Validation and performance of three-level procedure-based classification for laparoscopic liver resection

BACKGROUND

A procedure-based laparoscopic liver resection (LLR) classification (IMM classification) stratified 11 different LLR procedures into 3 grades. IMM classification assessed the difficulty of LLR differently than an index-based LLR classification (IWATE criteria), which scored each procedure on an index scale of 12. We validated the difference of 3 IMM grades using an external cohort, evaluated the IMM classification using the scores of the IWATE criteria, and compared the performance of IMM classification with the IWATE criteria and the minor/major classification.

METHODS

Patients undergoing LLR without simultaneous procedures were selected from a prospectively maintained database at the Institut Mutualiste Montsouris (IMM cohort) and from the database of 43 Japanese institutions (JMI cohort). Surgical and postoperative outcomes were evaluated according to the 3 IMM grades using the JMI cohort. The 11 LLR procedures included in the IMM classification were scored according to the IWATE criteria. The area under the curves (AUCs) for surgical and postoperative outcomes were compared.

RESULTS

In the JMI (n = 1867) cohort, operative time, blood loss, conversion rate, and major complication rate were significantly associated with a stepwise increase in grades from I to III (all, P < 0.001). In the IMM (n = 433) and JMI cohorts, IMM grades I, II, and III corresponded to three low-scoring, two intermediate-scoring, and six high-scoring LLR procedures as per the IWATE criteria, respectively. Mean ± standard deviation among the IMM grades were significantly different: 3.7 ± 1.4 (grade I) versus 7.5 ± 1.7 (grade II) versus 10.2 ± 1.0 (grade III) (P < 0.001) in the IMM cohort and 3.6 ± 1.4 (grade I) versus 6.7 ± 1.5 (grade II) versus 9.3 ± 1.4 (grade III) (P < 0.001) in the JMI cohort. The AUCs for surgical and postoperative outcomes are higher for the 3-level IMM classification than for the minor/major classification.

CONCLUSIONS

The difference of 3 IMM grades with respect to surgical and postoperative outcomes was validated using an external cohort. The 3-level procedure-based IMM classification was in accordance with the index-based IWATE criteria. The IMM classification performed better than the minor/major classification for stratifying LLR procedures.

Objective Surgical Skill Differentiation for Physical and Virtual Surgical Trainers via Functional Near-Infrared Spectroscopy

This study proposes a methodology to objectively differentiate surgical skill for physical and virtual trainers by measuring functional activation between expert and novice surgeons. Results indicate that there is a significant increase in functional activation for novices in the right lateral prefrontal cortex, and decrease in the left medial primary motor cortex, and the supplementary motor area for the physical trainer (p&lt;0.05). Results also indicate that there is a significant lower functional activation for novices compared to experts in the left medial primary motor cortex for the virtual skills trainer (p&lt;0.05).

Single port laparoscopy in gastroenterology and hepatology: A fine step forward

Single incision laparoscopy (SIL) has become an emerging technology aiming at a further reduction of abdominal wall trauma in minimally invasive surgery. Available data is encouraging for the safe application of standardized SIL in a wide range of procedures in gastroenterology and hepatology. Compared to technically simple SIL procedures, the merit of SIL in advanced surgeries, such as liver or colorectal interventions, compared to conventional laparsocopy is self-evident without any doubt. SIL has already passed the learning curve and is routinely utilized in expert centers. This minimized approach has allowed to enter a new era of surgical management that can not be acceded without a fruitful combination of prudent training, consistent day-to-day work and enthusiastic motivation for technical innovations. Both, basic and novel technical specifics as well as particular procedures are described herein. The focus is on the most important surgical interventions in gastroenterology and aims at reviewing the current literature and shares our experience in a high volume center.

[Laparoscopic treatment of perforated ulcers]

It was done comparative analysis the results of different treatment options using of laparoscopic treatment of 331 patients with perforated ulcers. It was defined that postoperative complications frequency is increased to 1.6% in case of perforated ulcers suturing with diameter to 0.7 cm. This indication is increased to 7.1% in case of perforated ulcers suturing and plugging by greater omentum with holes diameter to 1.0 cm. The complications are absent in case of perforated ulcer excision with subsequent vagotomy and pyloroplasty.

Comparison of the different types of “laparoscopic total hysterectomy”

STUDY OBJECTIVE

To review the operative outcomes among different types of laparoscopic total hysterectomy (LH) classified according to the Munro and Parker classification system.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II).

