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M Gagner

Publications and source records attributed to M Gagner.

At least 73 records · Page 4Linked to original sources
PubMed1998

Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy.

BACKGROUND: The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties. METHODS: After experimental success in an animal model, we recently performed our first case of endoscopic subtotal parathyroidectomy in a 37-year-old man. The patient, who had a history of severe pancreatitis and pancreatic calculi, was diagnosed as having hyperparathyroidism. The option of endoscopic parathyroidectomy was proposed and accepted. After placing the first trocar directly under the platysma, a space was created by bluntly dissecting with the tip of a 5-mm endoscopic camera. Four parathyroid glands were identified, and after a frozen-section diagnosis of parathyroid hyperplasia, three-and-one-half of the glands were resected. RESULTS: The patient developed slight hypercarbia and subcutaneous emphysema during the procedure, but no other problems were noted. His postoperative course was otherwise unremarkable. CONCLUSIONS: This is the first case reported of an endoscopic parathyroidectomy. This experience makes us optimistic about the future of endoscopic neck surgery.

Adult↗
PubMed1998

Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results.

BACKGROUND: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias >/=4 cm2) is being used in a prospective, multicenter, long-term study. METHODS: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. RESULTS: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. CONCLUSIONS: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.

Adult↗
PubMed1998

Robotically assisted laparoscopic microsurgical uterine horn anastomosis.

OBJECTIVE: To evaluate the feasibility, safety, and sterility issues with regard to the use of a robotic device to perform uterine horn anastomosis in a live porcine model. DESIGN: Prospective animal study. SETTING: Landrace-Yorkshire pigs in a conventional laboratory setting. INTERVENTION(S): Six female pigs underwent laparoscopic bipolar electrocoagulation of the distal uterine horns. Two weeks later, the uterine horns were reanastomosed laparoscopically with use of a robotic system for microsuturing. Necropsy was performed 4 weeks later to assess postoperative adhesions and anastomosis patency. MAIN OUTCOME MEASURE(S): Tubal patency; secondary measures were operative time, complications, and surgeon fatigue. RESULT(S): The mean (+/-SD) total operative time per animal was 170+/-34 minutes including setting up and dismantling the robotic arms. The robot functioned well with only minor technical problems. All pigs survived both surgeries with no perioperative complications related to the use of the robot. Patency was confirmed after completing each anastomosis (12 anastomoses; 100% patency). Four weeks later, necropsy showed that eight anastomoses were still patent (67%). Only one pig had bilateral occlusion. Surgeon's fatigue was mild for each animal study. CONCLUSION(S): Robotic technology can be used safely in creating laparoscopic microsurgical anastomoses. The robot functioned properly in a sterile operating room environment. Adequate patency rates were achieved during the acute phase and at 4-week follow-up. Robotic technology has the potential to make laparoscopic microsuturing easier.

Anastomosis, Surgical↗
PubMed1998

Laparoscopic repair of lumbar hernias.

BACKGROUND: Lumbar hernias are rare defects in the posterolateral abdominal wall that may be congenital or acquired. Repairing these defects is difficult by virtue of their location and the inherent weakness of the surrounding tissues. We report a series of seven patients who had their lumbar hernias repaired laparoscopically at two institutions. STUDY DESIGN: We retrospectively reviewed all lumbar hernias repaired laparoscopically in our institutions within the last 16 months (August 1996 to November 1997). Postoperative followup was 1-15 months. RESULTS: Seven patients underwent laparoscopic repair. Five hernias were acquired defects and two were congenital. One to three defects were found per patient. The average size of the hernia defect was 77.8 cm2. We used a polypropylene or a polytetrafluoroethylene mesh in all patients; the average size of the mesh used was 336.4 cm2. The average length of hospital stay was 1.7 days. One patient returned with an abscess over the mesh, which necessitated removal of the graft. Otherwise, there were no complications, and the remaining six patients had no recurrences after followup of 1-14 months. CONCLUSIONS: The laparoscopic approach is safe and effective for repairing lumbar hernias. Advantages of this approach include excellent operative visualization, decreased hospital stay postoperatively, and a solid repair without recurrence during shortterm followup.

Hernia, Ventral↗
PubMed1998

Robotically assisted laparoscopic tubal anastomosis in a porcine model: a pilot study.

