Surg Endosc (1997) 11: 460463

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Prospective evaluation of a new through-the-scope nasoduodenal enteral feeding tube

L. J. Damore, II, C. H. Andrus, V. M. Herrmann, T. P. Wade, D. L. Kaminski, G. C. Kaiser
Department of Surgery, Saint Louis University Health Sciences Center, 3635 Vista Avenue, Saint Louis, MO 63110, USA Received: 18 March 1996/Accepted: 5 August 1996

Abstract Background: With present techniques, transpyloric feeding tube placement is unreliable. This study evaluated a new nasoduodenal tube placed through a gastroscope. Methods: A therapeutic gastroscope was advanced into the distal duodenum, and through the 3.7-mm channel this feeding tube was advanced under direct vision into the small bowel. The tube/guidewire combination was then advanced with the concomitant equidistant retraction of the scope until the wire could be grasped at the lips and exchanged to the nose using a nasal transfer tube. The guidewire was removed, and a Y connector was then attached to the end of the tube. Results: Successful tube placement in all 21 patients (14M/ 7F) required an endoscopy time of 31 3.3 min and the tubes were utilized for 9.24 0.94 days. Tube tips were confirmed in the distal duodenum (10) or proximal jejunum (11) by radiographic contrast injection. Conclusion: This new through-the-scope tube can be placed in the distal duodenum quickly, safely, and consistently. Key words: Enteral feeding tube Gastroscopy Duodenum

The need for nutritional support in chronically ill, trauma, burn, or surgical patients has been well known. In those patients who are unable to ingest nutrition by natural oral methods of mastication, deglutition, and swallowing, some other form of nutritional supplementation must be employed. Options for supplementation include either the enteral or parenteral route (TPN). Unlike TPN, enteral tube nutrition is much less expensive and has a very low incidence of sepsis and metabolic complications. Enteral feed-

Correspondence to: C. H. Andrus, Fifth Avenue and Roosevelt Streets, P.O. Box 5000, Hines, IL 60141, USA

ing also avoids or minimizes bacterial translocation and the subsequent potential sepsis. In addition, enteral tubes can be safely placed for indefinite periods of time. Currently, there exist two major forms of enteral routes for nutritional supplementation: nasal or oral enteral tubes and operatively or endoscopically placed gastrostomy or jejunostomy tubes. Although more permanent, operative gastrostomies and percutaneous endoscopic gastrostomies (PEG) [3] and operative jejunostomies and percutaneous endoscopic jejunostomies (PEJ) [14] require a surgical incision for placement and carry added risks for wound infection, peritonitis, hemorrhage, and injury to other organs during placement [2]. These more permanent enteral tubes are indicated for long-term nutritional supplementation. Regarding short-term nutritional supplementation, the placement of oral or nasal enteral tubes is preferred [1]. The simplest method, blind placement of orogastric or nasogastric tubes, is associated with elevated risk of gastroesophageal reflux and subsequent enteral feeding aspiration [9]. In at least one study, the optimal tube position for minimizing reflux through the pylorus was found to be just distal to the ligament of Treitz [5]. Thus, the placement of transpyloric enteral feeding tubes can be advocated for the temporary enteral alimentation of critically ill patients who have a functioning intestinal system [15]. There now exist a great variety of methods for nasoenteral feeding tube insertion. One method involves blind placement of a nasoenteral tube into the stomach [15]. Blind passage also can result in the inadvertent intubation of the trachea and possible bronchopleural injuries [6]. Although nasoduodenal tube placement under fluoroscopic guidance is more reproducible and accurate, the procedure requires a cumbersome C-arm at the bedside or transportation of the patient to the Radiology Department with subsequent radiation exposure to the patient and staff. With the advent of fiberoptic flexible endoscopy, guidance of feeding tubes into the upper intestinal tract under direct vision has become possible. At present time, nasoduodenal tubes can be placed by endoscopic direction alongside the endoscope [11] or by several other methods described in the literature [1, 4, 7, 8,

461

Fig. 2. Sequential frames of the advancement of the KTE tube into the distal duodenum and jejunum.

Fig. 1. Kangaroo 9-French through-the-endoscope (KTE) nasoduodenal tube with guidewire in place. Y connector is included.

10, 13]. These previous methods have all had technical shortcomings that this newest study attempts to circumvent by using a newly designed through-the-endoscope nasoduodenal feeding tube. Materials and methods
Under an approved Institutional Review Board study, all patients who had failed placement of nasoduodenal tubes by more traditional methods such as blind placement, placement under fluoroscopy, or alongside the endoscope were offered attempted placement of a newly designed through-thescope nasoduodenal tube (Fig. 1) (Kangaroo endoscopically-placed clear feeding tube a with a radiopaque stripe [KTE], 9 French or 10 French 140 cm with a 280 cm guidewire, tungsten-weighted tip, Sherwood Medical, St. Louis, MO, 63103). (Commercially available nasoduodenal tubes at present have a nominal outer diameter of 8 or 10 French. Unfortunately, these cannot be placed through the endoscope due to larger outer diameter of the weight tips, the relative shorter length of the tube and wire, and the permanent fixation of the Y-connector to the proximal end of the tube.) Therapeutic gastroscopes (GIF2T10 [12.6 mm O.D], GIF1T100 [11.0 mm O.D.], GIF2T100 [12.6 mm O.D.]; Olympus, America Corporation, Lombard, IL 60148) with working channels of at least a nominal inside diameter of 3.7 mm were utilized for the placement of the KTE. The biopsy channel was initially irrigated with water mixed with silicone spray, while the full length of the feeding tube was moistened with tap water to activate the prelubricated surface coating. With its guidewire in place, the KTE was then inserted through the therapeutic channel to the endoscopes tip. After appropriate intravenous conscious sedation of the patient with a narcotic and a benzodiazepine, the gastroscope was then passed through the oral

cavity and upper gastrointestinal tract as far as possible into the distal duodenum (Fig. 2). Once the most distal duodenum was reached, the feeding tube was advanced through the endoscopic port under direct vision as far as possible into the small bowel. With continued KTE advancement through the biopsy port, the gastroscope was then methodically removed continuously an equivalent distance with regard to KTE advancement. Once the tip of the gastroscope had reached the patients lips, the KTEs position was secured by an assistants grasp. A lubricated nasal transfer tube (NTT) was inserted through the nose and grasped in the hypopharynx by the operators fingers; the tip of the NTT was brought out the mouth. The guidewire was then threaded through the NTT. The NTT with the wire was removed out the nose, thus transforming the external portion of the KTE out a nostril. The guidewire was then pulled out from the feeding tube, the end of the tube was cut, the tube was taped in place, and a Y connector was next attached to the end of the tube. Distal bowel placement was then confirmed by injection of 2030 ml of a radiopaque dye through the feeding tube followed immediately by an abdominal radiograph (Fig 3). Data regarding the sex, age, and diagnosis of the patient; size of the feeding tube and time required for placement; radiographic position of the feeding tube tip; patient tolerance to tube feedings; number of days of feeding tube utilization; and reason for removal of the feeding tube were collected concomitantly. The statistical analysis of the data (mean; standard error of the mean; and the appropriately indicated comparison tests: t-test, chi-square analysis, or ANOVA) is subsequently reported.

Results Twenty-one patients, 14 males (mean age 54.4 5.2 years) and seven females (mean age 62.4 5.8 years), underwent placement of either a 10-French (n 15) or 9-French (n 6) feeding tube through the therapeutic endoscopic biopsy port of the gastroscope. Of the 21 patients, 20 had failed fluoroscopic placement and one had failed endoscopic placement. There was no increased difficulty in the gastroscopic cannulation of the upper gastrointestinal tract even though therapeutic scopes have a slightly larger outer diameter (11.2-mm to 12.6-mm O.D. for a therapeutic scope vs 11.0

462

PEG) was eventually placed (3); tolerating oral feedings (four); one undocumented case; a death; and the unrelated development of an enteric fistula for which the patient was placed on long-term TPN. The length of utilization of the KTE tubes was similar (9 French: 7.33 1.43 days, 10 French: 10 1.16 days; p 0.21). Discussion The importance for nutritional support in the critically ill patient is well documented. Unlike TPN, enteral nutrition has much less risk of septic and/or metabolic complications. For short-term enteral nutritional support, placement of a nasoenteral feeding tube is preferred. These tubes avoid the complications of wound infections and peritonitis involved in the placement of the PEG or PEJ. The placement of the through-the-endoscope feeding tube (KTE) was simple, precise, and consistently reproducible. Since the tube is advanced in an equidistant fashion with the concomitant withdrawal of the endoscope, the tubes do not back out during the process and no tube placements had to be redone. In all patients in which these feeding tubes were placed, the tips of the tubes were transpyloric and located in the distal duodenum or proximal jejunum. Feeding was initiated immediately after proper placement was confirmed by an abdominal radiograph with radiopaque contrast injection. This clinical trial shows that the through-the-endoscope feeding tube is an adequate substitute for the placement of feeding tubes along the side of the endoscope and is at least equal if not superior to any previously described endoscopic nasoenteral feeding tube placement method. Through this study, the KTE tube has been shown to be an excellent method for placement of temporary transpyloric feeding tubes in critically ill patients for those who favor transpyloric enteral nutrition. Since these tubes were placed only after prior failure of attempted placement of nasoduodenal tubes by fluoroscopic or other endoscopic techniques, the Kangaroo through-theendoscope nasoduodenal tube and this placement technique was consistently reproducible (100% of the time) and definitely more successful than other attempted methods of placement in the patients studied.
Acknowledgment. Our thanks to the technical assistance of Mr. Raymond Bodicky, Sherwood Medical, St. Louis, MO.

Fig. 3. Confirmation of the distal tube placement utilizing a water-soluble contrast injection through the tube and a supine abdominal radiograph.

mm for a standard adult gastroscope). The mean procedure time was 31 3.3 min (range 1070 min), which was independent of the size of the tube used (9 French: 27.5 4.8 min; 10 French: 32.3 4.3 min; p 0.53); but the prolonged placement time in several individuals was associated with the 10-French version of the tube because of the increased friction between the 10-French tube (O.D. 3.2 mm) and the channel of the therapeutic gastroscope (nominal I.D. 3.7 mm but may decrease in size with scope angulation in older models). The only complication associated with the placement of any of the nasoenteral feeding tubes was nasal mucosa excoriation requiring packing in one coagulopathic patient. Confirmation of the position of the feeding tube was obtained by abdominal radiograph after injection of 2030 ml of a radiopaque dye through the feeding tube. The tip of the tube was confirmed to be in the jejunum in 11 patients, while in the remaining ten patients the tip of the KTE was noted to be in the distal duodenum. The distal tip position was independent of the tube size (p 0.73). After tube placement, all feeding tubes initially functioned without difficulty. While the mean number of days the tubes were used for enteral feeding was 9.24 0.94 days (range 222 days), the feeding tubes were removed for a variety of reasons: inadvertent tube extubation (eight); tube obstruction (three); a more permanent feeding tube (i.e.,

References
1. Bosco JJ, Gordon F, Zelig MP, Heiss F, Horst DA, Howell DA (1994) A reliable method for the endoscopic placement of a nasogastric feeding tube. Gastrointest Endosc 40: 740743 2. Gauderer MWL, Stellato TA (1986) Gastrostomies: evolution, techniques, indications, and complications. Curr Probl Surg 23: 661719 3. Gauderer MWL, Ponsky JL, Izant J (1980) Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 15: 872875 4. Ginsberg GG, Lipman TO, Fleischer DE (1994) Endoscopic clipassisted placement of enteral feeding tubes. Gastrointest Endosc 40: 220222 5. Gustke RF, Varma RR, Soergel KH (1970) Gastric reflux during perfusion of the small bowel. Gastroenterology 59: 890 6. Hedry PJ, Akyurekl Y, McIntyre R, Quarrington A, Keon W (1986)

463 Bronchopleural complications of nasogastric feeding tubes. Crit Care Med 14: 892894 Hudspeth DA, Thorne MT, Meredith JW (1995) A simple endoscopic technique for nasoenteric feeding tube placement. J Am Coll Surg 180: 229230 Kuipers EJ, van Mourik-van Steyn G, Rijsberman W, Klinkenberg Knol EC, Meuwissen SGM (1994) Direct endoscopic placement of nasoenteral feeding tubes. Endoscopy 26: 371 Metheny NA, Eisenberg P, Spies M (1986) Aspiration pneumonia in patients fed through nasoenteral tubes. Heart Lung 15: 256261 Mitchell RG, Kerr RM, Ott DJ, Chen M (1992) Transnasal endoscopic technique for feeding tube placement. Gastrointest Endosc 38: 596 597 11. Pleatman MA, Naunheim KS (1987) Endoscopic placement of feeding tubes in the critically ill patient. Surg Gynecol Obstet 165: 6970 12. Rombeau JL, Barot LR (1981) Enteral nutrition therapy. Surg Clin North Am 61: 605620 13. Stark SP, Sharpe JN, Larson GM (1991) Endoscopically placed nasoenteral feeding tubes: indications and techniques. Am Surg 57: 203 205 14. Westfall SH, Andrus CH, Naunheim KS (1990) A reproducible, safe jejunostomy replacement technique by a percutaneous endoscopic method. Am Surg 5: 141143 15. Whatley K, Turner W, Day M, Meier D (1983) Transpyloric passage of feeding tubes. Nutr Suppl Serv 3: 1821

7. 8. 9. 10.

Surg Endosc (1997) 11: 441444

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic vs conventional Nissen fundoplication

A prospective randomized study
S. Laine, A. Rantala, R. Gullichsen, J. Ovaska
Department of Surgery, Turku University Central Hospital, Kiinamyllynkatu 48, FIN-20520 Turku, Finland Received: 15 May 1996/Accepted: 10 September 1996

Abstract Background: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. Methods: Some 110 consecutive patients with prolonged symptoms of grade IIIV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery. Key words: Gastroesophageal reflux disease Laparoscopy Fundoplication Antireflux surgery Laparoscopic surgery

lent control of reflux symptoms in 91% of patients 10 years after the operation [5]. Very soon after the laparoscopic revolution in biliary surgery other intraabdominal diseases were treated with this new technique. In 1991 Dallemagne [4] described the operative technique and reported the early results of a laparoscopic Nissen fundoplication. Since then, several studies have demonstrated the safety and effectiveness of this procedure [7, 9, 10]. However, no randomized series comparing an open and a laparoscopic fundoplication have been published and many general surgeons have been suspicious about this technique. In this study we compared a laparoscopic and an open Nissen fundoplication in a randomized manner.

Patients and methods

Between April 1992 and June 1995, 110 consecutive patients, 65 males and 45 females, were randomized to either laparoscopic (LAP) or conventional (OPEN) Nissen fundoplication. The age of the patients ranged from 21 to 75 years, with a mean age of 47 years in the LAP group and 51 years in the OPEN group. All patients had a long history of chronic reflux esophagitis and every patient had been treated conservatively for more than 24 months with H2-blockers or proton-pump inhibitors. Preoperative clinical symptoms were assessed with a questionnaire and esophagogastroscopy was performed on all patients. Esophagitis was graded according to the SavaryMiller classification [15] (Table 1). Ambulatory 24-h pH measurement (Synetics Medical) and esophageal manometry (Lectromed) were performed at the Department of Clinical Physiology. The preoperative values of the pH recordings were available in 46 patients in the LAP group and in 41 patients in the OPEN group. Seven patients in LAP group and nine in OPEN group refused pH recording and esophageal manometry. In addition, these tests failed for technical reasons in seven cases. The pH electrode was placed 5 cm superior to the lower esophageal sphineter (LES); the position of the electrode was checked by advancing the electrode into the stomach and by pulling it slowly upward. The location of the LES was taken to the point where the pH change occurred. If positioning was uncertain, the location of the electrode was checked using X-rays. The proportion of episodes with pH below 4, the number of episodes lasting over 5 min, and the duration of the longest episode with pH below 4 were used to measure the severity of acid reflux. Esophageal manometry was performed using the pull-through technique to determine the LES pressure. The normal values of LES pressure used in our laboratory range from 9 to 32 mmHg, with a mean of 19.2 6.9 mmHg [6]. Preoperative manometry was carried out in 43 patients in the LAP group and in 39 patients in the OPEN group. The mean LES pressure was 13.7 mmHg in the LAP group and 15.1 in the

Since Nissens original description of fundoplication nearly 40 years ago [12] this procedure has undoubtedly been the most commonly used operation for the treatment of gastroesophageal reflux disease (GERD). The long-term results after this procedure have been very successful, with excelCorrespondence to: J. Ovaska

442

Fig. 1. Mean pH-% before and after surgery.

Fig. 2. Mean LES pressure before and after surgery.

Table 1. Severity of the esophagitis before surgery in the laparoscopic and conventional fundoplication groups (Savary-Miller classification) Grade of esophagitis I II III IV Total Type of procedure Laparoscopic 4 31 19 1 55 Conventional 7 32 12 4 55

Table 2. Complications during and after laparoscopic and conventional fundoplication Complication Esophageal perforation Intraoperative bleeding Splenic bleeding and splenectomy Pneumonia Subphrenic abscess Wound infection Laparoscopic 2 1 0 0 0 0 Conventional 0 0 2 1 1 3

OPEN group. The motor function of the tubular esophagus was normal in all cases that were included in the study. The laparoscopic operation was performed according to the same principles as the conventional Nissen fundoplication [13]. The laparoscopic technique used in this study is described in our preliminary report [14]. Ligation of the short gastric vessels was done in five operations in both groups. Hiatoplasty was done in four patients in the LAP group and in one patient in the OPEN group. All laparoscopically operated patients received a single-dose perioperative antibiotic prophylaxis (cefuroxime 1.5 g) at the induction of anesthesia. Antithromboembolic prophylaxis consisted of subcutaneous low molecular weight heparin (Fragmin, Pharmacia, Sweden), 2,500 units daily, and antithromboembolic stockings during the operation. The follow-up was carried out on an outpatient basis 3 and 12 months after the operation. The evaluation included a careful patient history, esophagogastroscopy, ambulatory 24-h pH recording, and esophageal manometry. Informed consent was obtained from all the patients. The data was analyzed using the Fishers test.

Results Of the operations on the patients randomized to the LAP group, (91%) could be completed laparoscopically. Five

conversions to open laparotomy were necessarytwo for esophageal perforation, two for technical difficulties, and one for bleeding. Further recovery was uneventful in all five patients. In the OPEN group two patients underwent splenectomy due to iatrogenic splenic bleeding and five patients had postoperative infectious complications (Table 2). Five patients complained of severe dysphagia in the LAP group, as did three patients in the OPEN group. Fundic dilatation with a pneumatic balloon was necessary in three patients in the LAP group and in one patient in the OPEN group 2, 4, 10, and 12 weeks after the operation to relieve the troublesome symptom. Postoperative morbidity was 14.5% in the LAP group and 18.2% in the OPEN group. There was no mortality in either group. The mean duration of the operation was 88 min (range 42180) in the LAP group and 57 min (30190) in the OPEN group. The average hospital stay was 3.2 days (25) in the LAP and 6.4 (415) in the OPEN group and the mean sick leave was 15.3 (327) and 37.2 (2060) days, respectively.

443

Fig. 3. Symptoms 3 months after surgery.

Fig. 4. Symptoms 12 months after surgery.

Follow-up Ninety-four patients (90%) kept the 3-month follow-up appointment, including 45 patients in the LAP group and 49 in the OPEN group. Esophagogastroscopy was performed on 85 patients. Four patients in the LAP group and five in the OPEN group refused the endoscopy because they were completely symptom-free. The endoscopy results were normal in all patients (100%) in the LAP group and in 39 patients (89%) in the OPEN group. Likewise, the 24-h pH tracing was normal in 97% (33/34 patients) in the LAP group and in 68% (23/34 patients) in the OPEN group (Fig. 1). The mean LES pressure increased from 13.7 mmHg to 24.7 mmHg (80%) in the LAP group and from 15.1 mmHg to 21.0 mmHg (39%) in the OPEN group (Fig. 2). During the first 3 months after the operation 18% (8/45 patients) of the patients in the LAP group and 16% (8/49 patients) in the OPEN group had had dysphagia and 22% of the patients in both groups (10/45 patients vs 11/49 patients) had suffered from increased bloating. Two patients in the OPEN group suffered from heartburn and one from upper abdominal pain (Fig. 3). Two patients in the LAP group suffered from upper abdominal pain of unknown origin; 95% of the patients in the LAP group and 89% in the OPEN group were subjectively satisfied with the operative result. One-year follow-up was completed in 48 patients, 18 from the LAP group and 30 from the OPEN group. The results of endoscopy were normal in all patients (100%) in the LAP group and in 24/27 patients (88%) in the OPEN group. The 24-h pH tracing was normal in 16/18 (89%) patients in the LAP group and in 12/16 (75%) patients in the OPEN group (Fig. 1). The results of esophageal manometry were available for 30 patients, 13 patients in the LAP group and 17 patients in the OPEN group (Fig. 2). The mean LES pressure in the LAP group was 25.1 mmHg and 20.8 mmHg in the OPEN group. Four patients in the OPEN group suffered from mild dysphagia and two patients experienced bloating; three patients in the LAP group also complained of bloating (Fig. 4). Two patients required continuous medication and one patient had been reoperated later on, all after OPEN proce-

dure. Subjectively all patients in the LAP group and 86% in the OPEN group were satisfied with the operative result. Discussion It is now generally accepted that laparoscopic operations offer a good cosmetic result, a short hospital stay, and a rapid return to the normal activities. However, in many intraabdominal operations it still remains to be seen whether the postoperative results of a procedure done laparoscopically are as good as the results of open surgery. In the case of cholecystectomy the benefits of the laparoscopic technique are obvious [3, 17], but when we consider laparoscopic antireflux surgery the situation is different because the question arises as to whether we are really doing the same operation as in open surgery. We started to perform laparoscopic fundoplications in 1992 and in principle we used the same technique that we used in open surgery. Our initial experience [14] with a laparoscopic Nissen fundoplication was good and encouraged us to start this randomized study. The main technical goals of both operations were to create a loose and short fundic wrap around the lowermost part of the esophagus and to anchor it to the esophagocardial junction with a suture. In the LAP group five patients had to be converted to open operations, two due to esophageal perforation, which was the most serious technical complication in this group. Both of these patients had severe periesophagitis, which made the dissection of the paraesophageal space difficult. In both cases the perforation site was retroesophageal, which is the most common place for this complication [16]. Fortunately the perforations were immediately recognized and after conversion the perforations were sutured and covered with the fundic wrap. The recovery period was uneventful in both cases. In open surgery esophageal perforation is a rare complication [16], but splenic injury which requires splenectomy occurs in about 2% [18]. In this series splenic injury occurred in 3.6% (two patients). One of the most common postoperative problems after

444

fundoplication is dysphagia, which is reported to occur in 21% of patients after open surgery [5] and is said to be even higher after a laparoscopic procedure [2]. Many authors recommend routine division of the short gastric vessels in order to abolish the lateral pull of the esophagus [1]. On the other hand, if one uses the anterior wall of the fundus to construct the wrap as described by Gaegea [8], only seldom there will be tension on the wrap. This is our experience also, and division of the short gastrics was necessary in only five patients in both groups. Actually, the question of fundal mobilization is still controversial, as has been shown by Luostarinen et al. [11], who in a randomized study could not find any advantage from fundal mobilization in reducing postoperative dysphagia when compared to patients without fundal mobilization. In our series during the early postoperative period there was no difference in the amount of dysphagia and bloating between the two groups, although the LES pressure was higher after the lapararoscopic operation. The higher LES pressure may be the reason for the better results in gastroscopy and pH monitoring in the LAP group. These objective differences in the results between the two groups mean that the laparoscopic and the open fundoplication are probably not functionally the same procedure, and the wrap after a laparoscopic operation tends to be tighter than after an open procedure, although both operations are performed in principle in the same way. The results 1 year after the operation were still very good; all the patients in the LAP group and 86% in the OPEN group were satisfied with the result. Dysphagia and bloating had disappeared in almost all patients, but two patients in the OPEN group had reflux symptoms and needed continuous medication. In addition, one patient in the OPEN group had been reoperated for reflux symptoms. In both groups there was a tendency for the LES pressure to diminish when compared to the result 3 months after the operation, but this did not have any influence on the symptoms of the patients or on the results in gastroscopy and pH monitoring. The real benefit of laparoscopic fundoplication over the open procedure was seen in the recovery period. There were five patients with infectious complications after the OPEN operation but none after the laparoscopic procedure. The mean hospital stay was 3.2 days vs 6.4 days and the mean sick leave 15.3 vs 37.2 days, favoring the LAP group. Because most of the patients operated on for gastroesophageal reflux disease are still at work, a rapid recovery period is not only beneficial to the patient but also to the whole community.

In conclusion, we feel that a laparoscopic Nissen fundoplication is a safe and feasible procedure. There are few complications, and the functional results are as good if not even better than after conventional open surgery, and we believe that laparoscopic fundoplication is the procedure of choice in the treatment of patients offered surgery for gastroesophageal reflux disease.

References
1. Cadiere CB, Houben JJ, Bruyns J, et al. (1994) Laparoscopic Nissen fundoplication: technique and preliminary results. Br J Surg 81: 400 403 2. Collard JM, Gheldere CA, De Kock M, et al. (1994) Laparoscopic antireflux surgery. What is real progress? Ann Surg 220: 146154 3. Cuschieri A, Dubois F, Mouiel J, et al. (1991) The European experience with laparoscopic cholecystectomy. Am J Surg 161: 385387 4. Dallemagne B, Weerts JM, Jehaes C, et al. (1991) Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1: 138 143 5. DeMeester TR, Bonavina L, Albertucci M (1986) Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Ann Surg 204: 920 6. Drossman DA (1993) Manual of gastroenterologic procedures. Raven Press, New York 7. Fontaumard E, Espalieu P, Boulez J (1995) Laparoscopic NissenRossetti fundoplication. Surg Endosc 9: 869873 8. Gaegea T (1994) Laparoscopic Nissen-Rossetti fundoplication. Surg Endosc 8: 10801084 9. Hinder RA, Filipi CJ, Wetscher G, et al. (1994) Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 220: 472483 10. Jamieson GG, Watson DI, Britten-Jones R, et al. (1994) Laparoscopic Nissen fundoplication. Ann Surg 220: 137145 11. Luostarinen M, Koskinen M, Isolauri J (1996) Effect of fundal mobilisation in Nissen-Rossetti fundoplication on oesophageal transit and dysphagia. Eur J Surg 162: 3742 12. Nissen R (1956) Eine einfache Operation zur Beeinflussung de Refluxo sophagitis. Schweiz Med Wochenschr 86: 590592 13. Nissen R (1961) Gastropexy and fundoplication in the surgical treatment of hiatal hernia. Am J Dig Dis 6: 954961 14. Ovaska J, Rantala A, Laine S, Gullichsen R, Hietanen E (1995) Laparoscopic Nissen fundoplication. Initial experience. Ann Chir Gynaecol 84: 385389 15. Savary M, Miller G (1977) Der OesophagusLehrbuch und endoskopischer Atlas. Verlag Gassman Ag, Solothurn, Schwitzerland 16. Schauer PR, Meyers WC, Eubanks S, et al. (1996) Mechanisms of gastric and esophageal perforations during laparoscopic Nissen fundoplication. Ann Surg 223: 4352 17. Schirmer BD, Edge SB, Dix J, et al. (1990) Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 213: 665677 18. Urschel JD (1993) Complications of antireflux surgery. Am J Surg 166: 6870

Case reports
Surg Endosc (1997) 11: 472473

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic removal of a swallowed toothbrush

J. D. Wishner, A. M. Rogers
Department of Surgery, St. Lukes-Roosevelt Hospital Center, 1000 Tenth Avenue, Suite 2B, New York, NY 10019, USA Received: 20 December 1995/Accepted: 1 March 1996

Abstract. Toothbrush swallowing is an uncommon occurrence. Unlike most cases of foreign-body ingestion, there have been no cases of spontaneous passage reported. Consequently, prompt removal is recommended before complications develop. We report a case of toothbrush ingestion which failed attempted endoscopic removal. This patient was managed successfully with laparoscopic assisted removal via gastrotomy. We recommend this approach for the removal of any ingested foreign bodies when surgical intervention is indicated. Key words: Foreign body Gastric Toothbrush Laparoscopic

to the operating room for laparoscopic assisted removal of the toothbrush. A pneumoperitoneum was created using a Veress needle and a 10-mm trocar was placed in the umbilicus. Three additional 10-mm trocars were placedone in the right upper quadrant in the midclavicular line, one in the right upper quadrant in the anterior axillary line, and one in the left upper quadrant in the midclavicular line. The stomach was grasped with a Babcock clamp and the end of the toothbrush was easily identified as it tented the gastric wall (Fig. 1). Prior to opening the stomach, the nasogastric tube was pulled back above the gastroesophageal junction to enable the lower esophageal sphincter to close and facilitate maintenance of the pneumoperitoneum. A small gastrotomy was made on the anterior wall of the body of the stomach in this region using the cautery scissors. A Babcock clamp was passed into the stomach and opened to dilate the gastrotomy. The laparoscope was passed into the stomach and the toothbrush was visualized. A second Babcock clamp was passed into the stomach, and the toothbrush was grasped and withdrawn through the trocar (Fig. 2). The gastrotomy was closed using interrupted 2-0 Vicryl sutures and the procedure was completed. The patient was discharged 36 h after the procedure and has recovered uneventfully.

Foreign-body ingestion is a well-recognized problem that confronts physicians. Many foreign bodies will pass uneventfully. Endoscopy or laparotomy may be required to facilitate removal. In situations which require surgery, the laparoscopic approach should provide many advantages. We report a case of laparoscopic removal of a swallowed toothbrush and review the available literature on the curious history of toothbrush swallowing.

Discussion Foreign-body ingestion is a common occurrence. Episodes have been reported as early as 1200 B.C. [2]. Although ingestion may be accidental, as in our patient, associated factors are frequently identified. Alcohol consumption, psychiatric disorders, and seizure disorders have all been reported as contributory factors. Bulimia is a recent addition to the list [7]. A wide variety of objects may be swallowed, but coins, pins, bones, and razor blades predominate [1, 6]. Single or multiple objects may be ingested. In 1928 Chalk and Foucar reported the removal of 2,533 foreign bodies from the stomach of a single patient [1]. The majority of these objects were pins, wire, and pieces of glass. Treatment options for ingested foreign bodies continue to evolve. At the turn of the century, patients were subjected to emergent laparotomy to remove the objects and prevent perforation [4]. This approach can no longer be recommended. Recent reports suggest that the majority (80%) of foreign bodies will pass spontaneously if they have reached the stomach [6]. In addition, endoscopic techniques can often facilitate removal without surgical intervention. Consequently, most patients can be managed without surgery. The first case of toothbrush ingestion was reported in

Case report
A 20-year-old Asian female presented to the emergency room complaining of having swallowed her toothbrush. She stated that she had been attempting to scratch her pharynx with the handle of her toothbrush when a spontaneous gag reflex caused her to swallow the toothbrush. She denied any pain or other symptoms. She had no known psychiatric history or history of bulimia. A lateral neck and chest X-ray were obtained. No foreign body or other abnormality was noted. Upper endoscopy was performed immediately following the X-ray studies. The toothbrush was easily identified; however, the ends were wedged between the gastric mucosal folds, preventing its removal. Due to the low likelihood of spontaneous passage, the patient was taken

Correspondence to: J. D. Wishner, 30 W. 60th Street 1H, New York, NY 10023, USA

473

Fig. 1. Toothbrush identified with Babcock clamp.

Fig. 2. Toothbrush extraction.

1882 [4]. This patient did well after successful surgical removal via laparotomy and gastrotomy. The first reported death from a toothbrush occurred in 1889 as the result of gastric perforation 3 days after ingestion [4]. In a recent review, Kirk and colleagues identified 31 cases of toothbrush ingestion [5]. No episodes of spontaneous passage were reported. In 1983 the first case of successful endoscopic toothbrush removal was reported [3]. In our case, we found the endoscopic approach unsuccessful due to the size and shape of the toothbrush. Wilcox and colleagues reported unsuccessful attempts at endoscopic removal in two patients for similar reasons [7]. In addition, there has been a report of esophageal perforation during endoscopic toothbrush extraction [6]. This is the first reported case of laparoscopic assisted toothbrush extraction. We proceeded with prompt surgical intervention after an unsuccessful attempt at endoscopic removal. The patient was discharged 36 h after surgery and recovered uneventfully. Most gastric foreign bodies pass spontaneously and can be managed by observation with serial examinations and abdominal radiographs. If these measures fail or are felt to be inappropriate in a specific ethical situation, endoscopic removal may be attempted. An ingested toothbrush will not

pass spontaneously, and prompt removal is advised to minimize morbidity and avoid a prolonged hospital course. Cautious endoscopic removal may be attempted by a skilled endoscopist. It this is not possible, or is unsuccessful, we recommend a laparoscopic approach as an alternative to laparotomy.
Acknowledgment. The authors would like to thank Jeovanni Rivas for his technical expertise and assistance in producing the photographs.

References
1. Chalk SG, Foucar HO (1928) Foreign bodies in the stomach. Arch Surg 16: 494500 2. Deslypere JP, Praet M, Verdonk G (1984) An unusual case of the trichobezoar: the Rapunzel syndrome. Am J Gastroenterol 77: 467470 3. Ertan A, Kedia SM, Agrawal NM, et al (1983) Endoscopic removal of a toothbrush. Gastrointest Endosc 29: 144145 4. Friedenwald AM, Rosenthal LJ (1903) A statistical report of gastrotomies for removal of foreign bodies from the stomach. NY Med J Phila Med J: 110123 5. Kirk AD, Bowers BA, Moylan JA, Meyers WC (1988) Toothbrush swallowing. Arch Surg 123: 382384 6. Selivanov V, Sheldon GF, Cello JP, Crass RA (1984) Management of foreign body ingestion. Ann Surg 199: 187191 7. Wilcox DT, Karamanoukian HL, Glick PL (1994) Toothbrush ingestion by bulimics may require laparotomy. J Pediatr Surg 29: 1596

Technique
Surg Endosc (1997) 11: 488490

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

A simplified approach to laparoscopic fundoplication

G. S. Ferzli, J. B. Hurwitz, A. Hallak, M. A. Fiorillo, T. Kiel
Department of Laparoendoscopic Surgery, Staten Island University Hospital, 78 Cromwell Ave., Staten Island, NY 10304, USA Received: 29 March 1996/Accepted: 28 May 1996

Abstract Background: There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural fibers when encircling the lower esophagus. Methods: We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult. Results: Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis (Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months. Conclusion: We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication to be both simple and effective. Key words: Laparoscopy Fundoplication Gastroesophageal reflux disease

of open surgery over medical treatment in the management of complicated gastroesophageal reflux disease (GERD) [13]. Many different laparoscopic techniques have been reported since that time, with some authors recommending systematic, extensive fundal mobilization and other favoring preservation of the short gastric vessels (SGV). We present here are methods for determining whether or not to divide the short gastrics intraoperatively, as well as several technical innovations in this procedure.