SETTING

6 major public hospitals in Hong Kong.

PATIENTS

143 patients underwent LH in a 6-month period.

INTERVENTIONS

Type I to type IV LH according to the Munro and Parker classification system.

MEASUREMENTS AND MAIN RESULTS

We studied 56 type I, 49 type II, 25 type III, and 13 type IV LH. The median operative time was 105 minutes, which was significantly longer in the type IV LH group (160 minutes). The median blood loss was significantly higher in the type I LH group (300 mL). The incidence of urinary tract infection in type I LH was 8.9%, which was significantly higher than other LH groups. The overall operative complication rate was 20.3%, which was highest in the type III hysterectomy group (36%), although the difference did not reach statistical significance among the various types of hysterectomy groups.

CONCLUSION

There has been a change from abdominal hysterectomy to LH in the past decades, and it is time for us to explore the best type of LH. Our findings suggest that type I LH is associated with significantly more blood loss and urinary tract infection; whereas type IV LH is associated with significantly longer operating time. However, we still cannot conclude which is the best type of LH until results from a randomized controlled trial will become available.

The difference between laparoscopic and keyhole surgery

The nomenclature needs to be sorted out

Laparoscopic repair of vaginal vault prolapse

PURPOSE OF REVIEW

Currently, the two laparoscopic techniques available and described in the literature for the treatment of vaginal vault prolapse are uterosacral ligament vault suspension and sacrocolpopexy. These two techniques are opposing each other fundamentally. While the first is reconstructive, the second is essentially palliative.

RECENT FINDINGS

In both methods the surgeon starts with the identification and dissection of the pubocervical and rectovaginal fascia. In the first technique however, the new vaginal vault, made by re approximation of the two fasciae, is attached to the uterosacral complex, while in the second one, each fascia is suspended from the sacral promontorium, using a mesh. In review of the existing literature, it seems that the palliative surgical approach is more successful in the long term, giving a cure rate of approximately 92%, probably as it involves using mesh instead of the native tissue.

SUMMARY

In this article we discuss the laparoscopic techniques available currently, analyse their results, discuss their differences and compare them with other non-laparoscopic techniques. Finally, we discuss the different options described, and offer some guidelines for the future of laparoscopic treatment of pelvic prolapse.

Laparoscopy in the last decade of the millennium: have we really improved?

BACKGROUND

The aims of the study were to evaluate the evolution of laparoscopic surgery during the past decade in terms of variations in the quality (complexity) of the procedures performed and of modifications in patient outcome.

METHODS

A retrospective analysis was performed of 3022 consecutive patients undergoing 99 different laparoscopic procedures at a center specialized in laparoscopic abdominal surgery. All the procedures were classified according to three classes of complexity. Results relating to the first 1511 patients were compared to those of the last 1511 patients.

RESULTS

In the second group, medium- to high-class complexity procedures significantly increased, conversion rate was higher only for straightforward procedures, duration of low- to medium-class complexity procedures decreased, only the rate of slight complications increased, and mean postoperative hospital stay was longer. Frequency of conversion in medium- to high-class complexity procedures and severe complications was not different in the two periods.

CONCLUSIONS

The quality of laparoscopic surgery has improved during the past decade, with no increase in the frequency of conversion or of major complications.

[Methodological aspects of laparoscopic sanitation in patients with diffuse peritonitis]

In 60 patients with acute diffuse peritonitis 103 laparoscopic sanitations of the abdominal cavity were performed. The personal experiences, investigation of hydrodynamic parameters and peculiarities of redistribution of liquid in the abdominal cavity affected by pneumoperitoneum were used by the authors for developing a method of the sanitation using an irrigation-aspiration device "Brusan". Experimental investigations in 50 rats were carried out for studying the degree of traumatic action on the stomach of different variants of sanitation of the abdominal cavity. They have shown advantages of the apparatus method. The indications and contraindications for using the method were developed. The working classification of the sanitation laparoscopy is proposed.

Laparoscopic surgery for the cure of colorectal cancer: results of a German five-center study

PURPOSE

The aim of this study was to assess the feasibility and safety of laparoscopic surgery for the cure of colorectal cancer with emphasis on oncologic follow-up in particular.

METHODS

A study was performed of patients with colorectal cancer treated by laparoscopy in five German centers between May 1991 and September 1997. Surgical and pathologic data were recorded in an anonymous registry database and analyzed by type of resection. Standard procedures were sigmoid or left colectomy, anterior resection, abdominoperineal resection, and right hemicolectomy. Follow-up information included incidence of local, distant, and port site recurrence and cancer-related death.

