Intraoperative and laparoscopic ultrasound

Intraoperative ultrasonography in laparoscopic partial nephrectomy for intrarenal tumors

Objective

To evaluate the feasibility and efficacy of intraoperative ultrasonography in laparoscopic partial nephrectomy (LPN) for intrarenal tumors.

Patients and methods

All patients who underwent LPN for renal tumors in our institution from January 2010 to October 2016 were assessed retrospectively. Patients were divided into two groups, the first with totally intrarenal tumors (TIT group), defined as a solid renal mass with no exophytic element on both preoperative and intraoperative evaluations, and the second with exophytic tumors (control group). General information and perioperative data of the two groups were compared, including tumor characteristics, operative time, estimated blood loss, warm ischemia time and pathological findings. Intraoperative laparoscopic ultrasonography (ILUS) was used to precisely locate and delineate the TIT border, as well as seeking for other suspected lesions.

Results

We identified 583 patients who underwent LPN in our center, including 46 in the TIT and 537 in the control group. All patients in the TIT group were evaluated by ILUS, and all TIT procedures were successfully performed with only one conversion to open surgery. The mean tumor sizes in the TIT and control groups were 2.42 ± 0.46 cm and 3.29 ± 1.43 cm (p < 0.001), respectively. The TIT group’s R.E.N.A.L. nephrometry score was higher than that of the control group (median 8.5 vs 6.0, p < 0.001), and their mean operation times were 127.2 ± 16.0 min and 120.1 ± 19.2 min, respectively. Mean estimated blood loss was higher in the TIT than in the control group (161.3 ml vs 136.6 ml, p = 0.003). Mean warm ischemia time differed in the TIT and control groups (22.2 ± 6.4 vs 20.6 ± 4.7 min, p = 0.105), but not significantly. Rates of open conversion and positive margins, as well as rates of major postoperative complications, pathological findings, and 1-month changes in renal function, were similar in the two groups.

Conclusion

Intraoperative ultrasonography is technically feasible in patients undergoing LPN for TITs. This method may reduce the need for radical nephrectomy in patients with endogenic renal masses.

The use of intraoperative ultrasound for diagnosis and stadiation in pancreatic head neoformations

The intraoperative staging of the pancreatic cancer is important to make a proper treatment. For this reason the intraoperative echography is playing an important role in the right treatment choice. The intraoperative echography, that can be performed with an open or laparoscopic probe, is used to confirm the preoperative diagnosis and assess the pancreatic cancer resecability. The intraoperative echography (IOUS) or laparoscopic intraoperative echography (LIOUS) are useful to identify the patients with a non resecable cancer and perform a faster neoadjuvant treatment. The LIOUS can also avoid an useless laparotomy. The aim of this study is to assess, both in our experience and in the cited literature, the concordance rate between the pancreatic cancer preoperative staging, performed with TC and MRI (when it is available), and intraoperative staging, performed with intraoperative laparotomic or laparoscopic echography.

MATERIAL AND METHODS

We have analyzed the treatment management of 34 patients, who were candidate to major surgery for suspected pancreatic head cancer and who underwent to intraoperative LIOUS or IOUS staging from 2001 to 2012.

RESULTS

LIOUS and IOUS have allowed to detect cases in which preoperative diagnosis, proved by CT and MRI, was not agreeing with intraoperative diagnosis (22 patients on 34, 64% discordance rate), avoiding the execution of a demolitive and uneseful surgery in order to guarantee the surveillance and life's quality of patients.

CONCLUSION

We suggest to perform in every patients undergone to pancreatic surgery an intraoperative ultrasound exam, to detect unresecable and unpredicted lesions.

Robot-integrated intraoperative ultrasound: Initial experience with hepatic malignancies

PURPOSE

A new robotic surgery tool allows intraoperative ultrasound to be performed using a fully robotic technique. Herein, we evaluate the feasibility and reliability of robotically integrated ultrasound to guide resection of malignant hepatic tumors.

MATERIAL AND METHODS

A consecutive series of ultrasound-guided robotic resections of primary and secondary hepatic malignancies was analyzed in terms of perioperative data and specimen evaluation, focusing on the reliability of the new robot-integrated ultrasound probe.

RESULTS

Ten consecutive patients underwent 15 robotic liver resections. Two patients were resected to excise primary hepatocellular cancers and eight underwent resections of liver metastases. R0 resections were achieved for all lesions. The median operative time was 247 min, and blood loss was limited. No mortality occurred.

