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Laparoscopically guided bipolar radiofrequency ablation of areas ofporcine liver

S. A. Curley,1 B. S. Davidson,1 R. Y. Fleming,1 F. Izzo,1 L. C. Stephens,2 P. Tinkey,2 D. Cromeens2

Department of Surgical Oncology, Box 106, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX,77030, USA

Department of Veterinary Medicine, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA

Received: 19 June 1996/Accepted: 30 October 1996

AbstractBackground: Bipolar radiofrequency ablation (BRFA) is apromising technique with which to treat unresectable pri-mary and metastatic liver tumors. Its effects on normal liverissue and postoperative liver function, however, are un-

known. We performed this study to determine (1) the fea-ibility of using laparoscopic ultrasound to guide placement

of BRFA needle electrodes in the liver and (2) the histo-pathologic, hepatic biochemical, and systemic hemody-namic responses to BRFA.Methods: Two BRFA lesions were created in the liver ofadult domestic pigs to ablate 810% of the normal livervolume. Laparoscopic ultrasound was used to guide cre-ation of one peripheral liver lesion and one central liveresion (with a major hepatic or portal venous vein branch inhe center of the BRFA lesions) in each animal. BRFA ofiver tissue was performed by passing 12 W of RF power for

16 min across two 16-gauge active-needle electrodes placed3 cm apart.Results: All animals survived the procedure without signifi-cant hemodynamic alterations during or after BRFA. Allanimals had a transient elevation in serum transaminaseevels that returned to normal within 1 week of the BRFA of

iver tissue. Gross and microscopic histopathology of theBRFA lesions revealed 2.02.5-cm zones of complete co-agulative necrosis around and between the BRFA needleracks without destruction of major blood vessel walls.

Conclusions: This study demonstrates (1) that laparoscopicultrasound can be used to guide placement of BRFA needlesn the liver and (2) that BRFA produces focal destruction ofiver without significant systemic hemodynamic responses

or alterations in liver function. Further studies of this tech-nique to ablate malignant liver tumors are ongoing.

Key words: Bipolar radiofrequency ablation Liver

Laparoscopic ultrasound

Hepatocellular carcinoma is one of the most common hu-man malignancies; approximately 1 million cases are diag-nosed annually worldwide [9]. Further, the liver is secondonly to lymph nodes as the most common site for metastaticcancer [21]. While surgical resection offers the best chancefor long-term survival for patients with hepatocellular can-cer or colorectal cancer liver metastases, the majority ofpatients are not candidates for resection because the tumoris too large, there are multiple tumor foci, key vascularstructures are involved by tumor, or hepatic reserve is in-adequate because of cirrhosis. In such cases, alternativetreatments are required.

Cryosurgery to freeze primary and metastatic liver tu-mors in situ is being used to treat unresectable liver tumors.However, technical difficulties with this approach remainproblematic. The cryoprobes range in size from 8 to 30 mmin diameter, so hemorrhage from the probe track can be asignificant problem in some patients [16, 18]. Renal andhepatic insufficiency have also occurred following hepaticcryosurgery [16, 18]. Finally, the number of lesions that canbe effectively frozen is limited by tumor proximity to majorblood vessels and the length of each freeze-thaw cycle.

Still other ablative procedures have been used to treat

unresectable tumors, including percutaneous ethanol injec-tion (PEI), but these, too, have serious drawbacks or limi-tations on their effectiveness. Systemic therapies, such aschemotherapy, immunotherapy, and biological therapy, arealso used, but they have low response rates, significant tox-icities, and usually dont provide a major improvement inoverall patient survival rates.

One local tumor ablative technique with considerablepromise is bipolar radiofrequency ablation (BRFA). A ra-diofrequency (RF) current applied across needle-electrodesplaced around a liver tumor can ablate the tumor in situ. TheRF current produces coagulative necrosis of the tumor tis-

sue [19]. Although the technique does not appear to have thetechnical drawbacks of cryosurgery or PEI, the effect ofBRFA on normal liver tissue, including major hepatic veins,intrahepatic arteries, and portal veins, and on post-treatmentrenal and liver function, is not known. To clarify some ofCorrespondence to: S. A. Curley

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urvival group (p < 0.01, Table 2). Seven days after BRFAof areas of normal liver, the serum CPK and LDH levels had

eturned to baseline values, while serum ALT and ASTevels remained slightly elevated (p < 0.05). Serum ALT

and AST levels also returned to baseline values 14 daysafter the BRFA procedures. In contrast, serum levels ofalkaline phosphatase, total bilirubin, creatinine, and thewhite blood count were not significantly different comparedo baseline values at any time after the BRFA proceduresTable 2). Similarly, serum blood urea nitrogen levels andhe prothrombin and partial thromboplastin times were not

elevated following BRFA of normal liver (data not shown).Serum hemoglobin levels were slightly elevated after theBRFA procedures; no animal had a decrease in hemoglobin

evels compared to baseline values.The gross pathologic findings showed that the laparo-

copic ultrasound probe was accurate in guiding the percu-aneous placement of the BRFA needles 3 cm apart in theiver. Gross examination revealed well-demarcated 2.02.5-

cm-diameter hemorrhagic zones around each needle track,overlapping between the needles (Fig. 1). This pattern wasobserved immediately, 7 days, and 14 days after BRFA.There was no evidence of hemorrhage into the needleracks. Microscopically, the sharply defined gross lesions

correlated with 2.02.5-cm zones of complete coagulativenecrosis of hepatic parenchyma abutted by normal-

appearing hepatocytes and liver architecture (Fig. 2). Therewas no gross or microscopic evidence of necrosis of thewalls of major intrahepatic portal or hepatic veins in any ofhe animals despite the necrosis of hepatic parenchyma cir-

cumferentially around the vessel. The temperatures mea-ured at each of the two needles during the BRFA proce-

dures are depicted in Fig. 3.In two control animals, BRFA needles were placed into

he liver but no RF current was passed across the needles.There was no evidence of any gross or microscopic liverdestruction in these two animals 7 days after the operation.

Discussion

Primary and metastatic liver malignancies, particularly fromcolorectal cancer, are a major cause of morbidity and mor-

tality in the United States and worldwide. Hepatocellularcancer is associated with chronic hepatitis B or C virus

infection and cirrhosis from any cause and has a mortalityindex of 0.94 [20]. A subset of patients with metastaticcolorectal cancer have liver-only disease, but less than 25%of these patients are candidates for resection based on num-ber or site of metastases [24]. Even in patients with colo-rectal cancer metastases in sites in addition to the liver,control of the liver metastases could provide significant pal-liative benefit.

Several local tumor ablative techniques have been usedin the treatment of liver malignancies. Percutaneous ethanolinjection (PEI) with real-time ultrasound guidance has beenused to treat hepatocellular cancer [11, 23]. PEI is generally

an outpatient treatment that requires multiple injections ofabsolute ethanol over a several-week period, although aone-shot injection technique under general anesthesiahas been described [12]. PEI for hepatocellular cancer canbe curative in some patients with solitary tumors less than 4cm in diameter, but PEI alone rarely cures patients withlarger or multiple hepatocellular tumors and has not beeneffective against metastatic tumors [10]. With BRFA, itshould be possible to completely ablate larger liver tumorsthat cannot be treated successfully with PEI because theBRFA needle-electrodes can be moved to several differentpositions in the primary or metastatic live cancer. Percuta-

neous and surgical placement of laser fibers under ultraso-nographic guidance has been used to produce interstitialthermal ablation of liver tissue [1, 2, 4, 15]. However, laserfiber ablation produces smaller zones of necrosis, generallyless than 2 cm in diameter, compared to BRFA lesions. Therapid vaporization of tissue near the laser fiber produces adense coagulum that inhibits propagation of cytotoxic heatmore than 1015 mm away from the fiber [4]. Cryoablationusing circulating liquid nitrogen probes has been used totreat hepatocellular cancer and colorectal cancer liver me-tastases [16, 18, 28]. The probes are much larger than the16-gauge BRFA needles, however, and life-threatening

hemorrhage has been reported after removal of the cryo-probes [16, 18].

Compared with cryoblation, bleeding from the liver fol-lowing BRFA is less likely because of the small diameter ofthe needles and the cauterization of the liver tissue along the

Table 2. Values of serum laboratory tests before (baseline) and for several days after bipolar radiofre-quency ablation (BRFA) of normal liver in adult domestic pigsa

Baseline Day 1 Day 3 Day 7 Day 14

CPK 1304.1 327.4 4676.7 1052.9* 4694.4 590.9* 1150.0 128.0 633.7 95.LDH 519.1 67.2 806.6 181.4* 807.7 125.8* 547.3 14.0 515.0 16.ALT 24.7 3.8 76.6 16.3* 48.4 5.3* 32.3 3.2** 30.0 2.6AST 25.6 1.8 32.4 3.4 35.3 3.8** 37.3 3.4** 30.4 3.9Alk Phos 97.0 3.0 103.0 5.7 79.3 3.0 100.3 7.5 107.8 10.T Bili 0.2 0 0.2 0 0.1 0 0.3 0 0.3 0Creat 1.2 0.1 1.3 0.1 1.3 0.1 1.3 0.1 1.3 0.1WBC 22.6 1.9 26.8 2.5 25.1 3.3 20.0 1.5 23.3 2.6Hgb 9.9 0.4 11.4 0.7** 10.6 0.6 11.5 0.7** 11.3 0.6

CPK, creatine phosphokinase (IU/l); LDH, lactic dehydrogenase (IU/l); ALT, alanine aminotransferaseIU/l); AST, aspartate aminotransferase (IU/l); Alk Phos, alkaline phosphatase (IU/l); T Bili, total

bilirubin (mg/dl); Creat, creatinine (mg/dl); WBC, white blood cell count (103); Hgb, hemoglobin (g/dl)p < 0.01 Students paired t-test, vs baseline value, n 8

** p < 0.05 Students paired t-test, vs baseline value, n 8

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needle-electrode tracks. Furthermore, the time needed toproduce complete necrosis of tumor tissue is five to 10imes shorter for BRFA than for cryoblation [5, 7, 22, 27].