Patients and methods

All patients referred to our institution for surgical treatment of GERD since September 1992 have been considered for the laparoscopic approach. A number of preoperative data were collected prospectively: age, gender, prior abdominal surgery, esophagogastroduodenoscopy findings with pathology report when biopsies were taken, barium swallow findings, lower esophageal sphincter (LES) pressure and esophageal body mamometry, and Johnson and DeMeester composite score on 24-h pH studies [7]. Operative data were: procedure performed, operative time, length of hospital stay, complications, and reoperations. Postoperative data were: symptoms of reflux or dysphagia. The procedure is performed with the patient under general anesthesia in a supine or modified lithotomy position (lower extremities minimally flexed at hips and knee joints). A 30 angled scope is used. After the establishment of pneumoperitoneum, five trocars are inserted in the supraumbilical, subxiphoid, right midclavicular (subcostal), left anterior axillary (subcostal), and left midclavicular (supraumbilical) positions. Following initial exploration, the gastrohepatic ligament is opened. The hepatic branch of the anterior vagus nerve is preserved. First the right and then the left crura are exposed by incising the covering parietal peritoneum. The gastroesophageal junction (GEJ) is retracted anteriorly, and the crura are further delineated by stripping the loose fatty areolar tissue caudad. Hiatal hernia is reduced if found. The posterior vagus is identified and preserved. Anteriorly, the phrenogastric ligament is incised from the left border of the GEJ to the first short gastric vessel. An attempt is then made to encircle the esophagus by dissecting posteriorly from the right side. If this proves difficult, which is often the case in obese patients, methylene blue is injected into the left crural fibers anterior to the esophagus (Fig. 1). As the dye tracks posteriorly it aids greatly in identifying the left side from below. After the esophagus has been freed posteriorly, a Penrose drain is passed around it. This facilitates later passage of instruments and the fundal wrap behind the GEJ. At this point the need to divide the SGV is assessed by trying to approximate the anterior gastric fundus to the abdominal wall (Fig. 2). The distance needed to reach the anterior abdominal wall is equal to the distance required to perform the wrap without tension. If this can be accom-

Laparoscopic fundoplication was first introduced by Dallemagne et al. and Geagea in 1991 [3, 6]. A year later, a prospective randomized study documented the superiority
Correspondence to: G. S. Ferzli

489

Fig. 1. Injection of methylene blue into the crural fibers. Fig. 2. Assessment of fundal mobility by lifting to the anterior abdominal wall. Fig. 3. Posterior approach to division of the short gastric vessels.

plished easily and without tension, the SGV are preserved; otherwise they are taken. If the vessels must be divided, a window is opened in the gastrocolic ligament to retract the stomach anteriorly. This maneuver places the short gastric vessels in a vertical plane, which in our opinion allows a more controlled approach with less chance of splenic injury (Fig. 3). Vessels are transected until the fundal lift to the abdominal wall can be performed. Finally, the fundus is passed behind and around the GEJ, retracting it laterally to expose both crura. The hiatus is closed with interrupted nonabsorbable sutures after passing a 5260 French bougie in the esophagus. A 360 circumferential loose wrap 1 to 2 cm long is then fashioned with nonabsorbable interrupted sutures tied intracorporeally.

division of the gastrophrenic membrane was necessary in 16; no vessels were divided in four, but a complete dissection of the gastrophrenic membrane and the posterior attachments of the gastric fundus was always performed. The median operative time 175 min (90405). The median hospital stay was 3 days (16). There was no mortality. One patient developed postoperative pneumonia, which was successfully treated with intravenous antibiotics. Dysphagia developed in three patients (15%) but resolved spontaneously within 6 weeks after surgery in every case. All patients are currently free of reflux symptoms, with follow-ups ranging from 7 to 42 months.

Results Between September 1992 and August 1995, 20 nonselected consecutive laparoscopic fundoplications were performed at our institution. There were 12 males and eight females, with a median age of 46 years (2175). None had undergone any prior abdominal surgery. All patients were symptomatic, with common complaints of heartburn (19) and regurgitation (16); four had dysphagia and two persistent upper respiratory tract symptoms. All had grade 3 or higher esophagitis, using the Savary-Miller scale [12]. Three patients had Barretts esophagus, but none had dysplasia on multiple biopsies. The medial DeMeester composite score on 24-h pH studies was 165, and the median LES pressure was 6 mmHg on manometry. None had grossly abnormal esophageal body motility. Division of short gastric vessels along with complete Discussion Comparative studies have demonstrated that laparoscopic fundoplication produces faster recovery [9, 10], shorter hospital stay [1, 9, 10], lower cost [9], and, most important, similar outcome [1], when compared with open surgery. Controversies regarding complete vs incomplete wraps and preservation vs division of the short gastric vessels are still being resolved. A randomized trial from Sweden comparing Nissen (360 wrap) with Toupet (270 wrap) in open surgery reported superior functional results for the Toupet [15]. This has not, however, been supported by other studies [2]. No prospective randomized trials have yet compared laparo-

490

scopic Nissen with laparoscopic Toupet, although a retrospective review showed an increased delay in resumption of normal swallowing in the Nissen group [8]. The reported incidence of successful reflux symptom relief and of postoperative dysphagia were similar in different series of Toupet and Nissen fundoplications. In light of the above data, we felt that the only strong contraindication to a Nissen would be significant aperistaltic simultaneous contractions on preoperative esophageal manometry. Since these were not present in any of our patients, we elected to perform a complete wrap on all. There are of course proponents both for and against division of the short gastric vessels [4, 11], although there is probably a consensus that the ideal fundoplication should be loose and without tension. Worldwide, a slightly greater number of laparoscopic fundoplications are done with division of the vessels than without, but there seems to be no demonstrable advantage for either procedure. We therefore developed the method described earlier for making this decision intraoperatively. The lift of the fundus to the anterior abdominal wall proved to be a quick and reliable test for determining whether an appropriately loose wrap could best be fashioned with or without transection of the short gastric vessels. The posterior gastric approach originally described for laparoscopic splenectomies [5] was found to aid greatly in the safety and speed of dividing these vessels if necessary, particularly when used in combination with ultrasonic coagulating shears [14]. The posterior approach also allows for a better mobilization of the gastric fundus by totally freeing the gastrophrenic membrane and allowing direct access to the short gastric vessels that are most cephalad. This permits vessel division to proceed in a craniocaudad direction so that the need for extensive division of vessels in the region of the splenic hilum (which occurs in the traditional anterior anesthesia) is obviated. Short gastric vessel division in mostly limited to one or two vessels. We believe that the hiatus should be routinely closed around a 5260 French bougie placed inside the esophagus. As noted by Watson et al., this closure may reduce the incidence of acute and chronic paraesophageal herniation [16]. Secure identification of crural fibers is necessary to accomplish this, and the injection of methylene blue into these fibers in difficult cases may reduce the risk of posterior gastric injury, pneumothorax, or esophageal perforation. The surgeon simply stays inferior and anterior to the left crus along the blue-tinged fibers. By adopting strict indications for surgery, and by following the methods outlined above, we feel that we have achieved results comparing favorably with those from larger series, while considerably simplifying intraoperative decision-making.

Conclusion Laparoscopic fundoplication is becoming increasingly employed on the basis of two facts: the recognition that surgical as opposed to medical management offers superior results in the treatment of GERD, and the recognition that laparoscopy can attain outcomes equivalent to those of open surgery, with the benefits of a minimally invasive procedure. We believe that the simple and efficient operative approach we have outlined above, combined with adherence to strict operative indications, will enable the growth of this procedure to continue.

References
1. Collard JM, DeGheldere CA, DeKock M, Otte J, Kestens PJ (1994) Laparoscopic antireflux surgery: what is real progress? Ann Surg 220: 146154 2. Crookes PF, DeMeester TR (1994) Does Toupet fundoplication outperform the Nissen procedure as the operation of choice for gastroesophageal reflux disease? Dis Esophagus 7: 265267 3. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R (1991) Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1: 138143 4. DeMeester TR, Bonavina L, Albertucci M (1986) Nissen fundoplication for gastro-esophageal reflux disease. Ann Surg 204: 920 5. Ferzli G, Fiorillo M (1995) A posterior gastric approach to laparoscopic splenectomy. Surg Endosc 9: 10171019 6. Geagea T (1991) Laparoscopic Nissens fundoplication: preliminary report on ten cases. Surg Endosc 5: 170173 7. Johnson LF, DeMeester TR (1974) 24-Hour pH monitoring of the distal esophagus: a quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62: 325332 8. McKernan JB (1994) Laparoscopic repair of gastroesophageal reflux disease: Toupet partial fundoplication versus Nissen fundoplication. Surg Endosc 8: 851856 9. Peters JH, Heimbucher J, Kauer WKH, Incarbone R, Bremner CG, DeMeester TR (1995) Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Coll Surg 180: 385393 10. Rattner DW, Brooks DC (1995) Patient satisfaction following laparoscopic and open antireflux surgery. Arch Surg 130: 289294 11. Rossetti M, Hell K (1977) Fundoplication for the treatment of gastroesophageal reflux in hiatal hernia. World J Surg 1: 439444 12. Savary M, Miller G (1977) Gassman AG (ed) Der oesophagus, lehrbuch and endoskopischer Atlas. Solothurn, Switzerland 13. Spechler SJ (1992) Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. N Engl J Med 326: 786792 14. Swanstrom LL, Pennings JL (1995) Laparoscopic control of short gastric vessels. J Am Coll Surg 181: 347351 15. Thor KBA, Silander T (1989) Long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg 210: 719724 16. Watson DI, Jamieson GG, Devitt PG, Matthew G, Britten-Jones RE, Game PA, Williams RS (1995) Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations. Surg Endosc 9: 961966

Surg Endosc (1997) 11: 476478

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic closure of esophageal perforation following pneumatic dilatation for achalasia

Report of two cases
R. C. W. Bell
Center for Advanced Endoscopic Surgery, 799 East Hampden, Suite 420, Englewood, CO 80110, USA Received: 28 December 1995/Accepted: 24 April 1996

Abstract. Esophageal perforation following pneumatic dilation of the esophagus is normally recognized shortly after the event. Two patients with esophageal perforation were repaired utilizing a transabdominal laparoscopic technique with suture closure of the perforation, contralateral Heller myotomy, and Toupet posterior partial fundoplication. Patients recovered excellently, were started on liquids within 3 days of surgery, and were discharged shortly thereafter. Details of the procedure are presented. This minimally invasive approach is well tolerated and appropriate in selected patients. Key words: Laparoscopic surgery Achalasia Pneumatic dilatation Esophageal perforation

Case reports and surgical technique Case 1

The first patient was a 49-year-old, 215-lb male with a 10-year history of dysphagia. Achalasia was diagnosed 5 years previously, and confirmed by esophageal motility studies. Two prior pneumatic dilations had partially succeeded, but the patient persisted with grade 2 of 3 dysphagia (able to eat only minced foods), grade 3 of 3 heartburn (severe, disruptive), and grade 2 of 3 regurgitation (frequent). Pneumatic dilation for the third time to 35 mm was performed. The patient immediately complained of chest pain, and blood was observed on the dilator. Gastrograffin esophagram showed free extravasation into the mediastinum from the distal esophagus on anterior posterior projection. Following intravenous antibiotic administration, the patient was taken to surgery. The patient underwent a laparoscopic transabdominal repair of the distal esophageal perforation, which was 4 cm long and on the posterolateral aspect of the distal esophagus. A contralateral myotomy was performed extending 5 cm on the esophagus and 1 cm onto the stomach, sparing the anterior vagus nerve. A Toupet posterior fundoplication was then performed. Operative time was 210 min and blood loss was minimal. A gastrograffin swallow the following day demonstrated no leakage from the esophagus and prompt gastric emptying; the nasogastric tube was therefore removed. Liquids were begun on postoperative day 2, and the patient was discharged postoperative day 7 eating solid foods. Chest X-ray revealed a left basilar pulmonary process which did not require thoracentesis. Intravenous antibiotics were administered until discharge. At 6-month follow-up the patient has no dysphagia and no heartburn. Postoperative motility demonstrated an aperistaltic esophagus, with a midrespiratory lower esophageal sphincter pressure (LESP) of 11 mmHg (normal midrespiratory LESP is >12 mmHg); 24-h pH testing demonstrated no pathologic reflux.

Perforation following pneumatic dilation of the esophagus for achalasia occurs with a frequency of 015% [3]. Treatment of contained perforations may be conservative; but free perforations typically require immediate surgical intervention [1, 2, 4, 10]. Surgical intervention most commonly consists of closure of the perforation with a contralateral myotomy and, when indicated by the extent of the myotomy, an antireflux procedure. Video-endoscopic surgical techniques have been proven effective in performing esophageal myotomy and antireflux procedures. A single case report of a videothoracic approach to esophageal perforation after pneumatic dilation demonstrated a favorable outcome [7]. To our knowledge, a transabdominal video-endoscopic approach to this type of esophageal perforation has not previously been reported. We describe here the treatment of two patients with esophageal perforation using an abdominal laparoscopic approach.
Correspondence to: R. C. W. Bell, South Surgical Group, P.C., 499 East Hampden, Suite 210, Englewood, CO 80110, USA

Case 2
The patient was a 42-year-old, 180-lb male admitted to the hospital with a 3-month history of progressive dysphagia and a 10-lb weight loss. He had grade 3 of 3 dysphagia (liquids only), grade 3 heartburn, and grade 2 regurgitation. Barium esophagram on admission showed a classic birds beak distal esophagus. The patient underwent a pneumatic dilation to 35 mm with a Rigiflex balloon. Postdilation esophagram showed a 2-cm contained perforation of the distal esophagus on the anteriorposterior projection. Intravenous antibiotics were promptly administered and oral intake

477

Fig. 1. Trocar placement. The ports should be placed high in the abdomen to allow adequate access to the mediastinal esophagus. Fig. 2. The completed Toupet fundoplication with anterior myotomy.

was restricted. However, within 6 h the patient complained of severe chest pain and dyspnea, and a decision was made to operate. A transabdominal laparoscopic approach was used. A small mediastinal abscess was found and cultured. The perforation was 3 cm long, on the lateral aspect of the distal esophagus. Following closure and contralateral Heller myotomy (5 cm of distal esophagus, extended 1.5 cm onto the stomach), a posterior Toupet fundoplication was performed. Operative time was 135 min. The postoperative course was similar to case 1, but the patient was discharged on postoperative day 4 on oral antibiotics (ciprofloxacin, metronidazole, and fluconazole). At 1-month follow-up the patient is free of dysphagia and reports no heartburn. Postoperative esophageal motility showed an aperistaltic esophageal body with a resting midrespiratory lower esophageal sphincter pressure of 7 mmHg; 24-h pH test was normal and at only 2% of the time demonstrated acid reflux (Johnson-DeMeester score of 9.9, normal < 22).

taking care to stay away from the area of perforation. The myotomy may be extended onto the proximal stomach. Again, an air insufflation test is performed to check for any leakage from the esophagus. The short gastric vessels are divided. Ultrasonic shears (Ultracision, USA) facilitate this dissection greatly. The posterior crura are reapproximated if needed. A posterior fundoplication in the manner of Toupet is performed, suturing the edges of the myotomy to the limits of the plicated stomach over a length of 4 cm [9] (Fig. 2). This has the advantage of covering the closed esophageal perforation with a gastric serosal patch. A closed suction drain is placed into the mediastinum, and the procedure is completed by fascial and skin closure. The patient is kept on antibiotics postoperatively as appropriate for the degree of contamination. A gastrograffin swallow on postoperative day 1 to evaluate the esophagus and gastric emptying will permit early removal of the Levene tube and resumption of a liquid diet. A pleural effusion is not uncommon, and may be observed without thoracentesis if the patient is clinically without evidence of infection. Discharge can be anticipated within 35 days when the patient remains afebrile, has a normal white blood cell count, and is tolerating a full liquid diet.

Surgical technique
The patient is placed in lithotomy position as for antireflux surgery, with the surgeon between the legs. Trocar placement is outlined in Fig. 1. It is important to place the trocars as high as possible to facilitate suture placement in the thoracic esophagus. The diaphragmatic hiatus is dissected and the esophagus is isolated circumferentially. The posterior phrenoesophageal membrane is divided to facilitate full mobilization of the distal esophagus, enabling visualization of the linear tear in the esophagus on the left posterior aspect. A thorough dissection of the distal 6 cm of esophagus is performed. A nasal Levene tube may be gently inserted at this time, and its passage just past the perforation is observed. The proximal extent of the perforation is identified. The perforation is closed with a running suture of 3-0 PDS (Ethicon, USA), placing the first suture above the proximal extent of the perforation. Monofilament is preferable in a running suture, as a running suture is difficult to follow laparoscopically and braided sutures bind up. A single layer is sufficient. After closure, air is insufflated into the Levene tube while the distal esophagus is immersed in irrigation to check for any further leakage, which would be evidenced by air bubbling. A Heller myotomy is then performed on the right anterior aspect of the esophagus. Gentle dissection of the mucosa from muscularis is performed,

Discussion The approach to esophageal perforation following pneumatic balloon perforation for achalasia depends on the severity of the perforation. All free perforations and contained perforations which progress clinically should be treated surgically. The location of the perforation is typically the left posterior distal esophagus. Therefore both anterior and lateral projections of gastrograffin swallow are necessary to completely define the area of perforation. Full-thickness perforations tend to begin within a centimeter of the squamocolumnar junction and extend proximally from a few millimeters to as much as 10 cm. Early recognition of the perforation and prompt surgical intervention within 1624 h allows successful primary clo-

478

sure in the majority of instances without the need for muscular flaps or esophageal exclusion. Patients with evidence of shock, respiratory failure, or advanced mediastinitis may require more than simple primary closure [5, 6, 8]. The most common open surgical approach has been transthoracic. However, the excellent visualization of the distal thoracic esophagus provided by transabdominal laparoscopy makes the distal 67 cm of the esophagus amenable to a transabdominal laparoscopic approach. Our experience with elective transabdominal laparoscopic esophageal myotomy for achalasia, and the finding in these two patients of gastrograffin swallow confirmation that the leak was limited to the distal 45 cm of esophagus, led us to use this approach, and there were excellent results. The laparoscopic approach to this type of esophageal perforation has the advantagecompared to a thoracoscopic approachof allowing a partial fundoplication to be created with ease. The partial fundoplication creates a gastric serosal patch over the closed esophageal tear. Definitive treatment of the inciting condition (achalasia) is permitted by laparoscopic performance of the myotomy with concomitant fundoplication, diminishing the risk of postmyotomy reflux. Additionally, the anatomic orientation is familiar to the laparoscopist experienced in esophageal reflux surgery, whereas the transthoracic anatomy may not be so familiar. Proximal exposure of the lower esophagus is adequate for a good 67 cm, which will enable the great majority of balloon dilation associated esophageal perforations to be managed laparoscopically. However, the esophagram must be carefully evaluated with regard to the proximal extent of the disruption to select this approach. A transthoracic approach should probably be used if the tear extends more than about 5 cm proximally or if there is gross extravasation of contrast into the left pleural space. Adequate visualization of the posterior esophagus is available laparoscopically by gentle rotation of the esophagus, so the location of the tear on the circumference of the esophagus is not an issue in deciding upon this approach.

Conclusion Esophageal perforation following pneumatic dilation of the esophagus for achalasia can be managed successfully with a transabdominal laparoscopic approach. Barium swallow to evaluate the proximal extent of the perforation is important to determining the feasibility of this approach, which is appropriate for the majority of perforations limited to the distal 5 cm of the esophagus. Circumferential dissection of the esophagus enables proper exposure of the perforation, which can then be closed with a running suture laparoscopically. If desired, a contralateral myotomy or posterior fundoplication can then be performed. This minimally invasive approach is well tolerated and appears to be safe in properly selected patients. Reference
1. Arrigoni E, Dederding JP, Baumann R, de Peyer R, Loizeau E (1991) Conservative treatment of esophageal perforations following pneumatic dilatation. Schweiz Med Wochenschr 121: 793796 2. Cameron J, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR (1978) Selective nonoperative management of contained intrathoracic disruptions. Ann Thoracic Surg 27: 404 3. Castell DO (1995) The Esophagus. 2nd ed. Little, Brown, Boston 4. Michel L, Grillo HC, Malt RA (1981) Operative and nonoperative management of esophageal perforations. Ann Surg 194: 57 5. Miller RE, Tiszenkel HI (1988) Esophageal perforation due to pneumatic dilation for achalasia. Surg Gynecol Obstet 166: 458460 6. Nair LA, Reynolds JC, Parkman HP, Ouyang A, Strom BL, Rosato EF, Cohen S (1993) Complications during pneumatic dilation for achalasia or diffuse esophageal spasm. Analysis of risk factors, early clinical characteristics, and outcome. Dig Dis Sci 38: 18931904 7. Nathanson LK, Gotley D, Smithers M, Branicki F (1993) Videothoracoscopic primary repair of early distal oesophageal perforation. Aust N Z J Surg 63: 399403 8. Schwartz HM, Cahow CE, Traube M (1993) Outcome after perforation sustained during pneumatic dilatation for achalasia. Dig Dis Sci 38: 14091413 9. Swanstrom LL, Pennings J (1995) Laparoscopic esophagomyotomy for achalasia. Surg Endosc 9: 286290 10. Swedlund A, Traube M, Siskind BN, McCallum RW (1989) Nonsurgical management of esophageal perforation from pneumatic dilatation in achalasia. Dig Dis Sci 34: 379384

Consensus statement
Surg Endosc (1997) 11: 413426

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)

Results of a Consensus Development Conference Held at the Fourth International Congress of the European Association for Endoscopic Surgery (E.A.E.S.), Trondheim, Norway, June 2124, 1996
Conference Organizers: E. Eypasch,1 E. Neugebauer2 with the support of F. Fischer1 and H. Troidl1 for the Scientific and Educational Committee of the European Association for Endoscopic Surgery (E.A.E.S.) Expert Panel: A. L. Blum, Division de Gastro-Ente rologie, Centre Hospitalier, Universitaire Vaudois (CHUV) Lausanne (Switzerland); D. Collet, Department of Surgery, University of Bordeaux, (France); A. Cuschieri, Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland (U.K.); B. Dallemagne, Department of Surgery, Saint Joseph Hospital, Lie ` ge (Belgium); H. Feussner, Chirurgische Klinik u. Poliklinik rechts der Isar, Universita t Mu nchen, Mu nchen (Germany); K.-H. Fuchs, Chirurgische Universita tsklinik und Poliklinik lvsborgs Wu rzburg, Universita t Wu rzburg, Wu rzburg (Germany); H. Glise, Department of Surgery, Norra A La nssjukhus, Trollha ttan (Sweden); C. K. Kum, Department of Surgery, National University Hospital, Singapore; T. Lerut, Department of Thoracic Surgery, University Hospital Leuven, Leuven (Belgium); L. Lundell, Department of Surgery, Sahlgrens Hospital, University of Go teborg, Go teborg (Sweden); H. E. Myrvold, Department of Surgery, Regionsykehuset, University of Trondheim, Trondheim (Norway); A. Peracchia, Department of Surgery, University of Milan, School of Medicine, Milan (Italy); H. Petersen, Department of Medicine, Regionsykehuset, University of Trondheim, Trondheim (Norway); J. J. B. van Lanschot, Academisch Ziekenhuis, Department of Surgery, University of Amsterdam, Amsterdam (Netherlands) Representative of Prof. Dr. Tytgat (Netherlands)
1 2

Surgical Clinic Merheim, II Department of Surgery, University of Cologne, Ostermerheimer Str. 200, 51109 Cologne, Germany Biochemical and Experimental Division, II Department of Surgery, University of Cologne, Ostermerheimer Str. 200, 51109 Cologne, Germany

Received: 29 November 1996/Accepted: 14 December 1996

Abstract Background: Laparoscopic antireflux surgery is currently a growing field in endoscopic surgery. The purpose of the Consensus Development Conference was to summarize the state of the art of laparoscopic antireflux operations in June 1996. Methods: Thirteen internationally known experts in gastroesophageal reflux disease were contacted by the conference organization team and asked to participate in a Consensus Development Conference. Selection of the experts was based on clinical expertise, academic activity, community influence, and geographical location. According to the criteria for technology assessment, the experts had to weigh the current evidence on the basis of published results in the literature. A preconsensus document was prepared and distributed by the conference organization team. During the E.A.E.S. conference, a consensus document was prepared in

three phases: closed discussion in the expert group, public discussion during the conference, and final closed discussion by the experts. Results: Consensus statements were achieved on various aspects of gastroesophageal reflux disease and current laparoscopic treatment with respect to indication for operation, technical details of laparoscopic procedures, failure of operative treatment, and complete postoperative follow-up evaluation. The strength of evidence in favor of laparoscopic antireflux procedures was based mainly on type II studies. A majority of the experts (6/10) concluded in an overall assessment that laparoscopic antireflux procedures were better than open procedures. Conclusions: Further detailed studies in the future with careful outcome assessment are necessary to underline the consensus that laparoscopic antireflux operations can be recommended. Key words: Consensus development conferences Laparoscopic antireflux operations Outcome assessment

Correspondence to: E. Neugebauer

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In the last 2 years, growing experience and enormous technical developments have made it possible for almost any abdominal operation to be performed via endoscopic surgery. Laparoscopic cholecystectomy, appendectomy, and hernia repair have been going through the characteristic life cycle of technological innovations, and cholecystectomy, at least, seems to have proven a definitive success. To evaluate this life cycle, consensus conferences on these topics have been organized and performed by the E.A.E.S. [76b]. Currently, the interest of endoscopic abdominal surgery is focusing on antireflux operation. This is documented by an increasing number of operations and publications in the literature. The international societies such as the European Association for Endoscopic Surgery (E.A.E.S.) have the responsibility to provide a forum for discussion of new developments and to provide guidelines on best practice based on the current state of knowledge. Therefore, a consensus development conference on laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD) was held, which included discussion of some pathophysiological aspects of the disease. Based on the experience of previous consensus conferences (Madrid 1994), the process of the consensus development conference was slightly modified. The development process was concentrated on one subjectreflux diseaseand during the 4th International Meeting of the E.A.E.S., a long public discussion, including all aspects of the consensus document, was incorporated into the process. The methods and the results of this consensus conference are presented in this comprehensive article. Methods At the Annual Meeting in Luxemburg in 1995, the joint session of the Scientific and Educational Committee of the E.A.E.S. decided to hold a Consensus Development Conference (CDC) on laparoscopic antireflux surgery for gastroesophageal reflux disease. The 4th International Congress of the E.A.E.S. in June 1996 in Trondheim should be the forum for the public discussion and finalization of the Consensus Development Conference. The Cologne group (E. Neugebauer, E. Eypasch, F. Fischer, H. Troidl) was authorized to organize the CDC according to general guidelines. The procedure chosen was the following: A small group of 13 internationally known experts was nominated by the Scientific Committee of the E.A.E.S. The criteria for selection were 1. 2. 3. 4. Clinical expertise in the field of endoscopic surgery Academic activity Community influence Geographical location

and Troidl [190a]. Each panelist was asked to indicate what level of development, in his opinion, laparoscopic antireflux surgery has attained generally, and he was given a form containing specific TA parameters relevant to the endoscopic procedure under assessment. In this form, the panelist was asked to indicate the status of the endoscopic procedure in comparison with conventional open procedures and also to make a comparison between surgical and medical treatment of gastroesophageal reflux disease. The panelists view must have been supported by evidence in the literature, and a reference list was mandatory for each item. Each panelist was given a list of relevant specific questions pertaining to each procedure (indication, technical aspects, training, postoperative evaluation, etc.). The panelists were asked to provide brief answers with references. Guidelines for response were given and the panelists were asked to send their initial evaluation back to the conference organizers 3 months prior to the conference. In Cologne, the congress organization team analyzed the individual answers and compiled a preconsensus provisional document. In particular, the input and comments of gastroenterologists were incorporated to modify the preconsensus document. The preconsensus documents were posted to each panelist prior to the Trondheim meeting. During the Trondheim conference, in a 3-h session, the preconsensus document was scrutinized word by word and a version to be presented in the public session was prepared. The following day, a 2-h public session took place, during which the text and the tables of the consensus document were read and discussed in great detail. A further 2-h postconference session of the panelists incorporated all suggestions made during the public session. The final postconsensus document was mailed to all expert participants, checked for mistakes and necessary corrections and finalized in September 1996. The full text of the statements is given below.

Consensus Statements on Gastroesophageal Reflux Disease (GERD)

1. What are the epidemiologic facts in GERD? In western countries, gastroesophageal reflux has a high prevalence. In the United States and Europe, up to 44% of the adult population describe symptoms characteristic of GERD [124, 127, 242]. Troublesome symptoms characteristic of GERD occur in 1015% with equal frequency in men and women. Men, however, seem to develop reflux esophagitis and complications of esophagitis more frequently than women [23]. Data from the literature indicate that 1050% of these subjects will need long-term treatment of some kind for their symptoms and/or esophagitis [34, 195, 225, 242]. The panelists agreed that the natural history of the disease varies widely from very benign and harmless reflux to a disabling stage of the disease with severe symptoms and morphological alterations. There are no good long-term data indicating how the natural history of the disease changes

Internationally well-known gastroenterologists were asked to participate in the conference in the interest of a balanced discussion between internists and surgeons. Prior to the conference, each panelist received a document containing guidelines on how to estimate the strength of evidence in the literature for specific endoscopical procedures and a document containing descriptions of the levels of technology assessment (TA) according to Mosteller

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from one stage to the other and when and how complications (esophagitis, stricture, etc.) develop. Topics which were the subject of considerable debate but which could not be resolved during this conference are listed here [8, 11, 23, 28, 68]:

The cause of the increasing prevalence of esophagitis The cause of the increasing prevalence of Barretts esophagus and adenocarcinoma The discrepancy between clinically and anatomically determined prevalence of Barretts esophagus The problem of ultrashort Barretts esophagus and its meaning The relationship between Helicobacter pylori infection and reflux esophagitis Gastroesophageal reflux without esophagitis and abnormal sensitivity of the esophagus to acid The role of so-called alkaline reflux, which is currently difficult to measure objectively

GERD is frequently classified as a synonym for esophagitis, even though there is considerable evidence that only 60% of patients with reflux disease sustain damage of their mucosa [8, 91, 150, 200, 231, 243]. The MUSE and Savary esophagitis classifications are currently used to stage damage, but they are poor for staging the disease [8]. The modified AFP Score (Anatomy-FunctionPathology) is an attempt to incorporate the presence of hiatus hernia, reflux, and macroscopic and morphologic damage into a classification [83]. However, this classification lacks symptomatology and should be linked to a scoring system for symptoms or quality of life; both scoring systems are extremely important for staging of the disease and for the indication for treatment [195a,b].

4. What establishes the diagnosis of the disease? A large variety of different symptoms are described in the context of gastroesophageal reflux disease, such as dysphagia, pharyngeal pain, hoarseness, nausea, belching, epigastric pain, retrosternal pain, acid and food regurgitation, retrosternal burning, heartburn, retrosternal pressure, and coughing. The characteristic symptoms are heartburn (retrosternal burning), regurgitation, pain, and respiratory symptoms [150, 204]. Symptoms are usually related to posture and eating habits. In addition, typical reflux patients may have symptoms which are not located in the region of the esophagus. Patients with heartburn may or may not have pathological reflux. They may have reflux-type nonulcer dyspepsia or other functional disorders. The diagnostic tests that are needed must follow a certain algorithm. After the history and physical examination of the patients, an upper gastrointestinal endoscopy is performed. A biopsy is taken if any abnormalities (stenosis, strictures, Barretts, etc.) are found [8]. If no morphologic evidence can be detected, only functional studies, e.g., measuring the acid exposure in the esophageal lumen by 24-h esophageal pH monitoring, are helpful and indicated to detect excessive reflux [65]. It is of vital importance that the pH electrode be accurately positioned in relation to the lower esophageal sphincter (LES). Manometry is the only objective way to assess the location of the LES. Ordinary esophageal radiologic studies (barium swallow) are considered another mandatory basic imaging study [105a]. At the next level of investigation there are a number of tests that look for the cause of pathologic reflux using esophageal manometry as a basic investigative tool for this purpose to assess lower esophageal sphincter and esophageal body function [27, 65, 91, 134, 283]. Video esophagography or esophageal emptying scintigraphy may also be helpful. Optional gastric function studies are 24-h gastric pH monitoring, photo-optic bilirubin assessment to assess duodenogastroesophageal reflux, gastric emptying scintigraphy, and antroduodenal manometry [81, 93, 95, 118, 146, 234]. Currently these gastric function studies are of scientific

2. What is the current pathophysiological concept of GERD? GERD is a multifactorial process in which esophageal and gastric changes are involved [27, 65, 98, 251, 283]. Major causes involved in the pathophysiology are incompetence of the lower esophageal sphincter expressed as low sphincter length and pressure, frequent transient lower esophageal sphincter relaxations, insufficient esophageal peristalsis, altered esophageal mucosal resistance, delayed gastric emptying, and antroduodenal motility disorders with pathologic duodenogastroesophageal reflux [27, 65, 92, 95, 134, 251, 283]. Several factors can play an aggravating role: stress, posture, obesity, pregnancy, dietary factors (e.g., fat, chocolate, caffeine, fruit juice, peppermint, alcohol, spicy food), and drugs (e.g., calcium antagonists, anticholinergics, theophylline, -blockers, dihydropyridine). All these factors might influence the pressure gradient from the abdomen to the chest either by decreasing the lower esophageal sphincter or by increasing abdominal pressure. Other parts of the physiological mosaic that might contribute to gastroesophageal reflux include the circadian rhythm of sphincter pressure, gastric and salivary secretion, esophageal clearance mechanisms, as well as hiatal hernia and Helicobacter pylori infection. 3. What is a useful definition of the disease? A universally agreed upon scientific classification of GERD is not yet available. The current model of gastroesophageal reflux disease sees it as an excessive exposure of the mucosa to gastric contents (amount and composition) causing symptoms accompanied and/or caused by different pathophysiological phenomena (sphincter pressure, peristalsis) leading to morphological changes (esophagitis, cell infiltration) [65, 98]. This implies an abnormal exposure to acid and/or other gastric contents like bile and duodenal and pancreatic juice in cases of a combined duodenogastroesophageal reflux.

416 Table 1. Diagnostic test ranking order for GERD Basic diagnostic tests Endoscopy + histology Physiologic/pathologic criteria Savary-Miller classification I, II, II, IV, V MUSE classification (M) metaplasia (U) ulcer (S) stricture (E) erosions Barium swallow Percentage time below pH 4 DeMeester score LES: Overall length Intraabdominal length Pressure (Transient LES relaxations) esophageal body disorders weak peristalsis Optional tests 24-h gastric pH monitoring Gastric emptying scintigraphy Photo-optic bilirubin assessment
a

References Savary [231] Armstrong [8]

Radiology 24-h esophageal pH monitoring Stationary esophageal manometrya

Gelfand [105a] DeMeester [65] DeMeester [65]

Dent [69a] Eypasch [78] Barlow [14b] Fuchs [93, 95] Schwizer [234] Clark [40] Kauer [146] Fein [81]

Persistent gastric acidity Excessive duodenogastric reflux Delayed gastric emptying Esophageal bile exposure Gastric bile exposure

The concise numerical values for sphincter length, pressure, and relaxation depend on the respective manometric recording system used in the esophagealfunction lab

interest but they do not yet play a role in overall clinical patient management, apart from selected patients. The diagnostic test ranking order is displayed in Table 1. 5. What is the indication for treatment? Pivotal criteria for the indication to medical treatment in gastroesophageal reflux disease are the patients symptoms, reduced quality of life, and the general condition of the patient. When symptoms persist or recur after medication, endoscopy is strongly indicated. Mucosal damage (esophagitis) indicates a strong need for medical treatment. If the symptoms persist, partially persist, or recur after stopping medication, there is a good indication for doing functional studies. Gastrointestinal endoscopy, already mentioned as the basic imaging examination in GERD, should be performed in context with the functional studies. Indication for surgery is again centrally based on the patients symptoms, the duration of the symptoms, and the damage that is present. Even after successful medical acid suppression the patient can have persistent or recurrent symptoms of epigastric pain and retrosternal pressure as well as food regurgitation due to the incompetent cardia, insufficient peristalsis, and/or a large hiatal hernia. With respect to indication, one important factor in the patients general condition is age. On the one hand, age plays a role in the risks stratification when the individual risk of an operation is estimated together with the comorbidity of the patient. On the other hand, age is an economic factor with respect to the break-even point between medical and surgical treatment [21b]. Concerning the indication for surgery, a differentiation in the symptoms between heartburn and regurgitation is considered important. (Medical treatment appears to be more effective for heartburn than for regurgitation.)

Therefore the indication for surgery is based on the following facts:

Noncompliance of the patient with ongoing effective medical treatment. Reasons for noncompliance are preference, refusal, reduced quality of life, or drug dependency and drug side effects. Persistent or recurrent esophagitis in spite of currently optimal medical treatment and in association with symptoms. Complications of the disease (stenoses, ulcers, and Barretts esophagus [11, 68]) have a minor influence on the indication. Neither medical nor surgical treatment has been shown to alter the extent of Barretts epithelium. Therefore mainly symptoms and their relation to ongoing medical treatment play the major role in the indication for surgery. However, antireflux surgery may reduce the need for subsequent endoscopic dilatations [21a]. The participants pointed out that patients with symptoms completely resistant to antisecretory treatment with H2blockers or proton-pump inhibitors are bad candidates for surgery. In these individuals other diseases have to be investigated carefully. On the contrary, good candidates for surgery should have a good response to antisecretory drugs. Thus, compliance and preference determine which treatment is chosen (conservative or operative).