CONCLUSIONS

Our present analysis confirmed the reliability of fully robotic liver resection guided via robotically integrated ultrasonic assessment. Robotic surgery, particularly hepatic resection, may benefit greatly from better manageability, and the fact that the surgeon can directly manage both the operative and the diagnostic parts of the procedure.

Applications of intraoperative ultrasound in the treatment of complicated cases of acute and chronic pancreatitis and pancreatic cancer - own experience

Both acute and chronic inflammation of the pancreas often lead to complications that nowadays can be resolved using endoscopic and surgical procedures. In many cases, intraoperative ultrasound examination (IOUS) enables correct assessment of the extent of the lesion, and allows for safe surgery, while also shortening its length.

AIM OF THE RESEARCH

At the authors' clinic, intraoperative ultrasound is performed in daily practice. In this paper, we try to share our experiences in the application of this particular imaging technique.

RESEARCH SAMPLE AND METHODOLOGY

Intraoperative examination conducted by a surgeon who has assessed the patient prior to surgery, which enabled the surgeon to verify the initial diagnosis. The material presented in this paper includes 145 IOUS procedures performed during laparotomy due to lesions of the pancreas, 57 of which were carried out in cases of inflammatory process.

RESULTS AND CONCLUSIONS

IOUS is a reliable examination tool in the evaluation of acute inflammatory lesions in the pancreas, especially during the surgery of chronic, symptomatic inflammation of the organ. The procedure allows for a correct determination of the necessary scope of the planned surgery. The examination allows for the differentiation between cystic lesions and tumors of cystic nature, dictates the correct strategy for draining, as well as validates the indications for the lesion's surgical removal. IOUS also allows the estimation of place and scope of drainage procedures in cases of overpressure in the pancreatic ducts caused by calcification of the parenchyma or choledocholitiasis in chronic pancreatitis. In pancreatic cancer, IOUS provides a verification of the local extent of tumor-like lesions, allowing for the assessment of pancreatic and lymph nodes metastasis, and indicating the presence of distant and local metastases, including the liver. IOUS significantly improves the effectiveness of intraoperative BAC aspiration or drainage of fluid reservoirs.

Near-infrared fluorescence goggle system with complementary metal-oxide-semiconductor imaging sensor and see-through display

We have developed a near-infrared (NIR) fluorescence goggle system based on the complementary metal-oxide-semiconductor active pixel sensor imaging and see-through display technologies. The fluorescence goggle system is a compact wearable intraoperative fluorescence imaging and display system that can guide surgery in real time. The goggle is capable of detecting fluorescence of indocyanine green solution in the picomolar range. Aided by NIR quantum dots, we successfully used the fluorescence goggle to guide sentinel lymph node mapping in a rat model. We further demonstrated the feasibility of using the fluorescence goggle in guiding surgical resection of breast cancer metastases in the liver in conjunction with NIR fluorescent probes. These results illustrate the diverse potential use of the goggle system in surgical procedures.

Imaging in percutaneous nephrolithotomy

Image guidance is a critical factor for the performance of urologic interventions. Percutaneous minimally invasive procedures have been developed and are being used with constantly increasing frequency. Procedures such as percutaneous nephrolithotomy (PCNL) are not performed without any image guidance. Recent developments in medical imaging, such as three-dimensional radiographic fluoroscopy, CT, and magnetic resonance (MR) fluoroscopy, four-dimensional ultrasonography, and image fusion techniques, propose a new generation of image-guidance tools that promise to improve patient care. These developments have been used or have the potential to be used in PCNL and other urologic interventional procedures. Moreover, advanced needles and needle guidance systems provide a new perspective for the nephrolithotomy suite of the future. The current review presents existing imaging technology in PCNL and interventional urology as well as advanced imaging techniques that are being or are expected to be evaluated in PCNL practice.

Intraoperative ultrasound of the pancreas

Intraoperative ultrasound provides spatial resolution of the pancreas superior to computed tomography, magnetic resonance imaging, and transabdominal sonography. This pictorial essay will review common benign and malignant pancreatic processes including the following: pancreatic ductal adenocarcinoma, pancreatitis, endocrine tumors, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, serous cystadenoma, and solid pseudopapillary tumor. The use of intraoperative ultrasound in specific surgical situations will be discussed, which include the following: (1) identification of insulinoma(s) which are not detectable preoperatively, (2) identification of the pancreatic duct to determine dissection planes for chronic pancreatitis surgery (eg, Puestow procedure) and for tumor resection, and (3) staging purposes for malignant disease.