RESULTS

A total of 399 patients (212 females) with a mean age of 66.6 years underwent laparoscopic curative resections (sigmoid resection, 89; left colectomy, 11; anterior resection, 157; abdominoperineal resection, 102; right hemicolectomy, 40). Conversion was necessary in 6.3 percent (n = 25). Complications requiring reoperation occurred in 9 percent (n = 35). Complications that were treated conservatively occurred in 27.6 percent (n = 110). Thirty-day mortality was 1.8 percent (n = 7). First bowel movements resumed on the third postoperative day; patients did not use analgesics after a mean of five days. Mean postoperative hospitalization was two weeks. According to International Union Against Cancer classification, 147 patients had Stage I cancer, 35 had Stage II cancer, and 217 underwent curative resection for Stage III cancer. Mean number of lymph nodes resected was 12.1. At a mean follow-up of 30 months, one port site recurrence was documented. No local recurrence was observed after curative resection of Stage I colorectal cancer. Of 399 patients, local recurrence occurred in 6 patients (Stage II, 2; Stage III, 4), and distant metastases were documented in 25 patients (Stage I, 3; Stage II, 3; Stage III, 19). The highest incidence of cancer-related death occurred after abdominoperineal resection (4.9 percent).

CONCLUSION

To assess the role of laparoscopic colorectal surgery for the cure of cancer objectively, prospective randomized trials are necessary.

[Laparoscopic surgery in gynecology. Experience at the Luis Castelazo Ayala Hospital]

The purpose of the present study was to demonstrate the various applications of the laparoscopic surgery in the field of gynecology. 40 patients who were submitted to laparoscopic surgery were studied and divided into 5 groups accordingly to the surgical procedure: adhesiolysis, surgery of ovarian tumors, hysterectomy, surgery of the Fallopian tube and myomectomy. All the patients had a preoperative study and once completed they were selected for laparoscopic surgery. The laparoscopic procedure was able to solve the gynecologic pathology. The mean overall surgical time was of 66.8 min with a maximum time of 180 and a minimum of 30 min, accordingly to the groups the surgical mean times were as follows: 1) adhesiolysis 111 min 2) ovarian surgery 69 min 3) hysterectomy 113 min 4) tubal surgery 60 min and 5) myomectomy 58 min. There were no surgical complications and they all had a brief hospitalization period and a fast return to active life. All procedures were done with a bipolar cautery. We conclude that laparoscopic surgery is a useful resource for the resolution of the majority of the benign gynecologic pathology and when indicated in the proper way there is no rise in the morbid-mortality, and offers a short hospitalization period and a quick return to active life.

[Classification of operative laparoscopy]

We are proposing a new approach in the classification of Operative Laparoscopy, divided in 3 areas: Area 1: Reproductive laparoscopy, that is exclusively to techniques of assisted reproduction, Area 2: Reconstructive laparoscopy that includes all the pathology of the female's inner organs its treatment in sterility and Area 3: Ablative laparoscopy related to the extraction of tissues and organs with gynecological pathology.

Proposed classification of hysterectomies involving laparoscopy

A common terminology for the use of laparoscopy at hysterectomy is necessary so that collected data can be interpreted and conclusions applied. Many procedures are termed laparoscopic hysterectomy regardless of the extent to which laparoscopy is performed. We divided hysterectomy into seven steps and propose a common nomenclature based on the number of steps performed laparoscopically.

Laparoscopic hysterectomy

We describe the use of laparoscopic techniques in hysterectomy, and the epidemiology of hysterectomy. We review the advantages and complications of total laparoscopic hysterectomy and subtotal laparoscopic hysterectomy. Finally, we discuss long-term outcomes and the cost of these techniques.

Safety and training

Provided progress is made systematically, the surgeon never attempts to perform operations that are too difficult, and all the safety protocols are adhered to, hysteroscopic surgery should be within the capabilities of most gynaecologists. Failure to appreciate the risks and failure to undergo continuous training in the learning period will inevitably lead to complications which should otherwise be avoidable. Hysteroscopic surgery offers many advantages over conventional surgery and, like many other types of minimal access surgery, appears to be the surgery of the future. Endoscopic surgery will not supplant open surgery but will become another essential part of our practice which the patient will expect and, indeed, demand. There will be problems. Training programmes must be established to try to prevent complications which will be encountered if inadequately trained surgeons perform these new forms of surgery. There must be continuous education in existing methods and research into value and results of new techniques and instruments both for laser and electrosurgery. It is possible that in the future new biophysical or pharmacological approaches may render laser and electrosurgery obsolete. Safer forms of physical energy, photosynthesis and new forms of hormone therapy are all undergoing trials with preliminary results which are encouraging. Whichever techniques eventually prove to be the most effective and safe, we must learn to use them because we owe to our patients the opportunity to benefit from them.