As with standard microsurgical procedures performed at laparotomy, laparoscopic tubal anastomosis requires great dexterity. Handling fine suture materials under magnification to anastomose tubal segments with lumens less than 3 mm in diameter while working with your hands at a distance from the tissue makes these fine movements even more difficult. This is exacerbated by the tremor induced by the fatigue caused by a prolonged laparoscopic procedure and the need for precise control. We conducted a pilot study to evaluate the feasibility of performing laparoscopic tubal anastomosis with robotic assistance in a live porcine model. Two anastomoses were performed on one uterine horn via each of the following techniques: laparoscopy, laparoscopy with robotic assistance, and open microsurgery. Immediate necropsy demonstrated all the anastomoses to be patent. There were no intraoperative complications. Laparoscopic tubal anastomosis was associated with surgeon fatigue and neck, shoulder, and back pain. The surgeons were more comfortable performing the procedure with robotic assistance. The device functioned well and without incident. This acute animal study suggests that robotic assistance in laparoscopic tubal anastomoses is safe and feasible. It enhances surgeons' dexterity and precision while reducing fatigue. It is promising for future use in chronic experimental studies.

Anastomosis, Surgical↗
PubMed1998

A porcine model for laparoscopic ventral hernia repair.

Ventral hernia repair is one of the most common abdominal operations. Recurrence rate remains high despite all preventive measures. "Tension-free" repair has been postulated as the surgical method of choice. A laparoscopic approach to ventral hernia repair has been described recently. Theoretical advantages of a laparoscopic repair include faster recovery, less postoperative pain, less morbidity, and a better cosmetic result. However, the approach requires advanced laparoscopic skills and familiarity with its technique. An animal model of ventral hernia, suitable for laparoscopic repair, was developed to be used for educational and experimental purposes. The model is simple, reliable, and reproducible in any minimally invasive surgery facility. We conclude that the pig can be used as an excellent model to learn the technique and evaluate a variety of endpoints for laparoscopic ventral hernia repair.

Animals↗
PubMed1998

Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments.

Interest has grown in reducing the size of laparoscopic instruments. We define as "needlescopic" those instruments that have a diameter of < or =3 mm. We compared data from 60 needlescopic cholecystectomies with a matched group of laparoscopic procedures. No intraoperative complications occurred in either group. Operative time was 20% longer for the needlescopic operations. Hospital stay was similar for both groups. Postoperative analgesia requirements for the needlescopic group were 70% lower than for the laparoscopic group. From a scale (0, no scar visible, to 10, worst scar), patients scored their scars as 1 for the needlescopic cases and 5 for the laparoscopic group. Likewise, we have used needlescopic instruments to perform appendectomy, inguinal herniorrhaphy, adrenalectomy, splenectomy, and fundoplication. In conclusion, needlescopic procedures are safe and efficient. While they result in longer operative times, they decrease the need for postoperative analgesia, which may shorten convalescence and improve the cosmetic result.

Abdomen↗
PubMed1998

Needlescopic retrograde cholecystectomy.

Needlescopic surgery is a refinement of laparoscopic surgery wherein instruments smaller than 3 mm are used. The advantage is the minute wounds that heal imperceptibly. Initial reports of needlescopic cholecystectomy were confined to uninflamed gallbladders where the antegrade technique was invariably used. This case demonstrates a needlescopic cholecystectomy by the retrograde approach for an inflamed gallbladder.

Aged↗
PubMed1998

Laparoscopic repair of recurrent ventral hernias.

Break down after repair of recurrent ventral hernias can exceed 50 per cent. Laparoscopic techniques offer an alternative. This study evaluated the efficacy of the laparoscopic approach for recurrent ventral hernias. A retrospective review on all patients with a recurrent ventral hernia who underwent laparoscopic repair at our institution from August 1995 to June 1997 was performed. Demographic, operative, postoperative, and follow-up data were collected. Thirty-one patients underwent an attempted laparoscopic ventral hernia repair. Sixteen were for recurrent hernias; 15 were successfully repaired laparoscopically. The patients were typically obese (mean body mass index, 30 kg/m2), had an average of 2.4 previous open repairs (range, 1-7), and six patients had previously placed intra-abdominal mesh. An average of 3.5 (range, 1-16) defects were found per patient with a mean total hernia size of 130 cm2 (6-480 cm2). In all cases, expanded polytetrafluoroethylene mesh (average, 299 cm2) was secured with transabdominal sutures. Postoperatively patients required an average of 19 mg of narcotics (MSO4 equivalent). Bowel function returned in 1.7 days. Length of stay averaged 2.0 days (1-4 days). There were two complications: cellulitis, which resolved with antibiotics, and skin break-down, which required mesh removal. With follow-up averaging 18 months (7-29 months), there is one recurrence; the case in which the mesh was removed. Laparoscopic repair of recurrent ventral hernia seems promising. Decreased hospital stays, postoperative pain, wound complications, and a low rate of recurrence are benefits of this technique.

