Alternative site entry for laparoscopy in patients with previous abdominal surgery

Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis

Laparoscopy has become widely accepted as the preferred surgical approach in the management of benign and malignant colorectal diseases. Once considered a relative contraindication in patients with prior abdominal surgery (PAS), as surgeons have continued to gain expertise in advanced laparoscopy, minimally invasive approaches have been increasingly incorporated in the reoperative abdomen and pelvis. Although earlier studies have described conversion rates, most contemporary series evaluating the impact of PAS in laparoscopic colorectal resection have reported equivalent conversion and morbidity rates between reoperative and non-reoperative cases, and series evaluating the impact of laparoscopy in reoperative cases have demonstrated improved short-term outcomes with laparoscopy. The data overall highlight the importance of case selection, careful preoperative preparation and planning, and the critical role of surgeons' expertise in advanced laparoscopic techniques. Challenges to the widespread adoption of minimally invasive techniques in reoperative colorectal cases include the longer learning curve and longer operative time. However, with the steady increase in adoption of minimally invasive techniques worldwide, minimally invasive surgery (MIS) is likely to continue to be applied in the management of increasingly complex reoperative colorectal cases in an effort to improve patient outcomes. In the hands of experienced MIS surgeons and in carefully selected cases, laparoscopy is both safe and efficacious for reoperative procedures in the abdomen and pelvis, with measurable short-term benefits.

Minimally Invasive Reoperation following Laparotomy

The surgical indications for laparoscopic techniques continue to expand as experience is gained. This includes patients who have had a previous open abdominal operation and require surgical intervention. In addition to the generally accepted indications for laparoscopy, conditions such as reversal of colostomy, small bowel obstruction, and early reoperation for surgical complications may be managed using minimally invasive techniques. Specific considerations in this group of patients include peritoneal access and establishing domain, lysis of adhesions, and situations that should prompt conversion.

Systematic guide to complex cases from adhesive disease

Intestinal adhesions are inevitable after abdominal surgery. The presence of intra-abdominal adhesions can create very complex situations which require careful preoperative planning, meticulous intra-operative technique and detailed postoperative management. This manuscript will review the management of these complex cases of adhesions.

Laparoscopic Insertion of Gastric Electrodes for Electrical Stimulation

Gastric electrical stimulation can provide symptomatic relief for patients with refractory gastroparesis. Traditionally, these wires are placed through a midline laparotomy. This paper describes and illustrates, in detail, the laparoscopic technique for successful implantation. Thirty-one consecutive patients from October 2003 to March 2005 underwent laparoscopic insertion of gastric stimulating wires for gastroparesis. Twenty-six patients were female. Four laparoscopic ports were used to insert a pair of electrodes. Anterior, cephalad retraction of the gastric wall is critical for accurate seromuscular placement of gastric leads. Intraoperative endoscopy was used to verify the seromuscular placement of the leads. Both leads were secured to a subcutaneous generator and electrical parameters were immediately established in the operating room. Patient demographics, operative details, and postoperative morbidities were recorded. All procedures were completed laparoscopically. The mean operative time was 114.4 +/- 20.9 minutes (range, 95-140). No perioperative mortality occurred. Two patients developed cellulitis at the generator site postoperatively and oral antibiotics were prescribed for one week postoperatively. No hardware was removed. Two patients had their generators repositioned due to pain at the pocket site. Gastric electrical stimulation is a novel treatment modality for patients with refractory gastroparesis and can be accomplished safely via laparoscopy. Laparoscopic insertion is successful even in patients with prior surgery and intact gastrointestinal tubes. Long-term follow-up and the current prospective multicenter trial continue to assess the efficacy of this treatment modality.

Experience with the Bailez technique for laparoscopic access in children

PURPOSE

We describe a variation of the Hasson technique for laparoscopic access.

MATERIALS AND METHODS

All laparoscopic procedures performed in children and completed between September 1999 and May 2002 at 2 institutions were reviewed retrospectively. All access to the peritoneal cavity was accomplished in the same manner using the following approach-a small semicircumferential incision was made in the inferior part of the umbilicus, and the umbilical skin was dissected to expose the area of the umbilical scar where the peritoneum and the skin meet. At this point the peritoneum was opened under direct vision without an incision. A blunt trocar was then easily introduced into the peritoneal cavity without forceful manipulation. The rest of the procedure was accomplished as usual.

RESULTS

Seventy-seven laparoscopic procedures were completed in 77 patients (mean age 4.8 years, range 1 month to 17.75 years). Patient weight ranged from 8 to 66 kg. The procedures included diagnostic laparoscopy for undescended testis (52), varicocelectomy (11), nephrectomy (6), nephroureterectomy (1) and others (7). All attempts were successful. Mean followup was 15.9 months.

CONCLUSIONS

The most important advantage of this technique is that it offers easy and safe access to the peritoneal cavity even in obese individuals. In addition, this access is rapidly accomplished and offers good cosmetic results.