6. What are the essentials of laparoscopic surgical treatment? The goal of surgical treatment for GERD is to relieve the symptoms and prevent progression and complications of the disease creating a new anatomical high-pressure zone. This must be achieved without dysphagia, which can occur when the outflow resistance of the reconstructed GE junction exceeds the peristaltic power of the body of the esophagus. Achievement of this goal requires an understanding of the

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natural history of GERD, the status of the patients esophageal function, and a selection of the appropriate antireflux procedure. Since the newly created structure is only a substitute for the lower esophageal sphincter, it is a matter of discussion to what extent it can show physiological reactions (normal resting pressure, reaction to pharmacological stimuli, appropriate relaxations during deglutition, etc.). There is no agreement on how surgical procedures work and restore the gastroesophageal reflux barrier. With respect to the details of the laparoscopic surgical procedures, the following degree of consensus was attained by the panel (11 present participants) (yes/no): 1. Is there a need for mobilization of the gastric fundus by dividing the short gastric vessels? (7/4) 2. Is there a need for dissection of the crura? (11/0) 3. Is there a need for identification of the vagal trunks? (7/4) 4. Is there a need for removal of the esophageal fat pad? (2/9) 5. Is there a need for closure of the crura posteriorly? (11/0) 6. Should nonabsorbable sutures be used (crura, wrap)? (11/0) 7. Should a large bougie (4060 French) be used for calibration? (5/6) 8. Should objective assessment be performed (e.g., calibration by a bougie, others) for Tightness of the hiatus? (9/0) Tightness of the wrap? (9/2) 9. If there is normal peristalsis should one Routinely use a 360 short floppy fundoplication wrap? (8) Routinely use a partial fundoplication wrap? (2) Use a short wrap equal to or shorter than 2.5 cm? (1) 10. In cases of weak peristalsis, should there be a tailored approach (total or partial wrap)? (5/6)1 7. Which are the important endpoints of treatment whether medical or surgical? The important endpoints for the success of conservative/ medical as well as surgical therapy must be a mosaic of different criteria, since neither clinical symptoms, functional criteria, nor the daily activity and quality-of-life assessment can be used solely to assess the therapeutic result in this multifactorial disease process. Patients show great variety in demonstrating and expressing the severity of clinical symptoms and, therefore, they alone are not a reliable guide. Functional criteria can be assessed objectively, but may not be used in the decisionmaking process without looking at the stage of mucosal damage or morphological abnormalities (hiatus hernia, slipped wrap; AFP Score). Complete evaluation includes assessment of symptoms, daily activity, and quality of lifeideally, in every single patient.
1 During the public discussion, Professor Montori (Rome) mentioned the Angelchick prosthesis as a rare alternativehowever, this was not discussed in the consensus group.

Instruments: The examples of instruments are listed in references 80a, 195a, and 195b. The earliest point at which one ought to collect functional data after the operation is 6 months. The reasonable time of assessment in the postsurgical follow-up phase is probably 1 year followed by 2-year intervals. Economic assessment is considered to be a significant endpoint and is dealt with in a later section. There is no evidence that laparoscopic surgery should be any better than conventional surgery. If laparoscopic surgery is correctly performed, apart from the problems of abdominal wall complications like hernia, infection, and wound rupture, there should be no difference in outcome as compared to the standard obtained in open surgery. Laparoscopic surgery, however, has the potential to reduce postoperative pain and limitations of daily activity. 8. What is failure of treatment? In gastroesophageal reflux disease, lifelong medication is needed in many patients, because the disease persists but the acid reduction can take away the symptoms during the time the medication is taken. The disease is treated by reducing the acid and not by treating or correcting the causes of the disease. This latter argument can be used by surgeons, since they mechanically restore the sphincter area and, therefore, correct the most frequent defect associated with the disease. In surgery, failure of a treatment is defined as the persistence or recurrence of symptoms and/or objective pathologic findings once the treatment phase is finished. In GERD, a definite failure is present when symptoms which are severe enough to require at least intermittent therapy (heartburn, regurgitation) recur after treatment or when other serious problems (slipped Nissen, severe gas bloat syndrome, dumping syndrome, etc.) arise and when functional studies document that symptoms are due to this problem. Recurrence can occur with or without esophageal damage (esophagitis). Professor Blum (Lausanne) suggested that further long-term outcome studies of medical and surgical treatment are needed. Quality-of-life measurements are able to differentiate whether and to what extent recurrent symptoms are really impairing the patients quality of life. It was agreed upon that a distinction is necessary between the two types of failures of the operation: the unhappy 510% (i.e. slipped Nissen, etc.) and the 1040% of individuals who only become aware of their dyspeptic symptoms postoperatively while the reflux-related symptoms are treated. Dyspeptic symptoms occur in the normal population in 2040% [174b]. Some of the postfundoplication symptoms are present already before the operation and are due to the dyspeptic symptomatology associated with GERD. Patients with failures should be worked up with the available diagnostic tests to detect the underlying cause of the failure. If there is mild recurrent reflux, it usually can be treated by medication as long as the patient is satisfied with this solution and his/her quality of life is good. In the case of severe symptomatic recurrent reflux or other complications, and if endoscopy shows visible esophagitis, the indication for refundoplication after a thorough diagnostic workup must be established. Surgeons very experienced in pathophysiology, diagnosis, and the surgical technique of

418 Table 2a. Ratings of published literature on antireflux operations and medical treatment: strength of evidence in the literature-antireflux operations Study type Clinical randomized controlled studies with power and relevant clinical endpoints Cohort studies with controls prospective, parallel controls prospective, historical controls Case-control studies Cohort studies with literature controls Analysis of databases Reports of expert committees Case series without controls Anecdotal reports Belief Strength of evidence III II References 202, 203, 246, 274 32, 37, 49, 80, 87, 110, 130, 147, 163, 188, 217, 221, 272, 274, 281 3, 4, 12, 19, 22, 36, 44, 47, 49, 55, 60, 61, 63, 72, 73, 95, 89, 107, 113, 126, 132, 159, 162, 163, 177, 184, 187, 190, 192, 208, 212, 213, 216, 219, 237, 255, 267 Numerous

Table 2b. Ratings of published literature on antireflux operations and medical treatment: strength of evidence in the literature-medical treatment Study type Clinical randomized controlled studies with power and relevant clinical endpoints Cohort studies with controls prospective, parallel controls prospective, historical controls Case-control studies Cohort studies with literature controls Analysis of databases Reports of expert committees Case series without controls Anecdotal reports Belief Strength of evidence III References 10, 17, 24, 26, 39, 56, 70, 112, 115, 116, 120, 121, 139, 151, 161, 168, 171, 180, 189, 202, 223, 224, 227, 228, 240, 244, 246, 263, 265, 268, 270, 274, 282, 284 3, 6, 23, 29, 38, 85, 101, 130, 135, 139

II

I 0

16, 23, 50, 72, 117, 123, 135, 152, 157, 172, 174, 200, 229, 241, 260, 264 Numerous

the disease should perform these redo operations. Expert management of patients undergoing redo surgery for a benign condition is of extreme importance. 9. What are the issues in an economic evaluation? With respect to a complete economic evaluation the panelists refer to the available literature [14a, 76a]. Cost, cost minimization, and cost-effectiveness analyses of gastroesophageal reflux disease must take into account the following issues (list incomplete): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Costs of medications Costs of office visits Costs of routine endoscopies Frequency of sick leaves at work Frequency of restricted family or hobby activity at home Assessment of job performance and restrictions due to the disease Costs of diagnostic workup including functional studies and specialized investigations Costs of surgical intervention Costs for treatment of surgical complications Costs of treatment of complications of maintenance medical therapy, such as emergency hospital admissions, e.g., swallowing discomfort, bolus entrapment in peptic stenoses

11. Perspective of the analysis (patient, hospital, society) 12. Health care system (socialized, private) A special issue is the so-called break-even point between medical and surgical treatment (duration and cost of medical treatment vs laparoscopic antireflux treatment) [21b]. Ultimately, the results of medical or surgical treatment, especially with respect to age of the patient, should be translated into quality-adjusted life-years (QALYs) to differentiate which treatment is better for what age, comorbidity, and stage of disease. Literature list with ratings of references All literature submitted by the panelists as supportive evidence for their evaluation was compiled and rated. The ratings of the references are based on the panelists evaluation. The number of references is incomplete for the case series without controls and anecdotal reports. The result of the panelists evaluation is given in Table 2a for the endoscopic antireflux operations and in Table 2b for medical treatments (all options). The consensus statements are based on these published results. A complete list of all references mentioned in Table 2a and 2b is included. Question 1. What stage of technological development are endoscopic antireflux operations at (in June 1996)? The definitions for the stages in technological development follow the recommendations of the Committee for Evaluat-

419 Table 3. Evaluation of the status of endoscopic antireflux surgery 1996: level attained and strength of evidence Level attained/ strength of evidenceb II II 0I II III 0 Yes

Stages in technology assessmenta 1. Feasibility Technical performance, applicability, safety, complications, morbidity, mortality 2. Efficacy Benefit for the patient demonstrated in centers of excellence Benefit for the surgeon (shorter operating time, easier technique) 3. Effectiveness Benefit for the patient under normal clinical conditions, i.e., good results reproducible with widespread application 4. Costs Benefit in terms of cost-effectiveness 5. Ethics Issues of concern may be: long operation times, frequency of thrombo-embolization, incidence of reoperations, altered indication for surgery, etc.c 6. Recommendation

Consensus in %c 64 (7/11) 64 (7/11) 67 (6/9) 60 (6/10) 70 (7/10) 57 (4/7) 100 (11/11)

a Mosteller F (1985) Assessing Medical Technologies, National Academy Press, Washington, DC [190a]: and Troidl H (1995) Endoscopic Surgerya Fascinating Idea Requires Responsibility in Evaluation and Handling. Minimal Access Surgery, Surgical Technology International III (1995) pp 111117 [265a]. b Level attained to the definitions of the different grades. c Percentage of consensus was calculated by dividing the number of panelists who voted 0, I, II or III by total number of panelists who submitted their evaluation forms.

Table 4a. Antireflux surgery vs open conventional procedures: evaluation of feasibility parameters by all panelists at CDC in Trondheim* Assessment based on evidence in the literature Stages of technology assessment Feasibility Safety/intraop. adverse events Gastric or esophageal leaks/ perforations Hiatal entrapments of gastric warp with necrosis Vascular injury, bleeding, splenic injury Emphysema Operation time Postoperative adverse events Bleeding Wound infection Reoperation Warp disorders Hernias of abdominal wall Thrombosis/pulmonary embolism Mortality * Footnotes explained in Table 4b. 3 1 1 3 2 6 2 1 6 3 3 Definitely bettera Probably better Similar Probably worse Definitely worse Consensusb Strength of evidencec 0III

1 1 2 1 4

6 9 5 3 3 8 2 6 8 2 6 7

4 1

4 5

2 1

55% (6/11) similar 82% (9/11) similar 55% (6/11) better 60% (6/10) worse 67% (6/9) worse 73% (8/11) similar 82% (9/11) better 55% (6/11) similar 73% (8/11) similar 82% (9/11) better 55% (6/11) similar 70% (7/10) similar

III III III II II III III III III III I III

3 2

420 Table 4b. Antireflux surgery vs open conventional procedures: evaluation of efficacy parameters by all panelists prior to CDC in Trondheim Assessment based on evidence in the literature Stages of technology assessment Efficacy Postoperative pain Postoperative disorders Bloating Flatulence Dysphagia Recurrent reflux Hospital stay Return to normal activities and work Cosmesis Effectiveness (overall assessment)
a

Definitely bettera 6

Probably better 4

Similar

Probably worse

Definitely worse

Consensusb 100% (10/10) better

Strength of evidencec IIII III III III III III III III III III

9 10 9 10 4 7 7 1 7 3 2 5 1 2 4

1 1 2

90% (9/10) similar 91% (10/11) similar 82% (9/11) similar 100% (10/10) similar 100% (10/10) better 91% (10/11) better 82% (9/11) better 60% (6/10) better

Comparison: laparoscopic fundoplication techniques vs open conventional procedure. Percentage of consensus was calculated by dividing the number of panelists who voted better (probably and definitely), similar, or worse (probably and definitely) by the total number of panelists who submitted their evaluation forms. c Refer to Table 1.
b

ing Medical Technologies in Clinical Use (190a) (Mosteller F., 1985) extended by criteria introduced by Troidl (1995). The panels evaluation as to the attainment of each technological stage by endoscopic antireflux surgery, together with the strength of evidence in the literature, is presented in Table 3. Technical performance and applicability were demonstrated by several authors as early as 1992/1993. The results on safety, complications, morbidity, and mortality data depend on the learning phase (>50 cases) of the operations. The complication, reoperation, and conversion rates are higher in the first 20 cases of an individual surgeon. It is strongly advocated that experienced supervision be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures [278,a,b]. Data on efficacy (benefit for the patient) demonstrated in centers of excellence were based on type II studies. The benefit for the surgeon in terms of elegance, ease, and speed of the procedure is not yet clear cut. The operation time is the same or longer, and the technique is harder initiallyhowever, the view of the operating field is better. The effectiveness data are still insufficient, long-term results are missing, and the results reported come mainly from interested centers and multicenter studies. It is important to audit continually the results of antireflux operations, especially because different techniques are used. The economic evaluation of laparoscopic antireflux surgery is still premature (few data from small studies only). Future studies are recommended in different health care systems, assessing the relative economic advantages of laparoscopic antireflux surgery in comparison to the available and paid medical treatment. A major issue of ethical concern is the altered indication for surgery. A change of indication might produce more cost and harm in inappropriately selected patients. Laparoscopic

antireflux surgery should be recommended in centers withsufficient experience and an adequate number of individuals with the disease. Randomized controlled studies are recommended to compare medical vs laparoscopic surgical treatment and partial vs total fundoplication wraps. Question 2. What is the current status of laparoscopic antireflux surgery vs open conventional procedures in terms of feasibility and efficacy parameters? A table with specific parameters relevant to open and laparoscopic antireflux procedures summarizes the current status (Table 4). The evaluation is mainly based on type I and type II studies (see list of references). The results show that safety is comparable and rather favorable compared to the open technique. The incidence for complications, morbidity, and mortality is similar to the open technique once the learning phase has been surpassed. For specific intraoperative and postoperative adverse events see Table 4. In terms of efficacy, significant advantages of the endoscopic antireflux operations are: less postoperative pain, shorter hospital stay, and earlier return to normal activities and work. In general, laparoscopic antireflux surgery has advantages over open conventional procedures if performed by trained surgeons. Laparoscopic antireflux surgery has the potential to improve reflux treatment provided that appropriate diagnostic facilities for functional esophageal studies and adequately trained and dedicated surgeons are available.
Acknowledgments. The organizers would like to thank the panelists of the

421 conference for their tremendous work and input in reaching these consensus statements. We appreciate very much the time and energy spent to make the conference possible. The organization of the conference was only possible with the generous support of Professor Myrvold (Trondheim), the excellent assistance of Mrs Karin Nasskau (Cologne) and Dr. Rolf Lefering (Cologne) who strongly supported the conference evaluations. Thanks also to the E.A.E.S. for their financial support and to Professor Myrvold, the President of the 4th International Conference of the E.A.E.S. for enabling and supporting the conference. gastroesophageal reflux: laparoscopic placement of the Angelchik prosthesis in pigs. Surg Endosc 5: 123126 21a. Bonavina L, Bardini R, Baessato M, Peracchia A (1993) Surgical treatment of reflux stricture of the esophagus. Br J Surg 80: 317 21b. Boom VDG, Go PMMYH, Hameeteman W, Dallemagne B (1996) Costeffectiveness of medical versus surgical treatment in patients with severe or refractory gastroesophageal reflux in the Netherlands. Scand J Gastroenterol 31: 19 22. Bittner HB, Meyers WC, Brazer SR, Pappas TN (1944) Laparoscopic Nissen fundoplication: operative results and short-term follow-up. Am J Surg 167: 193200 23. Blum AL (1990) Treatment of acid-related disorders with gastric acid inhibitors: the state of the art. Digestion 47: 310 24. Blum AL (1990) Cisapride prevents the relapse of reflux esophagitis. Gastroenterology 98: A22 25. Blum AL, The EUROCIS-trialists (1990) Cisapride reduces the relapse rate on reflux esophagitis. World Congress of Gastroenterology, Sydney, Australia 26. Blum AL, Adami B, Bouzo MH (1991) Effect of cisapride on relapse of esophagitis. A multinational placebo-controlled trial in patients healed with an antisecretory drug. Dig Dis Sci 38: 551560 27. Bonavina L, Evander A, DeMeester TR, Walther B, Cheng SC, Palazzo L, Concannon JL (1986) Length of the distal esophageal sphincter and competency of the cardia. Am J Surg 151: 2534 28. Brossard E, Monnier PH, Olhyo JB (1991) Serious complications stenosis, ulcer and Barretts epitheliumdevelop in 21.6% of adults with erosive reflux esophagitis. Gastroenterology 100: A36 29. Brunner G, Creutzfeldt W (1989) Omeprazole in the long-term management of patients with acid-related diseases resistant to ranitidine. Scand J Gastroenterol 24: 101105 30. Cadiere GB, Houben JJ, Bruyns J, Himpens J, Panzer JM, Gelin M (1994) Laparoscopic Nissen fundoplication: technique and preliminary results. Br J Surg 81: 400403 31. Cadiere GB, Himpens J, Bruyns J (1995) How to avoid esophageal perforation while performing laparoscopic dissection of the hiatus. Surg Endosc 9: 450452 32. Cadiere GB, Bruyns J, Himpens J, Vertuyen M (1996) Intrathoracic migration of the wrap after laparoscopic Nissen fundoplication. Surg Endosc 10: 187 33. Castell DO (1985) Introduction to pathophysiology of gastroesophageal reflux. In: Castell DO, Wu WC, Ott DJ (eds) Gastrooesophageal reflux disease: pathogenesis, diagnosis, therapy. Future, New York, pp 39 34. Castell DO (1994) Management of gastro-esophageal reflux disease 1995. Maintenance medical therapy of gastro-esophageal reflux which drugs and how long? Dis Esophagus 7: 230233 35. Cederberg C, Andersson T, Skanberg I (1989) Omeprazole: pharmacokinetics and metabolism in man. Scand J Gastroenterol 24: 3340 36. Champault G (1994) Gastroesophageal reflux. Treatment by laparoscopy. 940 casesFrench experience. Ann Chir 48: 159164 37. Champion JK, Mc Kernan JB (1995) Technical aspects for laparoscopic Nissen fundoplication. Surg Technol Int IV: 103106 38. Chiban N, Wilkinson J, Hurst RH (1943) Symptom relief in erosive GERD, a meta-analysis. Am J Gastroenterol 88: 9 39. Chopra BK, Kazal HL, Mittal PK, Sibia SS (1992) A comparison of the clinical efficacy of ranitidine and sucralfate in reflux oesophagitis. J Assoc Physicians India 40: 162163 40. Clark GWB, Jamieson JR, Hinder RA, Polishuk PV, DeMeester TR, Gupta N, Cheng SC (1993) The relationship of gastric pH and the emptying of solid, semisold and liquid meals. J Gastrointest Mot 5: 273279 41. Cloud ML, Offen WW, Robinson M (1994) Nizatidine versus placebo in gastro-oesophageal reflux disease: a 12-week, multicentre, randomised, double-blind study. Br J Clin Pract 76: 310 42. Cloyd DW (1994) Laparoscopic repair of incarcerated paraesophageal hernias. Surg Endosc 8: 893897 43. Coley CR, Bang MJ, Spechler SJ, Williford WO, Mulley AG (1993) Initial medical vs surgical therapy for complicated or chronic gastroesophageal reflux disease. A cost effectiveness analysis. Gastroenterology 104: A5 44. Collard JM, de Gheldere CA, De Kock M, Otte JB, Kestens PJ (1994) Laparoscopic antireflux surgery. What is real progress? Ann Surg 220: 146154 45. Collard JM, Romagnoli R, Kestens PJ (1996) Reoperation for unsat-

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Editorial
Surg Endosc (1997) 11: 411412

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Genetic susceptibility testing

A challenge for the surgeon endoscopist
During the last five years, an explosion in interest and information relative to human susceptibility to cancer has centered on the molecular geneticists ability to recognize genes and gene mutations that can be readily measured in individuals who may be at risk for a variety of solid tumors. Using complex analyses of patient populations and sophisticated techniques of linkage analysis, clusters of familial cancers have been identified involving Multiple Endocrine Neoplasia (MEN syndrome), retinoblastoma (RB1 gene), and ataxia-telangiectasia (AT gene). The identification of these gene mutations has become standard in managing these diseases and in revealing family members at risk who may benefit from surveillance testing or early prophylactic surgical ablation (e.g., medullary carcinoma of the thyroid). Of interest to the general surgeon, and to all of us managing breast cancer, has been the recent cloning of the BRCA1 (chromosome 17) and BRCA2 (chromosome 13) mutated genes which may account for 510% of breast cancer in the United States [4]. These genes seem to function as altered tumor suppressor genes and, therefore, allow breast cancer to become likely in the host unfortunate enough to manifest this genotype. Identification of the BRCA1 mutation has not only highlighted a group of women with an 80% lifetime risk of breast cancer, but has shown that those affected also have a 4050% chance of being diagnosed with ovarian cancer during their lifetime (the Hereditary Breast-Ovarian Cancer syndrome) [2]. Furthermore, high risk groups such as Ashkenazi Jewish women may harbor these mutated genes at rates that far exceed the incidence noted in the general population. Indeed, a specific mutation of the BRCA1 gene (185 del AG) has been noted in Jewish women of Eastern European extraction [5]. In addition to the Breast and Ovarian Cancer Story, the culmination of many years of genetic sleuthing, especially by Henry Lynch and co-workers in Omaha, has now revealed the genotypic basis for the Hereditary NonPolyposis Colon Cancer (HNPCC) syndrome [3]. These patients with primary colonic cancer (Lynch I) may have multiple primary colonic tumors with 5060% of these found in the proximal colon. Colonic cancer in these patients is generally manifested in the mid-50 age group. An even more significant group (Lynch II) not only develops colonic cancer, but also manifests other solid tumors found in the proximal gastrointestinal tract and genitourinary system. HNPCC has now been identified in familial clusters by the identification of genes that cause mismatching of DNA sequences (a different mechanism than tumor suppression) [1]. These genes (MSH2, MLH1, PMS1, PMS2) while only accounting for perhaps 46% of colonic cancer burden in the United States, have become important because their recognition has identified a population group that may benefit from early surveillance and potential prophylactic colectomy. While this group may not show the same penetrance (>90%) as seen in Familial Adenomatous Polyposis characterized by the APC gene mutation on chromosome 5, the recognition of individuals at risk for HNPCC is predicted on our ability as clinicians to identify individuals who may display the genotype which causes mis-matching of DNA sequences. Recently, a variety of collaborative groups have begun setting standards for recommending patients for genetic testing in the clinical setting. In regard to the HNPCC, the International Collaborative Group on HNPCC [6] (the Amsterdam criteria) and a more recent commission (the Bethesda criteria) have recommended testing when three or more relatives are identified with colonic cancer and this malignancy is seen in at least two generations. Early age of onset (between 40 and 50) should also strongly suggest genetic counseling and testing. The implications and ramifications of genetic identification of high-risk individuals should be self-evident to all of us in the practice of surgery and surgical endoscopy. Not only do we have a responsibility to identify patients at risk from genetic breast and colon cancer by taking complete histories (two or three generation assessments and recording the age of onset of familial cancer), but we must take a leadership position as to the role of endoscopy and other methods of surveillance in these high-risk populations. Our ultimate responsibility as clinicians will be in the utilization of prophylactic maneuvers (mastectomy with reconstruction and colectomy) as a way of obviating the devastating consequences before the ultimate end result of gene penetrance is observed. Since the most difficult issues referable to gene testing relate to problems of insurability and job protection for those identified with genetic susceptibility to cancer, we, as organizations and as individuals, must be willing to support positive legislative issues and involve ourselves in appropriate policy making enclaves when called upon. The new and exciting concepts of genetic oncology represent the ultimate in translational research from laboratory to bedside. Although there are a myriad of questions to ask and answers to seek in this new genre of medicine, we as leaders in the

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surgical and endoscopic arena must be willing and able to carry on a dialogue. References
1. Bronner CE, Baker SM, Morrison PT, et al. (1994) Mutation in the DNA mismatch repair gene homologue hMLH1 is associated with hereditary non-polyposis colon cancer. Nature 368: 258 2. Lerman C, Narod S, Schulman K, et al. (1996) BRCA 1 testing in families with hereditary breast-ovarian cancer. A prospective study of patient decision making and outcomes. JAMA 275: 18851892 3. Lynch HT, Smyrk TC, Watson P, et al. (1993) Genetics, natural history, tumor spectrum and pathology of hereditary non polyposis colorectal cancer: An updated review. Gastroenterology 104: 1535 4. Miki Y, Swensen J, Shattuck-Edens D, et al. (1994) A strong candidate

for the breast and ovarian cancer susceptibility gene BRCA 1. Science 266: 66 5. Modan B, Gak E, Sade-Bruchim R. (1996) High frequence of BRCA 1 185 del AG mutation in ovarian cancer in Israel. JAMA 276: 1823 1825 6. Vasen HFA, Mecklin J-P, Khan PM, Lynch HT (1991) The International Collaborative Group on Hereditary Non-Polyposis Colorectal Cancer CICG-HNPCC. Dis Colon Rectum 34: 424

F. L. Greene
University of South Carolina School of Medicine Columbia, SC 29208 USA

Surg Endosc (1997) 11: 485487

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Successful treatment of a rectal anastomotic stenosis by transanal endoscopic microsurgery (TEM) using the contact Nd:YAG laser
K. Kato,1 T. Saito,2 M. Matsuda,1 M. Imai,1 S. Kasai,1 M. Mito1
1 2

Second Department of Surgery, Asahikawa Medical College, 4-5 Nishi-Kagura, Asahikawa, 078 Japan Department of Surgery, Higashi-Asahikawa Hospital, Kita 1-6 Higashi-Asahikawa, Asahikawa, 078 Japan

Abstract. We report the advantage of employing transanal endoscopic microsurgery (TEM) using the contact Nd:YAG laser for the treatment of a rectal anastomotic stenosis. A 72-year-old woman was admitted to our hospital with a postoperative rectal anastomotic stenosis. Twenty months prior to admission, the patient underwent a low anterior resection for the treatment of the rectal cancer using an EEA stapling device. A barium enema and colonoscopy revealed a rectal stenosis, 0.8-cm diameter. This stenosis was at the anastomotic site, approximately 4.0 from the dental line. An endoscopic treatment was performed transanally using the contact Nd:YAG laser. The stenotic rectal wall was fulgurated or vaporized completely. There were no intraoperative or postoperative complications. We concluded that TEM appears to be a safe and minimally invasive procedure. Furthermore, the contact Nd:YAG laser is very effective in treating the gastrointestinal stenotic area. To our knowledge, this is the first successful report of this novel procedure. Key words: Postoperative anastomotic stenosis Transanal endoscopic microsurgery (TEM) Contact Nd:YAG laser

postoperative anastomotic rectal stenosis which was successfully treated with TEM using the contact Nd:YAG laser. Case report
A 72-year-old women experienced lower abdominal pain for several months. She presented herself to a medical doctor because of constipation and abdominal pain. She was admitted to our hospital with a postoperative rectal stenosis. She had undergone a low anterior resection 20 months prior to admission for treatment of her rectal cancer. The end-to-end anastomosis was performed using a PCEEA-28 (United States Surgical Corporation, Norwalk, CT, USA). A barium study (Fig. 1A) and colonoscopy (Fig. 1B) showed the rectal stenosis, 0.8-cm diameter, located 4.0 cm from the dental line. Computed tomography and ultrasonography demonstrated no evidence of rectal cancer local recurrence. In addition, there was no evidence of postoperative anastomotic leakage or significant adhesions on the anastomotic sites. There had been attempts to treat the stenosis with a bougienage or balloon dilation, but these treatments were unsuccessful. Our operative strategy was treatment by TEM using the contact YAG laser.

Surgical instruments
Transanal endoscopic microsurgery (TEM; Wolf, Knittlingen, Germany). All instruments used were specially designed for endoscopic work. As with other forms of endoscopic surgery, the operative field was visualized using a rigid scope connected to video monitors (Fig. 2) [1, 2].

Endoscopic surgery currently is being used to perform cholecystectomies, appendectomies, bowel resections, and gastrectomies. This minimally invasive surgery is favored because it decreases the patients pain and length of hospitalization. The anatomical structure of the pelvis makes it difficult to administer local treatment in the rectum when the lesion is some distance from the anal verge. A new, minimally invasive technique for resection of rectal lesions was developed by Bue et al. [1, 2]. A 40-mm-diameter rectoscope permits surgical treatment under stereoscopic control in a gas-distended rectal cavity (transanal endoscopic microsurgery; TEM). We present a case report of a
Correspondence to: K. Kato

Neodymium yttrim aluminum garnet laser (Nd:YAG laser)

The SLT Contact Nd:YAG Laser system (Surgical Laser Technologies Inc., Malvern, PA, USA) was used [3]. The Nd:YAG laser produces light close to the infrared (invisible) portion of the spectrum (wavelength) [] 1.064 nm). The laser was delivered through a 300-m core flexible quartzfiber casing. The average laser is capable of delivering a maximum energy of 35 W (continuous wave). During laser treatment the suction tubing was placed proximal to the fiber tip for adequate smoke removal (Fig. 3) [8, 10]. This enabled us to maintain a visually clear operative field.

Operative procedure
The rectoscope was introduced into the rectum using an obturator. The glass window was inserted to the end of the rectum, and the stenosis was visualized once the rectum was distended by air insufflation. After obtain-

486

Fig. 1. A Barium enema showing a rectal anastomotic stenosis which is visualized 4.0 cm from the anal verge. Arrow: staplers. B Colonoscopy showing a rectal stenosis, 0.8-cm diameter. No local recurrence was found.

ing optimal positioning, the endoscope was fixed with a Martin arm (Fig. 2B). The rectal stenosis was released using the SLT contact Nd:YAG laser with a power setting of 5 W. There was no bleeding, and a smoke-free visual field was easily maintained. The laser light coagulated and vaporized the stenotic region of the rectum. The diameter of the anastomotic site was 2.0 cm following treatment (Fig. 4). The operative time was 30 min. The patients postoperative course was uneventful, and she was discharged 5 days after surgery. During a followup examination 9 months later, she reported no recurrent symptoms.

Discussion Mechanical staplers have a wide application in gastrointestinal surgery. The circular end-to-end stapler has proven to be especially useful for low anterior anastomoses following colon resection [5]. Strictures at the anastomotic site may occur, however, following the use of end-to-end anastomosis (EEA) stapling instruments for colorectal surgery [9, 11]. To date, non-neoplastic stenoses of the GI tract have been treated conservatively with bougies, balloon dilation, or electrocautery under endoscopy. If conservative measures fail, operative resection of the stenotic area may be necessary. Bougienage is often unsuccessful. There is a risk of perforation at the site of dilation, and results are often temporary. Perforation can be avoided by careful patient selection and avoidance of excessive dilation at the stricture site. In addition, surgery is associated with its own morbidity and mortality [4]. Today, minimally invasive surgery is becoming an important clinical skills, and the indications for its use are expanding. Lesions in the lower rectum often can be reached using manual equipment, i.e., the Parks retractor, but mechanical dilation may obstruct visualization, making the procedure difficult. Our use of the Nd:YAG laser to correct a rectal anastomotic stenosis to our knowledge rep-

Fig. 2. A Transanal endoscopic microsurgery system (TEM). All instruments are designed specially for endoscopic work. B After optimal positioning is obtained, the rectoscope is fixed in place with the Martin arm. The working insert is attached to the rectoscope. Sealing elements prevent gas loss when the instruments are introduced.

487

Fig. 3. SLT contact Nd:YAG laser system. A Contact laser CL-X. Nd:YAG lasers have a flexible quartz-fiber delivery system for endoscopic use. B Contact endoprobe for endoscopic Nd:YAG laser surgery.

Fig. 4. A The rectal stenosis was released using the SLT contact Nd:YAG laser with a power setting of 5 W. B There was no bleeding or smoke. C The laser light coagulated and vaporized tissue, and the diameter of the former stenotic region was 2.0 cm following treatment.

resents the first success of its kind under TEM. TEM enabled optimal visual control while working in a gasdistended rectum [1, 2]. Furthermore, with the introduction of artificial sapphire contact probes with low-power energy, one now has greatly expanded operative range. Lasers have potential application in many areas of surgery where electrocautery is routinely used. The advantages of the lowerpower contact Nd:YAG laser include an increased precision, reduced instrumentation, less damage to the adjacent tissue [8], and elimination of laser light backscatter and smoke. In addition, the excellent coagulating properties of the YAG laser greatly reduce the intraoperative blood loss. Sander et al. [7] has reported that the Nd:YAG laser was successfully used to restore patency to a stenosed anastomosis at the rectosigmoid junction following a prior colectomy. Follow-up, however, showed an ulcer which by 3 weeks had healed with appropriate reepithelialization [6]. In our case, an ulcer also occurred, but it had healed within 2 weeks without treatment. The definitive stenosis treatment can be performed by vaporizing the surrounding tissue with the contact Nd:YAG laser to sufficiently open a scarred ring. Alternately, one can use the contact-cutting endoprobes to incise the stenosis along the circumference in two to four separate areas [10]. Compared with the more extended conventional surgical techniques, TEM has several advantages. The procedure offers a painless postoperative course, unrestricted mobility, a short hospital stay, and a reduced rehabilitation time [2].

In sum, TEM with the contact Nd:YAG laser is a less invasive and more precise method for treatment of lesions in the lower rectum. References
1. Bue G, Hutterer F, Thei J, Bobel M, Isselhart W, Pichelmaier H (1988) Clinical results of transanal endoscopic microscopy. Surg Endosc 2: 7175 2. Bue G, Mentges B, Manncke K, Starlinger M, Becker HD (1992) Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg 163: 6370 3. Daiknzono N, Joffe SN (1985) Sapphire probe for contact photocoagulation and tissue vaporization. Med Instr 19: 173178 4. Mazier WP (1973) A technique for the management of low colonic anastomotic stricture. Dis Colon Rectum 16: 113116 5. Ravitch MM (1984) Varieties of stapled anastomoses in rectal resection. Surg Clin North Am 64: 543554 6. Sakako M, Iwasaki M, Konishi T (1982) Clinical application of the Nd:YAG laser endoscopy. Laser Surg Med 2: 137147 7. Sander R, Poesl H, Spuhler A (1984) Management of non-neoplastic stenosis of the GI-tract. A further indication of Nd:YAG laser application. Endoscopy 16: 149151 8. Schroder T, Brackett K, Joffe SN (1987) An experimental study of the effects of electrocautery and various lasers on gastrointestinal tissue. Surgery 101: 691696 9. Smith LE (1981) Anastomosis with EEA stapler after anterior colonic resection. Dis Colon Rectum 24: 236242 10. Stephen NJ, Schroder T (1987) Lasers in general surgery. Adv Surg 20: 125145 11. Waxman BP (1983) Large bowel anastomoses. II The circular staplers. Br J Surg 70: 6467

Surg Endosc (1997) 11: 449455

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Early experience with laparoscopic abdominoperineal resection

J. S. Wu, E. H. Birnbaum, J. W. Fleshman
Section of Colon and Rectal Surgery, Department of Surgery, Jewish Hospital, Washington University School of Medicine, 216 S. Kingshighway, St. Louis, MO 63110, USA Received: 23 April 1996/Accepted: 8 July 1996

Abstract Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (SEM) operative time and blood loss for completed and converted LAPR were 239 11 min and 424 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 144-month followup, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients.