Advances in imaging for urologic procedures

Improvements in imaging and device engineering have led to the rapid development of advanced, minimally invasive techniques in urologic care. While imaging advances have had a major effect in the areas of diagnosis, surgical planning and therapeutic assessment, the focus of this Review is on developments in intraoperative imaging that are currently making an impact in urology and are likely to provide additional opportunities to urologists in the years to come. While previous image-guided urologic procedures have mostly utilized two-dimensional X-ray images, it is expected that new technologies will involve the use of three- and four-dimensional multi-modality imaging, molecular imaging, and robot-assisted image-guidance techniques. Application of these procedures will bring together the complementary disciplines of endourology and interventional radiology in the development of multidisciplinary, cooperative approaches to providing optimal treatments and outcomes for urologic disease.

3-D ultrasound guidance of surgical robotics: a feasibility study

Laparoscopic ultrasound has seen increased use as a surgical aide in general, gynecological, and urological procedures. The application of real-time, three-dimensional (RT3D) ultrasound to these laparoscopic procedures may increase information available to the surgeon and serve as an additional intraoperative guidance tool. The integration of RT3D with recent advances in robotic surgery also can increase automation and ease of use. In this study, a 1-cm diameter probe for RT3D has been used laparoscopically for in vivo imaging of a canine. The probe, which operates at 5 MHz, was used to image the spleen, liver, and gall bladder as well as to guide surgical instruments. Furthermore, the three-dimensional (3-D) measurement system of the volumetric scanner used with this probe was tested as a guidance mechanism for a robotic linear motion system in order to simulate the feasibility of RT3D/robotic surgery integration. Using images acquired with the 3-D laparoscopic ultrasound device, coordinates were acquired by the scanner and used to direct a robotically controlled needle toward desired in vitro targets as well as targets in a post-mortem canine. The rms error for these measurements was 1.34 mm using optical alignment and 0.76 mm using ultrasound alignment.

Ultrasonography of the pancreas. 7. Intraoperative imaging

The usefulness of intraoperative ultrasonography (IOUS) has been documented in the Literature since the Eighties and, although its main applications are in hepatobiliary and pancreatic surgery, it has been used also in neurosurgery, cardiovascular and endocrine surgery. The continuous technical developments have led to an increase in the diagnostic accuracy of IOUS from the Eighties to now. The use of IOUS has increased in time together with the technical innovations until, mainly in the midnineties, its value was recognized by many surgeons. This results have been obtained with scanners that allow to depict fine anatomical details and detect small lesions in real time with extremely high spatial resolution. IOUS is able to shows fine details, such as primary or secondary lesions not detectable with other preoperative imaging modalities or tumor extension and its relationship with vessels. Assessment of resectability by IOUS may determine important changes in therapeutic planning. The role of IOUS, however, has recently been down-sized, especially in those centers where preoperative imaging is advanced. This article will review the clinical role of pancreatic IOUS in the different pancreatic pathologies.

Computed tomography, endoscopic, laparoscopic, and intra-operative sonography for assessing resectability of pancreatic cancer

Pancreas cancer is the fourth leading cancer killer in adults. Cure of pancreas cancer is dependent on the complete surgical removal of localized tumor. A complete surgical resection is dependent on accurate preoperative and intra-operative imaging of tumor and its relationship to vital structures. Imaging of pancreatic tumors preoperatively and intra-operatively is achieved by pancreatic protocol computed tomography (CT), endoscopic ultrasound (EUS), laparoscopic ultrasound (LUS), and intra-operative ultrasound (IOUS). Multi-detector CT with three-dimensional (3-D) reconstruction of images is the most useful preoperative modality to assess resectability. It has a sensitivity and specificity of 90 and 99%, respectively. It is not observer dependent. The images predict operative findings. EUS and LUS have sensitivities of 77 and 78%, respectively. They both have a very high specificity. Further, EUS has the ability to biopsy tumor and obtain a definitive tissue diagnosis. IOUS is a very sensitive (93%) method to assess tumor resectability during surgery. It adds little time and no morbidity to the operation. It greatly facilitates the intra-operative decision-making. In reality, each of these methods adds some information to help in determining the extent of tumor and the surgeon's ability to remove it. We rely on pancreatic protocol CT with 3-D reconstruction and either EUS or IOUS depending on the tumor location and operability of the tumor and patient. With these modern imaging modalities, it is now possible to avoid major operations that only determine an inoperable tumor. With proper preoperative selection, surgery is able to remove tumor in the majority of patients.

