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Biomedical subjects

N J Soper

Publications and source records attributed to N J Soper.

At least 55 records · Page 3Linked to original sources
PubMed1996

Teleproctoring laparoscopic operations with off-the-shelf technology.

Teleproctoring may be a viable approach to training surgeons in the near future. It may also be a superior form of instruction, providing for instantaneous visual and audio feed back to the participant. Conventional proctors are sometimes tempted to reach in and "help", thus infringing on the learning process of the participant. This is a problem that is averted by use of a teleproctoring system. Teleproctoring thereby challenges the proctor to expand the means by which he teaches. As new technologies mature teleproctoring may become the gold standard for teaching new surgical techniques.

Computer Systems↗
PubMed1996

Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms.

BACKGROUND: Laparoscopic adrenalectomy has recently been used for removing a variety of adrenal neoplasms. The purpose of the present study was to compare results and outcomes in patients who underwent either laparoscopic or open adrenalectomy at our institution from 1988 to the present. STUDY DESIGN: The records of 66 consecutive patients with benign adrenal neoplasms who underwent adrenalectomy from 1988 through 1995 were retrospectively reviewed. Patients were divided into three groups based on the operative approach: group I (n = 25), open anterior transabdominal approach; group II (n = 17), open posterior retroperitoneal approach; and group III (n = 24), laparoscopic transabdominal flank approach. Various parameters were compared and statistical analyses were performed. RESULTS: The three groups were similar in age, gender, American Society of Anesthesiologists class, and distribution of unilateral compared with bilateral adrenalectomy. Mean tumor size was slightly larger in group I (3.4 +/- 1.4 cm) than in group II (2.4 +/- 1.4 cm) or group III (2.7 +/- 1.4 cm) (p = NS). Mean operative times for unilateral adrenalectomy were 142 +/- 38 minutes in group I, 136 +/- 34 minutes in group II, and 183 +/- 35 minutes in group III (p < 0.001, groups I and II compared with group III). For bilateral adrenalectomy, mean operative times were 205 +/- 71 minutes (group I), 328 +/- 11 minutes (group II), and 422 +/- 77 minutes (group III). Patients who underwent laparoscopic adrenalectomy had significantly less operative blood loss (mean, 104 mL compared to 408 mL in group I and 366 mL in group II, p < 0.001) and a lower incidence of perioperative blood transfusion. Laparoscopic adrenalectomy was also associated with significantly reduced parenteral pain medication requirements (p < or = 0.001) and more rapid resumption of a regular diet (p < or = 0.01) compared to open adrenalectomy. Postoperative length of stay was significantly longer in group I (8.7 +/- 4.5 days) and in group II (6.2 +/- 3.9 days) after open adrenalectomy than after laparoscopic adrenalectomy (3.2 +/- 0.9 days) (p < 0.01). Total hospital charges were similar for groups II and III but somewhat higher for group I. Patients were able to resume 100 percent activity an average of 10.6 +/- 4.9 days after laparoscopic adrenalectomy and returned to work a mean of 16.0 +/- 6.1 days postoperatively. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and effective procedure and has several advantages over open adrenalectomy. Laparoscopic adrenalectomy should become the preferred operative approach for the treatment of patients with small, benign adrenal neoplasms.

Adrenal Gland Neoplasms↗
PubMed1996

Complications of laparoscopic general surgery.

With the growth of laparoscopic general surgery, both minor and major complications are being encountered. This article discusses complications related to operative laparoscopy, including those associated with access techniques and the pneumoperitoneum. Complications specific to certain procedures, including laparoscopic cholecystectomy, appendectomy, colon resection, anti-reflux surgery, and herniorrhaphy, are also discussed in detail.

Anesthesia, General↗
PubMed1996

Chronic acalculous cholecystitis: laparoscopic treatment.