Adult↗
PubMed1998

Primary nonampullary/periampullary adenocarcinoma of the duodenum.

Primary duodenal adenocarcinoma not involving the ampullary region is rare. Our aim was to review the outcome of these patients and determine the factors that affect survival. We performed a retrospective review of all patients with primary, nonampullary duodenal adenocarcinoma at the Cleveland Clinic Foundation from January 1986 through December 1996. Twenty-six patients with primary, nonampullary duodenal malignancies were identified. There were 16 adenocarcinomas, 3 gastrinomas, 3 stromal tumors, 3 leiomyosarcomas, and 1 carcinoid tumor. Patients with adenocarcinoma had symptoms present an average of 6.1 months. Tumors were identified by upper gastrointestinal contrast study and esophagogastroduodenoscopy in 90 per cent and 87 per cent of patients, respectively. Twelve of 13 (93%) cancers found in the third or fourth portion of the duodenum were adenocarcinomas. Seven of the 16 adenocarcinomas were resectable on exploration. Those that were contained within the serosa have not recurred (mean, 6 years); one of the two patients with locally invasive adenocarcinoma remains disease free. The average survival for patients with unresectable disease was 6.7 months. The 5-year survival rates were: all adenocarcinoma, 38 per cent; resectable, 86 per cent; and unresectable, 0 per cent. All patients presenting with weight loss or obstructive symptoms died of disease; those with melena survived long term. Patients with tumors other than adenocarcinoma had a 90 per cent 5-year survival. We conclude that patients typically present with a long history of symptoms. Distal duodenal malignancies are most frequently adenocarcinomas. Upper gastrointestinal contrast study or endoscopy is often diagnostic. Patients with weight loss and/or obstructive symptoms had invasive disease and a morbid prognosis. Aggressive surgery is warranted, and most with resectable disease (86%) had long-term survival.

Adenocarcinoma↗
PubMed1997

Laparoscopic inferior and superior lumbar hernia repair.

Lumbar hernias are rare defects that involve the extrusion of retroperitoneal fat or viscera through a weakness in the posterior abdominal wall. Repairing these hernias is often difficult because of the weakness of the surrounding structures. Techniques for reconstruction usually include an incision from the 12th rib to the iliac crest with mobilization of local flaps or onlay fascial flaps or the use of prosthetic mesh. Contemporary reports have advocated extensive retroperitoneal dissection with the placement of permanent mesh extraperitoneally. We have recently repaired an extensive, primary lumbar hernia laparoscopically, securing the mesh to the 12th rib superiorly, iliac crest inferiorly, erector spinae fascia medially, and external oblique fascia laterally. The patient resumed normal activities in less than 2 weeks; 4 months postoperatively, he seems to have a solid repair. To our knowledge, this is the first report of this technique.

Adult↗
PubMed1997

Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve.

BACKGROUND: Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery. METHODS: The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach, and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric bypass was performed. RESULTS: The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of the stomach and surrounding upper abdominal organs. CONCLUSIONS: The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to decrease operation time.

Adult↗
PubMed1997

The lateral approach to laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy has been shown to result in shorter hospital stays and a quicker return to work than conventional splenectomy. Having tried the anterior 5 trocar approach, we developed a 4 trocar lateral approach and now present our experience with 22 cases. METHODS: All patients were placed in the right lateral decubitus position. A 10-mm trocar was inserted in the left subcostal region, 2 in the flank, and a 5-mm trocar dorsally. A 30 degrees laparoscope was used. Splenectomy was performed for varying pathologies. RESULTS: Operating room (OR) time averaged 169 minutes, spleen weight 513 grams, and postoperative (post-op) stays 5.4 days (median 3 days). One patient was converted to laparotomy. There were no deaths, post-op abscesses, pancreatic injuries, or bleeding complications. CONCLUSIONS: The lateral approach affords superior exposure, allowing easier dissection of splenic hilar structures. Over varying patient habitus and spleen size it has been demonstrated to be the approach of choice for laparoscopic splenectomy.