Short- and-long term results of intraoperative radiofrequency ablation of liver metastases

BACKGROUND

Surgical resection is the only therapeutic option with curative effect on malignant liver tumours, but in over 70% of cases, this is not a feasible option. A prospective study was performed to assess the short- and long-term effects of intraoperative radiofrequency ablation on unresectable liver metastases.

PATIENTS

Between 1997 and 2001, 57 patients (mean age 61.9 years; range 31-83 years) with 297 unresectable liver metastases (colorectal adenocarcinoma, n=38; carcinoid tumour, n=4; malignant melanoma, n=3; other metastases, n=12) underwent intraoperative radiofrequency ablation.

RESULTS

No mortality was observed in patients managed solely with radiofrequency ablation. Eight postoperative complications occurred in eight patients (14%). Three occurred when radiofrequency ablation was combined with resection. Of the 33 patients completely ablated, 30 patients are still alive and 21 are disease-free after a median follow-up of 18.1 months (range 2-43). Ten patients underwent more than one intraoperative radiofrequency ablation episode. Overall survival was 72.5% at 1 year and 52.5% at 3 years. Complete ablation and the number of lesions were significant independent prognostic factors for survival, with p<0.001 and p<0.0001, respectively.

CONCLUSION

Radiofrequency ablation is a safe and effective option for patients with inoperable liver metastases without extra hepatic disease. Prospective controlled trials comparing the results of different treatments are required to assess which patients will benefit best from this emerging new treatment.

Real-time 3D laparoscopic ultrasonography

We have previously described 2D array ultrasound transducers operating up to 10 MHz for applications including real time 3D transthoracic imaging, real time volumetric intracardiac echocardiography (ICE), real time 3D intravascular ultrasound (IVUS) imaging, and real time 3D transesophageal echocardiography (TEE). We have recently built a pair of 2D array transducers for real time 3D laparoscopic ultrasonography (3D LUS). These transducers are intended to be placed down a trocar during minimally invasive surgery. The first is a forward viewing 5 MHz, 11 x 19 array with 198 operating elements. It was built on an 8 layer multilayer flex circuit. The interelement spacing is 0.20 mm yielding an aperture that is 2.2 mm x 3.8 mm. The O.D. of the completed transducer is 10.2 mm and includes a 2 mm tool port. The average measured center frequency is 4.5 MHz, and the -6 dB bandwidth ranges from 15% to 30%. The 50 omega insertion loss, including Gore MicroFlat cabling, is -81.2 dB. The second transducer is a 7 MHz, 36 x 36 array with 504 operating elements. It was built upon a 10 layer multilayer flex circuit. This transducer is in the forward viewing configuration and the interelement spacing is 0.18 mm. The total aperture size is 6.48 mm x 6.48 mm. The O.D. of the completed transducer is 11.4 mm. The average measured center frequency is 7.2 MHz, and the -6 dB bandwidth ranges from 18% to 33%. The 50 omega insertion loss is -79.5 dB, including Gore MicroFlat cable. Real-time in vivo 3D images of canine hearts have been made including an apical 4-chamber view from a substernal access with the first transducer to monitor cardiac function. In addition, we produced real time 3D rendered images of the right pulmonary veins from a right parastemal access with the second transducer, which would be valuable in the guidance of cardiac ablation catheters for treatment of atrial fibrillation.

Intraoperative ultrasound

Intraoperative ultrasound (IOUS) can provide various diagnostic information that is otherwise not available, and can guide or assist various surgical procedures in real time. With refinement of equipment, IOUS is currently used in a wide variety of surgical operations,such as hepatobiliary, pancreatic, endocrine, cardiovascular,and neurologic surgery. Our overview of IOUS, including instrumentation,techniques, indications, advantages, disadvantages,and future perspective, is described in this article. Being safe, quick, accurate, and versatile intraoperatively, IOUS is a valuable technique that surgeons are recommended to master to improve intraoperative decision making and surgical procedures.

Laparoscopic ultrasonography and biopsy of hepatic tumors in 310 patients

BACKGROUND

Laparoscopic ultrasonography is increasingly being recognized as an important tool in the evaluation of patients with possible hepatic tumors. The aim of this paper is to describe the technical aspects of imaging and biopsy based on our experience in 310 patients with 1,080 primary and metastatic liver tumors within a 6.5-year period.