From 1990 through 1993, we treated 36 patients with recurrent typical biliary colic but who showed no ultrasonic evidence of cholelithiasis by laparoscopic cholecystectomy. Associated symptoms included nausea (75%), bloating (56%), fatty-food intolerance (53%), vomiting (17%), weight loss (31%), bowel irregularity (28%), reflux or dyspepsia (25%), and fever (17%). Diagnostic evaluation included ultrasound (100%), upper gastrointestinal series (36%), oral cholecystogram (14%), computed tomographic scan (39%), endoscopic retrograde cholangiopancreatography (17%), upper gastrointestinal endoscopy (14%), and hepatobiliary scan (92%). Quantitative hepatobiliary scans in 33 patients revealed a low gallbladder ejection fraction (EF) of less than 35% in 29 patients (88%; mean EF = 9%), and 13 patients experienced reproducible pain after cholecystokinin provocation. All patients underwent attempted laparoscopic cholecystectomy; one case of unsuspected acute acalculous cholecystitis was converted to open laparotomy because of unclear anatomy. Gross and histological examination of the gallbladders revealed chronic inflammation (83%), cholesterolosis (31%), cholesterol crystals or small stones (17%), acute inflammation (8%), polyps (6%), and normal histology (6%); however, blind retrospective scoring of gallbladders revealed significant chronic inflammation in only 38%. In the 2 to 40 months (mean, 14 months) since operation, there have been no deaths (97% follow-up). Laparoscopic cholecystectomy relieved pain in 93% of patients with a low preoperative EF compared with 75% of patients with a normal EF (nonsignificant p value). Persistent abdominal or gastrointestinal complaints included flatulence (31%), loose stools or fecal urgency (29%), belching (29%), indigestion (20%), nausea (11%), and "typical" gallbladder pain (9%). We conclude that many patients with symptoms of biliary colic and scintigraphic evidence of biliary dyskinesia have histologic findings of chronic cholecystitis. Although laparoscopic cholecystectomy usually eliminates biliary colic, persistent nonbiliary complaints are frequent.

Adult↗
PubMed1996

Strangulated incisional hernia at trocar site.

An incisional hernia at a trocar site after laparoscopy may arise from infection, premature suture disruption, or failure to adequately reapproximate fascial wound edges. The condition is accurately diagnosed postoperatively on physical examination, and a bulge at a previous port site should immediately raise suspicion. A case is reported in which an incisional hernia strangulated soon after an elective laparoscopic inguinal herniorrhaphy in which, the fascia of the 10-mm trocar site was not closed. This report underscores the importance of meticulous closure of all abdominal port sites > 5 mm. Furthermore, early diagnosis of an incarcerated hernia may avoid the morbidity of an extensive intestinal resection.

Hernia, Inguinal↗
PubMed1996

The current management of common bile duct stones.

Choledocholithiasis is usually proven by cholangiogram during cholecystectomy, and today nearly all cholecystectomies are performed laparoscopically. Patients expect to be discharged from the hospital within 24 hours after laparoscopic surgery and return to work in 1 week. Surgeons must develop advanced laparoscopic skills to allow choledocholithiasis to be managed laparoscopically with one procedure and one anesthetic. Interventional radiologists and gastroenterologists can frequently detect and manage common duct stones that cause severe cholangitis and pancreatitis and that occur in patients too debilitated for general anesthesia. In the majority of patients, common duct stones demonstrated at laparoscopic cholecystectomy may be removed using laparoscopic transcystic techniques. Whether complicated CBD stones are optimally managed by laparoscopic choledochotomy, conversion to open common duct exploration, or left for postoperative ERC/ES is controversial and depends on the expertise of the surgeon, gastroenterologist, and wishes of the patient. Although the authors propose one algorithm for the current management of CBD stones, the superiority of the laparoscopic treatment for CBD stones is not yet proven. Multi-institutional, randomized trials comparing laparoscopic, endoscopic, and combined techniques for ductal clearance will be necessary to establish the optimal therapy of choledocholithiasis in the 1990s.

Cholangiography↗
PubMed1996

The influence of three-dimensional video systems on laparoscopic task performance.