Laparoscopic hysterectomy--a step forward?

Laparoscopic gynaecological surgery has made tremendous progress since the last decade and the introduction of laparoscopic hysterectomy has gained immense popularity amongst both gynaecologists and consumers alike in its short history of 5 years. This review surveys the literature available on this technique and critically evaluates the indications, limitations as well as the benefits and risks of this approach to hysterectomy. There is some evidence presently that laparoscopic hysterectomy may offer benefits to selected patients who otherwise have indications for an abdominal hysterectomy. Overall, the incidence of laparotomy for hysterectomy may be decreased by converting a portion of these patients to the laparoscopically-assisted vaginal approach.

Complications and results of 361 hysterectomies performed at laparoscopy

BACKGROUND

Before the appropriate use of laparoscopy in hysterectomy can be determined, it is necessary to evaluate the results, including complications. There must also be an accepted classification system to facilitate accurate comparison to total abdominal hysterectomy.

STUDY DESIGN

We retrospectively evaluated the charts of 361 women who underwent hysterectomy for various benign pathologic conditions. Intraoperative and postoperative complication rates for hysterectomy performed at operative laparoscopy were examined. The hysterectomies were classified as one of four types according to the number of steps performed laparoscopically. All women were candidates for total abdominal hysterectomy, but not vaginal hysterectomy.

RESULTS

The overall complication rate for hysterectomy performed at operative laparoscopy was 11.1 percent. Most complications were minor, including cystitis (1.66 percent), transient high fever (1.39 percent), abdominal wall ecchymosis (1.12 percent), and pneumonia and bronchitis (1.12 percent). There was no correlation between the type of laparoscopic hysterectomy performed and the complication rate.

CONCLUSIONS

Our rate of intraoperative and postoperative complications associated with laparoscopic hysterectomy compares favorably with published complication rates for vaginal and abdominal hysterectomy.

Laparoscopic treatment of ectopic pregnancy

Over the last decade and a half the success and safety of endoscopic surgery for ectopic pregnancy has been established. Shapiro and Adler (1973) reported laparoscopic salpingectomy using electrocoagulation followed by excision. Soderstrom (1981) followed with the snare technique of salpingectomy. Valle and Lifchez (1983) reported tubal patency rates approaching and attaining 100% following salpingostomy in the sole oviduct during laparotomy encouraged continued laparoscopic approach. DeCherney (1981) described linear salpingostomy via a cutting current in 18 women with an intrauterine pregnancy rate of 50% 1 year afterwards. No spontaneous abortions or repeat ectopics were reported. Pouly et al (1986) described laparoscopic salpingostomy in 321 women with a resultant 64% intrauterine pregnancy and 22% repeat ectopic rate. These studies support the realization that previous surgical approaches per laparotomy for ectopic pregnancy may be achieved endoscopically, but intraoperative and postoperative complications have occurred. As noted by Kelly et al (1979) and Richards (1984) these consist mainly of persistent or delayed haemorrhage along with continued trophoblastic growth. Haemorrhage is most often a result of failed salpingostomy in larger ectopics. Continued trophoblastic development requiring repeat surgical exploration due to incomplete removal of tissue has been reported by Pouly (1986) in as many as 5% of cases. This rare but reported consequence signals the importance of following quantitative HCG concentrations into the negative range. Occasionally HCG levels remain elevated more than 30 days postoperatively with eventual resolution; Cartwright et al (1986) claim that tubal patency rates appear to be unaffected by this prolonged clearance of tissue. Despite infrequent morbidity, laparoscopic treatment of ectopic pregnancy, in comparison to laparotomy, significantly shortens hospital stays, operating time, convalescence and postoperative analgesic requirements (Brumsted et al, 1988). Endoscopic surgery also reduces postoperative formation of pelvic adhesions (Fayez and Schneider, 1987). As familiarity and technical expertise with endoscopy continues to increase, exploratory laparotomy may be considered too radical an approach to ectopic pregnancy treatment regardless of the procedure performed.