METHODS

A 10-mm rigid or flexible, 7.5 MHz linear, side-viewing laparoscopic ultrasonography probe was used for imaging, and an 18G spring-loaded core biopsy gun was used for tissue diagnosis.

RESULTS

There were no complications. The entire liver was imaged using a right subcostal port. Using a free-hand technique, the needle was best targeted into the lesion when inserted parallel to the plane of the transducer. The rigid transducer was found to be more convenient to guide needle placement.

CONCLUSIONS

The use of this minimally invasive technique avoids laparotomy in many patients undergoing staging of malignancy and also offers increased sensitivity for tumor detection compared with conventional imaging modalities.

Utility of intraoperative liver ultrasound

Intraoperative ultrasound has become an essential tool for the surgeon in the field of hepatobiliary surgery. No preoperative study has been able to duplicate the sensitivity and specificity of IOUS in the identification of occult lesions. With recent improvements in technology, IOUS has now become an indispensable means of defining the extent of disease and respectability, and providing a guide to anatomic and nonanatomic hepatic resections and minimally invasive and percutaneous ablative techniques.

Comparison of ultrasonographic characteristics of the gastroduodenal junction during pyloroplasty performed laparoscopically or via conventional abdominal surgery in dogs

OBJECTIVE

To evaluate the use of ultrasonography to detect morphologic changes in the pylorus during pyloroplasty performed laparoscopically or via conventional abdominal surgery in dogs.

ANIMALS

10 healthy mixed-breed dogs.

PROCEDURE

Laparoscopic ultrasonography of the pylorus was performed in 5 dogs during laparoscopic pyloroplasty (LP), and ultrasonography of the pylorus was performed in 5 dogs during pyloroplasty via conventional abdominal surgery (CAP group). Appearance and dimensions of the pyloric sphincter were evaluated by use of a 7.5-MHz flexible laparoscopic linear-transducer probe.

RESULTS

Mean +/- SD duration of the ultrasonographic procedure was 11 +/- 3.04 minutes (range, 6 to 18 minutes). In the CAP group, cross-sectional views of the pylorus revealed significant differences between the overall transverse external diameter, overall craniocaudal external diameter, and transverse diameter of the pyloric lumen. After surgery, the pyloric area was significantly increased. Longitudinal views of the pylorus revealed that width of the pyloric ring was significantly less after surgery. Transverse views of the pylorus for the LP group revealed a significant increase in the transverse diameter and craniocaudal diameter of the pyloric lumen after LP. The pyloric area was also significantly increased after surgery. Longitudinal views of the pylorus revealed that width of the pyloric ring was significantly less after surgery. Transverse diameter of the pyloric lumen was significantly increased after LP.

CONCLUSIONS AND CLINICAL RELEVANCE

Analysis of results of this study suggests that ultrasonography is useful for detecting relevant morphologic changes in the pyloric sphincter after pyloroplasty.

Appraising surgeons learning sonography: measuring measurement variability

PURPOSE

Sonography is increasingly used by various clinicians in several task-specific situations. We present a method of assessing 1 aspect of a nonspecialist's ability in performing sonography, measurement variability.

METHODS

An experienced radiologist and a surgeon who had received 4 weeks of sonography training each made triplicate measurements of gallbladder dimensions in 19 adult patients undergoing abdominal sonography. The observers examined the subjects in immediate succession using the same ultrasound equipment and were blinded to each other's measurements until the end of the study. Intraobserver measurement variability rates were calculated for gallbladder length, height, and width by using analysis of variance techniques and were expressed as a within-subject standard deviation and a repeatability coefficient.

RESULTS

In terms of intraobserver measurements, the estimated within-subject standard deviations were comparable for the radiologist and the surgeon (length, 0.22 versus 0.17 cm; height, 0.14 versus 0.14 cm; and width, 0.12 versus 0.14 cm, respectively), as were the repeatability coefficients. The interobserver variability showed good agreement as well; the estimated within-subject standard deviations (and 95% limits of agreement) obtained were length, 0.47 cm (-1.08 to 1.48 cm); height, 0.34 cm (-1.08 to 0.49 cm); and width, 0.28 cm (-0.80 to 0.81 cm).