Many laparoscopic surgeons feel constrained by the two-dimensional (2-D) view provided by video monitors. Video-eye-hand coordination is further complicated by the diminished tactile feedback blunted by elongated instruments. Video systems capable of receiving and displaying three-dimensional (3-D) images are now available for laparoscopy. First-generation 3-D systems have been marketed with the promise of significant time savings in laparoscopic procedures compared with 2-D optics. We assessed whether laparoscopic task performance was better in 2-D or 3-D among individuals with varying levels of laparoscopic experience. Five different tasks were performed in random order using both 2-D and 3-D technology by medical students (n = 10), inexperienced surgical residents (n = 10), and laparoscopic attending surgeons (n = 10). There was no significant difference in task performance between 2-D and 3-D among groups performing simple or difficult tasks, although suturing and knot-tying were performed 12% (p = 0.06) faster in 3-D by all groups. With repetition of tasks three times, the difference between the 2-D and 3-D systems was indistinguishable. Subjective assessment of the video systems by participants revealed that only 46% (p = 0.72) preferred working in three dimensions, despite 60% (p = 0.27) sensing more motor control in 3-D. Our results suggest that first-generation 3-D video systems offer no significant advantage to the novice or expert surgeon performing laparoscopic procedures. Further trials with the next generation of 3-D video systems and a larger sample size may support the trend favoring 3-D for more complex maneuvers, such as suturing and knot-typing.

Humans↗
PubMed1996

Laparoscopic management of complicated biliary tract disease in children.

Laparoscopic cholecystectomy is a safe and feasible surgical treatment for children with symptomatic cholelithiasis. We describe the laparoscopic management of choledocholithiasis and biliary pancreatitis, two unusual but complicated pediatric biliary tract diseases. The operative techniques described were safe and effective and permitted early discharge with rapid return to diet, school, and full activity.

Adolescent↗
PubMed1996

Laparoscopic surgery of the bile ducts.

Laparoscopic surgery of the bile ducts is evolving rapidly. Laparoscopic bile duct exploration is reaching wide application and is competitive with postoperative ERCP for treatment of choledocholithiasis. Staging laparoscopy is an important laparoscopic advance that is increasing resectability rates for pancreatic and hepatic tumors through laparoscopic detection of unresectable tumors. Bile duct injury is an important problem in laparoscopic cholecystectomy. Classification, avoidance, and management are discussed.

Biliary Tract↗
PubMed1995

The influence of intraoperative gallbladder perforation on long-term outcome after laparoscopic cholecystectomy.

During laparoscopic cholecystectomy, gallbladder perforation with leakage of bile and/or gallstones into the abdominal cavity occurs frequently. When this occurs, our practice has been to lavage the operative field and retrieve as many gallstones as possible. We were concerned, however, that complications secondary to infection or adhesions might develop. To address this issue, our first 250 consecutive patients undergoing laparoscopic cholecystectomy were surveyed by postal questionnaire. In the 35-48 months (mean, 41 months) since operation, six patients (2.6%) died of nonbiliary causes. Of the 225 patients (90%) who completed the questionnaire, 73 (33%) suffered intraoperative gallbladder perforation. There were no late wound or intraabdominal infectious complications and no patient has required reoperation for intraabdominal sepsis or bowel obstruction. In the entire group, gastrointestinal symptoms were prevalent and included flatulence (40%), loose stools or fecal urgency (35%), belching (23%), and nausea (4%). The prevalence of these complaints was similar in patients with and without gallbladder perforation. Intraoperative gallbladder perforation during laparoscopic cholecystectomy, therefore, does not cause adverse long-term complications when accompanied by operative lavage and stone removal.

Adolescent↗
PubMed1995

Sutured or fibrin-glued laparoscopic choledochojejunostomy.

Minimally invasive techniques for choledochojejunostomy offer theoretical advantages for palliating unresectable periampullary neoplasms. Fibrin glue, a biologic adhesive containing concentrated fibrinogen, may obviate suturing and promote healing without stricture formation. We examined the technical ability to perform laparoscopic choledochojejunostomy (LCJ) and the applicability of thrombin-activated fibrin glue in an animal model of biliary obstruction. Domestic pigs underwent laparoscopic cholecystectomy and ligation of the distal bile duct. Three days later, a side-to-side LCJ was performed by intracorporeal sutured anastomosis (n = 7) or using four stay sutures and homologous fibrin glue (n = 7). Control animals underwent a similar bypass via open laparotomy (n = 7). The postoperative interval to ambulation and oral intake was recorded, and serial serum liver enzymes were measured. The animals were sacrificed at 6 weeks, and tensile strength of the anastomoses was assessed by tensometry. Liver function tests returned to normal values within 7 days following all methods of choledochojejunostomy. In the fibrin glue group, three anastomotic leaks (43%) occurred in the 1st postoperative week. At 6 weeks, all other anastomoses were intact and patent by cholangiogram, but there was moderate stenosis of two open and one fibrin-glue anastomosis. The sutured LCJ, while taking approximately 1 h longer to perform (P < 0.05), resulted in similar efficacy and more rapid recovery (P < 0.05) than open biliary-enteric bypass. Fibrin-glued LCJ was performed rapidly, but had less tensile strength (P < 0.05) and often leaked in the early post-operative interval. We conclude that while there may be a role for laser-activated solders for primary anastomosis, thrombin-activated fibrinogen cannot be advocated as the primary means of creating biliary anastomoses. Using intracorporeal suturing techniques, laparoscopic choledochojejunostomy may be performed safely.