Coagulative necrosis of tissue occurs if tissue temperature ismaintained above 60C for 2 min. In our experiments withBRFA of normal liver, we maintained the tissue tempera-ures between 60 and 70C for 16 min to determine the

hemodynamic and hepatic biochemical effects of prolongedBRFA current application. In actual BRFA treatments ofiver tumors, current would only need to be applied for 35

min in each area treated. A single 5-min application ofBRFA can effectively kill a liver tumor up to 4.0 cm indiameter. For larger tumors, the BRFA needles can beplaced at various points in and around the cancer to increasehe probability of complete tumor necrosis. A further dis-

advantage of cryosurgery is that it is usually a one-timereatment, as repeated treatments are technically difficult

and increase the risks of morbidity and mortality. In con-rast, since BRFA of superficial liver lesions can be per-

formed percutaneously with transcutaneous or laparoscopicultrasound guidance, tumors deep within the liver paren-chyma, near major intrahepatic blood vessels, or recurrentand new lesions can be treated repeatedly if necessary.

In our study, the combination of BRFA of areas withinhe liver and laparoscopy was well tolerated in all of the

animals. Excellent visualization of the liver for inspectionand laparoscopic ultrasonography was obtained with peri-oneal CO

2insufflation pressures of 1012 mmHg. The ani-

mals were hemodynamically stable at these insufflationpressures, unlike the decreased cardiac output that can occurat higher insufflation pressures [6, 26]. In our study, theBRFA procedures had no effect on the hemodynamic sta-bility of the animals.

BRFA of up to 10% of the normal liver volume inexperimental animals produced transient but completely re-

versible elevations in serum liver function tests. No animalhad an immediate or delayed decrease in serum hemoglobinevels, indicating that no significant hemorrhage from the

needle tracks or into the zone of thermal injury occurred.This is particularly significant because half of the lesions

were created around at least a 2.5-cm length of a majorintrahepatic portal or hepatic venous segment. It is impor-tant to assess the effects and possible life-threatening com-plications of BRFA in normal liver before proceeding withfull-scale treatment in patients with liver cancers. Tissuetemperature of 6070C for 16 min did not cause necrosis,hemorrhage, or thrombosis in large intrahepatic blood ves-sels. If it had damaged large vessel walls, BRFA for tumorsnear or surrounding these vessels would be precluded.

It remains to be determined if BRFA will produce com-plete killing of liver tumors near large intrahepatic bloodvessels or the inferior vena cava because of the heat sinkeffect produced by the high flow rates in these vessels. Toensure complete killing of a liver tumor by BRFA, it isnecessary to produce an approximately 1-cm-wide zone ofnecrosis of normal liver tissue surrounding the tumor. TheBRFA parameters we used12 W of power for 16 min with2.5-cm-long exposed electrode tips placed 3 cm apart

produced 2.02.5-cm-diameter zones of coagulative necro-sis.

Laparoscopic ultrasound was useful in guiding theplacement of the BRFA needles and in monitoring the pro-cedure while current was passed across the needles. Thehyperechoic area around and between the needles correlatedwith the area of coagulative necrosis on pathologic evalua-tion. This confirms in vivo the prior ex vivo observation thatthe size of the ultrasonographic hyperchoic region aroundthe needles corresponds to the area of thermal destruction inpieces of porcine liver subjected to RF currents [13]. Lap-aroscopic ultrasound guidance will be particularly important

to ensure accurate placement of the needle electrodes and tomonitor BRFA treatment of central or deep liver malignan-cies.

The thermal injury produced by BRFA is not the resultof direct heating from the needle electrodes. Rather, the RF

Fig. 2. A photomicrograph (magnification 65) of porcine liver treated 7days earlier with bipolar radiofrequency ablation (BRFA) for 16 min at 12W of power. There is a well-defined margin between the zone of coagu-ative necrosis produced by BRFA (open arrow) and the normal adjacent

hepatic parenchyma (solid arrow).

Fig. 3. Temperature readings from the thermistors built into the two activeneedle-electrodes used for bipolar radiofrequency ablation (BRFA) of nor-mal porcine liver. Time 0 represents the beginning of the 16-min-longBRFA and 18 min is the time point 2 min after completion of BRFA. Thereis no significant difference between the liver tissue temperatures measuredat the two active needle-electrodes.

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current passed across the needle electrodes produces ionicfluxes in the tissue surrounding the electrodes that followhe changes in the direction of the alternating current. Theonic fluxes produce frictional heating so that the tissues,

not the electrodes, are the source of the heat [14, 17]. Thus,he thermistors in the active needle-electrodes are measur-ng tissue temperature. To produce thermal necrosis of liver

and tumor tissue, it is necessary to heat the tissue to tem-

peratures greater than 4345C [8, 25]. However, to pro-duce complete, uniform, larger zones of necrosis, tempera-ures between 60 and 70C are necessary [5, 14, 27]. Whilet is possible to produce tissue temperatures that exceed

90C around the electrodes by increasing the wattage andcurrent amplitude, this actually decreases the efficiency ofBRFA because of rapid tissue desiccation near the needlesand a resultant decrease in current flow.

RF currents have been used to treat a small number ofpatients with malignant and benign liver tumors [8, 19].These studies have not been sufficient to establish the op-imal treatment approaches and long-term survival benefits

of BRFA treatment for liver cancers. Clearly, this is a localumor ablative technique which should be studied further

because of the potential advantages compared to other localherapies. From our study, we conclude that BRFA (1) pro-

duces a predictable volume of tissue necrosis that can beaccurately monitored by ultrasound, (2) can be performedpercutaneously with minimally invasive laparoscopic tech-niques, and (3) does not produce significant hemodynamicor hepatic toxicities.

References

1. Amin Z, Donald JJ, Masters A, et al. (1993) Hepatic metastases:interstitial laser photocoagulation with real-time US monitoring anddynamic CT evaluation of treatment. Radiology 187: 339347

2. Bosman S, Phoa SS, Bosma A, Van Gemert MJC (1991) Effect ofpercutaneous interstitial thermal laser or normal liver of pigs: sono-graphic and histopathological correlations. Br J Surg 78; 572575

3. Buscarini L, Rossi S, Fornari F, et al. (1995) Laparoscopic ablation ofliver adenoma by radiofrequency electrocautery. Gastrointest Endosc41: 6870

4. Dachman AH, McGehee JA, Beam TE, et al. (1990) Ultrasound-guided percutaneous laser ablation of liver tissue in a chronic pigmodel. Radiology 176: 129133

5. Daikuzono N, Joffe SN, Tajiri H, et al. (1987) Laserthermia: a com-puter-controlled contact Nd: YAG system for interstitial local hyper-thermia. Med Instrum 21: 275277

6. Davidson BS, Cromeens DM, Feig BW (1996) Alternative methods ofexposure minimize cardiopulmonary risk in experimental animals dur-ing minimally invasive surgery. Surg Endosc 10: 301304

7. Gage AA, Guest K, Montes M, et al. (1985) Effect of varying freezing

and thawing rates in experimental cryosurgery. Cryobiology 22: 175186

8. Haines DE (1993) The biophysics of radiofrequency catheter ablationin the heart: the importance of temperature monitoring. PACE PacingClin Electrophysiol 16: 586591

9. Kew MC (1986) The development of hepatocellular carcinoma inhumans. Cancer Surv 5: 719739

10. Livraghi T, Vettori C, Lazzaroni S (1991) Liver metastases: results ofpercutaneous ethanol injection in 14 patients. Radiology 179: 709712

11. Livraghi T, Bolondi L, Lazzaroni S, et al. (1992) Percutaneous ethanol

injection in the treatment of hepatocellular carcinoma in cirrhosis.Cancer 69: 92512. Livraghi T, Lazzaroni S, Pellicano S, et al. (1993) Percutaneous etha-

nol injection of hepatic tumors: single-session therapy with generalanesthesia. Am J Roentgenol 161: 10651069

13. McGahan JP, Browning PD, Brock JM, Tesluk H (1990) Hepaticablation using radiofrequency electrocautery. Invest Radiol 25: 267270

14. McGahan JP, Brock JM, Tasluk H, et al. (1992) Hepatic ablation withuse of radio-frequency electrocautery in the animal model. J VascInterv Radiol 3: 291296

15. Nelsoe CP, Torp-Pederson S, Burcharth F, et al. (1993) Interstitialhyperthermia of colorectal liver metastases with a US-guided Nd-Yaglaser with a diffuser tip: a pilot clinical study. Radiology 187: 333337

16. Onik G, Rubinsky B, Zemel R, et al. (1991) Ultrasound-guided hepatic

cryosurgery in the treatment of metastatic colon carcinoma. Cancer 67:901908

17. Organ LW (1976) Electrophysiologic principles of radiofrequency le-sion making. Appl Neurophysiol 39: 6976

18. Ravikumar TS, Kane R, Cady B, et al. (1991) A 5-year study ofcryosurgery in the treatment of liver tumors. Arch Surg 126: 15201526

19. Rossi S, Di Stasi M, Buscarini E, et al. (1995) Percutaneous radiof-requency interstitial thermal ablation in the treatment of small hepa-tocellular carcinoma. Cancer J 1: 7381

20. Rustgi V (1988) Epidemiology of hepatocellular cancer. Ann InternMed 108: 390401

21. Schwartz SI (1990) Primary malignant tumors. In: Moody F (ed) Sur-gical treatment of digestive diseases. Year Book Medical, Chicago, pp400407

22. Shier WT (1988) Studies on the mechanisms of mammalian cell killingby a freeze-thaw cycle: conditions that prevent cell killing using nucle-ated freezing. Cryobiology 25: 110119

23. Shiina S, Yasuda H, Muto H, et al. (1987) Percutaneous ethanol in-jection in the treatment of liver neoplasms. Am J Roentgenol 149: 949

24. Steele G, Ravikumar TS (1989) Resection of hepatic metastases fromcolorectal cancer. Ann Surg 210: 127138

25. Strohbehn JW (1983) Temperature distributions from interstitial RFelectrode hyperthermia systems: theoretical predictions. J Radiat On-col Biol Phys 9: 16551667

26. Westerband A, van de Water JM, Amzallag M, et al. (1992) Cardio-vascular changes during laparoscopic cholecystectomy. Surg GynecolObstet 175: 535538

27. Zervas NT, Kuwayama A (1972) Pathological characteristics of ex-perimental thermal lesions: comparison of induction heating and ra-diofrequency electrocoagulation. J Neurosurg 37: 418422

28. Zhou XD, Tang Zy, Yu YQ, et al. (1988) Clinical evaluation of cryo-surgery in the treatment of primary liver cancer: report of 60 cases.Cancer 61: 18891894

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Abdominal fat tissue necrosis as a cause of acute abdominal pain

Laparoscopic diagnosis and therapy

D. Aronsky, K. Zgraggen, M. Banz, C. Klaiber

Department of Surgery, Spital Aarberg, CH-3250 Aarberg, Switzerland

Received: 5 February 1996/Accepted: 25 June 1996

AbstractBackground: Infarctions of the greater omentum and of theepiploic appendages are rare etiologies of acute abdominalpain. The aims of the study were to determine the incidenceof abdominal fat tissue necroses and to discuss the clinicalfeatures and the role of laparoscopy in the treatment of theseconditions.Methods: A retrospective study in 563 consecutive patientswith acute abdominal pain was performed. In all patientsdiagnostic laparoscopy was indicated.Results: The incidence of abdominal fat tissue necroses in563 patients with acute abdominal pain was 1.1%. Six pa-ients had either infarctions of the omentum or of the epi-

ploic appendages. Pain was the predominant clinical symp-om and the preoperative diagnosis depended upon the lo-

cation of the omental or epiploic necroses. Diagnosis andreatment were performed laparoscopically without morbid-ty.