Adolescent↗
PubMed1997

Catheter-assisted totally thoracoscopic coronary artery bypass grafting: a feasibility study.

BACKGROUND: The purpose of this study is to examine the feasibility of performing totally thoracoscopic internal mammary-to-coronary artery bypass grafting with the assistance of radiologically guided catheter intervention. METHODS: Fourteen dogs were subjected to mobilization of the internal mammary artery and anastomosis of it to the left anterior descending coronary artery over an angiographic catheter inserted into the internal mammary artery under fluoroscopy. The anastomosis was completed over the catheter using sutures and the application of fibrin glue. Eight animals underwent the anastomosis after their sacrifice. The other 6 animals were put on closed chest cardiopulmonary bypass and had their anastomosis done after intraaortic balloon occlusion and cardioplegic arrest of the heart. All animals had an angiographic and pathologic examination at the completion of the anastomosis. RESULTS: Anastomosis was completed in all dogs. Three anastomoses leaked and two were noted to be stenosed at completion of the anastomosis. One leak was sealed by application of fibrin glue. Both stenotic anastomoses were caused by suturing of the back wall when a short angiographic catheter could not be positioned across the anastomosis. CONCLUSIONS: Minimally invasive totally thoracoscopic mammary-to-coronary artery bypass grafting with catheter assistance is feasible. Technical improvement and appropriate instrumentation are required to minimize anastomotic failure.

Animals↗
PubMed1997

The role of intraoperative ultrasonography during laparoscopic adrenalectomy.

BACKGROUND: The role of laparoscopic intraoperative ultrasonography (IOUS) in intraoperative decision making has grown rapidly in recent years. The purpose of this study was to evaluate its usefulness during laparoscopic adrenalectomy. METHODS: Since 1995, laparoscopic ultrasonography has been used to evaluate the adrenal gland and surrounding organs in selective laparoscopic adrenalectomies. IOUS was performed in 19 of 114 laparoscopic adrenalectomies. RESULTS: IOUS effected a change in management in 68% of these patients. IOUS displayed the location of the gland after a failed attempt at open resection; the adrenal vein, expediting control in four operations; no extraadrenal involvement by two large lesions (benign); vascular invasion in one tumor (carcinoma), prompting open resection; periadrenal invasion by one metastatic cancer and lymph node involvement in another; a 7 mm hyperaldosteronoma; no adenoma in two cases; bilateral hyperplasia; and a 14 cm cyst originating from the adrenal gland. IOUS facilitated partial adrenalectomy in two patients and revealed centrally located adenomas in two others requiring total adrenalectomy. CONCLUSIONS: Laparoscopic IOUS during adrenal operation is valuable in selected cases. It is helpful to locate the gland and vein, confirm the presence or absence of abnormality, discern the resectability of large masses, and facilitate a partial adrenalectomy when desirable.

Adrenal Glands↗
PubMed1997

Robotic surgical instruments for dexterity enhancement in thoracoscopic coronary artery bypass graft.

OBJECTIVES: Endoscopically sutured vascular anastomoses are complex, time consuming, and require great dexterity. We decided to evaluate performance enhancement using a robotic device to create sutured coronary artery bypass anastomoses with endoscopic techniques in a plastic model. METHODS: Seven coronary artery bypass anastomoses were endoscopically created in a plastic model using a robotic enhancement technology (Computer Motion, Goleta, CA). Anastomoses were created with a single running suture (7-0 monofilament). Our endpoints were operative time, intraoperative incidents, stability and dexterity of the robotic system, surgeon's fatigue, and anastomotic patency. RESULTS: Operative time was 46+/-12 min (mean+/-SD). There were no intraoperative incidents. Patency was confirmed in all anastomoses. The system's stability and dexterity were high. Surgeon's fatigue was mild. CONCLUSION: The use of robotic enhancement technology leads to an efficient performance of sutured coronary artery bypass anastomoses in a plastic model. The robotic device enhances dexterity, precision, and reduces surgeon's fatigue while preserving the quality of hand suturing.

Clinical Competence↗
PubMed1997

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures.

UNLABELLED: One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE: The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA: Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS: One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS: Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION: Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.

Adenocarcinoma↗