Alanine Transaminase↗
PubMed1995

Laparoscopic ultrasonography as compared with static or dynamic cholangiography at laparoscopic cholecystectomy. A prospective multicenter trial.

We compared laparoscopic ultrasonography (LICU) with static (S) or dynamic (D) cholangiography (IOC) for assessment of duct anatomy an calculi in 209 patients. LICU visualized ducts in 88% compared with 93% for IOC (P = 0.046). Nineteen patients (9%) had stones: 17 were found by LICU (89%) and 10 (53%) by IOC (P = 0.032). Time to perform LICU (7 +/- 3 min) was less than IOC (13 +/- 6 min) (P < 0.0001). Time to perform SIOC (12 +/- 5 min) and DIOC (14 +/- 6 min) did not differ (P = 0.48), nor did these tests differ in accuracy. LICU provided useful anatomical information but IOC better defined anatomic anomalies. LICU required less time but was less reliable at defining anatomy and complete duct visualization. LICU was more sensitive for stones. SIOC and DIOC did not differ objectively. LICU and IOC are complementary.

Bile Duct Diseases↗
PubMed1995

Impact of pneumoperitoneum on trocar site implantation of colon cancer in hamster model.

BACKGROUND: Numerous anecdotal reports have documented the spread of colon cancer to trocar sites after laparoscopic-assisted colectomy. We hypothesized that the pneumoperitoneum of laparoscopy potentiated tumor adherence to trocar sites. PURPOSE: This study was designed to determine the effect of CO2 pneumoperitoneum on the rate of tumor implantation at trocar sites. METHODS: Viable GW-39 human colon cancer cells were injected into the abdominal cavity of hamsters (2 x 10(6) cells/hamster). A midline laparotomy, insertion of four 5-mm trocars, injection of viable cells into the mesentery of the cecum, and free peritoneal cavity was performed in two groups: one control group (41) who did not receive a pneumoperitoneum and a comparison group (50) who underwent pneumoperitoneum for ten minutes at an insufflation pressure of 10 mmHg. Animals were killed at six weeks, and hematoxylin and eosin-stained sections of trocar wounds, midline wound, small intestine, cecum, liver, and lung were examined by a veterinary pathologist, who was blinded to operation. RESULTS: Pneumoperitoneum increased tumor implantation in the cecal mesentery and the midline incision (P < 0.05) but did not effect recurrence in the liver, lung, or jejunum. Trocar site implantation tripled with the addition of pneumoperitoneum increased implantation of pneumoperitoneum (26 vs. 75 percent) (P < 0.0001). CONCLUSION: Pneumoperitoneum increased implantation of free intra-abdominal cancer cells at wound sites on the abdominal wall or within the abdominal cavity in this animal model. The use of pneumoperitoneum during laparoscopy in patients with colon cancer should only be performed in a protocol setting to evaluate the effect of pneumoperitoneum on the treatment of cancer.

Animals↗
PubMed1995

Results of a change to routine fluorocholangiography during laparoscopic cholecystectomy.