Key words: Laparoscopic surgery Abdominoperineal resection Rectal cancer Anal cancer

The first laparoscopic colon operations were performed by several groups of surgeons in 1990. Jacobs et al. reported the first laparoscopic-assisted right colectomy in a patient with an intermittent cecal volvulus in July 1990 [9]. After laparoscopic mobilization and transection of the right colon, the anastomosis was performed outside the abdominal cavity through a minilaparotomy. In late 1990, Fowler and White performed the first laparoscopically assisted left colon resection [6] and Phillips et al. performed the first complete intracorporeal laparoscopic colon resection [16]. Soon afterward, in 1992, Sackier [17] and Coller [3] described the technique of laparoscopic abdominoperineal resection (LAPR). The rectum was cleanly dissected down to the levator muscle and then resected and removed by the perineal approach. The indications for laparoscopic colorectal resections quickly expanded from benign diseases to include malignancies. Shortly thereafter, many surgeons began reporting LAPR as a treatment for rectal cancer [2, 4, 8, 10] and anal cancer [20]. Decanini et al. have documented the feasibility of an oncologic laparoscopic abdominoperineal resection [5]. These operations are technically demanding procedures because of the need to mobilize the left colon and splenic flexure, ligate its mesenteric blood supply proximally, and perform a complete mesorectal excision deep into the pelvis. Successful completion of each of these components of the operation depends on advanced laparoscopic skills which include the ability to operate from multiple viewpoints and to recognize anatomy from unfamiliar aspects, familiarity with complex laparoscopic surgical instrumentation, and facility in vascular dissection and control. In this study, we examined the feasibility and early clinical outcomes of LAPR for rectal and anal cancer as well as inflammatory bowel disease. Materials and methods
Between July 1992 and February 1996, 21 patients underwent attempted LAPR. The indications for the operation included rectal adenocarcinoma

Poster presentation at the 5th World Congress of Endoscopic Surgery of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, 1317 March 1996 Correspondence to: J. W. Fleshman

450 Table 1. Prior abdominal operations in 21 patientsa No. of patients Prior abdominal operations None TAH/BSO Cholecystectomy Vagotomy and pyloroplasty Appendectomy Subtotal colectomy and ileostomy Subtotal colectomy and ileoanal anastomosis
a b

Total 12 3 2 1 1 1 1

LAPRb 9 3 2 0 1 1 1

CAPRc 3 0 0 1 0 0 0

Mean SEM. LAPR laparoscopic abdominoperineal resection. c CAPR converted to open abdominoperineal resection.

(14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease involving the rectum (two patients), and rectal melanoma (one patient), all proven by biopsy. The mean age (SEM) was 65 4 years (range, 2687). There were 13 female and eight male patients in this series. Nine patients had previous abdominal surgery (listed in Table 1). All patients underwent conventional preoperative mechanical and antibiotic bowel preparation. Patients with rectal and anal cancer were all treated preoperatively with pelvic radiation with or without chemotherapy. The decision to perform an APR was based on deep tumor invasion into the anal sphincter or tumor so close to the anoderm as to prevent coloanal reconstruction. The patients with anal squamous cell carcinoma had recurrent or persistent disease after chemoradiation. The APR was performed as salvage in these patients. The patient with anal melanoma elected to have an APR rather than observation after local excision with close deep margins. The two patients with inflammatory bowel disease underwent endoanal perineal dissection of the distal rectumone for anal Crohns disease with rectovaginal fistula and one for retained rectal stump after total abdominal colectomy with ileostomy for indeterminate colitis (patient refused a pelvic pouch procedure). Twelve patients with bulky T3 and/or N1 adenocarcinoma of the rectum received preoperative adjuvant radiation therapy which consisted of 4,500 cGy in 25 fractions of 180 cGy, using 18 MeV photons, delivered over a 5-week period. The radiation treatment was delivered to the pelvis (with the distal margin extended at least 5 cm caudad to the tumor) using a four-field-box technique with AP/PA apposed and bilateral ports. Following the radiation, patients underwent a rest period of 67 weeks before surgery to allow recovery of normal tissues and tumor shrinkage. In addition to radiation treatment, three of these 12 patients received chemotherapy with 5-FU infusion during the first and last weeks of preoperative radiation as part of a randomized protocol at our institution. There is a subset of patients with T3 rectal lesions that are not deeply tethered; two patients in our series fit this description and received preoperative radiation treatment consisting of 2,000 cGy in five fractions of 400 cGy delivered over a 1-week period followed by immediate surgery (within 3 days). The four patients with anal squamous cell carcinoma all received preoperative adjuvant radiation therapy which consisted of 3,000 cGy in 15 fractions, using 6-MeV photons delivered over a 3-week period. The radiation treatment was delivered to the anus and pelvis using a four-fieldbox technique (AP, PA, and bilateral ports). In addition, all patients received concomitant chemotherapy with infusional 5-FU and mitomycin C or cisplatin during the first and last weeks of radiation treatment. This was followed by an anal boost with cobalt 60 via an en face portal for 2,000 cGy in ten fractions for 2 weeks. Following this, patients underwent a rest period of 67 weeks prior to surgery.

positions: right lower quadrant, left lower quadrant, left lower rectus abdominis region, and suprapubic area. The patient was airplaned to the left and placed in steep Trendelenburg. While retracting the sigmoid colon medially and cephalad with an atraumatic Babcock clamp, the lateral and pelvic peritoneal attachments were sharply incised using curved cautery scissors dissection (Fig. 1). As the sigmoid and distal descending colon were mobilized along the white line of Toldt, the ureter was identified and seen crossing the iliac artery. The splenic flexure of the colon was then mobilized from the left upper quadrant and the omentum while the patient was in reverse Trendelenburg position (Fig. 2). The peritoneum overlying the sigmoid mesentery was scored with curved electrocautery along the right side, anterior to the aorta from the pelvic brim cephalad. The inferior mesentery artery was identified, dissected free, and divided either proximally at the aorta for oncologic indications (Fig. 3) or at the superior hemorrhoidal artery for inflammatory bowel disease. The mesenteric vessels at the level of the planned proximal resection were then divided with cautery and clips to control the marginal vessels up to the descending colon. The colon was divided at the left colon sigmoid junction with a cutting stapler introduced through the left rectus abdominis port (Fig. 4). The rectal dissection began posteriorly in the avascular plane between fascia propria of rectum and presacral fascia (Fig. 5). The peritoneal leaves were incised down to the peritoneal reflection anteriorly to expose the lateral ligaments. Retraction by the opposite-wall Babcock provided tension on the vascular pedicles of the lateral ligaments which were then divided with electrocautery scissors. The anterior dissection was initiated at the cul de sac behind the uterus-vagina or the prostate. A Babcock clamp through the left port provided anterior traction on the anterior pelvic structures (Fig. 6). The perineal dissection proceeded in the standard fashion. The sigmoid and rectum, now completely mobilized (freed circumferentially from the levator muscles), were extracted through the perineal wound. The perineal incision was closed in layers from the pelvic floor. While the perineal dissection was underway, the transected bowel was pulled through the left rectus abdominis colostomy site, which was also the site through which the cutting stapler was introduced (Fig. 7). This fascial defect was enlarged to accommodate the colon and two fingers. The colostomy was then fashioned in a manner identical to that used in conventional surgery. Large suction drains were placed into the pelvis through the right lower quadrant port site. All other port sites were closed with 2-0 polyglactan suture for the fascia and 4-0 suture for the skin. Bilateral ureteral stents were placed in four patients prior to operation for guidance during dissection.

Statistical analyses
The chi-square test was used to compare discrete variables, and the twotailed Students t-test was used to compare continuous data. Statistical significance was designated at p < 0.05 level. Summary data were expressed as mean standard error of the mean (SEM) or standard deviation (SD).

Pathology
All specimens were reviewed by an independent pathologist unaware of the type of procedure. The extent of the inflammatory bowel disease and tumor involvement, i.e., depth of lesions, serosa involvement, histologic margins, and number of lymph nodes, were analyzed.

Results Operative results Of the 21 attempted LAPR, 17 (81%) were completed laparoscopically and four (19%) were converted to open abdominoperineal resection (CAPR) for various reasons. These patients had rectal cancer (two), anal cancer (one), and anal melanoma (one). The reasons for converting to

Operative technique
The patient was positioned in a modified lithotomy position using Allen stirrups and a bean bag which was deflated to immobilize the patient. Pneumoperitoneum was established to 15 mmHg with CO2. An angled (30) or flexible laparoscope was placed through the umbilical 10/12-mm trocar and four additional 10/12-mm ports were placed in the following

451 Table 2. Postoperative results Postoperative daysa to: Ambulation Bowel function/flatus Bowel movement Regular diet Discharge
a b

Table 3. Complications Converted to open APR (n 4) 21 41 51 62 10 5 Type Unpaired t-test NSb NS NS p < 0.05 p < 0.02 Intraoperative: Iliac vein injury Urethral injurya Postoperative: Ileus Perineal wound infectionb Stoma necrosis Trocar site infection
a b

Completed LAPR (n 17) 1 31 41 41 52

No. of patients 2 (10%) 1 1 7 (33%) 2 3 1 1

Mean SD. NS not significant.

Patient with rectal and prostate cancer s/p prostatectomy and radiation tx. Two patients with cancer s/p chemoradiation tx; one patient with anal Crohns and rectovaginal fistula.

open were adhesions from prior abdominal surgery (one), injury to the left iliac vein requiring repair (one), poor exposure due to obesity (one), and extensive anal cancer with a sigmoid-ileal fistula which required an extended resection including a TAH/BSO with small-bowel resection (one). Additional procedures were performed in three of the 17 patients undergoing LAPR: Two patients underwent posterior vaginectomies for tumor invasion of the posterior vagina and one underwent TAH/BSO with posterior vaginectomy and partial cystectomy for tumor invading the posterior uterus, vagina, and bladder. There was no relationship between prior abdominal surgery and the need to convert to an open operation. The mean operative time (SEM; skin incision to closure) for LAPR was 240 13 min (range, 150300) as compared to 233 26 min (range, 180300) for the CAPR group. The operative times included maturation of the end colostomy and complete closure of the perineal wound but do not reflect total anesthesia time. The average blood loss was 418 50 ml (range, 2001,000) for the LAPR group and 450 33 ml (range, 300700) for the CAPR group. The mean hematocrit drop from preoperative value to that on postoperative day (POD) 1 was 9.3 4.9% compared to 3.7 0.9% for the CAPR group (p not significant). Blood transfusion was required for a postoperative hematocrit <25% in four patients in the LAPR group (24%) and one patient in the CAPR group (25%). Additional procedures were performed in three of these patients who were transfused and three had multiple adhesions from prior open abdominal operations. In a univariate analysis, there was no relationship between the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement with the length of hospitalization, complication rates, or conversion to open. Postoperative results Patients began ambulation early, whether in the LAPR or CAPR group: 16 of 17 laparoscopic patients ambulated on POD 1. However, only one of four CAPR patients was able to ambulate by day 1. Bowel function/flatus also returned in 34 days in most patients (Table 2). The LAPR group resumed regular diet significantly earlier (4 vs 6 days, p < 0.05), and they were discharged significantly sooner (POD 5 vs 10, p < 0.02) than the CAPR group. The earliest day of discharge for the LAPR group was 3 days (two patients) compared to 6 days in the CAPR group (one patient). Patients undergoing either LAPR or CAPR required pa-

tient-controlled analgesia (PCA) for an average of 2 postoperative days. Only three patients returned to work postoperatively from the LAPR group 1421 days after discharge. The remainder of the group were either retired or unemployed. Upon questioning the patients on the severity of their pain, 17/21 (81%) described it as mild, 4/21 (19%) reported moderate pain, and none complained of severe pain. Moderate pain was reported by three of the four patients in the CAPR group. All patients in the LAPR group attributed their pain to the perineal wound and not to their abdominal incisions.

Complications There was one (5%) intraoperative complication requiring conversion to open (Table 3). This was an injury to the iliac vein during posterior mobilization of the rectum. The patient had received prior chemoradiation for a large tumor and was noted to have thick, friable, and inflamed mesorectum. No permanent sequelae from the repair of the left iliac vein were noted. The other intraoperative complication was a urethral injury which occurred during the perineal dissection in a patient with prostate cancer persistent after a radical prostatectomy and an anteriorly positioned rectal cancer. The patient had received pelvic radiation. The urethral injury was repaired primarily but healed only after 8 weeks of bladder drainage and bilateral nephrostomies. Postoperatively, two patients (10%) had ileus which required nasogastric decompression and prolonged their discharges by 1 day. Only one patient (5%) had an abdominal trocar site infection after a capacitance discharge injury through the trocar. Colostomy necrosis occurred in one patient (5%) above the level of the fascia and responded to conservative, expectant management. The perineal wound was the major source of morbidity with three infected wounds (14%).

Pathologic results and follow-up The mean (SEM) length of the resected rectum and sigmoid was 43 5 cm with a range of 3370 cm, and the average distal margin was 6.0 0.7 cm. The mean number of lymph nodes in a laparoscopic specimen was 13 (range, 437). Five of the 14 patients with rectal cancer were found to have TNM stage I or II disease, seven patients were stage

452

III, and two patients had liver mets (stage IV) at the time of operation. All four of the patients with anal squamous cell cancer had recurrent or persistent stage III disease. In the patients subsequent follow-up of 144 months (Table 4), four of the 14 rectal adenocarcinoma patients (29%) died due to the progression of their stage III or IV disease (6, 7, 8, and 28 months postoperatively). One patient developed local recurrence in the posterior vaginectomy suture line after 12 months. There were no trocar site implants of tumor. Two of the four patients with anal squamous cell carcinoma died (50%)one, who had known distant disease, died 18 months postoperatively from a cerebrovascu-

lar accident and one died from widespread poorly differentiated stage IV disease 12 months after operation.

Discussion The description by W. Ernest Miles in 1908 of the abdominoperineal resection to tumors of the rectum was a landmark in the history of colorectal surgery [12]. Since the original publication, only minor modifications in the surgical technique have been introduced. With the introduction of laparoscopy into the surgical armamentarium, a new approach to

453

Fig. 1. Mobilization of the sigmoid. Fig. 2. Mobilization of the splenic flexure. Fig. 3. Ligation of proximal inferior mesenteric artery. Fig. 4. Division of the left colon sigmoid junction with a cutting stapler. Fig. 5. Posterior mobilization of the rectum. Fig. 6. Anterior dissection of the rectum. Fig. 7. Formation of colostomy through the left rectus abdominis.

the Miles procedures has been developed, i.e., laparoscopic abdominoperineal resection. Nevertheless, experience in laparoscopic rectal surgery remains in its infancy. To date, no prospective randomized trial to compare it to its open counterpart has been reported. In our study, we found that laparoscopic pelvic dissection of the rectum was technically feasible in 81% of our attempts, despite preoperative radiation therapy in many cases, and could be performed adequately for a variety of disease, including rectal cancer, anal cancer, and inflammatory bowel disease, even when patients had prior abdominal operations. We agree with other authors who believe that

the view provided in the pelvis by laparoscopy is significantly better than at laparotomy and allows excellent anatomical definition and meticulous dissection [4, 10]. The cancer-bearing area could be widely excised in the combined perineal phase. Preoperative radiation therapy did not affect the conduct of the procedure at all. There were no intraoperative complications which could be related to the use of radiation alone in these patients. However, one of the two patients who received chemotherapy during the preoperative radiation suffered an iliac vein laceration during dissection in a thickened, friable rectosigmoid mesentery. Postoperatively,

454 Table 4. Outcome of cancer treatment Rectal adenocarcinoma No. of patients Follow-up (mean months, range) Local recurrence (n) Trocar site implants (n) Distant recurrence (n) Died of diseaseb mean postop months
a b c

Anal squamous cell carcinoma 4 18 (434) 2 (50%) 2 (50%)c 20

Anal melanoma 1 4

14 17 (144) 1 (7%)a 2 (14%) 4 (29%) 12

One year postop in vaginal cuff after LAPR and posterior vaginectomy. Stage III or IV at operation. One patient died from cerebral vascular accident with distant disease; one patient died from liver and lung metastases.

two of the four anal carcinoma patients and one of the 14 rectal carcinoma patients developed perineal wound complications. The latter patient preoperatively received 4,500 cGy without any chemotherapy. It is conceivable that preoperative adjuvant chemoradiation therapy may increase perineal wound breakdown or infection. Postoperative recovery was rapid, with return of bowel function within 34 days in most patients. All patients had early ambulation, quick resumption of oral intake, reduced postoperative pain, and improved cosmesis with small wounds. The stoma was very conveniently constructed through the left lower rectus abdominis port site. Most patients were discharged from the hospital 46 days postoperatively, a much shorter postoperative stay than usually reported [15]. It was not surprising to find that if patients were converted to an open procedure, the postoperative recoveries (including resumption of a regular dietwhich depended on stoma functionand length of hospital stay) were significantly longer than those for the successfully completed laparoscopic group. The earliest day of discharge for the LAPR group was 3 days (two patients). These patients had full return of bowel function and tolerated solid foods on POD 2. Overall, our peri- and postoperative data (operative time, return of bowel function, and length of hospital stay) were comparable to other small series of LAPR [4, 7] and confirm the feasibility of the laparoscopic approach. LAPR was designated as an 8.1 (moderate) on a 115 complexity scale [7]. Geis et al. proposed prerequisites for safe and efficient performance of a variety of laparoscopic colorectal procedures to reflect the complexities of each procedure; the prerequisite for a LAPR was proficiency in laparoscopic appendectomy, right colon resection, and sigmoid colon resection [8]. These procedures should enable the surgeon to gain experience in mobilization and devascularization. Geis and Kim also reported a reduction of their LAPR operative times to 85145 min using a two-team laparoscopic approach at the same time diminishing the complexity rating to a 5.0 from 8.1 [7]. A major concern regarding laparoscopic colorectal surgery for malignant disease is the adequacy of tumor excision [17]. Total mesorectal excision is important for prevention of local recurrences in rectal cancer [11]. In our study, we found a mean of 13 lymph nodes in our resected

rectal cancer specimen. Scott and Grace, using a meticulous mesenteric fat clearance technique, reported that in order to accurately stage 90% of colorectal cancers, a retrieval of at least 13 lymph nodes from the specimen was necessary [18]. This does not mean that a specific number of excised lymph nodes guarantees that an oncologic resection was properly performed but it does mean that a specific number of lymph nodes are necessary to stage the tumor accurately. The only number of lymph nodes which might prove that an oncologic resection has or has not been accomplished is the number of lymph nodes left inside the patient along the major mesenteric vessels or pelvic side walls. Decanini and colleagues recently analyzed the laparoscopic oncologic abdominoperineal resection in 11 cadavers, thus allowing them to perform an autopsy in every case immediately after the operation in order to assess and document adequate anatomic resection of the rectosigmoid and its adjacent mesentery and soft tissue [5]. They found that their median number of removed lymph nodes in the mesorectum was 12 (range, 622), similar to our findings, and no remaining lymph nodes were found at the base of the inferior mesenteric artery at autopsy. Wide clearance of pelvic side walls was noted in all patients. Another concern of the LAPR technique relates to the potential risk of tumor cell shedding and subsequent implantation. There can be no doubt that cells shed by the tumor can implant into the soft tissues of the pelvis or the divided bowel ends [19]. There have been a number of case reports of tumor implantation at a port site or minilaparotomy incision after laparoscopic surgery for malignant disease [1, 14]. The reported period between laparoscopic surgery and presentation of wound metastasis varies widely from 7 days to 10 months in the literature [13]. Why malignant disease should recur at a port site rather than the formal wound used for delivery of the specimen is not fully understood. Whether such a small number of reports represents a true increase over wound recurrences occurring in open surgery is also unknown. In our series, early results of cancer treatment were reasonable without increased dissemination or trocar site implantation. Conclusion Laparoscopic APR is technically feasible in our patient population with rectal cancer, anal cancer, and inflammatory bowel disease, whether or not they had prior abdominal operations. The inferior mesenteric artery can be divided and ligated close to the aorta and a radical resection of the rectal and sigmoid mesenteries with their lymph nodes can be performed deep in the pelvis using laparoscopic techniques. Our early clinical outcomes and intermediate-term follow-up (up to 3.5 years) support the use of laparoscopic techniques to this procedure. However, only prospective, randomized trials comparing recurrence and long-term survival (up to 510 years) after laparoscopic vs open colorectal resections for cancer can determine if LAPR will provide the same clinical outcome as that in the conventional operation.
Acknowledgment. We are grateful for the assistance of Kass Meyer, R.N., in data collection. We would also like to thank Ethicon-Endosurgery, Inc.,

455 for their continued support for the Washington University Institute of Minimally Invasive Surgery and John Craig, M.D., for his outstanding illustrations of the technique. 10. Larach SW, Salomon MC, Williamson PR, Goldstein E (1993) Laparoscopic assisted abdominoperineal resection. Surg Laparosc Endosc 3(2): 115118 11. MarcFarlane JK, Ryall RDH, Heald RJ (1993) Mesorectal excision for rectal cancer. Lancet 341: 457460 12. Miles WE (1908) A method of performing abdominoperineal excision for carcinoma of the rectum and the terminal portion of the pelvic colon. Lancet 2: 18121813 13. Monson JRT, Hill ADK, Darzi A (1995) Laparoscopic colonic surgery. Br J Surg 82: 150157 14. Nduka CC, Monson JRT, Menzies-Gow N, Darzi A (1994) Abdominal wall metastases following laparoscopy. Br J Surg 81: 648652 15. Petrelli NJ, Nagel S, Rodriguez-Bigas M, Piedmonte M, Herrera L (1993) Morbidity and mortality following abdominoperineal resection for rectal adenocarcinoma. Am Surg 59: 400404 16. Phillips EH, Franklin M, Carroll BJ, Fallas MJ, Ramos R, Rosenthal D (1992) Laparoscopic colectomy. Ann Surg 216(6): 703707 17. Sackier JM (1992) Laparoscopic abdominoperineal resection of the rectum. Br J Surg 79: 12071208 18. Scott KW, Grace RH (1989) Detection of lymph node metastases in colorectal carcinoma before and after fat clearance. Br J Surg 76: 11651167 19. Skipper D, Jeffrey MJ, Cooper AJ, Alexander P, Taylor I (1989) Enhanced growth of tumour cells in healing colonic anastomoses and laparotomy wounds. Int J Colorectal Dis 4: 172177 20. Targarona EM, Pons MJ, Anglada MT, Taura P, Trias M (1993) Laparoscopic abdominoperineal resection of the rectum. Br J Surg 80(4): 535

References
1. Alexander RJT, Jaques BC, Mitchell KG (1993) Laparoscopically assisted colectomy and wound recurrence. Lancet 341: 249250 2. Chindasub S, Charnpreecha C, Nimitvanit C, Akkaranurukul P, Santitarmmanon B (1994) Laparoscopic abdominoperineal resection. J Laparoendosc Surg 4(1): 1721 3. Coller J (1992) Laparoscopic colectomy. Laparosc Focus 1: 8 4. Darzi A, Lewis C, Menzies-Gow N, Guillou PJ, Monson JRT (1993) Laparoscopic abdominoperineal excision of the rectum. Surg Endosc 9: 414417 5. Decanini C, Milson JW, Bohm Bartholomaus, Fazio VW (1994) Laparoscopic oncologic abdominoperineal resection. Dis Colon Rectum 37: 552558 6. Fowler DL, White SA (1991) Laparoscopy-assisted sigmoid resections. Surg Laparosc Endosc 1: 183188 7. Geis WP, Kim C (1994) Improved efficiency in laparoscopic abdominoperineal resection: the Kim-Geis approach. Int Surg 79: 226227 8. Geis WP, Coletta AV, Verdeja JC, Plasencia G, Ojogho O, Jacobs M (1994) Sequential psychomotor skills development in laparoscopic colon surgery. Arch Surg 129: 206212 9. Jacobs M, Verdeja JC, Goldstein HSC (1991) Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1: 144150

Surg Endosc (1997) 11: 438440

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Comparison of two-dimensional vs three-dimensional camera systems in laparoscopic surgery

A. C. W. Chan, S. C. S. Chung, A. P. C. Yim, J. Y. W. Lau, E. K. W. Ng, A. K. C. Li
Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Received: 14 September 1995/Accepted: 5 July 1996

Abstract Background: The lack of depth perception and spatial orientation in video vision are the drawbacks of laparoscopic surgery. The advent of a three-dimensional camera system enables surgeons to regain binocular vision and may be advantageous in complex laparoscopic procedures. Methods: We prospectively studied two groups of surgeons (with and without experiences in laparoscopic surgery) who performed a designated standardized laparoscopic task using a two-dimensional camera system (Olympus OTV-S4) vs a three-dimensional camera system (Baxter-V. Mueller VS7700) and compared their time performances. Results: The results suggested that only experience in laparoscopic surgery had significant effect on individuals performance. We could not demonstrate any superiority of the 3D system over the 2D system. However, two-thirds of the surgeons commented that the depth perception did improve. Conclusions: With further refinement of the technology, the 3D system may improve its potential in laparoscopic surgery. Key words: Laparoscopic surgery two-dimensional camera system three-dimensional camera system

Imaging technology plays an important role in the success of laparoscopic surgery. Given the technical innovations that now provide better image resolution, complex surgery can be performed laparoscopically with more confidence. The prosperity of laparoscopic surgery and the public demand have driven numerous surgeons and trainees to undergo laparoscopic training which essentially targets eye cerebrumhand coordination. For the novice to master the techniques, the first obstacle that needs to be overcome is the loss of binocular vision (three-dimensional image) when facing the television monitor. Surgeons need to relearn their operative skills and to gear up the cerebrum to acquire spatial orientation toward the two-dimensional (2D) laparoCorrespondence to: A. K. C. Li

scopic images. The introduction of the three-dimensional (3D) camera system may be helpful in shortening this learning period and in reducing the operative time in difficult surgery. The basic mechanism of 3D the camera system consists of two video cameras mounted on the tip of laparoscope. Two separate image signals are captured and alternately transmitted to a high-resolution video monitor at a high frequency. Surgeon can perceive the stereo image by two methods. The first method involves wearing an active eyeware made of liquid crystal glasses that receive the signal from an infrared transmitter. The transmitted signal controls the alternate optical shuttering of the glasses to enable the surgeon to receive the two images with the respective eyes. The cerebrum composes these images as a 3D image. In the second method, the same principle is adopted but the shutter is placed in the video monitor instead of the eyeware. The video monitor contains a large liquid crystal shutter that changes polarization and synchronizes with the right and left image signals. The surgeon wears a passive eyeware with a right circular polarized lens in the right eye and a left circular polarized lens in the left eye. The right eye can then only perceive right-image signal, since it is similarly polarized, and likewise for left eye and left-image signal. The 3D image is then composed in the brain. In our unit, we have studied whether a 3D laparoscopic camera system could improve surgeons efficiency in a designated manipulative task.

Materials and methods

Surgeons with or without laparoscopic experience were invited to perform two exercises using a 2D laparoscope (Olympus OTV-S4) and a 3D laparoscope (Baxter-V. Mueller VS7700). After a warm-up exercise (transfer of 10 cotton-wool pledgets from one galley pot to another), the time taken to string up 10 beads onto a suture with a straight needle was measured. Each participant performed the exercises twice, once with the 2D camera and once with the 3D system. To minimize the carry-over effect of learning in result analysis, the participants started the exercises with either the 2D or 3D system in a randomized sequence generated by the computer. After the tests, all participants also filled out a questionnaire which asked about their comments on the 3D camera system. The time performance and

439 Table 1. Time taken for the task in relation to the laparoscopic experiences of participants Mean SD (seconds) Number Time taken Laparoscopic experience with without Mann-Whitney U test 32 11 21 2D 659.1 388.1 488.7 230.0 748.4 427.4 p 0.05 3D 638.2 387.1 443.8 242.7 740.0 413.8 p 0.03 Signed-rank test p 1.0 p 0.6 p 0.9

Table 2. Time taken for the task in relation to the assigned sequence of exercises Number 2D (seconds) 3D (seconds) Signed-rank test p 0.01 p 0.01 p 0.4

Sequence of exercises 2D first 17 690.4 430.0 433.0 216.7 3D first 15 623.7 346.0 870.7 411.2 Signed-rank test: Improvement in 2D first subgroup vs improvement in 3D first subgroup

within-subject comparison were analyzed using signed-rank test and Mann-Whitney U test. Subgroup analyses on the years of laparoscopic experience and sequence of exercises were also performed.

of exercises using the 3D system. Nevertheless, 40% of participants thought that the 3D camera system would have good prospects after refinement.

Results Thirty-two surgeons (11 with and 21 without experience in laparoscopic surgery) participated in this study. The overall average times to finish the task using the 2D and 3D systems were 659.1 and 638.2 s, respectively. Within-subject comparison of the time performance between the two systems was not statistically significant (p 1.0). The results were further analyzed in light of the consideration of surgeons experiences (Table 1) and the assigned sequence of exercises (Table 2). Surgeons with laparoscopic experiences took significantly less time to finish the exercises when compared with surgeons without experience, irrespective of the camera systems being used (p 0.05 for 2D, p 0.03 for 3D). Within the same subgroup of surgeons, there was no significant time difference between the 2D and 3D system (p 0.6 for experienced surgeons, p 0.90 for inexperienced). When the sequence of completing the exercises was considered, both groups of surgeons improved their efficiencies significantly on the second exercise by 30% (p 0.01 for 2D first, p 0.01 for 3D first). However, the magnitude of improvement was not significantly different when compared the two groups (p 0.4). The reduction of time was mostly attributed to the surgeons learning process in performing the task rather than to the system itself. In summarizing the comments from the participants, half of the surgeons commented that there was no subjective improvement in the handling ability during the test, although two-thirds of them commented that the depth perception was improved with the 3D camera system. Forty percent of surgeons said that the image resolution was less clear and that the illumination seemed dimmer compared to the conventional 2D camera system. Ten percent of participants complained of dizziness or eyestrain after completion

Discussion Laparoscopic surgery is generally a two-dimensional surgery. The loss of depth perception and spatial orientation are the main drawbacks for the novice to overcome. Advanced complicated laparoscopic surgery requires precise manipulation of the instruments. The success of surgery, the operating time, and the morbidity rate are directly related to the manipulation skills. A three-dimensional camera system may improve the efficiency, shorten the learning curve, and reduce the operating time. Evaluation of new camera technology can be done, in vitro and in vivo, by testing the perceptual motor abilities. Bhoyrul et al. [1] demonstrated high correlation of individual surgeons perceptual power with their motor performance in both a laparoscopic simulator and a porcine model. For the 3D camera, Nagy et al. [4, 5] conducted a bench-top threading experiment in comparison with the 2D system; they reported that the average number of errors during the threading procedure was markedly reduced when a 3D system was used. In our study, the exercise was designed to test the operators manipulation skill and spatial orientation. The left-hand forceps was required to hold a small bead with the central hole facing laterally or upward so that the needle could be threaded through accurately. This action depends much on depth perception and spatial orientation, and theoretically a 3D camera would have been helpful in this situation. However, we were unable to demonstrate any superiority in the 3D system (Baxter-V. Mueller VS7700). The present experiment showed that surgeons who were experienced in 2D laparoscopic surgery performed equally well with the 3D system. In addition, the learning process in laparoscopic surgery had more pronounced effect in improving performance instead of system superiority. As shown in our analysis on the sequence of the

440

exercises, the time performance of the same exercise in the second system was generally better than the first system by 30%. Clinical applications of the 3D system on various laparoscopic operations with excellent result have also been reported [2, 3]. However, it is expensive equipment that may not be available in many hospitals. The comments from our participants suggested that this 3D system still has room for improvement. First, the current 3D image appears less clear and darker, as noted by 40% of our participants. The current 3D system consists of two smaller separate optical channels inside a standard 10-mm laparoscope, which contrasts with the 2D single-lens system. The image resolution and light illumination need to be refined, and be comparable to a three-chip camera. Furthermore, the stereoscopic perception relies entirely on the convergence of visual axes of both eyes. Compared to human eyes which have an interpupillary distance 60 mm or more, the two distal mounted cameras in the laparoscope are only separated by 10 mm. Therefore a sharp 3D image can only be perceived at the center of focus (point of fixation) while a blurred image is seen at the periphery of the monitor. Finally, it will be more

readily acceptable if the cost can be reduced. The current price of a 3D camera system is eight times higher than a single-chip camera and three times that of a three-chip camera. In our opinion, this 3D system still needs to be refined before any true benefit can be demonstrated in laparoscopic surgery.

References
1. Bhoyrul S, Tendick F, Mori T, Way S, Way LW (1995) An analysis of perceptual motor ability in laparoscopic surgery. Surg Endosc 9: 215 2. Birkett DH, Josephs LG (1993) Use of a prototype 3-dimensional (3D) laparoscope in gastrointestinal laparoscopic surgery (abstract). Surg Endosc 7: 216 3. Jakimowicz JJ (1993) 3D Laparoscopy system. Proceedings of 1st Asian Pacific Congress of Endoscopic surgery, Singapore 1993, p 206 4. Mitchell TN, Robertson J, Nagy AG, Lomax A (1993) Threedimensional endoscopic imaging for minimal access surgery. J R Coll Surg Edinb 38: 285292 5. Nagy AG, Robertson JA, Mitchell TN (1993) The future: telepresence and other developments. In: Cuesta MA, Nagy AG (eds) Minimally invasive surgery in gastrointestinal cancer. Churchill Livingstone, New York, pp 171175

Surg Endosc (1997) 11: 431437

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Hemodynamic changes in the inferior caval vein during pneumoperitoneum

An experimental study in pigs
F. Lindberg, D. Bergqvist, I. Rasmussen, U. Haglund
Department of Surgery, University Hospital, S-751 85 Uppsala, Sweden Received: 2 April 1996/Accepted: 7 June 1996

Abstract Background: Laparoscopic procedures of increasing difficulty and duration are becoming more and more common. This may cause significant challenges to the circulatory system and possibly influence thrombogenicity. Methods: Experimental study of carbon dioxide pneumoperitoneum in pigs. Results: Inferior caval vein blood flow remained unchanged, whereas inferior caval vein pressure increased during pneumoperitoneum. Inferior caval vein, pulmonary, and systemic vascular resistance increased during pneumoperitoneum and remained increased after exsufflation. Conclusions: Pneumoperitoneum leads to an increased inferior caval vein pressure, which could cause a dilation of peripheral veins. The similar patterns of vascular resistance in the inferior caval vein, pulmonary artery, and systemic arteries (a gradual increase remaining elevated after exsufflation) suggest a common humoral factor or increased sympathetic nerve activity. Key words: Pneumoperitoneum Carbon dioxide Circulatory effects

postoperative deep-vein thrombosis with these laparoscopic procedures in unknown. Fatal pulmonary embolism has been reported [16]. The introduction of these new therapeutic laparoscopic surgical procedures has sometimes resulted in pneumoperitoneum of long duration, which, especially when applied to old patients, may cause significant challenges to the circulatory system. Whether increased intraabdominal pressure for prolonged periods of time influences thrombogenecity is not known. The aim of the present investigation was to study changes in pressure and blood flow in the inferior caval vein during prolonged carbon-dioxide-induced pneumoperitoneum at a constant pressure in pigs. Materials and methods Experimental design
The study was approved by the Institutional Review Board for the Care of Animals at Uppsala University, and the care and handling of the animals were in accordance with National Institute of Health guidelines. Swedish Landrace pigs of either sex, weighing 2025 kg, were used. They were allowed only water during the 12 h preceding the experiment. The animals were sedated with 10 mg kg1 of pentobarbital and 0.5 mg of atropine, intraperitoneally; anesthesia was induced with pentobarbital, 20 mg kg1 intravenously, and maintained with continuous infusion of ketamine 1.5 mg kg 1 (Ketalar, Parke-Davis, NJ), diazepam 0.15 mg kg1 h1 (Apozepam, AL, Oslo, Norway), and pancuronium bromide 0.36 mg kg1 h1 (Pavulon, N.V. Organon Oss, The Netherlands). After tracheostomy, the animals were mechanically ventilated (Servo Ventilator System 900 D, Siemens-Elema AB, Stockholm, Sweden) with 70% nitrous oxide in oxygen. Ventilation was adjusted to achieve an arterial carbon dioxide tension of 4.05.5 kPa (3042 mmHg). Fluid was given as a continuous intravenous infusion of a balanced crystalloid solution with 2.5% glucose 15 ml kg1 h1 (Rehydrex, Pharmacia, Uppsala, Sweden). The animals were also given an intravenous infusion of Ringers acetate 30 ml kg1 h1 throughout the experiment. The total amount of crystalloid fluid given was 45 ml kg1 h1. Body temperature was maintained between 38 and 39C with a heating lamp.