Assessment of risk for intra-abdominal adhesions at laparoscopy for urological tumors

PURPOSE

Abdominal wall adhesions at laparoscopy may predispose patients to access related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of laparoscopy in patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of adhesions at laparoscopy a retrospective cohort study was performed.

MATERIALS AND METHODS

All patients who underwent a transperitoneal urological laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for adhesions, such as previous abdominal or pelvic surgery, radiation and/or intra-abdominal inflammatory disease. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed.

RESULTS

During the study period 127 patients underwent transperitoneal laparoscopy and videotapes on 82 (65%) were available for review. A total of 44 patients (54%) were identified with preoperative risk factors for adhesions (group 1), while 38 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI 0.89 to 2.01, p = 0.18) when risk factors were identified. There were no differences in the groups in patient age, operative time, access technique, conversion to open surgery or complications. Estimated blood loss was significantly higher in group 2, likely due to the preponderance of cytoreductive laparoscopic nephrectomy in this group.

CONCLUSIONS

There was no difference in the risk of intra-abdominal adhesions in patients with and without identifiable preoperative risk factors. Preoperative risk factors for adhesions should not contraindicate the transperitoneal laparoscopic approach for urological oncology procedures.

Umbilical stalk technique for establishing pneumoperitoneum

The Veress needle technique for establishing pneumoperitoneum is widely used yet associated with slow insufflation and potentially life-threatening complications. The open or Hasson technique is relatively safer but considered cumbersome by many. We describe a mini-open technique that uses a 5-mm transumbilical incision and placement of a 5-mm blunt cannula without the trocar. We have employed this technique for 4 years in 600 patients without a midline laparotomy incision incorporating the umbilicus and have accessed the abdomen safely for laparoscopy without any complications. The time from skin incision to the start of the procedure is usually under 2 minutes. Our umbilical stalk technique provides rapid and safe access to the abdomen, eliminating the dangers of a blind sharp needle or trocar insertion and the need for a larger incision with placement of stay sutures. We recommend this simple technique for entry into the uncomplicated abdomen.

Lateral approach to laparoscopic cholecystectomy in the previously operated abdomen

BACKGROUND

In the past, prior abdominal surgery was often felt to be a contraindication to laparoscopic cholecystectomy. The presence of adhesions precludes using a simple paraumbilical open approach for insufflation and initial trocar insertion because of an increased risk of bowel perforation and the difficulty in obtaining adequate exposure.

PATIENTS AND METHODS

We report 32 consecutive patients with previous upper midline incisions who underwent laparoscopic cholecystectomy with cholangiography and describe the technique and lateral positioning to facilitate this approach.

RESULTS

In our series, there were no complications. The mean length of hospital stay was 1.3 days, and the conversion rate to an open procedure was 3%: one patient who had had 22 previous abdominal operations.

CONCLUSION

Laparoscopic cholecystectomy performed with the patient in the lateral position is safe and effective for patients who have had previous midline incisions.

Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.

Laparoscopic ventral and incisional hernia repair in 407 patients

BACKGROUND

Recurrence rates after primary repair of ventral and incisional hernias range from 25% to 52%. Recurrence after open surgery is less likely if mesh is used, but the wide fascial dissection and required flap creation increase complication rates. Laparoscopic techniques offer an alternative.

STUDY DESIGN

To assess the safety and efficacy of laparoscopic ventral and incisional herniorrhaphy, we reviewed the records of all our patients who underwent such a procedure from November 1993 to August 1999. A laparoscopic approach was attempted in all patients considered to require a mesh repair. Patient demographic characteristics, operative details, and outcomes were recorded.

RESULTS

Of 415 patients scheduled to undergo laparoscopic ventral or incisional herniorrhaphy, conversion to an open procedure was necessary in 8. All the remaining 407 patients (205 men and 202 women; mean age 53.2 years; range 13 to 88 years) were included in the study. Mean fascial defect size was 100.1 cm2 (range 1 to 480 cm2). In 97% of patients, expanded polytetrafluoroethylene mesh was used. Mean operating time was 97 minutes (range 11 to 270 minutes). Mean estimated blood loss was 35 mL (range 10 to 150 mL). Average hospital stay was 1.8 days (range 0 to 17 days). There were 53 complications (13.0%), including cellulitis of a trocar site, infection requiring mesh removal, prolonged suture pain, persistent seroma, intestinal injury, hematoma or postoperative bleeding, prolonged ileus, urinary retention, respiratory distress, fever, intraabdominal abscess, and trocar site herniation. There were no deaths. During a mean followup time of 23 months (range 1 to 60 months), there were 14 hernia recurrences (3.4%), 6 in patients in whom only a stapling device (no sutures) had been used to secure the mesh to the abdominal wall.

CONCLUSIONS

Laparoscopic repair was completed in 98.1% of patients in whom it was attempted. The complication rate was acceptable. A short hospital stay and minimal blood loss were documented. The recurrence rate was 3.4%. Laparoscopic ventral and incisional hernia repair appear to be safe and effective.