Conclusion: The incidence of abdominal fat tissue necrosesn our patients was increased compared to the prelaparo-copic period. Omental and epiploic necroses are significantn the differential diagnosis of appendicitis, acute cholecys-itis, and diverticulitis.

Key words: Acute abdominal pain Omentum Appen-dix epiploica Fat necrosis Laparoscopy

nfarction of the greater omentum and of the epiploic ap-pendages can cause acute abdominal pain. Although rare inoccurrence, they are clinically relevant as they mimic morecommon diseases in patients with acute abdominal pain. Weeport six cases of abdominal fat tissue necrosis diagnosed

by laparoscopy over a period of 5 years in patients showingclinical suspicion of appendicitis, acute cholecystitis, or di-

verticulitis. Laparoscopy allowed us at the same time toidentify and treat these rare pathologies. The incidence ofabdominal fat tissue necrosis in our patient population is incontrast to their infrequent mention in the literature.

Methods

The technical details of diagnostic and therapeutic laparoscopies have pre-viously been described by us [12]. Briefly, a transumbilical access by aVeress needle was gained and a CO

2pneumoperitoneum was established.

Intraabdominal pressure was limited to 12/15 mmHg. An umbilical 10-mmtrocar for a 25 telescope and one additional 5- or 10-mm trocar areinserted. The location of the second trocar depended upon the clinicaldiagnosis and the site of the expected pathology. A thorough inspection ofthe abdominal cavity was then carried out. This systematic revision al-lowed diagnosis of abdominal fat tissue necroses, i.e., omental necrosis ortwisted epiploic appendages. At this stage another trocar is inserted to helpin the resection of the pathology. Laparoscopic resection of the omentalnecroses and the necrotic epiploic appendages was performed by Endo-GIA stapler (Autosuture) in five patients, using a Roeder loop in onepatient. The resected specimens were removed directly from the abdominalcavity; no endobags were used to prevent wound infections. Prophylacticantibiotics were used in only one patient (No. 4) with the preoperativeclinical diagnosis of acute cholecystitis. One patient (No. 5) was givenantibiotic therapy starting the day of admission. Four patients did notreceive antibiotics.

Four patients (No. 13, 6) underwent concomitant appendectomy. Pa-tient No. 4 had undergone appendectomy previously. Although it is ourstandard policy to perform routine concomitant appendectomy in patientsunder 50 years of age, patient No. 5 did not undergo this procedure.Resected specimens were sent for histopathological examination. Follow-up was complete and carried out by telephone.

Patients

Relevant clinical symptoms and findings are summarized in Table 1. Theaverage age of our patients was 36 years (1661 years). Four of the six

patients were male. Three patients were obese; the body mass indices ofpatients 35 were 26.9, 36.2, and 32.0, respectively. Clinical diagnosis wasappendicitis in four patients, acute cholecystitis in one patient, and diver-ticulitis in one patient. The duration of symptoms prior to hospital admis-sion was 1272 h. None of the patients experienced nausea, vomitus, ordiarrhea. The axillar temperature averaged 37.7C (37.4C38.0C), the

Correspondence to: K. Zgraggen, Department of Visceral and Transplan-ation Surgery, Inselspital, University of Bern, CH-3010 Bern, Switzerland

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mean axillar-rectal temperature difference was 0.9C. The white blood cellount (WBC) averaged 8,650/mm3 (6,00011,300/mm3). The WBChowed a shift in only one patient. The erythrocyte sedimentation rateESR) averaged 8 mm/h and the C-reactive protein 16 mg/l. In patients 13

nd 6 laparoscopy was performed on the day of admission; in patient 5 itwas done on the 4th day of hospitalization after an abdominal ultrasoundnd a water-soluble contrast enema. Patient 4 was operated on the 3rd dayfter a diagnostic workup with abdominal ultrasound, computed tomogra-

phy (CT) scan, and upper-gastrointestinal (GI) endoscopy.

Results

From 1990 to 1995 some 563 laparoscopies in patients withacute abdominal pain were performed. Laparoscopy wasndicated in cases with suspected appendicitis, acute chole-

cystitis, and diverticulitis and in patients with unclear clini-

cal presentation but suspected surgical pathology. In sixpatients the diagnosis of abdominal fat tissue necrosis wasmadean incidence of 1.1%.

A primary segmental necrosis of the omentum occurredn one patient. A secondary segmental necrosis of the omen-um with torsion was discovered in three patients duringaparoscopy (Figs. 1 and 2). A necrosis of a twisted appen-

dix epiploica was diagnosed once (Fig. 3). In one patient aorsion of the necrotic epiploic appendage could not be posi-ively identified. In none of the six patients was free serous

or sanguineous abdominal fluid detected. All procedureswere performed without intraoperative complications. The

mean operative time was 62 min (40120 min). The histo-ogic examination confirmed the macroscopic finding of fatissue necrosis in all patients. No complications occurred inhe postoperative course and the duration of hospitalization

averaged 5.8 days (47 days). Patients were followed up

after an average of 10 months (715 months). None of thepatients had remaining symptoms.

Discussion

The literature on abdominal fat tissue necroses is scarce.Only a few references on omental infarctions [1, 4, 9, 18]and necrotic epiploic appendages [3, 14, 16] exist and lap-aroscopic diagnosis and treatment in particular are only de-scribed as case reports [6, 8, 11]. Pathogenetically the rare,primary segmental necrosis of the omentum is distinguishedfrom the more common secondary necrosis, generally fol-lowing torsion of a mobile omental segment [1, 1820].There is no preferred age classchildren can also be af-fected [1, 9, 17, 19]. Obesity and cardiovascular diseases are

considered predisposing conditions [1, 7, 18]. Obesity waspresent in 50% of our patients, and one patient had a pre-existing cardiovascular disease.

The infarctions tend to occur in the right side of theomentum [7, 9]. An anomaly with reduced vascularizationof the affected part is discussed as the cause of this phe-nomenon [19]. A secondary impaired vascularization of thelarger, right-sided part of the omentum due to systemicdiseases, e.g., arteriosclerosis and diabetes mellitus, offersan alternative explanation. Necroses of epiploic appendagesoccur almost exclusively following torsion.

Depending upon their localization, necroses of the

omentum and the epiploic appendages present with a similarbut atypical clinical pattern compared to the more commonetiologies of acute abdominal pain. Nausea, diarrhea, andvomitus are only occasionally described and were absent inall of our patients. Abdominal pain is the predominant and

Table 1. Summary of relevant clinical, laboratory, and pathological findings of the six patients with abdominal fat tissue necroses

Patient Age Sex WBC ShiftC-reactiveprotein

Localizationof pain

Suspecteddiagnosis

Postoperativediagnosis

Size(cm)

Histopathologicalfindings

29 M 11,300 Y 8 Right lowerquadrant

Appendicitis Primary omentalnecrosis

3.5 3 1.8 Recent hemorrhagicnecrosis with slightgranularinflammation

2 17 M 10,500 N


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only consistent symptom and, occurring for 15 days, wasof short duration [1, 9, 18]. The discrepancy between thepatients good general condition and the marked abdominalsymptoms must be emphasized and is consistent with theliterature and our experience. Laboratory results are usuallynonspecific and show no or only a slight increase of WBCbut hardly ever a shift to the left or toxic signs.

Considering the above-mentioned possible pathogenetic

factors, it is not surprising that omental necroses are usuallylocated in the right lower abdomenaccording to the lit-erature, 84% of the time [9]. The most commonly reportedpreoperative diagnosis was therefore appendicitis (6474%)followed by acute cholecystitis in 2126% [9, 10]. Necrosesof epiploic appendages 40% of the time are situated in theleft lower abdomen, corresponding to their frequent originin the sigmoid colon [5], but they lead to the clinical diag-nosis of appendicitis in 3860% [5, 13]. A correct preop-erative diagnosis of abdominal fat tissue necrosis is rare [1,5]. Even additional diagnostic procedures such as CT scanand ultrasound do not allow a conclusive diagnosis [17], andin the reviewed literature abdominal fat tissue necrosis wasalways diagnosed at laparotomy. In contrast to these de-scriptions our standard policy is to perform diagnostic lap-aroscopy in patients presenting with acute abdominal pain.Comparison of our reported incidence of 1.1% to the inter-national literature is therefore difficult.

The value of laparoscopy in the diagnosis and therapy ofnonspecific acute abdominal pain is well known [11, 15].Laparoscopy enables the surgeon to inspect the entire ab-dominal cavity, which is an advantage over a limited openaccess, e.g., a McBurney incision in suspected appendicitis.The result of the frequent use of diagnostic laparoscopy isthat rare atypical findings such as abdominal fat tissue ne-croses can be detected consistently. The incidence of ab-dominal fat tissue necroses of 1.1% in patients with acuteabdominal pain shows that these etiologies are rare but ofdefinite clinical relevance. We assume that necroses of theomentum and the epiploic appendages are usually missed inopen surgery, particularly in cases with suspected appendi-citis. Therefore in patients presenting with acute abdominalpain, especially those with rare etiologies, laparoscopy rep-resents a refined diagnostic procedure and closes a diagnos-tic gap. We are convinced that the use of laparoscopy willallow the diagnosis of abdominal fat tissue necroses morefrequently in future.

