumoperitoneum is maintained, and uses the hand to assist with dissection, palpation and retraction, control of blood vessels, manipulation of organs, and removal of the specimen. We present a review of our experience and of the world literature on hand-assisted laparoscopic pancreatic resection. Based on the first encouraging results, we believe that the hand-assisted technique should allow for substantial advantages to laparoscopic pancreatic surgery in the future.

Dissection↗
PubMed2001

Laparoscopic exclusion of a splenic artery aneurysm using a lateral approach permits preservation of the spleen.

Splenic artery aneurysms have commonly accepted therapeutic indications. Operative therapy for splenic artery aneurysms has traditionally consisted of aneurysm resection with a possible splenectomy. Recently, laparoscopic splenic artery aneurysm exclusion has been shown to provide adequate therapy without incurring the morbidity associated with aneurysmectomy and splenectomy. However, an anterior approach to exclusion may result in short gastric and left gastroepiploic artery disruption leading to splenic infarction. Preservation of the spleen can best be assured by a lateral approach, which preserves collateral splenic perfusion. A 51-year-old woman with a distal splenic artery aneurysm, who underwent an uncomplicated laparoscopic splenic artery aneurysm exclusion using a lateral approach, is described.

Aneurysm↗
PubMed2000

Surgery of the adrenal glands.

Because widespread use of imaging techniques has led to the frequent detection of incidentalomas, radiologists, endocrinologists, and endocrine surgeons must be knowledgeable about the appropriate evaluation of patients, and the selection of the appropriate surgical approach, including conventional open and laparoscopic adrenalectomy. This article reviews the authors' preferences based on experience with nearly 200 laparoscopic adrenalectomies.

Adrenal Cortex Hormones↗
PubMed2000

Endoscopic endocrine neck surgery with carbon dioxide insufflation: the effect on intracranial pressure in a large animal model.

BACKGROUND: Endoscopic endocrine neck surgery requires insufflation with carbon dioxide (CO(2)) at 10 to 15 mm Hg, which may decrease the cerebral venous return and increase intracranial pressure. This study evaluated the effect of CO(2) neck insufflation on intracranial pressure (ICP) and hemodynamic parameters. METHODS: Fifteen pigs underwent endoscopic thyroid dissection. Insufflation was performed with CO(2) at 0 (sham), 10, 15, and 20 mm Hg and with helium at 20 mm Hg with 3 pigs in each group. ICP, mean arterial pressure, central venous pressure (CVP), cardiac output, and blood gas were measured at baseline, 30, 60, and 120 minutes. RESULTS: There were no differences in mean ICP between the sham group and CO(2) insufflation at 10 mm Hg. Mean ICP increased significantly with CO(2) at 15 and 20 mm Hg and with helium at 20 mm Hg. A significant increase in CVP occurred in pigs operated with CO(2) at 20 mm Hg. We observed jugular vein collapse under all insufflation pressures; however, pigs operated at 10 mm Hg were able to maintain an intermittent blood flow. CONCLUSIONS: A severe increase in ICP occurs with insufflation pressures higher than 15 mm Hg, possibly as a result of decreased cervical venous blood flow. Carbon dioxide insufflation up to 10 mm Hg does not alter ICP and is recommended for clinical application in endoscopic neck surgery.

Animals↗
PubMed2000

Laparoscopic release of celiac artery compression syndrome facilitated by laparoscopic ultrasound scanning to confirm restoration of flow.

A 43-year-old woman presented with symptomatic mesenteric ischemia caused by median arcuate ligament compression of her celiac artery. Magnetic resonance angiography clearly demonstrated stenosis of the proximal celiac artery. She underwent laparoscopic decompression by division of the ligament and excision of the celiac plexus. Laparoscopic Doppler ultrasound scanning demonstrated markedly improved flow in the artery. She was discharged in 15 hours and reported complete resolution of her symptoms at the 3-month postoperative visit. Laparoscopy provides a less invasive but equally effective method for decompressing the celiac artery as well as assessing adequacy of flow after its release.

Adult↗
PubMed2000

Minimally invasive spine surgery: an animal model for endoscopic approach to the anterior cervical and upper thoracic spine.

BACKGROUND: Minimally invasive video-assisted techniques are currently used for thoracic and lumbar spine surgery with the aim of reducing the morbidity. Recently, an endoscopic approach has been used for endocrine neck surgery, with reduced pain and improved cosmetic results. PURPOSE: To develop an animal model for an endoscopic neck approach to the anterior cervical and upper thoracic spine. METHODS: Five pigs were used. A combination of one 5- and two 3-mm laparoscopic instruments was used to dissect the spine, and dedicated instrumentation was then used to perform discectomies. Carbon dioxide was insufflated at 10 mm Hg. Dissection was carried out upward and downward on the anterior aspect of the spine; discectomy was performed at various levels and evaluated at autopsy. RESULTS: All pigs tolerated the procedure well. Visibility of the cervical spine was excellent, and exposure from C1 to T3 was obtained. For discectomy, an additional 10-mm trocar was inserted, and discectomy of C3-C4 and C4-C5 was performed. Proper location and adequacy were confirmed at autopsy. CONCLUSION: The endoscopic neck approach allows exposure of the entire cervical spine and the upper thoracic spine in the porcine model. This approach has the potential to reduce the morbidity associated with the open cervical approach and provides a wider view and exposure than conventional open surgery. The availability of the porcine model allows the acquisition of the necessary technical skills before introducing this advanced procedure in humans.