Laparoscopy has long been one of the most commonly encountered routine operative procedures in gynecological surgery. Recently, therapeutic laparoscopic procedures have become widely used also in general surgery, including laparoscopic cholecystectomy, laparoscopic Nissen fundoplication, and laparoscopic large-bowel surgery. The risk of

Correspondence to: F. Lindberg

432

Surgical procedure and instrumentation

A polyethylene catheter (PE 160) was positioned in the thoracic aorta via the left carotid artery and used for mean arterial blood pressure (MAP) recordings and blood sampling for blood gas analysis. The left cephalic vein was cannulated and a catheter (PE 160) was positioned in the superior caval vein and used for fluid and drug infusions. A Swan-Ganz catheter (P7110 Opticath, Oximetrix Inc., Mountain View, CA) was introduced via the right jugular vein into the pulmonary artery to the monitor oxygen saturation in pulmonary arterial blood (paO2sat), mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP), and cardiac output measurements. The location of the catheter was determined by observing the characteristic pulmonary arterial pressure tracing on the monitor (Sirecust 1281, Siemens, Danvers, MA, USA). A catheter (PE 160) was introduced into the right atrium through the right cephalic vein and used to measure central venous pressure (CVP) and inject the indicator for measuring of cardiac output by thermodilution. After a midline laparotomy, a catheter was inserted in the urinary bladder for urine deviation. Thereafter a catheter (P7110 Opticath) was introduced into the left femoral vein, and the tip was positioned just above the iliac difurcation in the inferior caval vein; it was used to measure caval venous pressure (ICVP) and oxygen saturation in the blood (ICVO2sat). Caval venous blood flow (Qcv) was measured with an ultrasound flow probe (Transonic Systems Inc., Ithaca, NY) positioned around the inferior caval vein. The probe was placed at a distance from the intracavalpositioned catheter. A Veress needle was inserted in the right upper quadrant of the abdomen and used for intraperitoneal insufflation of carbon dioxide. In order to monitor the oxygenation of the gut, intramucosal pH (pHi) was determined indirectly using a tonometer (TRIP, Tonometrics, Inc., Hopkinton, MA). The tonometer was placed in the lumen of midileum through an antimesenteric enterotomy and secured with a purse-string suture. The preparation time was approximately 60 min. After the monitoring devices had been inserted, the laparotomy was closed in two layers to effect an airtight seal and the animals were allowed to recover for at least 60 min. MAP, MPAP, PCWP, ICVP, and CVP were measured with pressure transducers connected to a monitor (Sirecust 1281, Siemens, Danvers, MA) and cardiac output was determined by thermodilution. This was performed by injecting 5 ml of 5% glucose at room temperature at each measurement. The estimations were timed with the ventilatory cycle. The mean of three computed measurements (Oximetrix 3 SO2/CO computer, Oximetrix Inc., Mountain View, CA) was used; less than 10% variation was required for acceptance. Inferior caval venous blood flow was continuously recorded (Transonic T201D blood flowmeter, Transonic Systems Inc., Mountain View, CA) and registered on an MT 6/8 Recorder and Multitrace (Lectromed Ltd., Jersey, UK). Cardiac index (CI) and Qicvi were calculated by dividing cardiac output and Qicv, respectively, by body weight. Oxygen saturation in pulmonary arterial blood and inferior caval venous blood was measured continuously by a spectrophotometric method. The light-transmitting catheters were connected to an optical module (OS/ 1271 Optical Module, Oximetrix Inc., Mountain View, CA) and this was connected to the oximeter (Oximetrix 3 SO2/CO computer, Oximetrix Inc., Mountain View, CA). Calibration was performed in vitro and kept in the module. Following insertion of the catheter actual oxygen saturation could be measured. Arterial blood samples were analyzed for arterial oxygen and carbon dioxide tension, pH, base excess, and [HCO3] using a ABL300, Radiometer (Copenhagen, Denmark) and analyzed for arterial oxygen saturation in a OSM3, Hemoximeter (Radiometer). The tonometric method for calculation of pHi has been described in detail previously [1]. The gas-permeable balloon of the tonometer was filled with 2.5 ml of saline. After 30 min 1 ml was aspirated and discarded. The remaining 1.5 ml was aspirated and the carbon dioxide tension was determined in a blood gas analyzer (ABL300, Radiometer). This value together with the simultaneously obtained [HCO3] from arterial blood was used in the Henderson-Hasselbalch equation for calculation of pHi, using the correction factor for the equilibration period given by the manufacturer. Pneumoperitoneum was established with a Wolf Pneumo CO2 insufflator (Richard Wolf GMBH, Knittlingen, Germany), and the intraabdominal pressure was monitored with an aneroid manometer. Mean airway pressure was registered on the ventilator (Servo Ventilator System 900 D, Siemens-Elema AB, Stockholm) and end-tidal carbon dioxide concentra-

tion (%) was monitored with a CO2 Analyzer 930 Servo Ventilator (Siemens-Elema AB, Stockholm).

Calculations
For calculation of the vascular resistances, the following formulas were used: systemic vascular resistance (SVRi) ( MAP CVP)/CI and inferior caval venous vascular resistance (ICVRi) ( MAP ICVP)Qicvi.

Experimental design
Six animals were used for the experiments. Before carbon dioxide was insufflated through a Veress needle into the abdominal cavity, the animals were observed for 1 h. Pneumoperitoneum was maintained for 150 min at a constant pressure of 15 mmHg. After exsufflation of the carbon dioxide, the animals were observed for 90 min. Total observation time was 300 min, and measurements were performed every 30 min. At the end of the observation period, the animals were killed with intravenous potassium chloride. The experiments were performed with the animals in a supine position. This model has previously been used in our laboratory and has been shown to be hemodynamically stable [18]. The animals were allowed to recover for 1 h after the surgical manipulation. Observation during this time showed that stable baseline values were obtained, and the animals were thus used as their own controls.

Statistical analysis
For statistical evaluation, a two-way analysis of variance (ANOVA) for repeated measures was used for overall time related change of each variable. Dunnets multiple comparison test was used to compare other values with the start point value. Statistical significance was defined as p < 0.05. All data are presented as mean standard deviation (SD).

Results The packed cell volume and hemoglobin in arterial and central venous blood were unchanged during the entire observation period. The heart rate did not change during the experiment, whereas mean arterial blood pressure increased significantly after induction of pneumoperitoneum to about 167% of baseline at 150 min. This increase remained throughout the observation period (Fig. 1A). Cardiac index was relatively unchanged during the experiments except at 90 min, where is was significantly increased to about 125% of baseline (Fig. 1B). Central venous blood pressure rose significantly during pneumoperitoneum, after which it returned to baseline values (Fig. 1C). Systemic vascular resistance increased significantly after completing pneumoperitoneum (Fig. 1D). Mean pulmonary arterial blood pressure increased during increased abdominal pressure, at the highest to about 197% of baseline at 150 min. After exsufflation, there was a fall, but it was significantly increased during the rest of the observation period compared to baseline (Fig. 2A). Pulmonary capillary wedge pressure (Fig. 2B) and pulmonary vascular resistance (Fig. 2C) increased during pneumoperitoneum. The latter remained increased after gas exsufflation. Mean airway pressure was elevated during the increased intraabdominal pressure. Although there was a reduction after termination of pneumoperitoneum, it remained significantly increased (Fig. 2D). Intrathoracal pressure increased

433

Fig. 1. Changes in arterial blood pressure (A), cardiac index (B), central venous pressure (C), and systemic vascular resistance (D) during and after pneumoperitoneum. (* Statistically significant change [p < 0.05] from baseline values.)

after 1 h of pneumoperitoneum and remained elevated half an hour after exsufflation of carbon dioxide (Fig. 2E). Inferior caval vein blood flow remained unchanged during the observation period (Fig. 3A), whereas the inferior caval vein blood pressure increased significantly during increased intraabdominal pressure to about 280% of baseline (Fig. 3B). Inferior caval vein vascular resistance increased markedly at the end of pneumoperitoneum and remained increased thereafter (Fig. 3C). Oxygen saturation in inferior caval vein, arterial, and arterial pulmonary blood remained unchanged throughout the observation period. Arterial pH fell during pneumoperitoneum, whereafter it increased significantly compared with baseline (Fig. 4A). Arterial bicarbonate increased during pneumoperitoneum and thereafter (Fig. 4B). Arterial carbon dioxide tension (Fig. 4C) and end-tidal carbon dioxide concentration (Fig. 4D) were increased during increased elevated intraabdominal pressure. There was a good correlation between arterial carbon dioxide tension and end-tidal carbon dioxide concentration (r 0.95). Intestinal intramucosal pH remained unchanged before,

during, and after pneumoperitoneum except for a significant drop at 150 min.

Discussion The extent of the hemodynamic changes associated with intraoperative pneumoperitoneum will depend on the intraabdominal pressure attained, the volume of carbon dioxide absorbed, the patients intravascular volume as well as cardiac and pulmonary function, the position of the patient, the ventilatory technique used by the anaesthesiologist, the surgical conditions, and the anesthetic agents employed. Our findings confirm that increase of intraabdominal pressure (IAP) due to carbon dioxide insufflation induces significant changes in central hemodynamics such as increase in mean arterial blood pressure, central venous pressure, and systemic vascular resistance. These findings are in accordance with what was demonstrated in earlier studies [7]. Cardiac index was relatively unchanged as observed in previous investigations [8], although Westerband et al. [19] found a significant decrease in cardiac index during lapa-

434

Fig. 2. Changes in mean pulmonary arterial blood pressure (A), pulmonary capillary wedge pressure (B), pulmonary vascular resistance (C), mean airway pressure (D), and intrathoracal pressure (E) during and after pneumoperitoneum. (* Statistically significant change [p < 0.05] from baseline values.)

roscopic cholecystectomy, possibly due to the reverse Trendelenburg position and/or the anesthetic agents. Arterial pH decreased, whereas arterial carbon dioxide tension and end-tidal carbon dioxide concentration increased during pneumoperitoneum, which was expected due to absorption of carbon dioxide. The correlation between arterial carbon dioxide tension and end-tidal carbon dioxide concentration was excellent (r 0.95), just as in a previous

study from our institution [18]. This is slightly surprising, since several authors have warned that the increase in endtidal CO2 is an unreliable marker for arterial pCO2 [12, 20]. In a study by Wittgen et al. [20], however, the worst correlation between end-tidal pCO2 and arterial pCO2 was found in patients with cardiopulmonary disease. In an experimental study, Liem and co-workers [12] postulated that the poor correlation between end-tidal pCO2 and arterial

435

Fig. 3. Changes in inferior caval venous blood flow (A), blood pressure (B), and vascular resistance (C) during and after pneumoperitoneum. (* Statistically significant change [p < 0.05] from baseline values.)

pCO2 was due to the smaller muscle mass of young swines (1012 kg) compared to adult, thus constituting a smaller CO2-buffering capacity. The pigs in both our studies were presumably without cardiopulmonary disease and were twice the size of the pigs used by Liem and co-workers, which may explain the difference in results. Arterial bicarbonate increased during pneumoperitoneum and remained elevated during the postpneumoperitoneum observation period, possibly due to a beginning metabolic compensation of the respiratory acidosis, although this generally is thought to take much more time to develop than a couple of hours. The fact that the arterial pH was not only normalized but actually significantly increased compared with baseline values after the pneumoperitoneum would seem to support this assumption. The inferior caval vein (ICV) pressure was significantly increased during pneumoperitoneum (to approximately 280% of baseline), whereas the ICV blood flow remained unchanged during the experiment. The ICV vascular resistance increased continuously until it was significantly elevated at 150 min and remained so during the whole postpneumoperitoneum period studied. Several previous studies have shown that the ICV pressure goes up during pneumoperitoneum and returns to baseline almost momentarily after the IAP is returned to normal, just as in the present study [6, 12]. Furthermore, it has been shown that this increased pres-

sure is transmitted peripherally to the femoral veins during laparoscopic cholecystectomy [3, 7], and that the crosssectional area of the femoral veins may increase slightly [9]. Arcelus et al. [2], however, have shown that both these phenomena appear in the reverse Trendelenburg position also without anesthesia or pneumoperitoneum, and venous dilation has been shown to appear in the cephalic vein during hip arthroplasty [5]. Increased intraabdominal pressure is thus just one factor in a complex process leading to intraoperative peripheral venous dilation. There is a decreased peek pulsatile flow in the femoral veins as well as a decreased venous outflow from the legs during pneumoperitoneum [3, 9], reflecting an increased venous resistance [10]. Release of pneumoperitoneum has generally normalized these changes. In the present study, however, the ICV vascular resistance increased slowly and continuously, the increase becoming significant only after 150 min. It then remained significantly elevated during the 90-min observation period after pneumoperitoneum. The systemic vascular resistance and the pulmonary vascular resistance showed similar patterns, suggesting a common humoral factor responsible for these phenomena. It has previously been speculated that the increase in vascular resistance is due to a reflex activation of sympathetic nerve activity by the surgical stimulus or afferent stimulation from the splanchnic region [11, 14] or possibly due to an increase in arterial

436

Fig. 4. Changes in arterial pH (A), arterial bicarbonate (B), arterial carbon dioxide tension (C), and end-tidal carbon dioxide concentration (D) during and after pneumoperitoneum. (* Statistically significant change [p < 0.05] from baseline values.)

carbon dioxide tension [13]. In addition, Punnonen and Viinama ki [17] have shown that vasopressin is released during laparoscopy. Consequently, the mechanism responsible for these phenomena remains to be evaluated. The inferior caval vein volume flow showed no significant changes during this experiment. Previous studies have yielded conflicting results from an increase during a pneumoperitoneum of 15 mmHg [15] (measured by as SwanGanz catheter in the abdominal inferior caval vein) to a decrease (at an IAP of 20 mmHg and higher) [7] (measured in the thoracic inferior caval vein). In the latter experiment, however, the flow in the inferior caval vein decreased in parallel with decreasing cardiac output, at all measurements being 80% of cardiac output, thus reflecting more the influence on central than peripheral hemodynamics by intraabdominal pressures considerably higher than normally used today. This is logical, since the inflow of blood to the legs could not exceed the outflow by more than a tiny fraction for any sustained period of time, since the extra volume of blood that the legs could harbor is limited. The likely thing to happen would be a sudden, significant pooling of blood in the legs during the first couple of minutes of pneumoperitoneum and thereafter the inflow exceeding the out-

flow by no more than a tiny fraction, due to the prolonged reverse Trendelenburg position in upper abdominal surgery and the maintained elevation in venous pressure leading to extravasation of fluid and, possibly, increased dilation of the veins. This, in turn, could be of importance to enhance the development of thrombosis, since an increase in vein diameter exceeding approximately 20% is significantly correlated to the development of postoperative deep-vein thrombosis [5]. The findings in this study, and in a previous study of Ortega et al. [15], that the blood flow in the inferior caval vein is unchanged or even increased at approximately 15 mmHg if intraabdominal pressure, and those of Ivankovitch et al. [7], that it is decreased (in parallel with a decreased cardiac output) at an intraabdominal pressure of 20 mmHg and above, could all agree. At low intraabdominal pressures in hypervolemic subjects, Kashtan et al. [10] suggested that the increase in systemic resistance was canceled out by an increase in venous return due to the compression of splanchnic venules. This increases preload of the heart and allows the heart to overcome the increase in afterload, maintaining cardiac output. At higher intraabdominal pressures, or in hypovolemic subjects, this compensation mechanism is ex-

437

hausted, leading to a fall in cardiac output, a decrease in the amount of blood flowing to the legs, and a subsequent fall in inferior caval vein blood flow. If this is the explanation, it is important to keep the intraabdominal pressure as low as possible and the patients well hydrated during laparoscopic surgery, especially if the reverse Trendelenburg position is to be used. Overenthusiastic fluid replacement, however, could turn out to be detrimental, as infusion of 0.9% saline intraoperatively further increases the distention of leg veins caused by anesthesia and/or surgery [4], with a possible increase in risk of deep-vein thrombosis. The statistically significant drop in intestinal intramucosal pH after 150 min of pneumoperitoneum, returning to baseline values after release of the pneumoperitoneum, suggests the possibility of an impaired intestinal blood flow during prolonged pneumoperitoneum. Further studies are, however, necessary in order to verify this phenomenon. In conclusion, pneumoperitoneum induced by carbon dioxide to an intraabdominal pressure of 15 mmHg increases the inferior caval vein pressure, whereas the ICV volume flow remains constant, at least as long as the cardiac output is not affected by the elevated intraabdominal pressure. It has previously been shown that carbon dioxide pneumoperitoneum leads to an almost instant increase in the inferior caval vein vascular resistance with a concomitant increase in femoral venous pressure and evidence of venous stasis in the lower extremities. Release of the pneumoperitoneum has generally been shown to return these parameters to baseline values. Our study, however, showed a more gradual increase not only in inferior caval vein vascular resistance but also in systemic and pulmonary vascular resistance, all three parameters remaining increased during the 90-min period after pneumoperitoneum, suggesting the possibility of a common humoral factor or increased sympathetic nerve activity.
Acknowledgment. We thank Mrs. Elisabeth Pihl for technical assistance. Financial support for this study was provided by the Swedish Medical Research Council (proj. No. 00759 and 4502) and by the Swedish Heart and Lung Foundation.

3.

4. 5.

6.

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8.

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10. 11.

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15. 16.

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1. Antonsson J, Boyle C, Kruithoff K, Wang H, Sacristan E, Rothschild H, Fink M (1990) Validation of tonometric measurement of gut intramural pH during endotoxemia and mesenteric occlusion in pigs. Am J Physiol 259: G519G523 2. Arcelus JI, Caprini JA, Traverso CI, Size G, Hasty JH (1993) The role

19.

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of elastic compression stockings in prevention of venous dilatation induced by a reverse Trendelenburg position. Phlebology 8: 111115 Bebee DS, McNevin MP, Crain JM, Letourneau JG, Belani KG, Abrams JA, Goodale RL (1993) Evidence of venous stasis after abdominal insufflation for laparoscopic cholecystectomy. Surg Gynecol Obstet 176: 443447 Coleridge-Smith PD, Hasty JH, Scurr JH (1990) Venous stasis and vein lumen changes during surgery. Br J Surg 77: 10551059 Comerota AJ, Stewart GJ, Alburger PD, Smalley K, White JV (1989) Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis. Surgery 106: 301309 Ishizaki Y, Bandai Y, Shimomura K, Abe H, Ohtomo Y, Idezuki Y (1993) Changes in splanchnic blood flow and cardiovascular effects following peritoneal insufflation of carbon dioxide. Surg Endosc 7: 420423 Ivankovich AD, Miletich DJ, Albrecht RF, Heyman HJ, Bonnet RF (1975) Cardiovascular effects of intraperitoneal insufflation with carbon dioxide and nitrous oxide in the dog. Anesthesiology 42: 281287 Johannsen G, Andersen M, Juhl B (1989) The effect of general anesthesia on the haemodynamic events during laparoscopy with CO2insufflation. Acta Anaesthesiol Scand 33: 132136 Jorgensen JO, Lalak NJ, North L, Hanel K, Hunt DR, Morris DL (1994) Venous stasis during laparoscopic cholecystectomy. Surg Laparosc Endosc 4: 128133 Kashtan J, Green JF, Parsons EQ, Holcroft JW (1981) Hemodynamic effects of increased abdominal pressure. J Surg Res 30: 249255 Kelman GR, Swapp GH, Smith I, Benzie RJ, Gordon NLM (1972) Cardiac output and arterial blood-gas tension during laparoscopy. Br J Anaesth 44: 11551162 Liem T, Applebaum H, Herzberger B (1994) Hemodynamic and ventilatory effects of abdominal CO2 insufflation at various pressures in the young swine. J Pediatr Surg 29: 966969 Marshall RL, Jebson PJR, Davie IT, Scott DB (1972) Circulatory effects of carbon dioxide insufflation of the peritoneal cavity for laparoscopic. Br J Anesth 44: 680684 Odeberg S, Ljungqvist O, Svenberg T, Gannedahl P, Ba ckdahl M, von Rosen A, Sollevi A (1994) Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparoscopic surgery. Acta Anaesthiol Scand 38:276283 Ortega AE, Peters JH, Anthone GJ, Richman M (1993) Inferior vena cava blood flow during laparoscopy. Surg Endosc 7: 136 Peters J, Gibbons G, Innes J, Nichols K, Front M, Roby S, Ellison E (1991) Complications of laparoscopic cholecystectomy. Surgery 110: 769778 Punnonen R, Viinama ki O (1982) Vasopressin release during laparoscopy: role of increased intra-abdominal pressure. Lancet 8264: 175 176 Rasmussen I, Berggren U, Arvidsson D, Ljungdahl M, Haglund U (1995) Effects of pneumoperitoneum on splanchnic hemodynamics: an experimental study in pigs. Eur J Surg 161: 819826 Westerband A, Van De Water JM, Amzallag M, Lebowitz PW, Nwasokwa ON, Chardavoyne R, Abou-Taleb A, Wang X, Wise L (1992) Cardiovascular changes during laparoscopic cholecystectomy. Surg Gynecol Obstet 175: 535538 Wittgen CM, Andrus CH, Fitzgerald SD, Baudendistel LJ, Dahms TE, Kaminski DL (1991) Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 126: 9971000

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Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Computer-based desktop system for surgical videotape editing

E. Vincent-Hamelin, J. M. Sarmiento, J.-M. M. de la Puente, M. Vicente
Departamento de Cirug a, Universidad Complutense de Madrid, Hospital Universitario San Carlos, C. Martin lagos s/n, 28035, Madrid, Spain Received: 20 August 1996/Accepted: 30 September 1996

Abstract Background: The educational role of surgical video presentations should be optimized by linking surgical images to graphic evaluation of indications, techniques, and results. We describe a PC-based video production system for personal editing of surgical tapes, according to the objectives of each presentation. Methods: The hardware requirement is a personal computer (100 MHz processor, 1-Gb hard disk, 16 Mb RAM) with a PC-to-TV/video transfer card plugged into a slot. Computer-generated numerical data, texts, and graphics are transformed into analog signals displayed on TV/video. A Genlock interface (a special interface card) synchronizes digital and analog signals, to overlay surgical images to electronic illustrations. The presentation is stored as digital information or recorded on a tape. Results: The proliferation of multimedia tools is leading us to adapt presentations to the objectives of lectures and to integrate conceptual analyses with dynamic image-based information. We describe a system that handles both digital and analog signals, production being recorded on a tape. Movies may be managed in a digital environment, with either an on-line or off-line approach. System requirements are high, but handling a single device optimizes editing without incurring such complexity that management becomes impractical to surgeons. Conclusions: Our experience suggests that computerized editing allows linking surgical scientific and didactic messages on a single communication medium, either a videotape or a CD-ROM. Key words: Endoscopic surgery Surgical education Computerized video editing Surgical video presentation

From the beginning of endoscopic surgery, the impact of video presentations highlighted the driving force of the im-

age in the development and broad diffusion of new surgical procedures. There is no doubt that television is the primary communication medium of the twentieth century, and thus it makes sense to consider that video may be one of the most powerful instruments for the diffusion of scientific and technical knowledge. In addition, computer-based systems enable us to display surgical sequences as digitized files, to overlay and mix these frames with graphics, and then drive them through networks [10] and teleconferencing [6]. This will increase the use of image-based presentations and their diffusion among the surgical community. However, when the content of surgical videos is analyzed, we may observe a tendency to show the best operation for the ideal patient. The surgical images are selected according to their quality, but they are rarely linked to indications or evaluation of results, which are analyzed as independent reports, in different sessions. A strict construction of films, according to the rules of scientific communication [12], and a direct evaluation of techniques and results, integrating high-quality image information with accompanying drawings, text, and numerical data, would increase the didactic role of surgical films. Currently, multimedia technology seems the best solution for handling surgical images together with scientific information, and for editing didactic presentations, but most editing stations are specialized, and managed by experts, at a high cost [9]. It is our belief that surgical departments might produce their own videos, provided, they use simple systems, fulfilling two main conditions. The first is usability by surgeons, with a short learning curve, so effort and time to edit images would be similar to those spent in preparing a scientific manuscript. The second is the ability to provide high-quality videotapes at a reasonable price. The aim of our presentation is to describe a computerbased desktop video editing system that fulfils these conditions and allows personal editing of didactic surgical videotapes. Materials and methods

Correspondence to: E. Vincent-Hamelin, Fresnedillas 2, 28035 Madrid, Spain

The basic configuration for the treatment of images is a personal computer (PC) with an electronic card plugged into a slot of the PC and connected

465 MPEG (hardware-dependent codec, created by the Motion Picture Experts group). The digitized movies are displayed on the computer monitor after decompression, in full screen and full motion, and managed by an appropriate software package for digital editing (Fig. 3B). The whole movie is stored on hard disk (or CD-ROM) but may also be displayed and recorded as analog documentation if a PC-to-TV/video transfer card is available. The first necessary phase of editing is to define the communication message and then design the structure and content of the presentation according to the stated objectives. The second step consists of preparing the text, drawings, charts, and illustrations required to explain, illustrate, or evaluate the surgical procedure. The VCR player is connected to the input of the transfer card, and selected frames from the surgical tapes are stored as picture files. Most photographic management programs allow enhancement of the quality of the picture, and insertion of text and drawings. Appropriate anatomical indications may thus be added to photographic images. For the third step of video editing, surgical operations are previewed, and important sequences are chosen and marked. Color correction may be done whenever necessary. When analog editing is performed, tapes are overwritten with marks in and out and a switching Genlock interface allows one to switching between computer and VCR image so either one or the other is displayed on the screen. When surgical sequences must be explained, drawings, titles, autoshapes, or any other file is mixed or superimposed on operation, by overlay function. For off-line editing, movie-making software will manage all the functions. Here again, the presentation will be stored as a digital video or recorded on a tape, via output of the PC-to-video/TV transfer card. Each sequence of the video is previewed, time is adjusted, and animation settings or transitions are added. The project may be corrected at any time.

Fig. 1. The incoming analog signals from videotapes enter the PC via a VHS or S-VHS input and are digitized and mixed with a computergenerated graphic. Digitized signals are output as analog images by the PC-to-TV/video transfer module.

by a lead to the computer graphic card in use. The heart of the system is a masterboard TV/video to PC and PC to TV/video transfer adapter (Multivideo system LTD). The electronic circuit has various types of input and output, suitable for connecting to television, videos, monitors, or projectors (Fig. 1). PC features are a high-speed processor of at least 100 MHz, enough memory to manage graphic files (32 Mb recommended), with high-speed and large hard diskat least 1 Gb. ISA and PCI slot extensions are useful to allow upgrade of the system. The masterboard video card has the ability to freeze and capture surgical images (frames) recorded during operative procedures and to transform the incoming analogue signals from video into a grid of pixels with numerically described colors. Frames are stored as compressed files using the JPEG compression scheme (Joint Photographic Experts Group). The masterboard video card may also translate the digital data, either pictures or videos or computer files, into analog signals, which are either displayed on television or recorded. A special interface card, called Genlock, synchronizes the digital and analog information sources and allows one to switch between each source and/or to mix and overlay the surgical images with drawings, charts, numerical data, and texts from any computer program. The masterboard provides a software interface to handle images. Postproduction of the video may be done by mixing analog and digital signals or involve an off-line approach, digitized stored signals being totally managed on the computer. To carry out mixed analog and digital signal editing, two videocassette recorders (VCR) are required. Either high-8 or S-VHS or Betacam format is recommended to record high-quality surgical images. An important feature of the VCR is the ability to write a VITC (Vertical Interval Time Code) code on the tape to synchronize frame editing. This codes each frame with a standard and unique number that can be recognized by almost any VCR. In between, a simple video editor is connected to mark the starting and ending points of the selected surgical sequences. A VCR with editing functions may also be used. The device does not need to provide special effectswhich are prepared on the computerbut it must be able to read the VITC code in order to get perfectly synchronized editing (Fig. 2). Alternatively, production may be done on the computer with editing as on-line editing, all images being digitized in real time and displayed on the PC monitor by a TV/video-to-PC-tuner card. Both the video player and the recorder are totally controlled by a video editing card plugged in a slot of the PC, and the video editor is no longer necessary (Fig. 3A). The tapes are carefully cataloged, and software marks in and out the selected images may link them by transitions and inserts or overlay files from any other program. The system creates an editing project that may be previewed, stored, and modified until recorded on tape as a movie. Off-line editing is done entirely on hard disk, and only one video is required to enter analog signals to the PC. All fields of either PAL or NTSC signals are digitized, and the surgical documentation is stored on hard disk or saved on CD-ROM. A codecs (compression/decompression system) is necessary to reduce the file size, either a motion JPEG (software), or an

Discussion Surgical films and videos are important instruments for the diffusion of surgical techniques, but filming open procedures requires external technical assistance and cannot be easily done in the daily practice of surgery. However, the nature of endoscopic surgery has transformed both the VCR and the monitor into basic devices of the operating room [9], and the ability to record all operations has increased the trend to use dynamic images for the description of operative techniques. The wide documentation allows review of operations, analysis and correlation of failures or mistakes with clinical results in each patient and the better establishment of a technical gold standard. Sharing of powerful surgical images has widely contributed to the development and diffusion of endoscopic surgery [4], and it would not be currently conceivable to describe a new procedure without the support of videotape. Furthermore, the changing pattern of communication technology tends to integrate dynamic image-based information and conceptual analyses of problems in multimedia interactive books [2] to update both texts and images as time goes and to guarantee the end-user access to complete and practical information. However, behind attempts to use video as a scientific communication medium, two problems may be identified that concern the content of presentations and the technique of image editing. Where the content of presentations is concerned, almost all operations may be done by the endoscopic approach, but indications cannot be settled by the description of an operation, even if this is technically well done. The European Association for Endoscopic Surgery has emphasised that surgical films should not be videoclips and that all procedures must be carefully assessed. When the best operation for the ideal patient is presented, the easy ap-

466

Fig. 2. A simple video editor is connected to allow editing in an analog mode. Given that special effects are generated by the PC, editing may be done with a VCR with editing functions. An electronic presentation or animation file may be recorded.

Fig. 3. Schematic representation of digital editing. Real-time or on-line editing holds the advantage of avoiding large storage systems, and it may use a compression algorithm that provides better quality for full-screen display of analog images. Postproduction may also be stored on hard disk. Off-line editing in a totally digital environment provides all the functions of the desk-top PC.

pearance of a technique as seen in a video may lead one to underestimate difficulty, which may then increase the risk of complications. The danger points of operations need to be highlighted, and the complications should be clearly correlated to both the indications and the technical approach to each procedure. In our opinion, the didactic and scientific role of surgical videotapes could increase by linking the surgical images to the evaluation of techniques on the same communication medium. Obviously, video should be prepared as are oral or written scientific reports [7], clearly stating the objectives, using surgical images to describe the technical aspects, complications and results being graphically presented and related to techniques in order to assess further indications. This means that a logic construction or scenario of the presentation should precede the video production. Regarding the technique and technology, there is no doubt that image editing by professional multimedia com-

panies is expensive and that production of complex presentations, including drawings, texts, and charts, largely increases its cost. In addition, even if multimedia experts provide excellent technical support, it is our task to write a clear and detailed outline of the film and to prepare the graphics and the drawings that will be mixed with surgical images. Meetings with the experts are necessary, But we must keep in mind the objective of transferring a scientific surgical message. Otherwise, top-quality equipment and media expertise may lead to choose and handle the images depending on their aesthetic quality, instead of thier didactic, regardless of their didactic importance or scientific content. However, the question to be asked is whether it is possible to take video editing out of the hands of broadcast and computer experts. It is not an easy task to run out a video editing platform without a basic knowledge of multimedia techniques, and computer-based editing is still a mystery for many people, who may be overwhelmed by the technology, especially if a lot of expertise is required for its operation. But computers are being used by almost all physicians, who handle databases, statistical analyses, and graphic software packages as basic instruments for scientific work. Slides are designed and prepared by authors, and with adequate technology may be displayed directly through the computer as electronic presentations. In our opinion, the proliferation of multimedia tools and the increasing quality and understanding of well-thought-out interfaces [5] are leading to personal-computer-based image editing. At the moment, the major difficulty seems to be understanding what a platform can do and finding appropriate equipment with close costperformance relationship [3]. In the authors experience, the friendly help of an expert in imaging techniques and technology has played an important role in clarifying our needs, according to communication objectives, and in testing systems and tools. Where technology is concerned, we have described a postproduction system that may handle both analog and digitized signals. To the extent that our surgical images are in analog form, it makes it easy to manage the amount of documentation, and the learning curve for technical process is simple. Two video recorders and players are needed, but a professional editing station is unnecessary, since title generation, video and computer files mixing, and effects are prepared on the PC. The Genlock card enables one to overlay the computer-generated graphic and texts to the analog picture, and complex effects can be achieved even with a rudimentary editing console. Some advice should be given regarding editing stations. The cost of professional VCR is high and it would be too expensive to purchase three professional devices (operating room camera, video player, and recorder). Consumer systems in S-VHS format are currently available at a reasonable price even if they are equipped with a TBC (Timebase Corrector to stabilize images) and write a VITC time code on the tapes at the time of recording. It is important to remember that tape quality decreases as copies are done, but inasmuch the video project may be stored on PC, and the tapes are duly classified after selection of the frames, the final presentation may be reedited as a first copy on as many tapes as required. There is no doubt that images are better processed and manipulated in a totally digital environment, but great chal-

467

lenges still exist regarding the amount of analog information that must be digitized, compressed, processed, stored, and retrieved [1]. At the present time, most broadcasting companies use a kind of hybrid system, information being stored as analog, but completely processed on a computer. As compared to the previously described system, when on-line editing is performed, each frame is immediately converted to a digitized signal in a real-time process. Several digital video adapters are currently available with the ability to manipulate and to mix images and to prepare a project that includes any Windows graphic or text-processing application [8]. The project may be previewed and corrected before production, as often as necessary, and finally recorded on a tape, with a PC-to-TV transfer card. The main technical issue is the computer processing power, even if some video display adapters possess a special chip for image manipulation. The great advantage of online editing is that the VCR is directly handled by the computer and that all the functions (image selection, transition effects, computer file insertion and mixing) are controlled on a single board. But hardware and software management require more skill and experience, and the learning curve may be difficult for customers totally new to computerized editing. Totally computerized editing with an off-line approach requires a complex encoding and decoding process to store and play back full-motion video. The 30 frames per second of an NTSC format requires over 22 Mb (1.3 Gb per minute) storage capacity so when analog signals are captured, a compression algorithm has to be applied to reduce the motion video size file. Thereafter, decompression must be done to display and manipulate the frames. There is no doubt that surgical presentations require high-resolution images, with no video artifacts, and that the frame rate cannot be reduced. It is thus impossible to store the whole surgical documentation as computer files, and all the tapes should be checked to select the start and stop points of the important sequences before capture and conversion. Thereafter, stored images are manipulated with moviemaking applications. Since the user interfaces reproduce the model of analog editing, documentation is shown and directly handled by the software with play, playback, frame-to-frame, transition, and special effects tools. The interface also provides options to overlay or to mix the video with graphics or text. As compared to other editing systems, this totally digital one performs a perfect synchronization, no mechanical device being used to manage the images [11]. Here again, the learning curve for such programs may be troublesome. Most applications have been designed for multimedia expert use, with a high performance level that does not really seem necessary to manage surgical documentation. On the other hand, even if these applications may be managed with a standard PC configuration, besides time spent in preparing the project, more time is necessary for the computer to produce the presentation [11]. Additional equipment is required if more tasks are to be done. We have tested a 100-MHz processor which takes over 10 h to edit 1 min of video, when highest-resolution, full-

screen, and 30 frames/s options are settled. Reducing the screen size considerably reduces this time, but quality drops and is not acceptable to display the movie for a lecture or a meeting presentation. Furthermore, the size of the video, even encoded, is still large, and external hard disk or recordable devices are necessary to save the files. However, one goal of research on digital image is the development of better codecs (as MPEG-2) that would enhance quality of motion video, reduce file size, and allow faster processing [3]. On the other hand, the consumer market for digital video editing is leading engineers to design simple interface applications. We personally believe that off-line editing in a totally digital environment will gain ever-more acceptance among nonexpert users and become a basic tool for many professional purposes, out of multimedia studios. Just as a written report, a surgical video presentation must be clear and clean to reach the stated objectives. It must be attractive to the target audience, without any attempt to realize special effects or to remake Jurassic Park. Computer-based video editing is fascinating and challenging but with the tools directly installed on a desktop PC, the scientific and didactic message of a surgical presentation may be produced on a single communication medium, which is now video but will probably be CD-ROM in the near future.
Acknowledgment. We wish to thank Andre s Martinez from SONICAR for his technical assistance in testing several systems and for his friendly help in running the platform. We would like to also acknowledge the sound advice of Pedro Pan izo on selection and management of software tools.