References

1. Adams JT (1973) Primary torsion of the omentum. Am J Surg 126:102105

2. Angulo JM, Ruiz I, Villanueva A, San Vicente M, Tovar JA (1990)Patologia quirurgica primaria de epiplon. Cir Pediatr 3: 125129

3. Anton JI, Jennings JE, Spiegel MB (1945) Primary omental torsion.Am J Surg 68: 303

4. Bernatz PE (1956) Unusual conditions simulating acute appendicitis.Proc Staff Meet Mayo Clin 31: 5356

5. Carmichael DH, Organ CH (1985) Epiploic disorders: conditions ofthe epiploic appendages. Arch Surg 120: 11671172

6. Chung SCS, Ng KW, Li AKC (1992) Laparoscopic resection for pri-mary omental torsion. Aust NZ J Surg 62: 400401

7. Crofoot DD (1980) Spontaneous segmental infarction of the greateromentum. Am J Surg 139: 262264

8. Diaco JF, Diaco DS, Brannan AN (1993) Endoscopic removal of aninfarcted appendix epiploica. J Lap Surg 3: 149151

Fig. 1. Omental necrosis in the right upper quadrant in a patient withlinical signs of acute appendicitis (patient 2).

Fig. 2. Omental necrosis in a patient with acute abdominal pain (patient 3).Histopathology subsequently found the appendix to be normal.

Fig. 3. Torsion of an epiploic appendage of the sigmoid colon in a patientwith acute abdominal pain (patient 5).

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9. Epstein LI, Lempke RE (1968) Primary idiopathic segmental infarc-tion of the greater omentum: case report and collective review of theliterature. Ann Surg 167: 437443

0. Federmann G, Maeo-Guitierrez C, Schneider A (1991) Torsion vonNetz oder Appendix epiploicaseltene Ursachen eines akuten Abdo-mens. Chirurg 62: 571

1. Giuly J, Francois GF, Gaujoux J, Reynaud B (1991) Infarctus id-iopathique segmentaire du grand epiploon. J Chir (Paris) 128: 204206

2. Klaiber Ch, Metzger A, Petelin JB (1993) Manual of laparoscopicsurgery. Hogrefe and Huber, Bern

3. Lynn TE, Docherty MB, Waugh JM (1956) A clinicopathologicalstudy of the epiploic appendages. Surg Gynecol Obstet 103: 4234334. Mattarelli G, Roth B, Rossetti M (1985) Omentale und epiploische

Torsion in der Differentialdiagnose des akuten Abdomens. Helv ChirActa 52: 665669

15. Paterson-Brown S, Eckersley JRT, Sim AJW, Dudley HA (1986)Laparoscopy as an adjunct to decision making in the acute abdomen.Br J Surg 73: 10221024

16. Puppala AR, Mustafa SG, Moorman RH, et al. (1981) Small-bowelobstruction due to disease of epiploic appendage. Am J Gastroenterol75: 382383

17. Puylaert JB (1992) Right-sided segmental infarction of the omentum:clinical, US and CT findings. Radiology 185: 169172

18. Schnur PL, McIlrath DC, Carney JA, Whittaker LD (1972) Segmentalinfarction of the greater omentum. Mayo Clin Proc 47: 751755

19. Tolenaar PL, Bast TJ (1987) Idiopathic segmental infarction of thegreater omentum. Br J Surg 74: 1182

20. Vertuno LL, Dan JR, Wood W (1980) Segmental infarction of theomentum. Am J Gastroenterol 74: 443446

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Acidbase balance alterations in laparoscopic cholecystectomy

V. Gandara,1 D. S. de Vega,2 N. Escriu,1 I. Garcia Zorrilla1

Service Anesthesiology, General Hospital of Mostoles, Madrid, SpainComplutense University of Madrid, Madrid, Spain

Received: 25 January 1996/Accepted: 29 May 1996

AbstractBackground: The purpose of this study is to determine al-erations of acidbase balance originated by pneumoperito-

neum with CO2

. Influence of other factors such as anes-hetic technique, duration of procedure, and volume of CO

2

nsufflated has also been analyzed.Methods: Some 132 patients were divided in three groupsaccording to anesthetic technique used. Arterial blood gaseswere determined before pneumoperitoneum, at 20 min aftert, and every 30 min, until procedures end, and in postop-

erative period up to a total of four samples.Results: Pneumoperitoneum originated a fall of pH (p 8 cm) of the esophageal hiatus repairedwith posterior cruroplasty. Subsequent barium meal in thesepatients confirmed a recurrent hiatal hernia with demon-strable reflux. In an attempt to prevent reherniation of thestomach into the chest, we reinforced the posterior cruro-plasty with polytetrafluoroethylene (PTFE) onlay in thenext patients with large hiatal hernia. Here we report lapa-roscopic Nissen fundoplication with mesh reinforcement of

posterior cruroplasty in three patients with symptomatic

GER and large hiatal hernia.

Case reports

Our technique of laparoscopic Nissen fundoplication and posterior cruro-plasty follows a previous description [5]. Cefazolin (2 g IV) is given withinduction of general anesthesia. Carbon dioxide pneumoperitoneum andfive 10-mm trocars are used. The lesser omentum and phrenoesophagealligament are incised, a 50 Fr bougie is placed within the esophagus, and awindow is created posterior to the esophagus with blunt dissection. Thehiatal hernia is reduced with sharp and blunt dissection of the hernia sacand with gentle traction on the stomach. The short gastric vessels areligated with a right-angle clip applier or an ultrasonic scalpel (Ehicon).The esophagus is circumferentially mobilized until the lower 5 cm is in-trabdominal.

A typical hiatal hernia for which mesh only was utilized is shown inFig. 1. Prior to the onlay posterior cruroplasty is performed with inter-rupted sutures of 2-0 polyester into the right and left bundles of the rightcrus, ensuring that full-thickness bites are taken.

The mesh onlay is an oval sheet (15 10 0.1 cm) of fenestrated PTFE(MycroMesh GoreTex, W. L. Gore and Associates). A radial slot with a3-cm defect in the center (keyhole) is cut into the mesh. The mesh ispushed through a 10-mm trocar into the peritoneal cavity and placedaround the gastroesophageal junction with the esophagus coming throughthe 3-cm defect and the radial slot oriented anteriorly (Fig. 2). The PTFEis stapled to the diaphragm with a straight hernia stapler (Ethicon); the twoleaves of the keyhole are stapled to each other.

Finally, a 3-cm-long 360 fundoplication is created loosely around the50 Fr bougie with three sutures of 2-0 polyester, taking bites of stomachwall only (Fig. 3). The most cephalad stitch incorporates the mesh and theanterior arch of the right crus.

This procedure was performed on three patients who all had severe

heartburn, reflux, a partially intrathoracic stomach, and an esophageal hia-tus8 cm in diameter. No perioperative complications occurred. At 5, 16,and 18 months of follow-up the patients are doing well and either bariummeal or endoscopy has confirmed a successful operation in each.

Discussion

The cause(s) of recurrent reflux after an antireflux proce-dure may be revealed by examining the reoperation for re-flux. In one series of 87 patients undergoing operation for afailed antireflux procedure, 72% had recurrent hiatal hernia[11]. Despite the problem of recurrence, the technique ofCorrespondence to: C. T. Frantzides

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Fig. 1. Intraoperative view of an enlarged esophageal hiatus which was repaired with posterior cruroplasty and PTFE onlay. (A) liver, (B) diaphragm, (C)stomach, (D) esophageal hiatus, (E) gastrohepatic omentum.

Fig. 2. Intraoperative view of the hiatus after posterior cruroplasty and PTFE onlay, but before the fundoplication: (A) inflatable balloon retractor, (B) PTFEstapled to diaphragm, (C) esophagus, (D) liver.

Fig. 3. Intraoperative view after completion of Nissen fundoplication: (A) liver, (B) inflatable balloon retractor, (C) PTFE stapled to diaphragm, (D)fundoplication.

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hiatal herniorraphy has not changed appreciably since itsinception. Cruroplasty has been done by suturing the crurawith 0 or 2-0 nonabsorbable material anterior and/or poste-rior to esophagus [12]. Cushieri et al. [3] has reported eightpatients with large hiatal hernia who were treated with lap-aroscopic posterior cruroplasty, with a good short-term re-sult.

Precedent for the use of prosthetic at the esophageal

hiatus is limited; one example is the Angelchik and Cohenprosthesis [1], a C-shaped ring of silicone gel contained ina silicone elastomer shell which is placed around the gas-troesophageal junction. The enthusiasm for this device wasended by reports of complications of prosthesis migration,lumenal penetration, and dysphagia [2]. The indication forthe purpose of PTFE placement in the present study aredifferent from those for placement of an Angelchik pros-thesis, so comparison of these two techniques is difficult.Migration of the PTFE is unlikely since it is stapled to thediaphragm. We do not as yet have long-term follow-up.

Edelman [4] has reported a series of 5 patients withparaesophageal hernia who were treated with laparoscopichiatal herniorrhaphy with polypropylene mesh, gastropexy,

and gastrostomy. Pitcher et al. [9] has reported a series of 12patients with paraesophageal hernia who underwent laparo-scopic repair; two of these required polypropylene mesh toclose a large hiatus. Since polypropylene mesh has beenassociated with enterocutaneous fistula secondary to thepolypropylene eroding into the bowel lumen [8], we em-ployed PTFE for the onlay because there have been noreports of bowel erosion secondary to PTFE.

Determination of the efficacy and safety of PTFE rein-forcement of posterior cruroplasty for the large hiatal defectwill require 5075 patients observed over 1015 years. Theshort-term result in our first three patients has been satis-factory. We do not, however, recommend routine use ofPTFE in hiatal herniorrhaphy. At the present we are placing

PTFE in patients with a large hernia sac and whose hiataldiameter is 8 cm or greater. The diameter indication wasarrived at empirically; we do not have data specifying thehiatal diameter at which the risk for cruroplasty disruption isincreased. We feel that the PTFE onlay provides a buttresswhere tissue is healing under tension and is subjected tostress from coughing, straining, retching, or obesity. Wepropose the use of PTFE when confronted with a large

defect of the hiatus.