Animals↗
PubMed2000

Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is an operation which provides one of the greatest maintained weight losses of any bariatric procedure. We looked at the safety and efficacy of laparoscopic BPD-DS for morbid obesity. METHODS: A 150-200 ml sleeve gastrectomy was created and anastomosed to the distal 250 cm of divided ileum. The median length of the common channel was 100 cm. All patients were prospectively followed up to 12 months. RESULTS: 40 consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity. Median patient body mass index (BMI) was 60 kg/m2 (range 42-85 kg/m2). Mean age was 43 +/- 1 years (+/- SEM), with 12 males and 28 females. One patient was converted to open laparotomy (2.5%). Median operative time was 210 +/- 9 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p = 0.04). Median length of stay was 4 days (range 3-210 days). There was one 30-day mortality (2.5%). Major morbidities occurred in 6 patients (15%), including 1 anastomotic leak (2.5%), 1 venous thrombosis (2.5%), 4 staple-line hemorrhages (10%) and 1 subphrenic abscess (2.5%). Median follow-up at 6 months (range 1-12 months) resulted in 46% +/- 2% excess weight loss (EWL) and at 9 months 58% +/- 3% EWL. CONCLUSION: Laparoscopic BPD-DS is a complex, yet feasible, procedure resulting in effective weight loss with an acceptable morbidity. A BMI >65 was associated with increased morbidity and mortality. A long-term study is needed to confirm efficacy and proper patient selection.

Adult↗
PubMed1999

Hand-assisted laparoscopic digestive surgery provides safety and tactile sensation for malignancy or obesity.

BACKGROUND: Some of the persistent problems associated with laparoscopic surgery stem from the inability of the surgeon to palpate the abdominal contents during the operation. This lack of tactile sensation can lead to poor abdominal exploration, difficulty in extracting the organs, and a relatively long operation time compared to conventional procedures. The Dexterity Pneumo Sleeve is a new device that allows the surgeon to insert his or her hand into the abdominal cavity through a small incision while preserving the pneumoperitoneum. METHODS: Recently, 13 of our patients underwent hand-assisted advanced laparoscopic surgery using this device. In this series, we had two cases of gastrectomy, two cases of gastric bypass for morbid obesity, two Whipple cases for periampullary tumor, and seven cases of bowel resection. On the basis of this series, we were able to assess the utility of this device. RESULTS: Satisfactory pneumoperitoneum was maintained in 12 of 13 cases. The length of the skin incision was 7.8 cm on average, which was almost the same size as surgeon's glove. The device proved to be very useful for tissue retraction and abdominal exploration in all cases and for intracorporeal knot tying in some cases. CONCLUSIONS: We found that the device permitted an easier dissection, resection, and anastomosis. It also helped to decrease the operation time.

Adult↗
PubMed1999

Laparoscopic side-to-side pancreaticojejunostomy (Partington-Rochelle) for chronic pancreatitis.

Intractable pain in chronic pancreatitis has been treated by several different procedures, including resection and drainage, or a combination of the two. We describe the technique of laparoscopic side-to-side pancreaticojejunostomy for chronic pancreatitis in five patients. The procedure is performed using five trocars. Stapling and direct suturing are required. Careful selection of patients is important. Preoperative and intraoperative ultrasound is necessary to assess the dilated pancreatic duct. In one of the five patients, the laparoscopic technique was converted to an open procedure because the preoperative findings were not confirmed at exploration. Four of the five patients are pain-free, with 5- to 30-month follow-up. Laparoscopic pancreaticojejunostomy can be performed safely, and it is a procedure that should be considered in the treatment of appropriate patients with chronic pancreatitis.

Anastomosis, Roux-en-Y↗
PubMed1999

Splenic artery aneurysms: methods of laparoscopic repair.

PURPOSE: Surgical therapy for splenic artery aneurysms (SAAs) has traditionally consisted of a laparotomy with resection of the aneurysm and possibly a splenectomy. Our early experience with the laparoscopic approach to treat SAAs is reported. METHODS: A retrospective review of medical records was conducted on all patients who underwent laparoscopic resection of SAAs at the Cleveland Clinic Foundation from May 1996 to August 1997. RESULTS: Four patients with SAAs, three women and one man, with an average age of 55 years (range, 37 to 63 years), underwent successful laparoscopic SAA repair. The average size of the aneurysm was 3.2 cm (range, 2.5 to 5.0 cm). Three patients underwent an aneurysm resection, whereas one patient underwent simple ligation. Intraoperative ultrasound scanning with Doppler was used in three cases as a means of localizing the aneurysm and identifying all feeding vessels; the complete cessation of flow within the aneurysm in the case in which the feeding vessels were simply ligated was also documented. The average intraoperative time was 150 minutes (range, 100 to 190 minutes). The mean estimated blood loss was 105 mL (range, 20 to 300 mL). There were no intraoperative complications. The average hospital stay was 2.2 days (range, 1 to 4 days). CONCLUSION: The laparoscopic approach to splenic artery aneurysm by aneurysmectomy or splenic artery ligation can be safe and effective. The laparoscopic approach affords a short hospital stay and an effective result.