References
1. Arnett N (1994) Foreword. In: Bunzel MJ, Morris SK (eds) Multimedia applications development. Using Indeo video and DVI technology. Intel, McGraw-Hill, New York 2. Barker J, Tucker RN (1990) The interactive learning revolution. Kogan Page, London 3. Feldman T (ed) (1994) The technology of multimedia. In: Multimedia. Blueprint, Chapman & Hall, London, pp 3367 4. Forde KE (1992) Endosurgical revolution, or convergence of multiple technical and socio-economic realities? Surg Endosc 6: 272 5. Gertler N (1994) Wise multimedia design. In: Cunningham M (ed) Multimedia illustrated. Que Corporation, Indianapolis, pp 120134 6. Go PMNYH, Payne JH, Satava R, Rosser JC (1995) Teleconferencing bridges two oceans and shrinks the surgical world. In: Szabo Z, Lewis JE, Fantini A (eds) Surgical technology international IV. Universal Medical Press, San Francisco, pp 2031 7. Hartley J, Davies I (1988) Using principles of text design to improve effectiveness of audiotapes. Prog Learn Educ Technol 19(1): 416 8. Luther AC (1990) Digital video in the PC environment. McGraw-Hill, London 9. Paz-Partlow M (1991) Imaging systems for laparoscopic surgery. In: Cuschieri A, Berci G (eds) Laparoscopic biliary surgery. Blackwell Scientific, London, pp 1415 10. Satava RM (1993) Surgery 2001. A technologic framework for the future. Surg Endosc 7: 111113 11. Vaugn T (1993) Multimedia: making it work. Osborn McGraw-Hill, New York 12. Wiggin NJB, Bailor JC, McPeek B, Mueller CB, Spitzer WO (1991) Writing for publication. In: Troidl H, Spitzer WO, McPeek B, Mulder DS, Mckneally MF, Wechsler AS, Balch CM (eds). Principles and practice of research. 2nd ed. Springer-Verlag, New York, pp 404410

News and notices

Surg Endosc (1997) 11: 609611

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

New Address for the European Association for Endoscopic Surgery (E.A.E.S.)
Effective January 1, 1997, the new correspondence, telephone, and fax numbers of the E.A.E.S. office are: E.A.E.S. Office, c/o Mrs. Ria Palmen Luchthavenweg 81 Unit 1.42 5657 EA Eindhoven The Netherlands or: P.O. Box 335 5500 AH Veldhoven The Netherlands Tel: +31 40 2525288 Fax: +31 40 2523102

Essentials of Laparoscopic Surgery Surgical Skills Unit University of Dundee Scotland, UK

Under the direction of Professor A. Cuschieri the Surgical Skills Unit is offering a three-day practical course designed for surgeons who wish to undertake the procedures such as laparoscopic cholecystectomy. This intensely practical program develops the necessary operating skills, emphasizes safe practice, and highlights the common pitfalls and difficulties encountered when starting out. Each workshop has a maximum of 18 participants who will learn both camera and instrument-manipulation skills in a purpose-built skills laboratory. During the course there is a live demonstration of a laparoscopic cholecystectomy. The unit has a large library of operative videos edited by Professor Cuschieri, and the latest books on endoscopic surgery are on display in our Resource area. Course fee including lunch and course materials is $860. For further details and a brochure please contact: Julie Struthers, Unit Co-ordinator Surgical Skills Unit Ninewells Hospital and Medical School Dundee DD1 9SY Tel: +44 382 645857 Fax: +44 382 646042

Volunteer Surgeons Needed Northwestern Nicaragua Laparoscopic Surgery Teaching Program, Leon, Nicaragua
Volunteer surgeons are needed to tutor laparoscopic cholecystectomy for this non-profit collaboration between the Nicaraguan Ministry of Health, the National Autonomous University of Nicaragua, and Medical Training Worldwide. The program consists of tutoring general surgeons who have already undergone a basic laparoscopic cholecystectomy course. Medical Training Worldwide will provide donated equipment and supplies when needed. For further information, please contact: Medical Training Worldwide Ramon Berguer, MD, Chairman Tel: 707-423-5192 Fax: 707-423-7578 e-mail: berguer.r@martinez.va.gov

Advanced Endoscopic Skills Surgical Skills Unit University of Dundee Scotland, UK

Each month Professor Cuschieri Surgical Skills Unit offers a 412 day course in Advanced Endoscopic Skills. The course is intensely practical with hands on experience on a range of simulated models. The program is designed for experienced endoscopic surgeons and covers advanced dissection techniques, extracorporeal knotting techniques, needle control, suturing, internal tying technique, stapling, and anastomotic technique. Individual workstations and a maximum course number of 10 participants allows for personal tuition. The unit offers an extensive collection of surgical videos and the latest books and publications on endoscopic surgery. In addition, participating surgeons will have the opportunity to see live advanced laparoscopic and/or thoracoscopic procedures conducted by Professor Cuschieri and his team. The course is endorsed by SAGES. Course fee including lunch and course materials is $1850. For further details and a brochure please contact: Julie Struthers, Unit Co-ordinator Surgical Skills Unit Ninewells Hospital and Medical School Dundee DD1 9SY Tel: +44 382 645857 Fax: +44 382 646042

Fellowship in Minimally Invasive Surgery George Washington Medical Center Washington, DC USA
A one-year fellowship is being offered at the George Washington University Medical Center. Interested candidates will be exposed to a broad range of endosurgical Education and Research Center. Active participation in clinical and basic science research projects is also encouraged. For further information, please contact: Carole Smith 202-994-8425 or, send curriculum vitae to: Dr. Jonathan M. Sackier Director of Endosurgical Education and Research George Washington University Medical Center Department of Surgery 2150 Pennsylvania Avenue, N.W. 6B-417 Washington, DC 20037, USA

The Practical Aspects of Laparoscopic Fundoplication Surgical Skills Unit University of Dundee Scotland, UK
A three-day course, led by Professor Cuschieri, designed for experienced laparoscopists wishing to include fundoplication in their practice. The

610 course covers the technical details of total and partial fundoplication using small group format and personal tuition on detailed simulated models. There will be an opportunity to observe one of these procedures live during the course. Maximum course number is six. Course fee including lunch is $1850. For further details and a brochure please contact: Julie Struthers, Unit Co-ordinator Surgical Skills Unit Ninewells Hospital and Medical School Dundee DD1 9SY Tel: +44 382 645857 Fax: +44 382 646042 to enable the surgeon to improve his or her laparoscopic dexterity, efficiency, and creativity. Exact and meticulous technique is emphasized so that the surgeon can apply these skills with confidence. Personal instruction is provided by Zoltan Szabo, Ph.D., F.I.C.S., Director of the MOET Institute, and surgeons are allowed to progress their own pace. Each participant has sole use of a laparoscopic training station equipped with high-quality clinical laparoscopic equipment and instrumentation. Inanimate, animal tissue, and optional live animal models are utilized. Features of these program include: fluently choreographed instrument movements; economy of movement and flawless technique; needle and suture handling skills (2-0 to 7-0); precision suturing, knotting, ligature, and anastomosis techniques; atraumatic, hemostatic tissue handling and dissection; optimal angles of approach (coaxial alignment of setup and geometry of port positioning); laparoscopic surgical strategy, technical nuances, and troubleshooting; visual perception problems and solutions; magnified eye-hand coordination; and two-handed (ambidextrous) technique. Courses are offered year-round by individual arrangement. The MOET Institute is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians and designates these CME activities for 2040 credit hours in Category 1 of the Physicians Recognition Award of the American Medical Association. These programs are also endorsed by the Society of Gastrointestinal Endoscopic Surgeons (SAGES). For further information, please contact: Wanda Toy, Program Administrator Microsurgery & Operative Endoscopy Training (MOET) Institute 153 States Street San Francisco, CA 94114, USA Tel: (415) 626-3400 Fax: (415) 626-3444

Courses at George Washington University Endosurgical Educational and Research Center

George Washington University Endosurgical Educational and Research Center is proud to offer a wide range of surgical endoscopy courses. These courses include advanced laparoscopic skills such as Nissen fundoplication, colon resection, common bile duct exploration, suturing, as well as subspecialty courses. Individual surgeons needs can be met with private tuition. The Washington D.C. area is a marvelous destination to visit for recreational pursuits which can be arranged by the facility to suit your personal agenda. For further details please contact: Carole Smith: Department of Surgery 2150 Pennsylvania Avenue NW 6B Washington, DC 20037, USA Tel: (202) 994-8425

Courses at the Royal Adelaide Centre for Endoscopic Surgery

Basic and Advanced Laparoscopic Skills Courses are conducted by the Royal Adelaide Centre for Endoscopic Surgery on a regular basis. The courses are limited to six places to maximize skill development and tuition. Basic courses are conducted over two days for trainees and surgeons seeking an introduction to laparoscopic cholecystectomy. Animal viscera in simulators is used to develop practical skills. Advanced courses are conducted over four days for surgeons already experienced in laparoscopic cholecystectomy who wish to undertake more advanced procedures. A wide range of procedures are included, although practical sessions can be tailored to one or two procedures at the participants request. Practical skills are developed using training simulators and anaesthetised pigs. Course fees: $A300 ($US225) for the basic course and $A1,600 ($US1,200) for the advanced course. For further details and brochure, please contact: Dr. D. I. Watson or Professor G. G. Jamieson The Royal Adelaide Centre for Endoscopic Surgery Department of Surgery Royal Adelaide Hospital Adelaide SA 5000 Australia Tel: +61 8 224 5516 Fax: +61 8 232 3471

Courses at WISE Washington Institute for Surgical Endoscopy Washington, DC, USA
The Washington Institute of Surgical Endoscopy is pleased to offer the following courses: Laparoscopic antireflux and hiatal hernia surgery (July 1415, 1997); Laparoscopic management of the common bile duct and difficult cholecystectomy (May 1516, August 1112, November 1011, 1997); Laparoscopic colon and rectal surgery (June 2021, September 1516, December 45, 1997). Also, courses for operating room nurses and technicians will be run on a monthly basis and personal instruction and preceptorship is available. For further information, please call: Carole Smith Washington Institute of Surgical Endoscopy 2150 Pennsylvania Avenue, N.W. Washington, DC 20037 Tel: 202-994-9425

4th International Meeting on Laparoscopic Surgery May 17, 1997 Berne, Switzerland
Main topic: Acute appendicitis: Standard treatment and the role of laparoscopic surgery For further information, please contact: Mrs. Caroline Zrcher Klinik fr Viszerale und Transplantationschirurgie Universitt Bern Inselspital CH-3010 Bern, Switzerland Tel: +41 31 632 97 22 Fax: +41 31 632 97 23

Advanced Laparoscopic Suturing and Surgical Skills Courses MOET Institute San Francisco, CA, USA
This intensive hands-on training program is intended to help the surgeon develop proficiency in the essential laparoscopic surgical techniques. A sequence of progressively challenging exercises has been designed

611

European Course on Laparoscopic Surgery (French language) May 1316, 1997 (English language) November 1821, 1997 Brussels, Belgium
Course director: G.B. Cadiere For further information, please contact: Administrative Secretariat Conference Services s.a. Avenue de lObservatoire, 3 bte 17 B-1180 Bruxelles Tel: (32 2) 375 16 48 Fax: (32 2) 375 32 99

Fellowships in Laparoscopic Surgery Staten Island University Hospital Staten Island, NY USA
A one year fellowship, to start July 1, 1997, in advanced laparoscopic surgery is being offered at Staten Island University Hospital. The selected fellow will be exposed to many advanced general laparoscopic surgeries including: hiatal hernia repair, splenectomy, adrenalectomy, bowel resection, and others. Participation in research projects will be encouraged. For further information, please contact: Barbara Coleman Coordinator, Surgical residency program Tel: 718-226-9508

Joint Euro Asian Congress of Endoscopic Surgery 5th Annual Congress of the European Association for Endoscopic surgery (EAES) 3rd Asian-Pacific Congress of Endoscopic Surgery June 1721, 1997 Istanbul, Turkey
The Congress will include a joint postgraduate course EAES/SAGES/ ELSA on June 17th. For information and registration: SETUR Congress Department Cumhuriyet Cad. No. 107 80230 Elmadag Istanbul, Turkey Tel: (90.212) 23003 36 Fax: (90.212) 240 82 37

9th International Meeting Society for Minimally Invasive Therapy July 1416, 1997 Kyoto, Japan
Scientific program to include: Plenary, Parallel, Poster, and Video sessions. Host Chairman: Professor Osamu Yoshida, Department of Urology, Kyoto University, 54 Shogoin Kawahara-sho, Sakyo, Kyoto 606, Japan. Phone: +81 75 751-3328, Fax: +81 75 751-3740. This meeting coincides with the Gion Festival in Kyoto, one of the greatest festivals in Japan. For further information, please contact: Secretariat of SMIT 9th Annual International Meeting c/o Academic Conference Planning 383 Murakami-cho Fushimika, Kyoto 612 Japan Tel: +81 75 611-2008 Fax: +81 75 603-3816

Fellowships in Minimally Invasive Surgery The University of Pittsburgh Medical Center Pittsburgh, PA, USA
One year fellowships in advanced minimally invasive surgery in both general and thoracic surgery are being offered at the University of Pittsburgh Medical Center beginning on July 1, 1997. Requirements include completion of residency training programs in the desired area. The fellowships include a competitive salary and travel allowance. Interested candidates should send a letter of inquiry with curriculum vitae to: Philip R. Schauer, MD (General Surgery) or James Luketich, MD (Thoracic Surgery) The University of Pittsburgh Medical Center 3471 Fifth Avenue Suite 300 Pittsburgh, PA 15213-3221

6th World Congress of Endoscopy Surgery Roma 98 6th International Congress of European Association for Endoscopic Surgery June 36, 1998 Rome, Italy
The program will include: the latest, original high quality research; symposia; plenary lectures; abstract presentations (video, oral, and posters); EAES and SAGES postgraduate courses, OMED postgraduate course on therapeutic endoscopy; working team reports; educational center and learning corner; meeting of the International Society of Nurses and Associates; original and non original scientific reports; and a world expo of new technology in surgery. For further information, please contact: Congress Secretariat: Studio EGA Viale Tiziano, 19 00196 Rome, Italy Tel: +39 6 322-1806 Fax: +39 6 324-0143

Surg Endosc (1997) 11: 474475

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic transdiaphragmatic diagnostic pericardial window in the hemodynamically stable patient with penetrating chest trauma
A brief report
D. J. McMahon, R. F. Sing, W. S. Hoff, C. W. Schwab
Division of Trauma and Surgical Critical Care, Department of Surgery, University of Pennsylvania Medical Center, 3400 Spruce Street, 3 Maloney Building, Philadelphia, PA 19104, USA Received: 20 September 1995/Accepted: 24 April 1996

Abstract. We report two cases of laparoscopically performed transdiaphragmatic diagnostic pericardial window following diagnostic laparoscopy for a penetrating wound to the central anterior thorax below the sixth intercostal space. In the hemodynamically stable patient, this approach permits evaluation of the diaphragm, abdominal viscera, and pericardial space using a single, minimally invasive surgical technique. Key words: Pericardial window Laparoscopy Penetrating chest trauma

The hemodynamically stable patient with a penetrating injury to the anterior chest demands evaluation for occult cardiac and diaphragmatic injury. The area at risk for these injuries is defined superiorly by the sternal notch, inferiorly by the costal margins, and laterally by the nipples. Subxyphoid pericardial window and two-dimensional echocardiography have been advocated for the diagnosis of occult cardiac injuries in stable patients who sustain penetrating trauma to the area of the anterior chest wall [1, 2, 6]. One of these procedures is performed in addition to a second procedure to evaluate the diaphragm and abdominal viscera (e.g., exploratory laparotomy, laparoscopy). We report two cases of diagnostic pericardial window performed laparoscopically in conjunction with diagnostic laparoscopy for simultaneous evaluation of both the pericardial and peritoneal cavities. Case reports Case 1
A 14-year-old male presented to the Trauma Admitting Area with a stab wound to the right seventh intercostal space 3 cm lateral to the sternal

border caused by a weapon of unknown length. On physical examination there were no signs of cardiac tamponade or abdominal visceral injury. His vital signs were stable. A chest radiograph revealed a small right pneumothorax. The patient was taken to the operating room for tube thoracostomy, diagnostic laparoscopy, and pericardial window. After a general anesthetic and right tube thoracostomy the patient was prepped and draped in the usual trauma configuration (from chin to knees). In addition, a sternal saw and thoracotomy instruments were open and in the field (as part of our standard protocol for diagnostic pericardial windows). The peritoneal cavity was insufflated with CO2 via a 10-mm Hasson trocar in the infraumbilical position. Under laparoscopic visualization, a 5-mm port and a 10-mm port were inserted in the right and left upper quadrants in the midclavicular line, respectively. Using a laparoscopic liver retractor, the liver, the peritoneum, and the diaphragm were inspected, with no sign of injury. Using electrocautery the falciform ligament was divided and a 1-cm flap was fashioned in the central tendon of the left hemidiaphragm to expose the pericardium. The pericardium was incised with endoshears and clear fluid was identified in the pericardial space (Fig. 1). The early postoperative course was uncomplicated and the patient was discharged on the 2nd hospital day following the removal of the thoracostomy tube. On the 10th postoperative day the patient presented with a fever, chest pain, and a pericardial rub. No signs consistent with tension physiology were appreciated. Plain chest radiography, CT scan of the chest, and transthoracic echocardiography confirmed a clinical diagnosis of pericardial effusion. The volume of the effusion was deemed too small for safe percutaneous aspiration. A subxyphoid pericardial window was performed, which yielded 500 cc of sanguinous fluid. The heart showed no evidence of injury. The pericardium was thickened with a fibrinous exudate. Gram stain and culture of the pericardial fluid was negative. Histological examination of the pericardium showed nonspecific inflammatory changes. A diagnosis of postpericardiotomy syndrome was made and treatment with indomethacin was initiated. The patient was discharged on the 5th hospital day after an uneventful recovery.

Case 2
A 47-year-old male presented to the Trauma Admitting Area after a stab wound from a 10-inch kitchen knife to the sixth left intercostal space 2 cm lateral to the sternum. On physical examination there were no signs of pericardial tamponade or abdominal tenderness with stable vital signs. A chest radiograph was unremarkable. He was taken to the operating room where, using the same approach described above, diagnostic laparoscopy and a transdiaphragmatic diagnostic pericardial window were performed.

Correspondence to: W. S. Hoff

475

Fig. 1. Laparoscopic photograph demonstrates the divided falciform ligament and the anterior surface of the liver with the heart visible through the incised pericardial sac.

No injury was detected. The patient had a subsequent chest radiograph 6 h after presentation and was discharged home on the same day.

Discussion Deep stab wounds to the anterior surface of the chest between the nipples mandate exclusion of a cardiac injury. Classically, the subxyphoid pericardial window or twodimensional echocardiography is performed to diagnose or exclude cardiac injury. In addition there is a subset of penetrating chest trauma patients with wounds below the sixth rib anteriorly who require evaluation of the diaphragm and abdominal viscera. Thus, both the pericardial and peritoneal cavities need evaluation. Laparoscopic procedures are being applied with increasing frequency in the hemodynamically stable trauma patient for both diagnostic and therapeutic purposes. Laparoscopy offers a minimally invasive approach to the direct inspection of the diaphragm and intraperitoneal structures. The value of laparoscopy in selected penetrating thoracoabdominal injuries has been previously demonstrated [5]. The laparoscopic pericardial window has been previously described in the management of malignant pericardial effusion [79]. As a diagnostic procedure it can be performed safely and expeditiously with conventional laparoscopic equipment. Visualization of the pericardial fluid through a small incision is excellent with the magnification provided by the laparoscope. This report represents the first description of the technique as a diagnostic tool for traumatic injuries. As an extension of diagnostic laparoscopy, laparoscopic pericardial window offers a reasonable diagnostic modality for the exclusion of cardiac injury in selected patients. Evaluation of the pericardial space by the laparoscope requires absolute hemodynamic stability. The patient should be adequately draped for immediate median sternotomy if

required, and the appropriate thoracic instruments must be immediately available. In addition we stress that the pericardial membrane must be incised with endoshears and that electrocautery must not be used to prevent possible dysrhythmia or myocardial damage. Gas embolism is a potential concern with an open cardiac injury as it is with any significant abdominal venous injury. To avoid this complication, the abdomen should be immediately desufflated, and laparoscopy should be abandoned as soon as hemopericardium is diagnosed. Others have described the ability to recognize hemopericardium via laparoscopy with subsequent confirmation by subxyphoid window [4]. The first case also highlights the potential complication of postpericardiotomy syndrome. The diagnosis is one of exclusion, made in the absence of bacterial culture and pathological evidence of an infective process. The etiology of this complication is believed to be an immunologic response, which may occur following even minor pericardial procedures, with greater frequency in young children and adolescents. Instrumentation of the pericardial sac is the presumed inciting event in this case. The course of postpericardiotomy syndrome, as in this case, is usually selflimiting and responds well to salicylates and nonsteroidal preparations; occasionally it may require corticosteroids [3]. For the subset of hemodynamically stable patients with penetrating injury to the low anterior chest wall a number of approaches to exclude injury to both the heart and the abdominal cavity have been described. The technique described allows for the rapid simultaneous evaluation of the diaphragm, abdominal viscera, and the pericardial space and may be considered a diagnostic option in selected stable patients for centrally oriented penetrating injuries to the lower thorax. This approach should be reserved for those patients with clear hemodynamic stability and is offered as an alternative to other diagnostic combinations. References
1. Bolton JWR, Bynoe RP, Lazar HL, Almond CH (1993) Twodimensional echocardiography in the evaluation of penetrating intrapericardial injuries. Ann Thorac Surg 56: 506509 2. Duncan A, Scalea T, Scalafani S et al. (1989) Evaluation of occult cardiac injuries using subxiphoid pericardial window. J Trauma 29: 255260 3. Engle MA (1992) Postpericardiotomy syndrome. In: Doyle EF, Engle MA, Gersony WM (eds) Pediatric cardiology. Springer-Verlag, New York, pp771773 4. Grewal H, Ivatury RR, Divakar M, Simon RJ, Rohman M (1995) Evaluation of subxiphoid pericardial window used in the detection of occult cardiac injury. Injury 26: 305310 5. Ivatury RR, Simon RJ, Weksler B, Bayard V, Stahl WM (1992) Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury. J Trauma 33: 101110 6. Jimenez E, Martin M, Krukenkamp I, Barrett J (1990) Subxiphoid pericardiotomy versus echocardiography: a prospective evaluation of the diagnosis of occult penetrating cardiac injury. Surgery 108: 676680 7. Mann GB, Ngyuyen H, Corbet J (1994) Laparoscopic creation of a pericardial window. Aust N Z J Surg 64: 853855 8. Mayer HJ (1993) Transdiaphragmatic pericardial window: a new approach. J Cardiovasc Surg 34: 173175 9. Sastic JW, Stalter KD, Goddard RL (1992) Laparoscopic pericardial window. J Laparoscopic Surg 2: 263266

Surg Endosc (1997) 11: 468471

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Feasibility of and interest in laparoscopic assessment in recurrent urinary stress incontinence after Burch procedure performed by laparotomy
P. von Theobald, P. Barjot, G. Le vy
Service de Gyne cologie, Centre Hospitalo-Universitaire de Caen, Avenue Georges Cle menceau, 14033 Caen Cedex, France Received: 8 March 1996/Accepted: 8 July 1996

Abstract Background: The Burch colposuspension, performed by laparotomy or laparoscopy, remains one of the most popular operations for the treatment of genuine stress incontinence. The average failure rate is 10% in patients followed up for 5 years or more in the literature. The etiology of the failure is difficult to assess by clinical or urodynamic investigations; the failure may be due to weak sutures on the Coopers ligaments or on the vagina, to excessive or insufficient elevation of the cervical neck, or to an incompetent urethral sphincter. Methods: The authors performed five preperitoneal laparoscopies for recurrent urinary stress incontinence in women after a colposuspension performed by laparotomy in order to determine the etiology of the recurrence (between 1992 and 1995 at the Department of Gynecology of the University Hospital of Caen, France). Results: Laparoscopic preperitoneal access was possible in all patients. No laparotomy had to be performed. One small bladder injury occurred during the dissection. It was sutured by laparoscopy. There were no postoperative complications. In one patient, both of the sutures had escaped. In two other patients both sutures were found in place, but urodynamics showed a decrease in closure pressure. In two other patients, complaining of dysuria (painful voiding and acute bladder distension) associated with urinary leakage, only the colposuspension on one side had failed, involving a lateral torsion of the bladder neck. Conclusion: Preperitoneal laparoscopy is feasible after a laparotomic colposuspension and gives a very interesting etiologic contribution to the recurrence of incontinence. It helps to choose the most appropriate procedure to treat these recurrent incontinent patients: a new colposuspension if the previous one has failed anatomically and a sling operation if it hasnt and if the sphincter is incompetent. Key words: Laparoscopic colposuspension Recurrent stress urinary incontinence
Correspondence to: P. von Theobald

About 10% of the colposuspensions performed according to the Burch procedure result in recurrence in the 2 following years [1, 7]. Urinary leakage at stress, sometimes dysuria, urinary retention, and painful urination lead to a new assessment of the incontinence. Clinical examination and urodynamics are useful to detect a prolapse, an insufficient sphincter, or a recurrent decrease in the transmission of abdominal pressure to the urether. Urethrocystoscopy and radiological investigations rarely show any abnormality. In most of the patients, recurrence after colposuspension leads the surgeon to perform a sling procedure. The authors describe here a new approach to these cases. In five patients without prolapse with recurrent stress incontinence after a Burch procedure a preperitoneal laparoscopic assessment was performed to see the etiology of the failure and to try to have a more accurate therapeutic attitude.

Materials and methods

Five patients with recurrent urinary stress incontinence after conventional colposuspension by laparotomy according to Burch were assessed at the Department of Gynecology of the University Hospital of Caen between 1992 and 1995 (Table 1). Average age was 43.8 years. Previous colposuspension had been performed between 19 and 60 months before, but recurrence of the urinary leakage occurred a few months after the procedure except in two cases. Clinical symptomatology was stress incontinence in all cases, but in two patients it was combined with dysuria, painful urination, and acute bladder distension requiring catheterization. Preoperative urodynamic investigation showed a lack of transmission of abdominal pressure to the urether in all patients and an insufficient sphincter in two patients. A cystoscopy and a urethrocystography were performed in the two women complaining of dysuria. These investigations showed no dysfunction and didnt allow any etiological conclusion. A preperitoneal laparoscopy was tried in all patients after informed consent as a diagnostic stage preceding the therapeutic stage performed during the same anesthesia. The choice of the kind of procedure (colposuspension or sling) depended on the endoscopic findings. Clinical results were assessed by the subjective satisfaction of the patient and by the pad test. Urodynamic assessment is described in Table 2.

469 Table 1. Features of the five patients with recurrent stress urinary incontinence Patient no. 1 Age Previous colposuspension (month) Recurrence after (month) Symptomatology Closure pressure (cm of water) Laparoscopy Treatment Complication Clinical result Follow up (month) 44 19 1 Incontinence Dysuria 69 1 side failed Dissection Burch Bladder injury Break in the peritoneum Excellent 14 2 37 36 12 Incontinence 3 45 27 6 Incontinence 4 39 15 3 Incontinence Painful voiding Bladder distension 55 1 side failed Dissection Burch 0 Excellent 4 5 54 60 48 Incontinence

80 2 sides failed Burch 0 Excellent 27

45 No side failed Sling 0 Good 11

35 No side failed Sling Break in the peritoneum Good 19

Table 2. Urodynamic resultsa Urodynamic resultsb Prior 1st Burch CP LPT DI R AU CP LPT DI R AU CP LPT DI R AU Patient 1 76 50% 0 0 0 69 50% ++ 20 ++ 65 10% 0 0 0 Patient 2 83 40% 0 0 0 80 60% 0 0 0 75 0% 0 0 0 Patient 3 50 25% 0 0 0 45 25% 0 0 0 61 15% + 10 0 Patient 4 54 45% 0 0 0 55 45% 0 15 ++ No No No No 0 Patient 5 No No No No No 35 20% 0 0 0 47 15% + <10 0

Prior to laparoscopy

After laparoscopy

Patient 4 has not performed yet the postoperative urodynamic examination, and patient 5 had no preoperative urodynamic assessment at first operation b CP: closure pressure (cm of water), LPT: lack of transmission of the abdominal pressure to the urether, DI: detrusor instability, R: residual urines (cm3), AU: abnormal uroflowmetry

Results The opening of the preperitoneal space was possible in all patients. The section of the adhesions below the abdominal scar led to small breaks in the peritoneum in three cases without consequences for the continuation of the procedure. In one patient the vagina was totally free, and we could find no remaining suture on the Coopers ligaments. The previous colposuspension had been performed with resorbable sutures, and the following fibrosis was insufficient. We performed a laparoscopic colposuspension using nonresorbable mesh bands stapled to the vagina and the Coopers ligaments as already published [14]. Clinical results are excellent after a follow-up of 27 months. In two patients the colposuspension failed on one side, the thread remaining on the Coopers ligament. On the opposite side the vagina was tightened to the Coopers liga-

ment. The clinical symptomatology of these two patients can be explained by the surgical finding: The excessive tension of the sutures involved vagina escaping on one side and torsion of the bladder neck increased by bladder repletion. Painful voiding and acute distension are logical consequences. We performed a laparoscopic dissection to free the vagina from the ligament and the pelvic wall. This dissection was difficult; one bladder injury occurred and was treated by a laparoscopic suture. A colposuspension as in the preceding patient without excessive elevation of the bladder neck led to good clinical results after a follow-up of, respectively, 14 and 4 months. In the two last patients, the previous colposuspension was perfectly in place and the recurrence may be attributed to progressive weakening of the sphincter. A laparoscopic suburethral sling procedure was performed in both cases with good results after 11 and 19 months. The mild detrusor

470 Table 3. Prognosis factors Author Alcalay et al. [1] (1995) Adverse factors Previous bladder neck surgery Weight > 80 kg Blood loss > 1,000 ml Postoperative detrusor instability Bad surgical technique Low closure pressure Inability to elevate the bladder neck Rigid urethra Not adverse factors

Guerinoni et al. [4] (1991) Monga and Stanton [7] (1994)

Previous bladder neck surgery Concomittant hysterectomy Degree of prolapse Increasing age Obesity Concomittant hysterectomy (increases good prognosis) Detrusor instability Obesity Postoperative weight increase Parity Detrusor instability

Pigne et al. [10] (1988)

Bad surgical technique Low closure pressure Postoperative enterocele Associated sacrocolpopexy Previous bladder neck surgery Stanton et al. [12] (1978) Previous bladder neck surgery Increasing age Detrusor instability Postoperative raise of detrusor pressure von Theobald et al. [14] (1995) Previous bladder neck surgery Low closure pressure

instability of these two patients was cured by anticholinergic drugs.

secondary procedure: laparoscopic colposuspension if the first one was not correct, or laparoscopic sling procedure in the other cases.

Discussion Few publications in the literature clearly codify the management of recurrent stress incontinence after colposuspension. Adverse factors which mitigate the success of the colposuspension are discussed by several authors (Table 3) [1, 4, 7, 10, 12]. Previous bladder neck surgery appears to be significantly correlated to poor results for Stanton et al. [1, 12] and Pigne et al. [10], but not according to Feyereisl et al. [3] and Guerinoni et al. [4]. The best procedure to cure these recurrences is also discussed, usually in a few lines: always a new colposuspension for Guerinoni et al. [4], Morgan et al. [8], and Sarramon et al. [11], a colposuspension except when the bladder neck is scarred and immobile (which seems to be a subjective clinical finding), or when the vagina is narrow and immobile for Chin and Stanton [2], anterior colporraphy and a sling operation for Parker et al. [9]. The alternative treatment to colposuspension is a sling procedure using aponevrosis, fascia lata or inorganic materials, such a Mersilene, Marlex, Silastic, or Gore-Tex. The cure rate of secondary surgery varies: 100% Guerinoni et al. [4], 90% Lefranc et al. [6], 84% Parker et al. [9], 60% Stanton et al. [12] and Haertig et al. [5], and 50% Steen et al. [13]. The difference between these series may be due to the selection procedure of the patients and, moreover, to the ignorance of the objective etiology of the failure. Neither clinical and urodynamic investigations, nor cystoscopy, nor urethrocystography is able to evaluate the quality and the persistence of the previous colposuspension. Laparoscopic examination is the only way to assess correctly the state of the sutures around the bladder neck. The preperitoneal laparoscopic approach is possible after first surgery and allows an accurate cure of the incontinence by dissecting the vagina and bladder neck if necessary and choosing an accurate Conclusion The laparoscopic preperitoneal approach is possible for a secondary operation in the Retzius space for surgeons used to the preperitoneal procedures. It seems to be the best way to evaluate the quality of the previous colposuspension. It helps to choose the most accurate procedure to treat these recurrent incontinent patients: a new colposuspension if the previous one has failed anatomically and a sling operation if it has not and if the sphincter is incompetent.