References

1. Angelchik JP, Cohen R (1979) A new surgical procedure for the treat-ment of gastroesophageal reflux and hiatal hernia. Surg Gynecol Ob-stet 148: 246248

2. Crookes PF, DeMeester TR (1994) The Angelchik prosthesis: whathave we learned in fifteen years? Ann Thorac Surg 57: 13851386

3. Cuschieri A, Shimi S, Nathanson LK (1992) Laparoscopic reduction,crural repair, and fundoplication of large hiatal hernia. Am J Surg 163:425430

4. Edelman DS (1995) Laparoscopic paraesophageal hernia repair withmesh. Surg Laparosc Endosc 5: 3237

5. Frantzides CT, Carlson MA (1995) Laparoscopic versus conventionalfundoplication. J Laparoendosc Surg 5: 137143

6. Hinder RA, Filipi CJ, Wetscher G, Neary P, DeMeester TR, PerdikisG (1994) Laparoscopic Nissen fundoplication is an effective treatmentfor gastroesophageal reflux disease. Ann Surg 220: 472483

7. Jamieson GG, Watson DI, Britten-Jones R, Mitchell PC, Anvari M(1994) Laparoscopic Nissen fundoplication. Ann Surg 220: 137145

8. Kaufman Z, Engelberg M, Zager M (1981) Fecal fistula: a late com-plication of Marlex mesh repair. Dis Colon Rectum 24: 543544

9. Pitcher DE, Curet MJ, Martin DT, Vogt DM, Mason J, Zucker KA(1995) Successful laparoscopic repair of paraesophageal hernia. ArchSurg 130: 590596

10. Rattner DW, Brooks DC (1995) Patient satisfaction following laparo-scopic and open antireflux surgery. Arch Surg 130: 289294

11. Stirling MC, Orringer MB (1986) Surgical treatment after the failedantireflux operation. J Thorac Cardiovasc Surg 92: 667672

12. Wichterman K, Geha AS, Cahow CE, Baue AE (1979) Giant para-esophageal hiatus hernia with intrathoracic stomach and colon: thecase for early repair. Surgery 86: 497506

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Laparoscopic colposuspension

Is it cost-effective?

K. Loveridge, A. Malouf, C. Kennedy, A. Edgington, A. Lam

Strathfield Private Hospital, University of Sydney, 3 Everton Road, Strathfield NSW 2135, Australia

Received: 19 August 1996/Accepted: 20 December 1996

AbstractBackground: The laparoscopic approach must be shown tobe cost-effective as well as safe and technically effectivebefore being widely adopted. A review of 54 consecutivepatients who underwent open and laparoscopic colposus-pension is presented and a cost-analysis is performed com-paring the two approaches.Methods: This study was a retrospective controlled reviewof patient records and accounts of in-hospital costs incurredat a private hospital.Results: Theater costs were significantly greater in the lap-aroscopic group but this was balanced by a shorter length of

tay and subsequent reduced accommodation cost. Therewas no difference in the overall in-hospital costs betweenhe two groups.

Conclusion: The laparoscopic surgical approach is safe andeffective and by no means more expensive than the openapproach. In the future, the laparoscopic approach can onlybecome more cost efficient; techniques will improve andhere will be earlier returns to work and, subsequently,

greater productivity.

Key words: Laparoscopic Colposuspension Cost

Urinary incontinence is a common problem affecting812% of all women. Of these, 5% will have daily incon-inence [1, 22, 48]. Many different operations have been

performed to treat urinary incontinence [3, 24, 25, 35, 38,42, 45]. The suprapubic approach first described by Burchhas been regarded as the operation of choice due to itsong-term success rates [8, 9, 11, 12, 46]. Since 1992 this

particular operation has been routinely performed laparo-

copically by one of the surgeons at Strathfield Private Hos-pital. In an earlier paper this surgeon reported upon the

advantages of the laparoscopic approach: easier access, im-proved magnified view, minimal intraoperative blood loss,shorter length of stay, and earlier return to normal lifestyle[27]. Other reports in the literature have also proven lapa-roscopic colposuspension to have similar advantages [2, 31,33, 40].

Aims

While the laparoscopic technique may provide a significant

improvement in patient management it must also be shownto be cost-effective before being widely adopted.

The aim of this paper is to compare the in-hospital costeffectiveness between the laparoscopic and open Burch col-posuspension.

Methods

This is a retrospective consecutive case-control study of all patients whounderwent colposuspension at one private hospital between March 1992and March 1995. Patients were divided into two groups. In the study groupwere all those patients who had a laparoscopic colposuspension and in the

control group were all patients who had an open procedure. Patients whohad a major procedurenamely, a total abdominal hysterectomyperformed concomitantly with the colposuspension were excluded. Onesurgeon performed the laparoscopic procedures but seven different sur-geons were responsible for the open cases.

Data was collected from hospital records. The two groups werematched for age, comorbidity, weight, previous abdominal surgery, previ-ous bladder neck surgery, concomitant minor surgery, and the incidence ofcomplications. Theater time, length of stay, and all resource usage wererecorded. Resource usage included all investigations performed, medica-tions and fluids given, instruments utilized, operations performed, andspecialist services consulted.

In-hospital costs were categorized into five areas: investigatory, me-dicinary, accommodation, theater, and consultant fees. Investigatory costsincluded pathology and radiology services and cross-consultation fees.

Medications included analgesics, antibiotics, and miscellaneous drugs suchas antiemetics, anticoagulants, and ted stockings. Regular medicationswere not included. These two areas were allocated standardized 1995prices per unit used.

Accommodation costs were based upon length of stay and the standardcost of a private room in 1995. Theater costs involved a fee for disposableCorrespondence to: K. Loveridge

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tems identified on patient accounts and a standardized fee allocated fromprivate health funds for an open or laparoscopic procedure. Consultant feesor both the anesthetist and surgeon were calculated according to the 1995

Medicare rates.Costs that were not taken into consideration were overheads or indirect

osts which were incurred in support of clinical services. This includedbuilding and equipment depreciation, administration, labor and wageshence, theater and nursing time requirements were not accountable),

meals, laundry/cleaning, and energy costs. Medications excluded were an-sthetic gases and drugs, regular routine medications, bandages/dressings,yringes, giving sets, needles, etc. Theater costs, including operation feesnd costs of disposable instruments directly incurred as a result of other

minor procedures performed at the time of surgery, were not included.The two groups were matched statistically using chi-squared tests for

ge, weight, comorbidity, and number of patients who had previous ab-

dominopelvic surgery or who had other minor procedures at the time ofurgery. The cost analysis was performed using Student t-tests.

Results

There were a total of 54 patients, of whom five patientswere excluded as they had hysterectomies at the time of

urgery. Of the remaining 49 patients, 26 underwent lapa-oscopic and 23 open operations. Patient demographics and

previous surgery performed are outlined in Table 1. Theaparoscopic group was significantly older (p 0.007);

however, as this difference occurred within the sixth decade

and all patients were women, the clinical significance washought to be negligible.

Sixteen of the laparoscopic and 18 of the open patientshad previous abdominopelvic surgery (p 0.06). The pa-ients that had open colposuspension tended to have a his-ory of a greater number operations per person (Fig. 1).

Figure 2 records the type of surgery previously performed.The number of patients having previous bladder neck sur-gery between the two groups was comparable. As describedn Table 2, the laparoscopic group contained a greater num-

ber of patients who had other minor procedures which wereperformed at the time of colposuspension (p 0.02). There

was no significant difference in complication rate as re-ported in Table 3 (p 0.214).

In the laparoscopic group the length of stay was signifi-cantly shorter with a mean of 3.7 2.3 days compared with6.3 3.0 days (p 0.001). Table 4 outlines the cost analy-

is results. In-hospital costs were comparable in terms ofmedications, investigations, and consultant fees. Theatercosts, however, were greater in the laparoscopic group (p


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c surgery, especially cholecystectomy, when comparedwith the open technique regardless of their methodology57, 1719, 33, 39, 43]. A few studies, however, report nouch significant difference, and some even report an in-

crease in laparoscopic costs [23, 47].These differences in reporting may be attributable to

methodology. Some papers fail to define how costs werederived [47]. Most papers rely on hospital charges becauseof the accessibility of details without taking into account allother indirect costs or overheads. In addition, certain com-ponents, in particular overheads or indirect costs for any oneoperation, differ between hospitals depending on a multi-ude of given variables [20, 32]. Ideally, all costs need to be

considered in any accurate cost analysis, but to date there isno widely accepted formula for estimating these costs. De-

pite this, the experience gained and trends noticed fromaparoscopic cholecystectomy can be extrapolated and com-

pared in principle to other forms of laparoscopic surgery.In our study as with others, one of the major factors

which determined the overall cost of the procedure wasength of stay. The cost of new technology in our study asn others balanced any advantage gained by a shorter length

of stay [16, 21, 23, 26, 41, 47]. However, in the future, withfurther improvement in length of stay, economic advantagescan be anticipated with the laparoscopic approach to colpo-

uspension. Previous research has shown that over the lastdecade, length of stay has not changed dramatically in those

patients who had an open colposuspension [40]. This sug-gests that the managed care of patients having an openprocedure has already been optimized and is unlikely to

ignificantly change in the future. In contrast, as more ex-pertise is gained in the laparoscopic approach, length of stay

should decrease. This has been the experience with laparo-scopic cholecystectomy in this country as hospital bed dayswere reduced by 1425% within a 2-year period of its in-troduction [34]. As with laparoscopic cholecystectomy,day-stay surgery may still become a possibility.

Cholecystectomy rates have increased since the incep-tion of the laparoscopic approach, and as Fletcher suggests,this rise has negated any economic benefit gained by a

shorter length of stay for health funders [13]. In the publicsector, a shorter length of stay can produce major savingsprovided that more aspects of treatment are transferred tothe outpatient setting and beds closed [14]. In the privatesector this may also be achieved provided bed occupancyrates are maintained. One might anticipate a similar rise inthe rate of laparoscopic colposuspension as a less-invasiveprocedure with fewer complications offers an opportunity topatients who might not otherwise have been considered suit-able for surgery.