CONCLUSIONS

The ability to measure organ dimensions accurately is an essential sonographic skill that can be readily appraised. The findings from this comparison study illustrate that this 1 small aspect of sonography can be learned by various clinicians and that their ability in this task can be appraised. In a clinical setting, the small degree of variability in measurements made by the experienced radiologist and the sonography-trainee surgeon is likely to be satisfactory.

Emerging technologies in uroradiologic imaging

Advances in imaging technologies have readily been incorporated into the practice of urology and have led to important advances in patient care and outcomes. In the area of oncology, advances in radiologic imaging are improving the ability of the urologist to diagnose and monitor urologic malignancies. Some of these technologies include positron emission tomography (PET), intraoperative ultrasound (IUS), 3-dimensional computerized tomography (3D-CT), and magnetic resonance spectroscopy (MRS). We provide an overview of these four emerging imaging modalities and their potential applications and limitations in the diagnosis and management of urologic malignancy.

[Ultrasonography in urology]

After its introduction more than twenty years ago, ultrasound has continually increased in importance in urology diagnostics and is currently one of the most frequent exploratory techniques used. It corresponds to one out of every four imaging techniques carried out in medicine. The possibility of intervention under echographic control, for either diagnostic or therapeutic purposes, has been studied ever since ultrasound first appeared. Nowadays, interventionist echography is a commonly used technique in urology and is applied in a wide range of procedures carried out on the prostate gland, bladder and kidney that require echography-guided puncture techniques. Timely modifications of ultrasound for control and monitoring of treatments such as shock wave extracorporeal lithotripsy or transperineal brachitherapy has increased even more its day-to-day use by urologists. New technologies currently under development such as high-energy ultrasound in the management of kidney and prostate cancer, 3-dimensional ultrasound, Doppler-energy and contrast ultrasound have also increased the importance of this procedure in urology.

Surgical management of colon cancer

The primary mode of therapy for colon cancer continues to be surgery. Although little has changed in the technical aspects of colonic resection, a great deal of research has taken place to develop procedures that enhance staging of disease, optimize postoperative recovery, and improve outcomes in obstructed patients without compromising cancer-related morbidity and mortality. This review explores the current use of laparoscopy, sentinel node biopsy, intraoperative ultrasound, and colonic stents in the elective and emergent management of colon cancer.

Diagnostic and interventional laparoscopy and intraoperative ultrasonography in the management of pancreatic disease

The laparoscopic management of pancreatic disorders has evolved dramatically from its inception in 1911 and its rediscovery in the 1970s. Although investigators once proclaimed that "it seems unlikely that laparoscopy will have any more than an extremely limited use in the investigation of pancreatic disorders," laparoscopy and LUS now have a well-recognized role in the staging of pancreatic cancer and an increasing part in the management of benign pancreatic disease at many institutions. Although the appropriate role of LS and LUS is debatable, the development and refinement of laparoscopic techniques and instrumentation and the improvement of noninvasive diagnostic modalities will provide new data, increase the rate of resection at laparotomy, and allow surgeons to treat a broader range of pancreatic disease by minimally invasive methods. The value of LS and LUS for benign and malignant pancreatic disorders has been clearly demonstrated, but the inevitable issues of hospital resource, operative expertise, and surgical philosophy will ultimately determine the role of laparoscopy and LUS in clinical practice.

Radiofrequency interstitial thermal ablation of hepatocellular carcinoma in liver cirrhosis. Role of the laparoscopic approach

BACKGROUND

The laparoscopic approach to radiofrequency interstitial thermal ablation (RITA) of hepatocellular carcinoma (HCC) with intraoperative ultrasound guidance has been proposed with the aim of obtaining additional information for a better neoplastic staging and a complete and effective treatment of the liver lesions in patients with a difficult percutaneous approach.

METHODS

In this pilot study, 29 patients with HCC in liver cirrhosis were submitted to laparoscopic RITA under sonographic guide. Most of these patients were in Child's A class of liver function. Patients with large tumors (> 5 cm), portal vein thrombosis, or severe liver disease (Child's C class) were excluded from the study.

RESULTS

The laparoscopic RITA procedure was completed in 27 of 29 patients (93% feasibility rate). The laparoscopic ultrasound examination identified new malignant liver nodules in five patients (18.5%). A total of 44 lesions were treated. The mean operative time was 75.8 +/- 20.5 min (range, 45-120 min), and the mean RITA time was 18 +/- 10 min (range, 10-56 min). There was no operative mortality, and postoperative morbidity was low (four cases) without any mortality. A complete tumor necrosis was observed in 90% of the patients via spiral computed tomography (CT) 1 month after treatment.