References
1. Alcalay M, Monga A, Stanton SL (1995) Burch colposuspension: a 1020 year follow up. Br J Obstet Gynaecol 102: 740745 2. Chin YK, Stanton SL (1995) A follow up of Silastic sling for genuine stress incontinence. Br J Obstet Gynaecol 102: 143147 3. Feiereisl J, Haenggi W, Zikmund J, Schneider H (1994) Long term results after Burch colposuspension. Am J Obstet Gynecol 171: 647 652 4. Guerinoni L, Treisser A, Klein P, Renaud R (1991) Resultats fonctionnels et urodynamiques de la colpopexie selon Burch. J Gynecol Obstet Biol Reprod 20: 231240 5. Haertig A, Brami C, Vallencien G (1982) Resultats des colposuspenions primitives et secondaires dans la cure dincontinence fe minine. A propos de 104 cas. J Urol Paris 88: 723724 6. Lefranc JP, Attignac P, Blondon J (1983) traitement de 282 cas dincontinence urinaire deffort par colpopexie retropubienne aux ligaments de Cooper. J Chir (Paris) 120: 707711 7. Monga AK, Stanton SL (1994) The Burch colposuspension. Curr Obstet Gynecol 4: 210214 8. Morgan JF, Farrow GA, Steward FE (1985) The Marlex sling opera-

471 tion for the treatment of recurrent stress urinary incontinence. Am J Obstet Gynecol 151: 224226 9. Parker RT, Addison WA, Wilson CJ (1979) Fascia lata urethrovesical suspension for recurrent stress urinary incontinence. Am J Obstet Gynecol 135: 843852 10. Pigne A, Keskes J, Maghioracos P, Boyer F, Marpeau L, Barrat J (1988) Resultats cliniques et urodynamiques de la colposuspension type Burch dans le traitement de lincontinence urinaire deffort fe minine. J Gynecol Obstet Biol Reprod 17: 922930 11. Sarramon JP, Lhez JM, Soulie R, Combelles JL, Rischmann P (1984) Les re cidives dincontinence urinaire deffort et leurs approches the rapeutiques. Acta Urol Belg 52: 326335 12. Stanton SL, Cardozo L, Williams JE, Ritchie D, Allan V (1978) Clinical and urodynamic features of failed incontinence surgery in the female. Obstet Gynecol 51(5): 515520 13. Steen W, Knud P, Maakon KJ (1978) Urinary stress incontinence in women: pre and post operative evolution. Urol Int 33: 144 14. von Theobald P, Guillaumin D, Le vy G (1995) Laparoscopic preperitoneal colposuspension for stress incontinence in women. Surg Endosc 9: 11891192

Original articles
Surg Endosc (1997) 11: 427430

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Postoperative immune function varies inversely with the degree of surgical trauma in a murine model
J. D. F. Allendorf, M. Bessler, R. L. Whelan, M. Trokel, D. A. Laird, M. B. Terry, M. R. Treat
Columbia University, Columbia-Presbyterian Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA Received: 14 May 1996/Accepted: 16 July 1996

Abstract Background: Major surgery through a laparotomy incision is associated with a postoperative reduction in immune function. Studies in rats involving sham procedures suggest that immune function may be preserved after laparoscopy. This study investigates the effects of incision length and exposure method for bowel resection with respect to postoperative immune function as assessed by delayed-type hypersensitivity (DTH) reactions. Methods: Male Sprague Dawley rats (n 175) were challenged preoperatively, immediately postoperatively, and on postoperative day 2 with an intradermal injection of 0.2 mg phytohemagglutinin (PHA), a nonspecific T-cell mitogen. The averages of two measures of perpendicular diameters were used to calculate the area of induration. Anesthesia control rats underwent no procedure. Minilaparotomy rats underwent a 3.5-cm midline incision. Sham full laparotomy rats underwent a 7-cm midline incision. The open bowelresection group underwent a cecal ligation and resection through a 7-cm midline incision. In the laparoscopicassisted resection group a CO2 pneumoperitoneum and four-port technique was utilized to deliver the cecum through a 4-mm port where the cecum was extracorporeally ligated and resected. Results: Preoperative responses were similar in all five groups. Incision length: Full laparotomy group responses were 20% smaller than anesthesia control responses on postoperative day (POD)1 through POD4 (p < 0.02). At no time point were the responses in the minilaparotomy group significantly different from either anesthesia control or full laparotomy group responses. Exposure method: The laparoscopic-assisted resection group responses were 20% larger than open group responses at the time of two of the four postoperative measurements (p < 0.05, both comparisons). At all postoperative time points, open resection group responses were significantly smaller than control responses

(p < 0.05, all comparisons), whereas at no time point were laparoscopic group responses significantly different from control responses. Conclusion: We conclude that postoperative cell-mediated immune function varies inversely with the degree of surgical trauma. Results from the minilaparotomy and laparoscopy groups suggest that procedures done through small incisions may result in preservation of postoperative immune function. Key words: Delayed hypersensitivity DTH Laparoscopy Phytohemagglutinin PHA Laparoscopicassisted colon resection Rat Murine

Correspondence to: R. L. Whelan

Major surgery has been shown to result in significant postoperative immunosuppression. Specifically, open surgery causes a reduction in (1) lymphocyte and neutrophil chemotaxis, (2) natural killer cell activity, (3) lymphocyte and macrophage interactions, and (4) delayed-type hypersensitivity (DTH) responses [3, 6, 8, 10, 11]. DTH testing is an easily performed method which assesses cell-mediated immune function. By measuring and comparing patients DTH responses to a series of intradermal antigen challenges, Hammer et al. [5] have estimated that the period of postoperative immunosuppression lasts for 69 days. Immune function may be better preserved after laparoscopic procedures. Thus far, preservation of the following parameters have been demonstrated after laparoscopic vs open surgery: (1) T cell mitogen response, (2) monocyte release of tumor necrosis factor, and (3) monocyte release of superoxide ion [7, 13]. In a previous study, our laboratory compared the DTH responses before and after sham laparotomy, peritoneal insufflation, and anesthesia alone in a rat model [15]. The purpose of this initial study was to compare exposure techniques and therefore no abdominal procedure was performed. Postoperatively, sham laparotomy rats

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mounted DTH responses that were significantly smaller than their preoperative reactions. In contrast, DTH responses after peritoneal insufflation were not significantly different from their preoperative baseline measures and were similar to the responses seen in the postoperative anesthesia control group. These results suggest that immune function is better preserved after laparoscopic surgery. This initial study raised several questions. Would the observed differences in DTH responses persist if an intraabdominal procedure were performed? At what incision length does significant postoperative immunosuppression follow? The first study utilized a xiphoid to pubis midline incision. Would immune function be better preserved if a smaller incision was made? The current study aims to answer these questions. Materials and methods Animals
All studies were performed under protocols approved by the Columbia University Institutional Animal Care and Use Committee. One hundred seventy-five 150-g male Sprague Dawley rats (Charles River Laboratories, Wilmington, MA) were acclimated to a climate-andlight-cycle-controlled environment for no less than 48 h prior to investigations and were allowed standard laboratory rodent chow and tap water ad libitum.

Fig. 1. Influence of incision length on DTH response to PHA at 24 h. *p < 0.01 vs control on postoperative (POD)1, **p < 0.01 vs control on POD3.

Laparoscopic cecectomy
The animal is placed in Trendelenburg position and the peritoneal cavity is insufflated with carbon dioxide gas at a pressure of 46 mmHg through a 25-gauge angiocatheter inserted into the right upper quadrant. A 4-mm midline defect is created in the abdominal wall just caudal to the xiphoid to allow introduction of a 4-mm rigid scope with camera attachment. Second and third incisions, 2 mm in diameter, are then made in the right and left lower quadrants to allow introduction of laparoscopic scissors and forceps into the peritoneal cavity. The cecum, which in rats extends about 2.5 cm below the ileocecal valve, is usually found in the left lower quadrant. Once located, the cecum is grasped and the filmy avascular ligament between the ileum and the cecum is divided. The left lower quadrant port is extended to 45 mm and the bowel is exteriorized. Extracorporeally, the cecum is ligated, resected, and irrigated before the stump is returned to the peritoneal cavity. The abdominal wall defects are then sutured closed. Operative time was standardized to 30 min.

Challenge schedule
Animals received three intradermal challenges in the right flank with a nonspecific T cell mitogen, phytohemagglutinin (PHA), using the method previously described by Mendenhall [9]. Each challenge was 0.2 mg PHA (Sigma Chemical, St. Louis, MO) in 0.1 ml of allergy skin diluent (Center Laboratories, Port Washington, NY). Rats were challenged 3 days prior to surgery, on the operative day, and on postoperative day 2. The area of induration was determined by measuring perpendicular diameters with calipers 24 and 48 h after each challenge. The area of induration was calculated from the average of the two measurements at each time point. We used the formula for the area of an ellipse to approximate the area of induration (A ( D1/2 D2/2) ). Sterile saline (0.1 ml) was also injected intradermally in several rats as a negative control.

Statistics
Significant differences among groups were determined by analysis of variance (ANOVA), followed by Students t-test. Significance was accepted at p < 0.05.

Results Five of the 180 rats (2.78%) died postoperatively; one death occurred in the anesthesia control group due to an overdose of anesthesia, two deaths occurred in the sham full laparotomy group due to an overdose of anesthesia, and one death occurred in both the open and laparoscopic resection groups due to an unknown cause. Responses to challenge with PHA prior to surgical intervention were similar in all groups (Figs. 14). No rat mounted a measurable response to challenge with normal saline.

Study groups
All rats were anesthetized with ketamine (50 mg/ml) and xylazine (5 mg/ ml) before being assigned to one of five experimental groups (n 35 per group). 1. Anesthesia control rats underwent no procedure. 2. Minilaparotomy rats underwent a 3.5-cm midline incision. The bowel was covered with moist gauze for 30 min and then the laparotomy was sutured closed with 3-0 silk in two layers. 3. Full laparotomy rats underwent a 7.0-cm midline incision. The bowel was covered with moist gauze for 30 min and then the laparotomy was sutured closed with 3-0 silk in two layers. 4. Open bowel resection rats underwent a cecal ligation and resection through a 7.0-cm midline laparotomy incision. The bowel was covered for 30 min with moist gauze and then the incision was sutured closed with 3-0 silk in two layers. 5. Laparoscopy group rats underwent a bowel resection as described below. Following the interventions the animals were offered standard rodent chow and tap water ad libitum. The DTH responses were measured in a blinded fashion according to the schedule outlined above.

Incision length At all postoperative time points, full laparotomy group rats mounted significantly smaller DTH responses than anesthesia control rats (p < 0.02 for all four comparisons, Figs. 1 and 2). Minilaparotomy group responses were smaller than control responses but larger than sham full laparotomy group responses. At no time point were the responses in the

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measure of the first postoperative challenge (p < 0.01) and at the 48-h measure of the second postoperative challenge (p < 0.05, Figs. 3 and 4). The differences between these two groups were not significant at the 48-h measurement of the first postoperative challenge nor at the 24-h measurement of the second postoperative challenge. At all time points, open resection group responses were significantly smaller than anesthesia control responses (p < 0.05 for all four comparisons), whereas at no time point were laparoscopic-assisted resection group responses significantly different from control responses.
Fig. 2. Influence of incision length on DTH response to PHA at 48 h. *p < 0.02 vs control on POD2, **p < 0.02 vs control on POD4.

Discussion Cell-mediated immune function can be safely, reliably, and economically evaluated using skin antigen testing. The significance of the DTH response has been demonstrated in both animals and humans. In rats, Tchervenkov et al. demonstrated an inverse relationship between the size of pustules after intradermal injection of Staphylococcus aureus and the area of induration in response to challenge with a common skin antigen [14]. Following injury, DTH response was significantly reduced whereas pustule volume was significantly increased as compared to preinjury baseline measurements. In human studies, anergic patients demonstrate a significantly higher incidence of sepsis and a higher mortality than normal DTH responders postoperatively [12]. One study of 727 patients found a postoperative sepsis rate of 7.5% and a mortality rate of 4.6% in normal DTH responders, whereas anergic and relatively anergic patients had a 30% sepsis rate and a 23% mortality [2]. In addition, anergy in cancer patients is associated with a significantly higher rate of unresectability and an increased rate of tumor recurrence postoperatively [4]. Delayed-type hypersensitivity is a three-phase process that can be elicited in animals and humans by intradermal injection of common skin antigens. The cognitive phase involves antigen presentation to CD4+ T cells in association class II MHC molecules by antigen-presenting cells. This is followed by the activation phase in which T cells release cytokines and proliferate. The effector phase has two components: (1) inflammation resulting from cytokine activation of endothelial cells and recruitment of leukocytes followed by (2) a period of resolution in which phagocytic mononuclear cells differentiate into activated macrophages and clear the foreign antigen [1]. A brief summary of what occurs at the challenge site follows. Approximately 4 h after challenge polymorphonucleocytes transiently infiltrate the postcapillary venules. By 12 h T cells and macrophages predominate at the site of injection. The local vascular endothelium becomes leaky and fibrinogen extravisates into the underlying tissue where the fibrinogen is enzymatically cleaved to become fibrin. The extravascular fibrin, the localized edema, and to a lesser extent the cellular infiltrate of T cells and macrophages collectively result in an area of induration referred to as a weal. The maximal response (area of induration) is seen from 24 to 48 h after challenge [1]. Abnormalities which may lead to a decrease in DTH response include (1) defective antigen presentation or recognition, (2) impaired T cell or macrophage function, and

Fig. 3. Influence of exposure method during bowel resection on DTH response to PHA at 24 h. *p < 0.01 vs control and laparoscopic resection on POD1, **p < 0.05 vs control on POD3.

Fig. 4. Influence of exposure method during bowel resection on DTH response to PHA at 48 h. *p < 0.02 vs control on POD2, **p < 0.02 vs control on POD4 and p < 0.05 vs laparoscopic resection on POD4.

minilaparotomy group significantly different from either anesthetic control group or the full laparotomy group.

Exposure method The laparoscopic-assisted resection group responses were 20% larger than open resection group responses at the 24-h

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(3) decreased neutrophil adherence. In this study rats were challenged with PHA, which is a commonly used mitogen that polyclonally activates CD4+ T cells in a nonspecific manner, thus bypassing the cognitive phase. The observed differences in the present study suggest that the postoperative immune suppression occurs in the effector arm of the DTH response since PHA bypasses the cognitive phase of the response. The results of this study demonstrate that postoperative immunosuppression may be related to the length of the laparotomy incision. Anesthesia control rats mounted a significantly greater response at all postoperative time points than rats that had undergone a full laparotomy. The responses of the minilaparotomy group fell between control and full laparotomy values, but at no postoperative time point were the minilaparotomy responses significantly different from controls. These findings suggest that limiting the size of the incision may better preserve cell-mediated immune function. The results of this study suggest that there is less postoperative immunosuppression after laparoscopic-assisted than after open bowel resection. This can be looked at in two ways: (1) Laparoscopic-assisted group responses were significantly greater than open group responses at two of the four postoperative time points, and (2) anesthesia control rats mounted significantly greater responses than open resection group rats at all postoperative time points. Laparoscopic-assisted group responses fell between control and open group values, but at no postoperative time point were the laparoscopic-assisted group responses significantly different from controls. These findings suggest that the laparoscopic-assisted approach may better preserve cellmediated immune function. Using DTH response as the outcome measure, our laboratory previously reported a significant reduction in cellmediated immune function after a sham laparotomy but preservation of immune function after a peritoneal insufflation [15]. In this study we have confirmed our earlier findings and demonstrated that the differences in DTH response persist despite the addition of an intraabdominal procedure (bowel resection). In addition, we have shown a graded decrease in the area of induration as the abdominal incision is lengthened. We found an inverse relationship between the area of induration and the incision length. Significant reductions in DTH responses in this study and in the previous report by Trokel occurred only when a large laparotomy incision was made, suggesting that procedures through small incisions may have a limited effect on cell-mediated immune function.

Absence of a DTH response has been associated with poor patient outcomes. Major surgery through a laparotomy incision causes a significant reduction in the DTH response postoperatively. Laparoscopic surgery has resulted in preservation of the DTH response in two animal models. These observations raise the question of whether patient outcomes will be improved using a laparoscopic or laparoscopicassisted approach.
Acknowledgment. This research was made possible by generous support from the Ethicon division of Johnson and Johnson, Inc.

References
1. Abbas AK, Lichtman AH, Pober JS (1994) Cellular and molecular immunology. 2nd ed. WB Saunders, Philadelphia, pp 262271 2. Christou NV, Meakins JL, MacLean LD (1981) The predictive role of delayed hypersensitivity in preoperative patients. Surg Obstet Gynecol 152: 297 3. Christou NV, Superina R, Broadhead M et al. (1982) Postoperative depression of host resistance: determinants and effect of peripheral protein-sparing therapy. Surgery 92: 786 4. Eilber FR, Morton DL (1970) Impaired immunologic reactivity and recurrence following cancer surgery. Cancer 25: 362 5. Hammer JH, Neilsen HJ, Moesgaard F et al. (1992) Duration of postoperative immunosuppression assessed by repeated delayed type hypersensitivity skin tests. Eur Surg Res 24: 133 6. Hjortso NC, Kehlet H (1986) Influence of surgery, age and serum albumin on delayed hypersensitivity. Acta Chir Scand 152: 175 7. Horgan PG, Fitzpatrick M, Course NF et al. (1992) Laparoscopy is less immunotraumatic than laparotomy. Min Invasive Ther 1: 241 8. Lennard TWJ, Shenton BK, Borzotta A et al. (1985) The influence of surgical operations on components of the human immune system. Br J Surg 72: 771 9. Mendenhall CL, Grossman CJ, Roselle GA et al. (1989) Phytohemagglutinin skin test responses to evaluate in vivo cellular immune function in rats. Proc Soc Exp Biol Med 190: 117 10. Neilsen HG, Pedersen BK, Moesgaard F (1989) Effect of ranitidine on postoperative suppression of natural killer cell activity and delayed hypersensitivity. Acta Chir Scand 155: 377 11. Neilsen JH, Moesgaard F, Kehlet H ( ) Ranitidine for prevention of postoperative suppression of delayed hypersensitivity. Am J Surg 157: 291 12. Pietsch JB, Meakins JL, MacLean LD (1977) The delayed hypersensitivity response: application in clinical surgery. Surgery 82: 349 13. Redmond HP, Watson WG, Houghton T, Condron C, Watson RGK, Bouchier-Hayes D (1994) Immune function in patients undergoing open vs laparoscopic cholecystectomy. Arch Surg 129: 1240 14. Tchervenkov JI, Diano E, Meakins JL, Christou NV (1986) Susceptibility to bacterial sepsis: Accurate measurement by the delayed-type hypersensitivity skin test score. Arch Surg 121: 37 15. Trokel MJ, Bessler M, Treat MR, Whelan RL, Nowygrod R (1994) Preservation of immune response after laparoscopy. Surg Endosc 8: 1385

Surg Endosc (1997) 11: 445448

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Partial fundoplication for gastroesophageal reflux

M. G. Patti, M. De Bellis, M. De Pinto, S. Bhoyrul, J. Tong, M. Arcerito, S. J. Mulvihill, L. W. Way
Department of Surgery, University of California, San Francisco, 533 Parnassus Avenue, U-122, San Francisco, CA 94143-0788, USA Received: 1 April 1996/Accepted: 1 July 1996

Abstract Background: About 20% of patients with gastroesophageal reflux disease (GERD) have severely impaired esophageal peristalsis in addition to an incompetent lower esophageal sphincter. In these patients a total fundoplication corrects the abnormal reflux, but it is often associated with postoperative dysphagia and gas bloat syndrome. We studied the efficacy of partial fundoplication in such patients. Methods: A partial fundoplication (240270) was performed laparoscopically in 26 patients (11 men, 15 women; mean age 50.5 years) with GERD (mean DeMeester score: 92 16) in whom manometry demonstrated severely abnormal esophageal peristalsis. Results: All operations were completed laparoscopically and the patients were dicharged an average of 39 h after surgery. The preoperative symptoms resolved or improved in all patients, and no patient developed dysphagia or gas bloat syndrome. Postoperative pH monitoring showed complete or nearly complete resolution of the abnormal reflux in every patient. Conclusions: Partial fundoplication is an excellent treatment for patients with GERD and weak peristalsis, for it corrects the abnormal reflux and avoids postoperative dysphagia. Key words: Gastroesophageal reflux disease Esophageal manometry Esophageal peristalsis Esophageal clearance Partial fundoplication

erative dysphagia and gas bloat syndrome were almost inevitable following fundoplication [1, 14]. Nevertheless, the indications for an antireflux procedure in such patients are compelling, for in addition to heartburn they have a high incidence of esophageal stricture formation, Barretts esophagus, and respiratory symptoms [9, 15]. The goal of this study was to determine whether a partial fundoplication controls the symptoms and the reflux, while avoiding troublesome side effects in patients with GERD and a panesophageal motor disorder. Patients and methods
Between June 1993 and August 1995, a laparoscopic partial fundoplication was performed in 26 patients (11 men, 15 women; mean age 50.5 years) for treatment of GERD.

Peroperative evaluation Symptoms. Patients were questioned regarding the presence of symptoms suggestive of GERD. Figure 1 shows the severity of the presenting symptoms. Symptoms had been present preoperatively for an average of 133 months (range, 4360). Upper gastrointestinal series. Twenty-two patients had a hiatal hernia. The study was normal in four patients.

Some patients with gastroesophageal reflux disease (GERD) have severely impaired esophageal peristalsis in addition to an incompetent lower esophageal sphincter (LES) [5, 10, 11, 15]. They have often been considered to be poor candidates for surgery on the assumption that postopPresented at the 5th World Congress of Endoscopic Surgery of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 15 March 1996 Correspondence to: M. G. Patti

Esophagogastroduodenoscopy. According to the SavaryMiller classification, 13 patients (50%) had grade I or II esophagitis, and 13 patients (50%) had grade III or IV esophagitis. Barrettts esophagus (verified by biopsy findings) was present in four patients (15%). Esophageal manometry. The patients were studied after an overnight fast. Medications which interfere with esophageal motor function (metoclopramide, cisapride, calcium-

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chest roentgenogram was always taken to confirm the proper position of the probe in the esophagus. During the study, the patients consumed a normal diet and were taking no medications. A commercial software program was used for data analysis (Gastrosoft, Synectics Medical, Irving, TX). All patients had abnormal gastroesophageal reflux (mean preoperative DeMeester score, 92 16; normal score <15) [4]. Radionuclide measurement of gastric emptying. The rate of gastric emptying of solids was selectively measured in six patients whose symptoms suggested delayed gastric emptying. Emptying was very slow in two of these six patients (85 8% of the test meal remained in the stomach after 3 h [normal, 22 10%]). The remaining four patients had normal emptying. Operative technique
The operation was performed under general anesthesia. An orogastric tube was inserted at the beginning and was removed at the end of the procedure. The patient was placed supine on the operating table in steep reverse Trendelenburg position with the legs extended in stirrups. Five 10-mm trocars were used. The operation involved seven steps: (1) The gastrohepatic ligament was divided from mid lesser curve to the diaphragm, allowing the right side of the crus to come into view. (2) The right side of the crus was separated by blunt dissection from the abdominal esophagus posteriorly all the way to the point where it joined the left crus. (3) The peritoneum and phrenoesophageal membrane anterior to the esophagus were divided, and the left border of the crus was dissected away from the esophagus to the point where it met the right side of the crus. (4) A window was created behind the abdominal esophagus between the crus and the gastroesophageal junction. A Penrose drain passed around the abdominal esophagus was used for retraction. (5) The short gastric vessels were divided from a point midway along the greater curvature up to the angle of His using Laparosonic Coagulating Shears (LCS). (6) The diaphragmatic hiatus was narrowed with 2-0 silk sutures tied intracorporeally. (7) The gastric fundus was pulled behind the abdominal esophagus, and a 240 270 posterior wrap was created over a 5660 F bougie. The total length of the fundoplication was 2 cm. Figure 2 shows the position of the stitches (2-0 silk) used for the reconstruction. Two or three stitches were used to close the hiatus (A); six stiches were used to suture the gastric fundus to the esophagus (B); two stiches were placed between the right side of the wrap and the closed crus to counteract lateral or cephalad traction on the wrap (C); and two stitches were placed apically (including the esophagus, the right or left crus, and the wrap) to counteract cephalad traction (D). The following concomitant laparoscopic procedures were performed in four (15%) patients: pyloromyotomy, two patients; cholecystectomy, one patient; and extensive lysis of adhesions, one patient.

Fig. 1. Severity of symptoms among 26 patients ( , preop; s, postop) with gastroesophageal reflux disease. Symptom score (04). *Statistically significant. **No patient developed postoperative dysphagia or gas bloat syndrome.

channel blockers) were discontinued 24 h prior to the study. Manometry was performed using an 8-lumen catheter which was continuously perfused at a rate of 0.5 ml/min by a low-compliance pneumohydraulic pump (Arndorfer Medical Specialties, Greefiel, WI) and connected to a polygraph (Synectics Medical, Irving, TX). The length and pressure of the LES were measured using the station pull-through technique. Amplitude, duration, and velocity of the peristalitic waves were then assessed in response to 10 swallows of 5 ml of water given at 30-s intervals. Computerized data analysis was done using a commercial software program (Gastrosoft, Synectics Medical, Irving, TX). Twenty (76%) patients had an incompetent LES according to the DeMeester criteria [16]. All patients had severe abnormalities of peristaltic amplitude, duration, or velocity, and/or morphology of the peristaltic waves (i.e., amplitude in the distal esophagus <40 mmHg; >20% segmented waves; >30% double-peaked waves; and presence of triple-peaked and/or dropped waves). Ambulatory 24-h pH monitoring. Acid-suppressing medications were discontinued 310 days before the test. Ambulatory pH monitoring was performed by using a pH probe with an antimony sensor which was positioned 5 cm above the upper border of the manometrically determined LES. A

Statistical analysis
Students t-test was used for statistical evaluation of the data. All results are expressed as mean standard error of the mean. Differences were considered significant at p < 0.05.

Results Hospital course All operations were completed laparoscopically, and there were no intraoperative complications. The average operat-

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tients; their preoperative DeMeester score of 125 40 decreased to 40 9 postoperatively. Three of these four patients are asymptomatic.

Discussion During the past decade it has become evident that the esophageal body plays a key role in the antireflux mechanism [5, 10, 15]. While the pressure and behavior of the LES regulate the amount of gastric contents that refluxes into the esophagus, esophageal peristalsis is the major determinant of esophageal volume clearance [6]. When peristalsis is weak, clearance is slow, and the time that gastric refluxate remains in contact with the mucosa lengthens, the upward extent of reflux increases, and the degree of mucosal injury worsens [5, 10, 15]. Severe concomitant abnormalities of the LES and esophageal peristalsis coexist in about 20% of patients with GERD [11], and the combination is especially common in patients with large hiatal hernias, in whom the LES is shorter and weaker, acid clearance is less effective, and the amount of refluxate is greater [13]. Furthermore, there is evidence that reflux of duodenal juices joins with acid reflux in producing the resulting disease [8]. Medical therapy in these patients is often ineffective. Patients such as these are most in need of a fundoplication, as stricutres and Barretts esophagus are more common [15], and respiratory symptoms are often present [9]. Some clinicians, however, have rejected surgery as an option, fearing that a fundoplication will cause dysphagia and gas bloat syndrome [1, 14]. Others have recommended a Nissen fundoplication for all patients with severe GERD regardless of their manometric findings, although postoperative dysphagia is common with this strategy [2, 3]. The question addressed in this report is whether a partial wrap is less likely to pose an obstacle to food passage while still preventing reflux [7, 11, 16]. If so, esophageal manometry and acid exposure should be measured preoperatively in all patients with GERD being considered for surgery, since there are no clinical findings that reliably identify patients whose peristalsis is especially weak. Then a partial wrap (240270) should be chosen when amplitude of peristalsis in the distal esophagus is below 50 mmHg and esophageal clearance is slow [11, 12]. An upper gastrointestinal series and endoscopy found out the standard preoperative workup. The results of this study confirm the validity of this approach. After a mean follow-up of 11 months, the patients were either free of heartburn and regurgitation (88%) or much improved, respiratory symptoms had resolved in twothirds of patients, and chest pain had been relieved in all. No patient developed postoperative dysphagia or gas bloat syndrome, and, in fact, dysphagia improved whenever it had been present preoperatively. Postoperative pH monitoring showed a small amount of residual reflux in four patients; only one of these patients experiences mild heartburn during follow-up, which is adequately treated with PRN antacids. Longer follow-up will determine if these results are longlasting. These results show that a partial fundoplication is clinically effective in patients with GERD and severely impaired

Fig. 2. Partial fundoplication: (A) stitches to approximate the crura; (B) stitches from the right side of the wrap to the closed crus; (C) stitches from the right and left side of the wrap to the esophagus; (D) apical stitches (incorporating the crus, the esophagus, and the wrap).

ing time was 184 10 min. The average blood loss was 30 ml. The patients were given oral liquids the evening of the procedure and were progressed to a regular diet the next morning (average 25 2 h). They left the hospital an average of 1.7 days (39 4 h) after surgery. No acidsuppressing drugs (e.g., H2-receptor blockers; omeprazole) were given after the operation. Postoperative complications developed in three patients (urinary retention, one patient; swollen labia due to patent canal of Nuck, one patient; angina pectoris, one patient).

Postoperative follow-up The mean length of follow-up is 11 months. Patients were seen in the office one and two months postoperatively. Subsequently, they were interviewed by telephone at 2-months intervals by one of the authors. Heartburn and regurgitation resolved in 23 (88%) of the 26 patients and improved substantially in the remaining three patients. Respiratory symptoms, which were present preoperatively in five patients, disappeared in 4 patients and improved in one. Before surgery, nine patients experienced intermittent dysphagia for solids and liquids; postoperatively, the dysphagia resolved in six (66%) of these patients and improved in three patients. No patient developed de novo dysphagia or gas bloat syndrome postoperatively. Chest pain resolved in 13 (100%) out of 13 patients (Fig. 1). Twenty-four pH monitoring was repeated 2 months after the operation in 13 (50%) of the 26 patients. In nine patients, the abnormal reflux was completely corrected (the DeMeester score went from 76 14 preoperatively to 6 1 postoperatively). Residual reflux was identified in four pa-

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esophageal peristalsis. This operation corrects the symptoms and the measurable reflux without incurring postoperative dysphagia or gas bloat syndrome. References
1. Bittner HB, Meyers WC, Brazer SR, Pappas TN (1994) Laparosocpic Nissen fundoplication: operative results and short-term follow-up. Am J Surg 167: 193200 2. Hinder RA, Filipi CJ, Wetscher G, Neary P, DeMeester TR, Perdikis G (1994) Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 220: 472483 3. Jamieson GG, Watson DI, Britten-Jones R, Mitchell PC, Anvari M (1994) Laparoscopic Nissen fundoplication. Ann Surg 220: 137145 4. Jamieson JR, Stein HJ, DeMeester TR, Bonavina L, Schwizer W, Hinder RA (1992) Ambulatory 24-hr esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility. Am J Gastroenterol 87: 11021111 5. Kahrilas PJ, Dodds WJ, Hogan WJ, Kern M, Arndorfer RC, Reece A (1986) Esophageal peristaltic dysfunction in peptic esophagitis. Gastroenterology 91: 897904 6. Kahrilas PJ, Dodds WJ, Hogan WJ (1988) Effect of peristaltic dysfunction on esophageal volume clearance. Gastroenterology 94: 7380 7. Kauer WKH, Peters JH, DeMeester TR, Heimbucher J, Ireland AP, Bremmer CG (1995) A tailored approach to antireflux surgery. J Thorac Cardiovasc Surg 110: 141147 8. Kauer WKH, Peters JH, DeMeester TR, Ireland AP, Bremner CG, Hagen JA (1995) Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. Ann Surg 222: 525533

9. Patti MG, Debas HT, Pellegrini CA (1992) Esophageal manometry and 24-hour pH monitoring in the diagnosis of pulmonary aspiration secondary to gastroesophageal reflux. Am J Surg 163: 401406 10. Patti MG, Debas HT, Pellegrini CA (1993) Clinical and functional characterization of high gastroesophageal reflux. Am J Surg 165: 163 168 11. Patti MG, Arcerito M, Pellegrini CA, Mulvihill SJ, Tong J, Way LW (1995) Minimally invasive surgery for gastroesophageal reflux disease. Am J Surg 170: 614618 12. Patti MG, Bortolasi L, Arcerito M, Tong J, Murgia AP, Way LW (1995) Clinical and radiographic findings are unreliable to diagnose gastroesophageal reflux disease (GERD). Gastroenterology (Abstract) 108: 1238 13. Patti MG, Goldberg HI, Arcerito M, Bortolasi L, Tong J, Way LW (1996) Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury. Am J Surg 171: 182186 14. Pitcher DE, Curet MJ, Martin DT, Castillo RR, Gerstenberger PD, Vogt D, Zucker KA (1994) Successful management of severe gastroesophageal reflux disease with laparoscopic Nissen fundoplication. Am J Surg 168: 547554 15. Stein HJ, Eypasch EP, DeMeester TR, Smyrk TC, Attwood SEA (1990) Circadian esophageal motor function in patients with gastroesophageal reflux disease. Surgery 108: 769778 16. Waring JP, Hunter JG, Oddsdottir M, Wo J, Katz E (1995) The preoperative evaluation of patients considered for laparoscopic antireflux surgery. Am J Gastroenterol 90: 3538 17. Zaninotto G, DeMeester TR, Schwizer W, Johansson K-E, Cheng S-C (1988) The lower esophageal sphincter in health and disease. Am J Surg 155: 104111

Surg Endosc (1997) 11: 479482

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic treatment of gallbladder duplication

A plea for removal of both gallbladders
J.-F. Gigot,1 B. Van Beers,2 L. Goncette,2 J. Etienne,1 A. Collard,1 P. Jadoul,1 A. Therasse,1 J. B. Otte,1 P.-J. Kestens1
1 2

Department of Digestive Surgery, Saint-Luc University Hospital, Louvain Medical School, Hippocrate Avenue, 10, B-1200 Brussels, Belgium Department of Medical Imaging, Saint-Luc University Hospital, Louvain Medical School, Hippocrate Avenue, 10, B-1200 Brussels, Belgium

Received: 11 March 1996/Accepted: 22 May 1996

Abstract Background: Gallbladder duplication is a rare congenital condition, which can now be detected preoperatively by imaging studies. Methods: We report a case of duplicated gallbladder with symptomatic unilobar gallstones. Appropriate biliary workup (ultrasound, oral cholecystography, and intravenous cholangiography) allowed a correct preoperative diagnosis. Results: Laparoscopic treatment included selective removal of the diseased accessory gallbladder. However, postoperative acute cholecystitis and symptomatic gallstone occurred in the remaining main gallbladder, and laparoscopic reintervention was required 27 months later. Conclusions: This case illustrates the need for complete removal of both gallbladders during initial surgery. Precise intraoperative recognition of vascular and biliary anatomyincluding abnormalitiesis highlighted to avoid mistakes during surgery. Key words: Laparoscopy Gallbladder duplication Cholangiography

Case report
A 29-year-old woman presented with right upper quadrant abdominal pain. Clinical examination and liver function tests were normal. Ultrasonography revealed two cystic structures in the gallbladder fossa, with gallstones in one of them (Fig. 1). Oral cholecystography demonstrated a normal main gallbladder, free of stones and contracting well after fatty meal administration. A second, smaller, gallbladder structure was poorly opacified, containing a 1-cm filling defect (Fig. 2). The diagnosis of duplicated gallbladder was suspected. In order to define the cystic duct anatomy, intravenous cholangiography was performed, which demonstrated normal cystic duct anatomy of the main gallbladder draining into the common bile duct but without visualization of the accessory cystic duct (Fig. 3). On November 4, 1992, the patient underwent laparoscopic cholecystectomy. At exploration, the accessory gallbladder was located inferiorly to the main one, in large part intrahepatically. Tedious dissection was undertaken from the liver bed, requiring parenchymal liver hemostasis with an argon-beam coagulator. Careful dissection of the Calot triangle isolated the accessory cystic artery, which originated from the right branch of the hepatic artery, and the accessory cystic duct, which originated from the right anterior bile duct system, as seen on intraoperative cholangiography (Fig. 4). Great care was taken to preserve the main cystic ductal and arterial structures. Because of the normal aspect and function of the main gallbladder, which was without gallstones, we performed only selective accessory cholecystectomy. Pathologic examination demonstrated features of chronic cholecystitis of the accessory gallbladder. The patient left the hospital 3 days after surgery. One week later, she presented with clinical, biochemical, and ultrasonic features of acute cholecystitis of the remaining gallbladder, which resolved progressively after treatment with antibiotics. Subsequently, the main gallbladder, although showing restored normal function and contraction on oral cholecystography, was found to contain multiple small gallstones on ultrasound. Ursodeoxycholic acid failed to dissolve these microlithiasis. Four months after the initial operation, the patient started to present typical biliary colic, without liver function abnormalities. On March 24, 1995, she finally underwent a second laparoscopic cholecystectomy. At surgical exploration, a few adhesions were present. Careful dissection of Calots triangle allowed safe dissection and clipping of the main cystic artery and cystic duct, after completion of a normal intraoperative cholangiography. The postoperative course was uncomplicated, and the patient left the hospital 3 days later. She remained free of symptoms 6 months later.