The other major area of in-hospital costs in our studyand in others was theater-related expenses, which includedoperation costs and disposable instruments [16]. As men-tioned previously, these costs counterbalanced any advan-tage gained by a shorter length of stay in our study. Fortu-nately, this is another area in which there should be im-provement with time and where costs can be consciouslyminimized. The use of nondisposable instruments is a ne-cessity in order to achieve this.

Although theater costs at our hospital were not basedupon time spent in theater, reduction in theater time sec-ondary to experience will also improve overheads associ-ated with theater costs. The difference in costs between thetwo approaches is therefore only likely to increase, showinga significant cost benefit associated with the laparoscopicapproach.

Most studies agree that the major cost differences occurafter discharge. In the case of laparoscopic cholecystecto-my, as with colposuspension, most patients are within theworking age group, and those that have a laparoscopic pro-cedure return to work or resume normal activity on average46 weeks earlier than those undergoing an open procedure.This increases national productivity and decreases costs in-curred by employers and insurers dramatically [18, 36, 37,44, 49, 50]. Our study did not consider this; hence, whencosts incurred secondary to a delay in return to work arealso considered, the benefits of the laparoscopic approach

should become even more apparent. Patient satisfaction interms of decreased waiting lists, shorter length of stay, andearlier return to normal activity are also factors which areinvaluable advantages.

A prospective randomized study detailing each item/resource used and overhead costs involved would be thebest means of accounting for all costs accurately. But webelieve this study to be adequate in terms of identifyingmajor differences in in-hospital costs between proceduresand proving the null hypothesis. Laparoscopic colposuspen-sion is certainly not significantly more costly than an openprocedure. Other studies have proven laparoscopic surgery

to be a safe and effective mode for the management ofurinary stress incontinence. This study now proves that it isalso a feasible option.

Acknowledgment. Surgeons: Boulas J, MBBS FRACS; Lalak A, MBBS

Table 3. Complications

Type Laparoscopic Open

UTI 4 1Urinary retention 4Home with SPC 3Cannula site infect 1Detrusor instability 1Wound infection 1PUO 1Paralytic ileus 1Bladder perforation 1Conversion to open 2nd to bleeding 1 N/AHypoglycemia 1Antibiotic reaction 1

Total 11 10

Table 4. Cost analysis per patient

Meandifference p

Accommodation $1,084.00 0.001Theater

Disposables $280.77


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FRCS(Ed.) FRACS; Maher P, MBBS FRCS(Eng.) FRACS; OToole V,MBBS FRACOG FRACDG; Sheldon J, MBBS FRACOG; Wong J, BScMBBS FRACS. Statistician: Hurst T. Research Assistant: Gane M, RN.

References

1. Abrams P, Blaivas JG, Stanton SL, Anderson JT (1990) The standardi-sation of terminology of lower urinary tract function. Br J Obstet

Gynaecol (Suppl) 97: 1162. Albala DM, Schuessler WW, Vancaillie TG (1992) Laparoscopic blad-der neck suspension. J Endourol 6: 137141

3. Aldridge AH (1942) Transplantation of fascia for relief of urinarystress incontinence. Am J Obstet Gynae 44: 398

4. Apelgren KN, Molnar RG, Kisala JM (1992) Is laparoscopic betterthan open appendectomy? Surg Endosc 6: 298301

5. Baird DR, Wilson JP, Mason EM et al (1992) An early review of 800laparoscopic cholecystectomies at a university affiliated communityteaching hospital. Am Surg 58: 206210

6. Barkun J, Caro J, Barkun A, Trindale E (1995) Cost-effectiveness oflaparoscopic and mini-cholecystectomy in a prospective randomisedtrial. Surg Endosc 9 (11): 12211224

7. Bass E, Pitt H, Lillemoe K (1993) Cost-effectiveness of laparoscopiccholecystectomy versus open cholecystectomy. Am J Surg 165: 466

4718. Bergnan A, Ballard CA, Konnings PP (1989) Comparison of three

different procedures for genuine stress incontinence: prospective ran-domised study. Am J Obstet Gynecol 160: 11021106

9. Bhatia NM, Bergman A (1985) Modified Burch versus Pereyra retro-pubic urethropexy for stress incontinence. Obstet Gynaecol 255261

0. Brooks DC (1994) A prospective comparison of laparoscopic andtension-free open herniorrhaphy. Arch Surg 129 (4): 361366

1. Burch JC (1961) Urethrovaginal fixation to Coopers ligament forcorrection of stress incontinence, cystocele and prolapse. Am J ObstetGynecol 81: 281290

2. Feyereisl J, Dreher E, Haenggi W, Zikmund J, Schneider H (1994)Long term results after Burch colposuspension. Am J Obstet Gynecol171: 647652

3. Fletcher D (1995) Laparoscopic cholecystectomy. What national ben-efits have been achieved and at what cost? MJA 163: 535538

4. Fletcher D (1995) Laparoscopic cholecystectomy in Australiaoutcomes and costs. Surg Endosc 9 (11): 12301235

5. Fritts LL, Orlando R (1993) Laparoscopic appendectomya safetyand cost analysis. Arch Surg 128: 521528

6. Fullarton GM, Darling K, McMillan R, Bell G (1994) Evaluation ofthe cost of laparoscopic and open cholecystectomy. Br J Surg 81:124126

7. Gilchrist BF, Vlessis AA, Kay GA, Swartz K, Dennis D (1991) Openversus laparoscopic cholecystectomy: an initial analysis. J Laparoen-dosc Surg 1: 193196

8. Grace PA, Quereshi A, Coleman J, et al (1991) Reduced postoperativehospitalisation after laparoscopic cholecystectomy. Br J Surg 78: 160162

9. Graves HA, Ballinger JF, Anderson WJ (1991) Appraisal of laparo-scopic cholecystectomy. Ann Surg 213: 655664

20. Hardy K, Miller H, NcNeil J, Shulkes A (1994) Measurement ofsurgical costs: a clinical analysis. Aust N Z J Surg 64: 607611

21. Hirsch NA (1992) Laparoscopic cholecystectomy. Aust Clin Rev 12:2327

22. Hoist K, Wilson DP (1988) The prevalence of female urinary incon-tinence and reasons for not seeking treatment. N Z Med J 101: 756758

23. Jordan AM (1991) Hospital charges for laparoscopic and open chole-cystectomy. JAMA 226: 3425

24. Karram MM, Bhatia NM (1989) Transvaginal needle bladder necksuspension procedures for urinary stress incontinence: a comprehen-sive review. Obstet Gynaecol 73: 906914

25. Kelly HA (1913) Incontinence of urine in women. Urol Cutan Rev 17:291

26. Kurzawinski T, Hayter B, Tate J et al (1992) The cost implications ofopen laparoscopic versus open cholecystectomy. Gut (Suppl) 33: S64

27. Lam AM, Jenkins GJ, Hyslop RS (1995) Laparoscopic Burch colpo-suspension for stress incontinence: preliminary results. MJA 162: 1821

28. Langebrekke A, Dahlstrom B, Eraker R, Urnes A (1995) The laparo-scopic Burch procedure. A preliminary report. Am J Obstet GynecolScand 74: 153155

29. Laycock WS, Oddsdottir M, Franco A, Mansour K, Hunter J (1995)Laparoscopic/Nissen fundoplication is less expensive than open Bel-sey Mark IV. Surg Endosc 9: 426429

30. Liu CY (1993) Laparoscopic retropubic colposuspension (Burch pro-cedure). A review of 58 cases. J Reprod Med 38(7): 526530

31. Liu CY, Peak W (1993) Laparoscopic retropubic colposuspension(Burch procedure). Gynacol Laparosc 1: 3134

32. Macario A, Vitez T, Dunn B, McDonald T (1995) Where are the costsin perioperative care? Analysis of hospital costs and charges for in-patient surgical care. Anaesthesiology 83: 6, 11381144

33. McDougall EM, Klutke CG, Clayman RV, Cornell T (1994) Com-parative analysis of vaginal (Raz) and laparoscopic bladder neck sus-pension for type 1 or type 2 stress urinary incontinence (abstract 1085).J Urol 151: 499A

34. Marshall D, Hailey D, Hirsch N et al (1994) The introduction oflaparoscopic cholecystectomy in Canada and Australia. Australian In-stitute of Health and Welfare, Canberra

35. Marshall VF, Marchetti AA, Krantz KE (1961) The correction of stressincontinence by simple vesicourethral suspension. Surg Gynaecol Ob-stet 88: 509518

36. Nathanson LK, Shimi S, Cuschieri A (1991) Laparoscopic cholecys-tectomy the Dundee technique. Br J Surg 78: 155159

37. Neugebauer E, Troidl H, Spangenberger W et al (1991) The Chole-cystectomy Study Group. Conventional versus laparoscopic cholecys-tectomy and the randomised control trial. Br J Surg 78: 150154

38. Pereyra AJ (1959) A simplified surgical approach for the correction ofstress incontinence in women. West J Surg Obstet Gynaecol 67: 223226

39. Peters JH, Ellison EC, Innes JT, et al (1991) Safety and efficacy oflaparoscopic cholecystectomy: a prospective analysis of 100 patients.J Laparoendosc Surg 1: 193196

40. Polascik TJ, Moore RG, Rosenber MT, Kavoussi LR (1995) Compari-son of laparoscopic and open retropubic urethropexy for treatment ofstress urinary incontinence. Urology 45(4): 647652

41. Prasad, Foley (1994) Br J Surg 81: 777

42. Richardson AC, Edmonds PB, William NL (1981) Treatment of stressurinary incontinence due to paravaginal fascia defect. Obstet Gynaecol57: 357362

43. Schirmer B, Dix J (1991) Cost effectiveness of laparoscopic cholecys-tectomy. Gastroenterology 100 (5 part 2): A17

44. The Southern Surgeons Club (1991) A prospective analysis of 1518laparoscopic cholecystectomies. N Engl J Med 324: 10731078

45. Stamey TA (1973) Endoscopic suspension of the bladder vesical neckfor urinary incontinence. Surg Gynecol Obstet 136: 547

46. Stanton SL, Cardozo LD (1979) A comparison of vaginal and supra-pubic surgery in the correction of incontinence due to uretral sphincterincompetence. Br J Urol 51: 497499

47. Stoker ME, Vose J, OMara PO, Maini BS (1992) Laparoscopic cho-lecystectomy. A clinical and financial analysis of 280 operations. Archof Surg 127: 589595

48. Thomas TM, Plymat KR, Blannin J, Meade TW (1980) Prevalence ofurinary incontinence. Br Med J 281: 12431245

49. Vandenbergh HC, Wilson T, Adams SE, Inglis MJ (1995) Laparo-scopic cholecystectomy its impact on national health economics. MedJ Aust 162: 587590

50. Wenner J, Graffner H, Lindell G (1995) A financial analysis of lapa-roscopic and open cholecystectomy. Surg Endosc 9: 702705

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Laparoscopic colectomy

G. A. Fielding, J. Lumley, L. Nathanson, P. Hewitt, M. Rhodes, R. Stitz

Royal Brisbane Hospital, Herston, Brisbane, Australia

Received: 26 March 1996/Accepted: 15 October 1996

AbstractBackground: Laparoscopic colectomy has developed with

he explosion of technology that has followed laparoscopiccholecystectomy. Accumulation of skills in general laparo-

copic surgery has made complex surgery, such as colec-omy, feasible.