CONCLUSIONS

Laparoscopic RITA of hepatocellular carcinoma proved to be a safe and effective technique, at least in the short term. Its role in the treatment of HCC needs to be defined in larger series.

Laparoscopic ultrasonography

The use of laparoscopic ultrasonography (LUS) allows visualization of tissues beyond the two-dimensional laparoscopic picture, enhancing the amount and quality of information available to the surgeon. Linear-array transducers with frequencies of 7.5 to 10 MHz are typically used for LUS, employing B-mode scanning and color Doppler capability on probes with articulating tips. In general surgery, LUS has become a common adjunct to the intraoperative staging of upper gastrointestinal malignancy to determine resectability, avoiding unnecessary laparotomy. In urology, LUS appears to be a promising adjunct for four current procedures: difficult pelvic lymphocele marsupialization, renal cyst decortication, nephrolithotomy and other renal stone surgery, and cryotherapy of renal masses. The role of LUS during varicocelectomy is limited, and enthusiasm for this procedure is waning. Laparoscopic ultrasonography is a critical adjunct to renal cryoablation, a developmental procedure that currently lacks long-term data but is promising as therapy for small, incidentally detected renal masses. It appears that as laparoscopic urologic procedures continue to expand, so will the application of this promising operative imaging modality.

Cirurgia videolaparoscópica nas doenças biliopancreáticas

Com a experiência adquirida na cirurgia da vesícula biliar, a videocirurgia está sendo indicada cada vez mais em outras doenças. Decorridos 15 anos da primeira cirurgia, os autores avaliam os resultados e analisam as perspectivas deste procedimento nas doenças biliopancreáticas. Seguem a proposta que divide este procedimento em procedimentos de rotina, avaliação e desenvolvimento. Nas doenças da vesícula biliar, a colecistectomia laparoscópica é considerada padrão ouro, levando vantagem em todos os itens sobre a laparotômica, excluídas as lesões da via biliar e o vazamento biliar pelo coto cístico. Enfatizam situações especiais: da colecistite aguda, da colecistectomia durante a gravidez, da vesícula em porcelana e do câncer da vesícula. Comentam as perspectivas da videocirurgia nas complicações da colecistectomia laparoscópica. No tratamento da coledocolitíase, consideram o procedimento como em avaliação pela falta de ensaios clínicos prospectivos randomizados com grupo controle comparáveis e acompanhados por prazo de tempo maior. Nas doenças do pâncreas, a videocirurgia é um procedimento em desenvolvimento, com exceção da pancreatite aguda biliar não complicada, que se beneficia com a colecistectomia laparoscópica. O mesmo ocorre com as cirurgias de derivação para desobstrução da via biliar. Embora factíveis dentro dos princípios da cirurgia convencional, faltam estudos comparativos com outras técnicas existentes analisando eficácia e efetividade.

Laparoscopic Ultrasound Enhances Diagnostic Laparoscopy in the Staging of Intra-Abdominal Neoplasms

Routine laparoscopy and laparoscopic ultrasound (LUS) for staging intra-abdominal malignancies remains controversial. Thus, we undertook a prospective study to assess the value of preoperative laparoscopy with LUS for patients with intra-abdominal tumors judged resectable by preoperative studies. Laparoscopy was successfully performed in 76 of 77 patients, and 60 underwent LUS. Of 33 patients with presumed pancreatic cancer, laparoscopic findings changed the operative management of 11 patients, and LUS altered the management of an additional 6 patients. Laparotomy was avoided in 9 patients (27%). Among 14 patients with hepatobiliary tumors, laparotomy was avoided in 9 patients in whom laparoscopy and/or LUS revealed either benign or advanced disease. Operative management was altered in 4 of 18 patients with gastric or esophageal cancer by laparoscopic findings. LUS did not add to the management of these patients. Of 12 patients with presumed intra-abdominal lymphoma, 9 were diagnosed with lymphoma and 3 with benign disease, without laparotomy in all but 1 case. Laparoscopy and LUS are valuable tools for evaluating the resectability of pancreatic and hepatobiliary tumors. Laparoscopy, and to a lesser degree LUS, greatly facilitates diagnosing patients with intra-abdominal lymphomas and spares an occasional patient with esophagogastric carcinoma from undergoing laparotomy.