Aneurysm↗
PubMed1999

Laparoscopic cryotherapy of the liver, pancreas and ardenal gland.

Laparoscopic hepatic cryotherapy, using intraoperative ultrasound monitoring, was introduced in the 1980s by Onik who combined the freezing process with intraoperative ultrasound for monitoring the extent of freezing. The results of open cryotherapy of the liver have been reported for more than 900 patients, the majority having received cryotherapy for liver metastases from colorectal carcinoma and primary hepatocellular carcinoma. While data on the long-term outcome of patients treated with cryotherapy are limited, some authors have documented survival comparable to that for hepatic resecrion. This is remarkable, considering these patients are often deemed unresectable and most do not even survive 1 year.

Journal Article↗
PubMed1998

Laparoscopic cryoablation of hepatic metastases.

OBJECTIVE: To evaluate the feasibility of laparoscopic cryoablation for the management of hepatic metastases. DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Nine patients were evaluated by laparoscopy for planned laparoscopic cryoablation of hepatic metastases at The Cleveland Clinic Foundation, Cleveland, Ohio, from April 1996 to May 1997. RESULTS: Laparoscopic exploration revealed diffuse extrahepatic disease not identified by preoperative studies in 2 patients. The remaining 7 patients underwent 9 cryotherapy sessions. During 4 of the cryotherapy sessions, ultrasonography demonstrated unrecognized additional treatable hepatic lesions. An average of 3 lesions (range, 2-5) were treated. Operative time averaged 3.5 hours with a mean intraoperative blood loss of 235 mL. One patient had significant intraoperative hemorrhage requiring conversion to open hepatic resection for bleeding control. Eight of the 9 patients tolerated normal diets and ambulated independently on the first postoperative day. Following cryotherapy, 4 of the patients developed fever without an infectious source. One patient developed a postoperative bile leak requiring percutaneous biliary stenting. Postoperative hospital stay averaged 4.5 days (median, 4 days; range, 2-14 days). At a mean follow-up of 9 months, 4 of the 7 patients treated are alive without evidence of disease, 2 are alive with disease, and 1 patient with a pancreatic primary tumor has died of disease. CONCLUSIONS: Laparoscopy with laparoscopic ultrasonography is a useful tool in evaluating patients with hepatic metastases. Laparoscopic cryoablation is feasible and may result in lower postoperative morbidity in patients receiving aggressive treatment for inoperable hepatic metastases.

Cryosurgery↗
PubMed1998

Manual vs robotically assisted laparoscopic surgery in the performance of basic manipulation and suturing tasks.

OBJECTIVE: To compare the surgical performance of manual and robotically assisted laparoscopic instruments on basic maneuvers and intracorporeal suturing in inanimate models. DESIGN: A set of laparoscopic tasks was used to evaluate basic endoscopic movements and intracorporeal suturing: positioning a cylinder on a Peg-Board, dropping beads into receptacles, running a 25-cm rope, and capping a hypodermic needle. Intracorporeal knot tying and running a suture through predetermined points were evaluated separately. The sutures used for these tasks were 2-0 and 4-0 silk and 6-0 and 7-0 polypropylene. PARTICIPANTS: Twenty surgeons completed the set of laparoscopic tasks manually and then with a robotically assisted system. None had used the robotic system before. MAIN OUTCOME MEASURES: Time required to complete the tasks and the precision in performing them. RESULTS: The robotic system accurately reproduced the movements of the surgeons and filtered their hand tremors efficiently. In the basic tasks, operative times were significantly longer for the robotic system (P<.001). In the suturing tasks, operative times were longer with the use of the robotic system for sutures sizes 2-0 and 4-0 (P<.001). However, time differences were not significant for suture sizes 6-0 and 7-0 (P> or =.07). Precision measurements were similar for all tasks using the manual instruments and the robotically assisted system. No significant differences were found between the performance of advanced laparoscopic surgeons and laparoscopic fellows. CONCLUSIONS: Laparoscopic maneuvering and suturing is faster and just as precise when performed manually as when performed with the prototype robotic system. These differences in speed are inversely proportional to the size of the suture. Future generations of the robotic system may eliminate these differences.

Equipment Design↗
PubMed1998

[Minimally invasive procedures of the pancreas].

Laparoscopic pancreatic surgery is technically difficult and demanding owing to its retroperitoneal location and its complex anatomic relationships. Performing these operations requires familiarity with the anatomy of the retroperitoneum and advanced laparoscopic skills. Intracorporeal suturing skills are also mandatory. Due to the small number of operations performed in centers, an evaluation period of at least 5 years is necessary to determine the role of laparoscopic procedures in pancreatic disease processes. However, laparoscopic procedures are beginning to represent an undeniable part of the surgical repertoire against pancreatic pathology.

Adult↗