Methods: Three hundred fifty-nine laparoscopic cases wereprospectively studied. Data has been kept on benign andmalignant cases, operative results, hospital stay, and mor-bidity. Special care has been taken to follow malignantcases, looking for recurrence of disease.Results: There were 359 cases (206 females, 153 male)average age 58.8 years (1894), and 149 patients had ma-ignancy. All types of resections were performed, including

151 anterior resections, 66 right hemicolectomies (RHC),36 total colectomies, and 22 rectopexies. Operating timesfell with experiencethe last 20 cases of anterior resectionook 150 min (110240) and of RHC took 130 min (65

210). Twenty-six (7%) cases were converted to open sur-gery. Hospital stays for anterior resection lasted 57 days233); in the last 20 cases the average stay was 4 days.

Morbidity included seven leaks (2.7%), four strictures1.2%), 12 wound infections (3.3%), and nine ileus (2.5%).

There were six deaths within 30 dayssepsis, myocardialnfarction, aspiration pneumonia, and disseminated liver

metastases. One hundred forty-nine cancer cases have had

en recurrences: one pelvic recurrence, six liver metastases,wo para-aortic nodal, and one case of disseminated disease.Average time of recurrence was 33 months (1546 months).Conclusions: Laparoscopy in the hands of experienced lap-aroscopic surgeons is a safe, efficient procedure. All typesof procedures are possible. Early results in 149 malignan-cies are encouraging and recurrence rates are low. Prospec-ive studies, now that skills are developed to a level com-

parable to that of open surgery, are now being performed tofurther assess laparoscopys possible role in treating cancer.

Key words: Laparoscopy Colectomy Laparoscopic

colectomy surgery

Following the rapid acceptance of laparoscopic cholecys-tectomy to treat disease of the gallbladder and bile duct,

surgeons with an interest in laparoscopic surgery turnedtheir attention to numerous other procedures such as Nissenfundoplication, splenectomy, hernia repair, and colectomy.There was hope that the benefits experienced with chole-cystectomy would be extended to these more complex pro-cedures and allow more rapid return to health after majorintra-abdominal surgery.

This paper reports our experience with 359 laparoscop-ic-assisted colorectal cases between June 1991 and January1996.

We have used the technique for both benign and malig-nant conditions (Table 1). In this paper we have sought to

address its application, and the effect on operating time,hospital stay, complications, and return to bowel function.We have analyzed results for benign and malignant condi-tions and attempted to compare laparoscopic-assisted colo-rectal surgery, in context, with open surgery.

Materials and methods

Between June 1991 and January 1996 we performed 359 consecutive casesof laparoscopic-assisted colorectal procedures.

We came to laparoscopic surgery with significant experience in lapa-roscopic cholecystectomy, having done well over 500 cholecystectomiesbefore commencing colorectal surgery. We instituted a policy of assistingeach other early on to rapidly gain exposure to as many cases as possible

and to allow transmission of skills learned from cholecystectomy by somemembers of the unit to the colorectal specialists involved who had had noprior laparoscopic exposure. This allowed for rapid accumulation of skillsby the colorectal specialists, and they were soon performing the laparo-scopic colorectal procedures without assistance by other members of theunit.

Data has been kept prospectively on all patients. The aim was to per-form exactly the same operation laparoscopically as done at open surgery.This included exposure of the ureters and dissection of the pedicle wellabove the pelvic brim for anterior resection and exposure of the ureter,pancreas, and duodenum for right hemicolectomy.

We initially chose benign diseases and, as experience grew, turned ourattention to malignancy. Initial malignant cases were either palliative pro-cedures or large adenomas that were not resectable at colonoscopy. Cer-tainly, early on in our experience, no difficult cases were attempted, nor

were curative resections for carcinoma. As our experience grew though,this changed, and we now perform resections with curative intent forcarcinoma and difficult benign cases of Crohns disease and diverticulitis.

Data on patient age, diagnosis, type of colorectal procedure, operativetime, return to bowel function, discharge from hospital, complications,cancer staging, and mortality were kept. Follow-up has been maintained for

Correspondence to: G.A. Fielding, Level 2, Wesley Medical Centre,Auchenflower, Brisbane, Australia

Surg Endosc (1997) 11: 745749

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ll colorectal malignancies, looking for both local recurrence and deathrom cancer.

With respect to colorectal malignancy we initiated a policy from thebeginning of using a no touch technique with minimal handling of theumor and bagging of all specimens prior to removal through the abdomi-

nal wall.In the very early part of our experience we converted the first four right

hemicolectomies performed for tumor to check that we had done an ad-quate resection by our normal standards, and this was the case. Further-

more, the lymph node count in specimens was the same at laparoscopy andopen surgery. We were then happy to continue with laparoscopic resectionor possible and known cancers.

ResultsThere were 359 patients, 206 females, 153 males, averageage 58.8 years, range 1894 years.

Procedures were as listed in Table 2. Thirty-six patientshad abdominoperineal resection and this reflects the referralbase to this unit for very low colorectal tumors (Table 2).

Three patients had a Hartmanns procedure for perfo-ated diverticular disease, two having had their Hartmannseversed laparoscopically. Two patients have had a left

hemicolectomy.The major group in the series was anterior resection

Table 3).

Twenty-six patients were converted to an open proce-dure. These include ten with failure to progress, particularlyearly on in our experience; three where the anatomy was notdentified due to severe adhesions or inflammatory disease;hree where there was uncertainty about the stage of disease,

three for equipment failure; two due to hemorrhage; one

suffering perforation; and four with second pathology re-quiring other treatment.Operating times improved with experience (Table 4).This improvement in operating time was reflected also

in comparison of the first 100 and last 100 patients. In thefirst 100 there were ten conversions and 26 complications,compared to the last 100, where there were five conversionsand 16 complications.

Hospital stay shows the same improvement with expe-rience (Table 5).

Overall for anterior resection (151 cases), the medianhospital stay is 5.7 days (233 days). Forty-four percent ofpatients were discharged within 5 days and 29% were dis-charged within 4 days.

Hospital stay for total colectomy reflects the underlyingtotal bowel transit problems these patients have, with anoften-prolonged ileus in the small bowel postoperatively.Return to bowel function occurred at 2 days with a range of2 days (15) for anterior resection, 2 days (14) for righthemicolectomy, 2.93 days (16) for total colectomy, and1.89 days (13) for rectopexy.

Morbidity is listed in Table 6.There were seven leaks (2.7% of anastomoses). Five

were treated by stoma diversion and two by conservativemanagement with drain and total parenteral nutrition. Fourpatients developed stricture requiring balloon dilatation.

There were six deaths within 30 days (Table 7). One wasafter necrotizing fasciitis developed following a right hemi-colectomy in a 75-year-old. The second was after a myo-cardial infarction following a right hemicolectomy in a 65-year-old female. Two patients, 76 and 78 years old, one arectal prolapse repair and one with dementia and inconti-nence, treated with a stoma, died of aspiration pneumonia.Two patients died within 30 days of their disseminated tu-mor, both after palliative stomas.

There were no other delayed procedural deaths. Tenfurther patients have died of disseminated cancer in the

intervening period and these will be discussed later.One hundred forty-nine patients were treated for malig-

nancy (Table 8). (Staging of these tumors is listed in Tables9 and 10). Table 6 lists tumor staging according to proce-dures performed.

Table 1. Laparoscopic colorectal surgeryindications for surgery

Carcinoma 149Polyps 14Crohns disease 46Slow transit constipation 23Bypass 4Ulcerative colitis 8Prolapse 26Diverticular disease 69

Diverticular fistula 10Diverticular perforation 8Volvulus 2

Table 2. Laparoscopic colorectal surgeryprocedures performed

Procedures Malignant

Stoma 31 23RHC 66 39Anterior resection 151 48

APR 36 35Total colectomy 31 -Total and reservoir 7 -Sling - rectopexy 4 -Resect - rectopexy 22 -Hartmanns 3 1Reverse Hartmanns 2 -Bypass 2 -leal resection 1 -

LHC 3 -Total 359 146

Table 4. Operating time (minutes)

First 20 cases Last 20 cases

RHC 180 130Anterior resection 240 150

Table 3. Laparoscopic colorectal surgeryanterior resection (151)

Carcinoma 48Benign tumour 14Diverticular disease 69Diverticular fistula 10Diverticular perforation 8Sigmoid volvulus 2Total 151

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These patients are being followed carefully for recurrentcancer, particularly in view of concern about port site re-

currence, wound recurrence, and pelvic recurrence (Table11).To date no patients with stage A (30) have had recur-

ence. Four patients with stage B have had tumor recurrencen each case, liver metastases. No stage B tumor has had

pelvic wound or port site recurrence. Four patients withtage C disease (32) have had further cancer. One was a

pelvic recurrence in a 65-year-old man; one was a para-aortic nodal recurrence and two were liver metastases.

One stage C patient developed a port site recurrenceafter a right hemicolectomy. This recurrence was part ofmore general para-aortic and liver recurrence. One stage Dpatient (35) has developed a port site recurrence as part ofdisseminated intra-abdominal malignancy developing froma carcinoma of the rectum already presenting with liver andperitoneal metastases at the time of presentation.

Recurrences have occurred, ranging from 15 to 46months with a median of 33 months after the initial proce-dure. Two of the ten patients have died of their recurrentdisease, both with liver metastases, including the patientwho presented with the port site recurrence concurrent withiver and peritoneal metastases.