BACKGROUND: Early in our experience with laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC) was performed selectively with static imaging techniques. We subsequently changed to routine digital fluorocholangiography (FIOC) and evaluated the results of this strategy. METHODS: In a consecutive series of 356 LCs, 11 patients (3%) were converted to open cholecystectomy. In the remaining 345 patients FIOC was attempted in 336 patients (97%) and was successfully completed in 328 patients (95%). Results of IOC and outcomes were compared prospectively in patients without indications for IOC (group I, n = 185) with those with criteria for selective IOC (group 2, n = 160) and retrospectively with patients without indications for IOC undergoing static IOC (group 3, n = 56). RESULTS: Time to perform FIOC was less than for static IOC (14 +/- 1 versus 24 +/- 1 minutes, p < 0.001). Aberrant ductal anatomy was appreciated by using FIOC in 11% but affected operative management in only 3% of patients. Choledocholithiasis was detected in 23 patients (7%) undergoing FIOC; only two of these patients with stones were in Group 1. Duct stones discovered by IOC were cleared laparoscopically in 89% of those attempted (73% of all patients). Neither morbidity nor duct injury caused by FIOC was noted. CONCLUSIONS: FIOC is much more rapid to perform than static IOC. Digital fluoroscopy is accurate and safe and permits rapid evaluation and management of bile duct stones. Selective use of FIOC efficiently assesses the common duct in the era of LC.

Cholangiography↗
PubMed1995

Imaging of the common bile duct during laparoscopic cholecystectomy: sonography versus videofluoroscopic cholangiography.

OBJECTIVE: The purpose of this prospective study was to compare the accuracies of laparoscopic sonography and laparoscopic videofluoroscopic cholangiography in detecting common bile duct stones and in identifying ductal anomalies during laparoscopic cholecystectomy. SUBJECTS AND METHODS: Ninety-five patients who underwent laparoscopic videofluoroscopic cholecystectomy were prospectively studied with laparoscopic sonography and laparoscopic videofluoroscopic cholangiography. The number of successful studies, the time required to complete the study, and complications resulting from the study were recorded. The biliary system was evaluated for complete visualization of the common bile duct, visualization of the cystic duct, ductal anomalies, maximum diameter of the common bile duct, and common bile duct stones and/or debris. Also determined was whether laparoscopic sonographic findings altered operative management. RESULTS: Laparoscopic sonography was successfully performed in 93 of 95 patients, and laparoscopic videofluoroscopic cholangiography was successfully performed in 90 of 95 patients. The time required to complete laparoscopic sonography ranged from 3 to 18 min (mean +/- SD, 8 +/- 3 min), and that required to complete laparoscopic cholangiography ranged from 5 to 28 min (mean +/- SD, 14 +/- 6 min). Laparoscopic sonography visualized the complete common bile duct in 84 of 93 patients, and laparoscopic cholangiography did so in 86 of 90 patients. Laparoscopic sonography showed the cystic duct in 87 of 93 patients, and laparoscopic cholangiography did so in 80 of 90 patients. Laparoscopic sonography showed no ductal anomalies in any of the 93 patients. Laparoscopic cholangiography showed ductal variants in 13 of 90 patients; however, 11 of the variants were proximal to the sonographic scan plane. Laparoscopic sonography showed common bile duct stones in 12 of 93 patients, and laparoscopic cholangiography did so in five of 90 patients. Laparoscopic sonography altered operative management in two of 93 patients. CONCLUSION: Our results show that laparoscopic sonography is as accurate as laparoscopic videofluoroscopic cholangiography in visualizing the common bile duct and cystic duct and in detecting common bile duct stones. However, the data are too limited to determine whether laparoscopic sonography is as accurate as laparoscopic cholangiography in detecting ductal anomalies.

Adult↗
PubMed1995

Prospective evaluation of the safety and efficacy of laparoscopic jejunostomy.

We prospectively assessed the safety and efficacy of laparoscopic jejunostomy done by 11 surgeons in 8 medical centers using the T-fastener technique. In all, 23 men and 13 women aged 19 to 84 (mean, 59) years required enteral feeding, but could not undergo gastrostomy and had no contraindication to laparoscopy. Of these patients, 12 had head and neck cancer and 11 had neurologic swallowing dysfunction. The procedure took 25 to 180 minutes (mean, 75). Three (8%) early cases were converted to open jejunostomy because of accidental enterotomies caused by inappropriate techniques that were avoided in later cases. Minor technical problems, such as passing a needle through the back wall of the jejunum, occurred in 7 patients, but they were easily corrected and produced no complications. Feedings were routinely begun within 24 hours of the surgical procedure. All jejunostomy catheters functioned well. This is a safe and effective technique when done by experienced laparoscopic surgeons, and serious complications are rare.

Adult↗