No patients with stage A or B disease have died fromheir malignancy to date.

Discussion

Following a cautious start using often rudimentary instru-ments, there has been an explosion of technology that has

allowed more complex laparoscopic procedures to be car-ried out. One of these is colorectal surgical resection. Thebiggest hurdle facing those commencing laparoscopic colo-

rectal surgery is the acquisition of general laparoscopicskills that will allow them to deal with this very complexprocedure.

It is essential to be able to retract, dissect, control bleed-ing, suture if necessary, and manipulate multiple instru-ments in a small field of view.

Our unit commenced laparoscopic colorectal surgeryearly but our enthusiasm was based on an already-wideexposure to laparoscopic skills. We believe this has been anessential part of the development of our program of lapa-roscopic colorectal resection.

The approach has been to extend our exposure to all

benign colorectal disease and to the majority of malignancy.Hesitation has been only at the prospect of transverse coloncarcinomas. There is difficulty in mobilizing omentum andin minimizing risk of entering into disease covered byomentum. There is risk also in low tumors, where stapling

Table 8. Laparoscopic colorectal surgerymalignancy

Stoma 23RHC 39Anterior resection 48APR 35Bypass 2Hartmanns 1Total 149

Table 9. Laparoscopic colorectal surgerystages and malignancy

StageMalignancyno.

A 30B 40C 32D 35Anal 10Total 149

Table 10. Laparoscopic colorectal surgerymalignancy

A B C D Anal

Stoma 16 3APR 6 6 12 4 7RHC 11 13 8 6Anterior resection 13 18 11 6

Table 11. Laparoscopic colorectal surgerymalignancy (149) and recur-

rence (10)

Pelvic 1Liver 5Nodal 2Ports 2 (1 D, 1 with liver)

aRecurrence at 1546 months, average 33 months; two have died of recur-rence (liver)

Table 5. Hospital stay (days)

First 20 cases Last 20 cases

RHC 5 (37) 5 (311)Anterior resection 6 (433) 4 (318)

Table 6. Laparoscopic colorectal surgerymorbidity

Anastomotic stricture 4Anastomotic leak 7 (1.9%)leus 9 (2.5%)

Wound infection 12 (3.3%)Haemorrhage: wound/intra-abdominal 8ntra-abdominal sepsis 2

Respiratory: atelectasis/pneumonia/PE 8Urinary: infection/retention 9Myocardial infarction 3Bowel obstruction 5Total 67

Table 7. Laparoscopic colorectal surgeryperi-operative deaths (6)

Necrotising fasciitis RHCMyocardial infarct RHCAspiration pneumonia ProlapseAspiration pneumonia StomaDisseminated tumour End stomaDisseminated tumour Loop stoma

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of the distal rectum without undue manipulation of the tu-mour is very difficult with existing instruments [4, 6]. Webelieve that careful selection, particularly early on, andmaintaining a careful policy and good surgical techniqueallows good results with minimal complications.

We have performed a full range of colorectal procedureswith laparoscopic assistance. Of particular interest has beenhe ability to perform complex procedures for diverticular

disease. Our policy has been one of aggression after a sec-ond presentation with acute diverticulitis due to the over-whelming evidence of further complications and mortalityfrom repeat attacks of acute diverticulitis, particularly ifassociated with peritonitis or stricture [3, 4].

For diverticular disease, our resection goes into the up-per third of the rectum to ensure removal of all sigmoiddiverticular disease. Fistulas can be tracked and resectedfrom the bladder, and the bladder defect can be repairedwith suturing and covered with omentum. Acute diverticu-itis can also be dealt with by doing a standard Hartmannsesection with a limited resection of the diseased portion of

bowel and bringing out an end stoma. At the time of Hart-manns hookup a wider resection of involved diverticulardisease to the upper rectum is performed, as would be doneat standard operation for diverticular disease.

There is nothing new or radical in this approach to co-orectal surgery. All that is different is the delivery system

using laparoscopic techniques rather than open surgery. Asothers have noticed, as skills are accumulated operatingime falls significantly, as is reflected in the operating times

for the last 20 cases each of right hemicolectomy and an-erior resection that we have studied [4, 9, 12].

An anterior resection performed in under 3 h is on equal

erms with any open series in the literature. This has beeneen by Wishner et al. [12]. They show a significant de-

crease in mean operative time from 250 to 156 min over thefirst 50 cases and have leveled out at a median of 140 min.This is also similar to the results of Tucker et al., whoeported 114 cases with a median operating time of 172 min8]. The learning curve is a difficult phase. We believehat the diminished operating time is just a reflection of

accumulation of skills and increased confidence with expo-ure to more cases.

Our conversion rate of 26 cases (7.3%) is low, and againwe believe this reflects our general laparoscopic experience

at the time of commencing colorectal surgery. It is certainlyconsistent with reports in numerous publications [4, 8, 9,12].

The most contentious issue in laparoscopic colorectalurgery is whether laparoscopic-assisted surgery is accept-

able in malignant cases [1, 5, 6, 11]. Franklin et al. ad-dressed this with a nonrandomized prospective study of lap-aroscopic vs open colon resection with a 3 1/2-year follow-up of 194 patients from several centers [1]. They found thataparoscopic surgery allowed a similar resection with an

equal number of mesenteric nodes, the same margin withhort follow-up, comparable survival and disease-free inter-

val with a mean follow-up of 22 months. Seven percent hadecurrent disease in that time after open surgery, 8% afteraparoscopic surgery.

When looking at stage-based comparisons there is nodifference between open and laparoscopic surgery. This

group felt that laparoscopic colorectal surgery was a validalternative to open surgery without claiming that it wasbetter.

Another randomized study was performed by Lacey etal. in three large departments of surgery in Spain, and theyagain showed no difference between lymph nodes removed,pathological staging, and margins [10]. They had fewercomplications in their laparoscopic patients than in open in

a study of 52 patients.Tait et al. in another prospective randomized trial insmall numbers with 11 laparoscopic and 14 open casesfound no difference in the histological/pathological speci-men [2]. The findings in our study reflect these three ran-domized trials, and we are confident that we are performingthe same procedure laparoscopically as we do at open sur-gery. This is reflected in our recurrence rates, both localrecurrence and late disease. We have had no deaths fromcancer in Dukes A and B and only one pelvic recurrence in48 anterior resections for carcinoma.

Wexner has raised the concern of port site recurrence[7]. Our own incidence has been very low. Both were inlate-stage disease, one of whom had peritoneal and livermetastases at the time of the original operation. We believethat by not manipulating the tumor, bagging the specimen,and protecting of all wounds before extraction, this compli-cation can be minimized.

Concerns still exist as to the possibility of spreadingshed cells through the pneumoperitoneum due to the in-creased pressure. This has not been reflected in our ownexperience of 148 malignancies treated laparoscopically.

Having accumulated laparoscopic skills to a level thatwe feel is comparable with our open skills, we feel it is nowthe time to commence a randomized trial with malignantcases and have done so as part of a national trial in Aus-tralia. At present we will not perform a curative resectionfor a carcinoma of the transverse colon due to the difficultyin being certain we are not breaching the tumor when clear-ing omentum. This is also the case for low rectal tumors,where it is still, with existing equipment, impossible to getbelow very low tumors. However, in this situation laparos-copy can be used to mobilize the splenic flexure and the leftcolon, divide the vessels, and dissect down to the tumor toallow the final resection and anastomosis to be performedthrough a Pfannenstiel incision, thus reducing morbidity.These patients are covered with a covering ileostomy after

resection.Laparoscopic-assisted colorectal surgery is a valid alter-

native to open surgery. We believe it has benefit over opensurgery for benign disease and palliative malignancy. Ourearlier results for the management of carcinoma are encour-aging and will be further evaluated using a randomizedprospective trial as mentioned above.

Surgeons contemplating undertaking this surgery shouldbe competent in laparoscopic techniques. It is of enormousbenefit to be assisted by a skilled laparoscopic surgeon andto work as a team. Surgeons should choose easy cases suchas resection of large polyps in the right colon and high

anterior resection for diverticular disease, early on, beforeprogressing to more complex cases. We feel that, with theexception of ultralow anterior resection for carcinoma, mostcases can be done laparoscopically. Further instrument tech-nology will make this surgery even more straightforward.

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References

1. Franklin ME, Rosenthal D, Norem RF (1995) Prospective evaluationof laparoscopic colon resection versus open colon resection for adeno-carcinoma. Surg Endosc 9: 811816

2. Lacy AM, Garcia-Valdecasas JC, Pique JM, Delgado S, Campo E,Bordas JM, Taura P, Grande L, Fuster J, Pacheco JL, Visa J (1995)Short-term outcome analysis of a randomized study comparing lapa-roscopic vs open colectomy for colon cancer. Surg Endosc 9: 11011105

3. Liberman MA, Phillips EH, Carroll BJ, Fallas M, Rosenthal R (1996)Laparoscopic colectomy vs traditional colectomy for diverticulitis.Surg Endosc 10: 1518

4. Lumley J, Fielding G, Rhodes M, Nathanson L, Siu S, Stitz R (1996)Laparoscopic assisted colorectal surgery. Lessons learned from 240consecutive patients. Dis Colon Rectum

5. Monson JFT, Hill ADK, Darze A (1995) Laparoscopic colonic sur-gery. Br J Surg 82: 150157

6. Stitz R, Lumley J, (1995) Laparoscopic resection for colorectal can-certhe Australian perspective. Semin Laparosc Surg 2: 235241

7. Tate JJT, Kwok S, Dawson JW, Lau Wy, Li AKC (1993) Prospectivecomparison of laparoscopic and conventional anterior resection. Br JSurg 80: 13961398

8. Tucker JG, Ambroze WL, Orangio GR, Duncan TD, Mason EM,Lucas GW (1995) Laparoscopically assisted bowel surgery. Surg En-dosc 9: 297300

9. Vernava AM, Liebscher G, Longo WE (1995) Laparoscopic restora-tion of intestinal continuity after Hartmann procedure. Surg Laparosc

Endosc 5(2): 12913210. Wexner SD, Cohen SM (1995) Port site metastases after laparoscopic

colorectal surgery for cure of malignancy. Br J Surg 82: 295298

surgical endoscopy 5

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