Duplication of the gallbladder is a rare disease, with an incidence of 1 in 4,000 autopsies [1]. Usually discovered during surgery in the past [13, 33], this congenital abnormality can now be detected preoperatively by imaging studies, mainly by ultrasonography [41]. Differential diagnosis includes gallbladder fold, phrygian cap, focal adenomyomatosis, intraperitoneal fibrous (LADDs) bands, choledochal cyst, pericholecystic fluid, and gallbladder diverticula [7, 8]. We present here a patient for whom a correct preoperative diagnosis was made on imaging studies but who required a two-stage cholecystectomy.
Correspondence to: J.-F. Gigot

Discussion With the development of new radiologic modalities, congenital anomalies of the biliary system and the gallbladder

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Fig. 1. Ultrasonographic examination shows two cystic structures lying side by side in the gallbladder fossa (arrowheads). A gallstone is present in one of them. Fig. 2. Oral cholecystogram confirms the presence of a double gallbladder. The one containing a gallstone is poorly opacified and contracted slowly after a fatty meal.

are more frequently diagnosed [41]. According to Boydens classification [1], congenital abnormalities of the gallbladder include vesica fellea divisa (bilobed or bifid gallbladder) and vesica fellea duplex, which represent true duplicated gallbladder, with two different cystic ducts. This last form is classified as a Y-shaped type (two cystic ducts uniting before entering the common bile duct, with, usually, two gallbladders adherent and occupying the same fossa) or a H-shaped type or ductular type (usually with two separated gallbladders and two cystic ducts emptying separately into the common bile duct) (Fig. 5). True duplication arises from splitting of the cystic primordium during the 6th embryonic week [9, 40]. Triple gallbladder has also been described [6, 17, 30]. The accessory gallbladder of the ductular type may be adjacent to the normal organ

Fig. 3. Intravenous cholangiogram demonstrates clearly the cystic duct of the main gallbladder draining into the common bile duct, but it fails to opacify the accessory cystic duct. Fig. 4. Intraoperative cholangiogram confirms duplication of the gallbladder and demonstrates the accessory cystic duct entering the right anterior bile duct of segment V (arrow).

in the gallbladder fossa, or it may be intrahepatic, subhepatic, or within the gastrohepatic ligament [11]. The prevalence of double gallbladder is reported by Boyden [1] to be one in 3,0004,000 cadavers in autopsy series (two in 9,221 autopsies), and three other cases were reported by him after review of 9,970 cholecystograms. Shehadi and Jacox [32] reported one case in 12,000 roentgenographic examinations of the biliary tract. In 1977, Harlaftis et al. [15] reported 207 cases of double gallbladder. There are no specific symptoms of double gallbladder, and the incidence of disease does not seem to be different

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Fig. 5. Various types of double gallbladder: A Bilobed or bifid gallbladder (with one cystic duct). B True duplicated gallbladder: Y-shaped type (two gallbladders with two uniting cystic ducts). C True duplicated gallbladder: H-shaped or ductular type (two separated gallbladders with two separated cystic ducts).

from that of a single gallbladder [14, 15]. Stone formation is the most common complication, usually developing in one lobe [5, 8, 15, 18, 21, 38, 40], but sometimes both lobes can be affected [2, 7, 20]. Twenty-six of 56 cases in which gallstone was confirmed at surgery or at autopsy had only one lobe affected in the series of Harlaftis et al. [15]. All kinds of the usual diseases affecting the gallbladder have been described, including acute cholecystitis and empyema [3], chronic cholecystitis [2], cholecystocolic fistula [29], torsion [28], papilloma [30], and carcinoma [27]. Combined use of ultrasound and oral cholecystography has been reported to be useful for the preoperative diagnosis of gallbladder duplication [38]. Duplicated gallbladder should be considered when two cystic structures are present in the gallbladder fossa on preoperative ultrasonograms [3, 5, 7, 8, 12, 14, 15, 21, 34, 38, 41] and oral cholecystograms [26, 38, 40, 41], with asymmetric contraction of one lobe at oral cholecystography after fatty meal administration [8, 34]. Oral cholecystography failed to reveal the duplication in 60% of surgically confirmed cases in the series of Harlaftis et al. [15]. Indeed, a second nonfunctioning gallbladder cannot be visualized at oral cholecystography [1315, 34]. A close correlation with ultrasonographic findings is thus important for a definitive diagnosis of gallbladder duplication. The specific diagnosis of the type of duplication is only possible if the two cystic ducts can be demonstrated [1]. This usually cannot be achieved by ultrasonography [24] but is sometimes achieved by intravenous cholangiography [20], and can always be accomplished by intraoperative cholangiography [36, 37], as in our patient, or by preoperative endoscopic retrograde cholangiography [24, 37, 40], which is actually the most efficient method of visualizing both cystic ducts. The development of new noninvasive imaging modalities, such as spiral computed tomographic cholangiography [39] and magnetic resonance cholangiography [19], may improve preoperative diagnostic accuracy in the future. McDonald and Lwin [21] were the first to describe the role of DISIDA biliary scintigraphy in the diagnosis of duplicated gallbladder, but the same limitation to visualizing the accessory gallbladder exists if it is diseased [5, 7].

Because there does not seem to be a significantly increased risk for subsequent disease [15, 31], prophylactic excision of a duplicated gallbladder in an asymptomatic patient without evidence of gallbladder disease is not recommended [36]. When the patient is symptomatic, cholecystectomy is the rule. Emphasis is placed on complete evaluation during surgery by intraoperative cholangiography to prevent potential damage to the ductal system [2, 15, 26, 36, 37]. Several arterial anomalies may also coexist [36], and meticulous dissection of the Calot triangle is mandatory [24]. Presence of an accessory cystic duct entering the right biliary ductal system, as in our observation, is extremely rare but has been reported [2, 10, 15, 37, 40]. Harlaftis et al. reported only three such observations in their extensive review of 207 cases of gallbladder duplication [15]. Another problem encountered in our observation was the partially intrahepatic location of the accessory gallbladder [2, 7, 10, 11, 26], which made the dissection from the liver parenchyma more difficult [10]. The intrahepatic location of an accessory gallbladder can lead to its being overlooked during surgery and to the need for a second cholecystectomy [10], as recently also reported following laparoscopic cholecystectomy [16]. In our observation, we found the argon-beam coagulator useful for achieving hemostasis during complete removal of the accessory gallbladder from the hepatic parenchyma of the right lobe of the liver. All reported cases of gallbladder duplication have been treated by open surgery, and only three cases of laparoscopic cholecystectomy have been reported [2, 16, 24]. To the best of our knowledge, therefore, this is the second case in which complete laparoscopic cholecystectomy was performed. The procedure unfortunately had to be undertaken in two stages, with the aim of preserving the normal and functioning main gallbladder during the first cholecystectomy [4, 26, 28]. The occurrence of postoperative acute cholecystitis in the remaining viscus in our patient was probably related to traumatic intraoperative retraction to expose the intrahepatic accessory gallbladder. In any case, despite a meticulous dissection of vascular structures within the Calot triangle, an ischemic cause could not be totally excluded. In accord with others [15, 20, 30, 35, 36], we thus

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strongly recommend removal of both gallbladders during the primary operation. Indeed, several observations have been reported describing the need for a second operation because symptoms were not relieved after the first cholecystectomy [4, 10, 20, 22, 23, 25]. All surgeons should be aware of this rare congenital abnormality of the gallbladder, which requires particular attention to preoperative radiographic studies and special attention to the biliary ductal and arterial anatomy during cholecystectomy. Our experience highlights the role of laparoscopy as an attractive approach for the treatment of gallbladder duplication. Total cholecystectomy with removal of both gallbladders should be the appropriate treatment for gallbladder duplication to avoid complications and reoperation.
Acknowledgment. The authors are deeply grateful to Miche ` le Lemaire for medical illustrations, to Doctor Werner Heidel for manuscript review, and to Nadine Thiebaut for secretarial assistance.

References
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Surg Endosc (1997) 11: 491494

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Laparoscopic splenectomy and nephrectomy in a rat model

Description of a new technique
M. C. Giuffrida, R. L. Marquet, G. Kazemier, Ph. Wittich, N. D. Bouvy, H. A. Bruining, H. J. Bonjer
Department of Surgery, University Hospital Dijkzigt, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands Received: 17 June 1996/Accepted: 14 October 1996

Abstract Background: In experimental studies on the effects of laparoscopic procedures on tumor biology, a localized tumor model is desirable. The spleen and the kidney are preferable, because these organs are amenable to tumor placement and subsequent removal. This study describes the technique of laparoscopic splenectomy and nephrectomy in the rat model. Methods: Pneumoperitoneum was established by CO2 insufflation. Laparoscopic splenectomy involved two-handed dissection, intracorporeal ligation, and division of gastrosplenic attachments and hilar and short gastric vessels. Laparoscopic nephrectomy was done by intracorporeal ligation and division of the renal vessels and the ureter after mobilization of the kidney. Results: Laparoscopic splenectomy was performed in six rats; laparoscopic nephrectomy was done in six rats. Operative time ranged from 45 to 90 min for splenectomy and from 40 to 65 min for nephrectomy. Postoperatively, two rats died from hemorrhage. Necropsy of the rats after 10 days revealed adhesion in three rats after splenectomy and in four rats after nephrectomy. Inflammatory processes were found around the silk ligatures in all rats after splenectomy; in two rats wound infections occurred at the port sites. Conclusions: Laparoscopic splenectomy and nephrectomy in the rat proved technically feasible and may provide new localized tumor models suitable to be used in further studies on the oncological effects of laparoscopic surgery. Key words: Laparoscopy Rat Model Splenectomy Nephrectomy Tumor

Laparoscopic surgery has become the preferred approach for several abdominal diseases which until a few years ago required laparotomy. The wide and rapid success of miniCorrespondence to: H. J. Bonjer

mally invasive techniques can be attributed to reduced postoperative pain, shorter hospital stay, and faster return to normal activities. To facilitate and evaluate laparoscopic procedures, studies in experimental animals are essential. Pathophysiological, metabolic, and immunological effects of minimally invasive techniques have been assessed in animal models [10, 11, 15, 16]. The feasibility of laparoscopic approaches is frequently evaluated in experimental animals prior to clinical application [9, 14]. Animal models are also used to train surgeons for laparoscopic procedures [5]. Large animals, such as pigs and dogs, are preferred for experimental laparoscopic surgery. These animals are well accepted by surgeons because their anatomy is similar to man. Nevertheless, they are expensive, and less of their physiology is known than that of small, better-studied animals, such as rabbits, rats, and mice. Mice have been used in laparoscopy as models to study the effects of pneumoperitoneum on immune status and tumor biology [1, 17], but their abdominal cavity is too small for complex laparoscopic procedures. The rat appears a convenient model for laparoscopic research because it is an inexpensive and wellstudied animal widely used in research, and laparoscopic procedures have been shown to be technically feasible with appropriate equipment and instrumentation [2, 3]. The rat has been used in our laboratory as laparoscopic model since 1993 [6] to investigate the differences between conventional and laparoscopic operations on postoperative metabolic and oncological consequences. To study the problem of port-site metastases, it would be valuable to perform laparoscopic surgery on a localized intraabdominal tumor. The colon carcinoma (CC 531) that we normally employ for such studies fails to grow when implanted in the wall of the intestine. In spite of extensive research, we have not succeeded in inducing a localized tumor in the bowel of rats. Therefore, our oncological studies employed peritoneal tumor take and growth as a model [7, 8]. Recently, we used the subrenal capsule assay, which involves implantation of a lump of tumor cells underneath the renal capsule [8]. Also the spleen is amenable

492 Table 1. Instruments and equipment used for laparoscopic splenectomy and laparoscopic nephrectomy in the rat Equipment Small-animal laparoscopic table Insufflator and carbon dioxide tank Cold light source Fiberoptic cable CCD video camera Trinitron color video monitora Coagulation sourceb Instruments 4-mm 0 arthroscope 5-mm disposable arthroscope sheath shortened venous catheters (No. 2)c 2-mm laparoscopic needleholder 2-mm laparoscopic tissue grasper (No. 2) 2-mm laparoscopic scissors
a

Sony, Chiba, Japan Erbe ICC 50, Germany c Arrow, Reading, PA

b

Fig. 1. Laparoscopic splenectomy. The spleen is elevated to show hilar vessels, splenic vein, pancreas, and stomach.

to tumor growth after injection of tumor cells [12]. Therefore, these organs represent possibly valuable models for studies which require a localized tumor model. This article reports the feasibility of laparoscopic splenectomy and nephrectomy in rats. Materials and methods Animals
Twelve male rats of the inbred WAG-Rij strain, weighing 200300 g and aged 34 months, were purchased from Harlan-CPB, Austerlitz, the Netherlands, and bred under specific pathogen-free conditions. The animals were housed in free-standing cages, acclimated to standard laboratory conditions (temperature 2024C, relative humidity 5060%, 12 h light/12 h dark), and fed a standard rat diet (Hope Farm, Woerden, the Netherlands). All the studies were performed under protocols approved by the Committee on Animal Research of the Erasmus University, Rotterdam, the Netherlands.

port of the laparoscopic sheath, the abdominal cavity was insufflated with carbon dioxide to a preset maximum pressure of 6 mmHg at a rate of 0.81.2 l/min (mean amount of CO2 insufflated 20 l), using a standard laparoscopic insufflator.

Laparoscopic splenectomy
After trocar placement, the peritoneal cavity was inspected and the bowels were gently pushed to the right side. While retracting the stomach with an atraumatic grasper, the gastrosplenic attachments were fenestrated, tied, and divided at the lower pole of the spleen. A two-handed dissection followed, using graspers and electrocautery. The stomach was reflected cephalad and the pancreas was retracted medially (Fig. 1). Hilar vessels were carefully dissected, tied with intracorporeal knots (ligatures were performed using 6-0 silk), and divided close to the spleen to avoid inclusion of the pancreas tail in the ligature (Fig. 2). The lower, central, and upper pole vessels were ligated in more steps. The spleen was gently retracted and elevated, and the short gastric vessels were ligated and divided. When the spleen was completely detached, it was withdrawn through the left port site. If residual bleeding was encountered, this was controlled by coagulation. In addition, a little gauze introduced through one of the ports, held by a grasper, was able to clean the operative field.

Laparoscopic procedure
Laparoscopic equipment and instruments used (shortened to a length of 130 mm and with a diameter of 2 mm) were provided by Karl Storz Endoscopes and Duffner (Tuttlingen, West Germany) and are listed in Table 1. Anesthesia was achieved with 2 mg/kg midazolam hydrochloride (DormicumRoche, Mijdrecht, the Netherlands) intramuscularly, 40 mg/kg ketamine (Ketalin Apharmo b.b, Arnhem, the Netherlands) intraperitoneally, and 0.06 mg/kg atropine sulfas (Centrofarm) subcutaneously. No supplemental fluids were given during or after the operation. The animals were shaved, weighed, and secured with adhesive tape to a small-animal operating table in a supine position; the abdomen was cleaned with 70% alcohol and dried with a gauze. A flexible arm held the laparoscope and the camera at the desired angle. The surgeon was sitting at the foot of the operating table, facing the video monitor. All the rats had a 5-mm skin incision in the midline of the abdomen, two-thirds of the way down xiphoid-pubic line. A 5-mm laparoscopic disposable sheath with the insufflation side port was introduced into the peritoneal cavity, followed by the introduction of a 4-mm 0 arthroscope. Two 2-mm skin incisions in the right and left lower quadrant of the abdomen allowed the placement of two operating ports, consisting of shortened venous catheters for insertion, under direct vision, of 2-mm instruments. Purse-string sutures (2-0 NC Silk BB Melsungen AG, Germany) fixed the ports to the abdominal wall to avoid gas leakage. Through the side

Laparoscopic nephrectomy
A transperitoneal approach was used. The rat was positioned in flank position with the ipsilateral side elevated. After trocar placement, the peritoneal cavity was inspected. The colon, in the rat not attached to posterior wall, and the small bowel, were pushed inferiorly and medially. Either the right or the left kidney was bluntly dissected from the retroperitoneal fat using graspers and electrocautery, proceeding from the lower to the upper pole. Following mobilization of the kidney, the renal pedicle, shorter on the right side, was mobilized by careful dissection of the surrounding perihilar tissue. The renal vein is anterior to the artery, on both sides. The renal artery on the right side gives two branches posteriorly to the caval vein, while on the left side the division of the artery is closer to the kidney. Small branches from the renal vessels run cranially to the adrenal gland and the iliopsoas muscle, while spermatic vessels run inferiorly, on the right side. These branches can easily bleed during the mobilization of the renal vessels, mandating accurate dissection and use of coagulation. After dissection, the renal vessels were tied with intracorporeal knots and divided. After complete mobilization of the kidney, the ureter was identified, dissected (Fig. 3), tied, and transected (Fig. 4). All the ligatures were performed using 6-0 silk, introducing the threads into the peritoneal cavity through the operating ports. The renal bed was inspected for hemostasis. The kidney was grasped and withdrawn through the left operating port; when needed, the abdominal access was enlarged to allow the extraction. Ports in the abdomen were closed by a one-layer suture, including

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Fig. 4. Laparoscopic nephrectomy. The ureter is tied and divided by scissors.

Fig. 2. Laparoscopic splenectomy. The hilar vessels are tied and divided by scissors close to the spleen. Fig. 3. Laparoscopic nephrectomy. After mobilization of the kidney and division of renal vessels, the kidney is elevated and the ureter identified and dissected. The ilio-psoas muscle and the ligatures on renal vessels are visible.

muscle and skin (2-0 NC Silk, BB Melsungen AG). Atipemazole hydrochloride 2mg/kg (AntisedanSmithKline Beecham, Zoetermeer, the Netherlands) was injected intramuscularly to end the anesthesia. The animals had free access to water and food after the operation. On day 10 the rats were sacrificed, weighed, and necropsied to inspect the peritoneal cavity and to assess the intraabdominal changes.

tively, by bleeding from the gastrocolic vessels after splenectomy, and by diffuse bleeding of the retroperitoneal fat, with ligatures on renal vessels in situ, after nephrectomy. All other rats recovered uneventfully. On day 10 the mean weight loss was 17.60 g (standard deviation 12.76 g) in the splenectomy group and 17.60 g (standard deviation 11.06 g) in the nephrectomy group. In the splenectomy group, necropsy in three rats showed adhesions in the left upper quadrant variously involving stomach, bowel, and kidney. In one rat, a pancreatic abscess, due to a ligature of the pancreatic tail, was found. In all rats, localized inflammatory processes existed around ligatures, varying in size from 0.2 to 1.5 cm. Following nephrectomy, adhesions were found in four out of six rats between the bowel and the posterior abdominal wall. In one rat, an abscess was found around the ligature of the renal vessels. Adhesions in correspondence to the port sites were found in three rats of the splenectomy group and in two rats of the nephrectomy group, often only or more extended on one side, but not correlating to the side of the operation. Wound infection in the port sites, represented by subcutaneous abscesses, was found in two rats, one after splenectomy, the other after nephrectomy.

Discussion Results Laparoscopic splenectomy was performed in six rats and laparoscopic nephrectomy in six rats, four on the left side, two on the right side. Operative time ranged from 45 to 90 min for splenectomy and from 40 to 65 min for nephrectomy. Intraoperative complications consisted of bleeding in two cases: in the gastrocolic omentum during splenectomy and in the retroperitoneal fat during nephrectomy. Both were controlled by coagulation. Conversion was not done in any case. The two rats with intraoperative bleeding died postoperatively, 6 h after splenectomy and 24 h after nephrectomy. Autopsy in both animals revealed hemoperitoneum, caused, respecThe present study was performed to investigate whether the laparoscopic removal of both spleen and kidney was feasible in rats in order to use these procedures as experimental models in laparoscopic research and to employ the rat as a laparoscopic training model. Laparoscopic splenectomy and nephrectomy appear applicable in the rat as experimental models in oncological research. The laparoscopic treatment of malignant diseases is still controversial, because, despite demonstrated benefits in recovery, metabolism, and immune status [7, 15], several abdominal wall recurrences have been reported after laparoscopic colon cancer resection [18]. The pathogenesis of abdominal wall recurrence is unresolved. To reproduce the clinical situation in experimental studies, a localized tumor in an intraabdominal organ, capable of being removed lapa-

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roscopically or conventionally, is necessary. Such an organ should be amenable to implantation of isolated tumor cells or of a solid tumor, and tumor growth should be easy to assess. Oncological sequelae of laparoscopic and conventional procedures can then be compared. The spleen has already been used for the transplantation of cell suspensions. Its sponge-like structure fixes and stabilizes transplanted cells, intercepting their flow into the portal system [13]. However, tumor cells may flow out of the splenic vein, generating metastases in the liver or in the pancreas [12]. Liver cell embolization can be reduced by the occlusion of the splenic vein during and immediately after the cell injection. The kidney has been frequently used as the site of implantation of solid tumors in the subrenal capsule assay. These tumors, grown subcutaneously in rats or mice, and then cut into cubed pieces, can be implanted and grow under the renal capsule. These localized tumors can be easily dissected and the measurement of tumor growth is rapid and precise [4]. In our study, the laparoscopic extraction of both spleen and kidney was feasible. Two rats died at the beginning of the experience. These deaths could probably have been avoided by a more appropriate use of coagulation; the intracorporeal knot tying was demonstrated to be safe, because the bleeding was not due in any case to loose ligatures. A ligature of the pancreas tail was the cause of a pancreatic abscess. Splenic vessels are short in length; therefore only an accurate dissection before tying and a division as close as possible to the spleen can prevent this complication. Adhesions were more common than expected after a laparoscopic procedure. We impute their presence, similarly to the granulomas and the infections found around the ligatures and at the port sites, to the use of silk ligatures. Silk is known to cause severe inflammatory reactions. Possibly either the use of a more biologically inert suture material, such as polypropylene or metal clips, or an antibiotic prophylaxis, would eliminate these complications. Nevertheless, adhesiolysis after 10 days was easily performed, and granulomas can be distinguished from intraabdominal metastases. The rat, despite the differences between the human and rat anatomy, proved a valuable training animal: dissection, handling intraabdominal organs, coagulation, tying with the use of intracorporeal knots, and dividing can be practiced. Less expensive than bigger animals and more educational than inanimate models, the rat is a good model to use to acquire laparoscopic skills. In conclusion, laparoscopic splenectomy and nephrectomy were feasible in the rat model. The use of inert suture materials and possible antibiotic prophylaxis deserve further studies. We emphasize the use of laparoscopic splenectomy and nephrectomy in experimental studies on oncological effects of laparoscopy. The kidney appears more adequate as localized tumor model because of the possibility of liver

metastases after tumor cell injection in the spleen. Both laparoscopic splenectomy and laparoscopic nephrectomy in rats appear to be valuable training models. References
1. Allendorf JDF, Bessler M, Kayton ML, Oesterling SD, Treat MR, Nowygrod R, Whelan RL (1995) Increased tumor establishment and growth after laparotomy vs laparoscopy in a murine model. Arch Surg 130: 649653 2. Berguer R, Gutt CN (1994) Laparoscopic colon surgery in a rat model. A preliminary report. Surg Endosc 8: 11951197 3. Berguer R, Gutt C, Stiegmann GV (1993) Laparoscopic surgery in the rat. Description of a new technique. Surg Endosc 7: 345347 4. Bogden AE, Griffin W, Reich SD, Costanza E, Cobb WR (1984) Predictive testing with the subrenal capsule assay. Cancer Treat Rev 11: 113124 5. Bo hm B, Milsom JV (1993) Animal models as educational tools in laparoscopic colorectal surgery. Surg Endosc 8: 707713 6. Bouvy ND, Marquet RL, Jeekel J, Bonjer HJ (1994) Laparoscopic surgery in the rat. Eur Surg Res 26: 75 7. Bouvy ND, Marquet RL, Hamming JF, Jeekel J, Bonjer HJ (1996) Laparoscopic surgery in the rat. Beneficial effect on body weight and tumor take. Surg Endosc 10: 490494 8. Bouvy ND, Marquet RL, Jeekel J, Bonjer HJ (1997) Laparoscopic surgery is associated with less tumour growth stimulation than conventional surgery: a comparative study in the rat. Br J Surg (accepted for publication) 9. de Cannie ` re L, Lorge F, Rosie ` re A, Joucken K, Michel LA (1995) From laparoscopic training on an animal model to retroperitoneoscopic or coelioscopic adrenal and renal surgery in human. Surg Endosc 9: 699701 10. Dugue L, Fritsch S, Felten A, Gossot D, Colomer S, Celerier M, Lagrange P, Revillon Y (1995) Effets de linsufflation intrape ritone ale sur la disse mination he matoge ` ne des infections abdominales. Re sultats pre liminaires dune e tude expe rimentale chez le rat. Ann Chir 49: 423426 11. Ho HS, Saunders CS, Gunther RA, Wolfe BM (1995) Effector of hemodynamics during laparoscopy: CO 2 absorption or intraabdominal pressure? J Surg Res 59: 497503 12. Lafreniere R, Rosenberg SA (1986) A novel approach to the generation and identification of experimental hepatic metastases in a murine model. J Natl Cancer Inst 6: 309322 13. Nieto JA, Escandon J, Betancor C, Ramos J, Canton T, Cuervas-Mons V (1989) Evidence that temporary complete occlusion of splenic vessels prevents massive embolization and sudden death associated with intrasplenic hepatocellular transplantation. Transplantation 47: 449 450 14. Soper NJ, Brunt LM, Brewer JD, Meininger TA (1994) Laparoscopic Billroth II gastrectomy in the canine model. Surg Endosc 8: 1395 1398 15. Trokel MJ, Bessler M, Treat MR, Whelan RL, Nowygrood R (1994) Preservation of immune response after laparoscopy. Surg Endosc 8: 13851388 16. Volz J, Ko ster S, Weis M, Schmidt R, Urbasheck R, Melkert F, Albrecht M (1996) Pathophysiologic features of a pneumoperitoneum at laparoscopy: a swine model. Am J Obstet Gynecol 174: 132140 17. Watson RWG, Redmond HP, McCarthy J, Burke PE, Bouchier-Hayes D (1995) Exposure of the peritoneal cavity to air regulates early inflammatory responses to surgery in a murine model. Br J Surg 82: 10601065 18. Wexner SD, Cohen SM (1995) Port site metastases after laparoscopic colorectal surgery for cure of malignancy. Br J Surg 82: 295298

Surg Endosc (1997) 11: 483484

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Gallbladder and cystic duct absence

An infrequent malformation in laparoscopic surgery
M. A. Cabajo Caballero,1 J. C. Martin del Olmo,1 J. I. Blanco Alvarez,1 R. Atienza Sanchez,2
1 2

Department of Surgery, Medina del Campo Hospital, Carretera de Pen aranda km 1, 47400 Valladolid, Spain Department of Gastroenterology, Medina del Campo Hospital, Carretera de Pen aranda km 1, 47400 Valladolid, Spain

Received 12 August 1996/Accepted 21 October 1996

Abstract. Gallbladder absence is an infrequent anomaly normally accompanied by lack of the cystic duct. Of unknown etiology, in general it is accepted to be a congenital malformation. A male patient (age 59) diagnosed with nonfunctional symptomatic scleroatrophic gallbladder by echography and ERCP was operated on using a laparoscopic approach. Gallbladder and cystic absence was diagnosed during the procedure. A new case of gallbladder and cystic duct absence, diagnosed by laparoscopy, is presented. This type of extrahepatic bile duct malformation is quite rare, but it must be taken into account due to the generalization of laparoscopic surgery in biliar pathology because of the high risk of serious lesions to the hepatocholedochal system. Key words: Gallbladder absence Laparoscopy Bile duct malformation

for supposed gallstones, apparently the first time that a diagnosis has been made using this procedure.

Case history
A male patient (age 59) without family or personal antecedents of interest (no previous abdominal surgery), with a 5-year history of dyspeptic syndrome and diffuse abdominal pain, was admitted for emergency treatment for epigastric and right upper quadrant pain with slight hyperamylasemia. The diagnosis based on echograph was scleroatrophic gallbladder with possible microlithiasis. Later outpatient studies also showed sigmoid diverticulosis with no clinical symptoms of activity. The persistence of postprandial symptomatology and positive amylasemia led to an endoscopic retrograde cholangiopancreatography (ERCP) which revealed a slightly dilated bile duct with no images of stenosis or replection defects. The intrahepatic bile duct and the pancreatic duct appeared normal, while the cystic duct was not seen (Fig. 1). With the diagnosis of nonfunctional symptomatic scleroatrophic gallbladder, the patient was transferred to the surgical service. The normal approach in laparoscopic surgery was used and, after sectioning the fattyparietal adhesions, the gallbladder was sought. The principal bile duct was completely dissected from the hepatocholedochal union to the duodenopancreatic block, and lack of gallbladder was diagnosed. The exploration was completed on the falciform ligament, retroduodenum, inferior face of the left hepatic lobule, and the abdominal wall. Postoperative evolution was uneventful, and the patient was released after 24 h. At present, he is asymptomatic at 2 years postoperative.

Gallbladder absence is an infrequent anomaly normally accompanied by lack of the cystic duct, and cases published up to 1982 number no more than 300, according to various sources[68]. Of unknown etiology, in general it is accepted to be a congenital malformation which may be accompanied by other anomalies inside or outside the biliary system [5] and be associated or not with choledocolithiasis [1]. Classically, different radiological and surgical techniques are used to classify gallbladder absence [4], but the current introduction of laparoscopic treatment of biliar pathology offers new diagnostic perspectives and serious surgical considerations which must be evaluated. We present a new case diagnosed during laparoscopy

Discussion The growing spread of laparoscopy in surgery for biliary pathology forces us to take into consideration the different anomalies and congenital malformations described in the extehepatic bile ducts. Such anomalies are difficult to diagnose in preoperative studies and existing descriptions are based on surgical findings. For this reason, the laparoscopic surgeon can make errors of interpretation with fatal consequences [3]. In the case of gallbladder absence, the presence of a case history indicative of some type of gallbladder pathology as presented in the literature [6], together with possibly incom-

Correspondence to: M. A. Carbajo Caballero

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all other malformations or anomalies of the extrahepatic bile ducts. These include hypogenetic gallbladder duplications (two cases in our series of laparoscopic cholecystectomies), choledochal cysts, nonanatomic gallbladder positions or anomalies in the number and placement of the bile ducts, and arterial irrigation in Calots triangle [2]. In all these cases, prudence is necessary; electrocoagulation must not be used indiscriminately and no structure should be sectioned until it has been adequately identified. Before any decision is made, the choledochal duct and the hepatocholedochal union must be located and amply exposed, testing to see if bile connections exist or not in any of the levels. Likewise, the hepatic artery paths should be identified and the falciform ligament, left liver, retroduodenal border, and the abdominal wall itself must be explored carefully in order to rule out other anomalous gallbladder positions as described [6]. In our case the possibility of intrahepatic gallbladder was eliminated by the integrity of the intrahepatic bile trunk in the ERCP, although gammagraphy and selective arteriography of the hepatic artery might have been useful [1]. References
Fig. 1. ERCP study. Slightly dilated bile duct, without visualization of cystic duct and gallbladder. 1. Asbert Sampere JM, Piriol Pascual M, et al. (1980) Agenesia de ves cula biliar y coledocolitiasis. Rev Esp Enferm Ap Digest LVII: 439 442 2. Fernandez Pontes J, Walter Pinotti H (1981) Anomalias de la ves cula biliar y del sistema biliar. In: Bockus HL (ed) Gastroenterology (III). Salvat, Barcelona, pp 697712 3. Ferraina PA (1994) Biliary injuries during laparoscopic surgery. In: Meinero M, Melotti G, Mouret PH (eds) Laparoscopic surgery. Masson, Milano, pp 176184 4. Frey CH, Bizer L, Ernist C (1967) Agenesis of the gallbladder. Am J Surg 114: 917921 5. Mcilrath DC, Remine WH, Baggenstoss AM (1962) Congenital absence of the gallbladder and cystic duct. JAMA 180: 782784 6. Rodriguez Montes JA, Fernandez de Lis S (1982) Anomal as del sistema biliar. Consideraciones quiru rgicas. Rev Esp Enferm Ap Digest 4: 321331 7. Sanders GB, Flores T, Arriola P (1968) Congenital absence of the gallbladder and cystic duct: a review of the literature and report of a case. Am Surg 10: 750754 8. Valtonen ET (1967) Duplication and agenesis of the gallbladder: report of two cases. Acta Chir Scand 133: 504507

plete, erroneous, or imprecise data from X-rays and echography, will determine the surgeons attempt to visualize a nonexisting anatomic structure. This mistaken basis may lead to the identification of the gallbladder remnant with the hepatocholedochal union. This in turn may lead to electrocoagulation, pinching, ligation or section of the main bile trunk, compounded by the fact that the lesion is perhaps not included in the surgery itself. It is true that gallbladder absence is a rare human malformation and that bibliography search of the last 10 years provides only 300 cases. However, in this new era of bile duct surgery, the problems we have described also apply to

Surg Endosc (1997) 11: 456459

Surgical Endoscopy
Springer-Verlag New York Inc. 1997

Abnormal cholangiograms during laparoscopic cholecystectomy

Is treatment always necessary?
A. A. Ryberg,1 R. J. Fitzgibbons, Jr.,1 A. Tseng,1 T. R. Maffi, L. J. Burr,2 P. E. Doris2
1 2

Department of Surgery, School of Medicine, Creighton University, 601 North 30th Street, Omaha, NE 68131, USA Department of Radiology, School of Medicine, Creighton University, 601 North 30th Street, Omaha, NE 68131, USA

Received: 29 March 1996/Accepted: 29 July 1996

Abstract Background: Laparoscopic common bile duct exploration (LCBDE) is more expensive and time consuming than its conventional counterpart. Therefore, it should only be performed when there is near certainty that stones are present. The purpose of this study was to identify patients who should be spared LCBDE despite an abnormal intraoperative cholangiogram. Methods: Of 700 consecutive laparoscopic cholecystectomies performed between 1989 and 1994 by a single surgeon (R.J.F.), 41 had abnormal intraoperative cholangiograms (6%). All 41 patients were treated by either immediate CBDE (19) (conventional or laparoscopic) or had postoperative follow-up cholangiograms (22). The patients were retrospectively assigned to one of three groups. Group I patients had a single soft indicator of choledocholithiasis. Group II patients had one or more of the following: (1) a highly suspicious abnormal intraoperative cholangiogram, (2) two or more soft indicators of choledocholithiasis, or (3) preoperative clinical findings such as elevated liver function studies or positive preoperative radiological studies. Group III patients had proven choledocholithiasis. Results: In group I, there were 11 patients, none of whom underwent immediate CBDE. Eight of the 11 (73%) had normal follow-up cholangiograms due to either spontaneous stone passage or a false-positive intraoperative cholangiogram. There were 27 patients in group II; 19 underwent immediate CBDE with 100% stone recovery. The remaining 8 had delayed treatment and in five stones were recovered, while three had normal postoperative cholangiograms suggesting spontaneous stone passage. In group III, all three had negative follow-up cholangiograms despite proven choledocholithiasis. Spontaneous stone passage in this group seemed highly likely. Conclusions: The finding of a single soft indicator results in a low rate of stone recovery postoperatively, and these patients should not undergo LCBDE. In this series, spontaneous stone passage seemed highly likely in at least 3/22 (14%) and possibly as high as 14/22 (64%).
Correspondence to: R. J. Fitzgibbons, Jr.

Key words: Abnormal cholangiogram Laparoscopic cholecystectomy Soft indicator

Management of common bile duct stones in patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis remains a subject of considerable controversy. Although common bile duct (CBD) exploration during conventional cholecystectomy is a straightforward, expedient way to deal with an abnormal cholangiogram, laparoscopic CBD exploration (LCBDE) is not nearly as simple. The procedure requires special equipment as well as advanced training and significant experience on the part of the surgeon. In addition, it is time consuming and adds considerable expense [6, 8]. The purpose of this study was to identify patients who could be spared LCBDE despite an abnormal intraoperative cholangiogram, because they were unlikely to have persistent abnormalities on postoperative follow-up cholangiograms. These would include patients whose intraoperative cholangiograms (IOC) were false positive or patients whose stones were likely to pass spontaneously. Materials and methods
A prospectively maintained database of 700 consecutive laparoscopic cholecystectomies performed by a single surgeon (R.J.F.) between 1989 and 1994 was analyzed. There were 41 abnormal cholangiograms (6%). To assess the probability of persistent stone presence, the 41 patients were retrospectively assigned to one of three groups based on preoperative clinical findings, operative findings, and a retrospective review of intraoperative cholangiograms by expert radiologists. Early in our experience, a selective approach to operative cholangiography was used but a policy of routine operative cholangiography in all patients was eventually adopted primarily because of medicallegal considerations. All films were reviewed by the radiologists retrospectively. The intraoperative decisions were based solely on review of the films by the surgeon. Intraoperatively ultrasound was used only as an adjuvant to operative cholangiography and was not used routinely. Group I, possible choledocholithiasis, included patients with one soft indicator of choledocholithiasis on their cholangiograms. A soft indicator was defined as one of the following: (1) nonpassage of contrast into the duodenum, (2) a dilated cystic duct, (3) a dilated CBD, or (4) an equivocal filling defect. Group II patients had probable choledocholithiasis. Patients were assigned to this group if they had a highly suspicious

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Fig. 1. Intraoperative sonogram of CBD with stone. Fig. 2. Milking of CBD stone with forceps. Fig. 3. Postoperative day 1 follow-up cholangiogram showing retained CBD stone. abnormal intraoperative cholangiogram, two or more soft indicators, or clinical indications of choledocholithiasis, such as abnormal liver function studies or preoperative radiological findings of choledocholithiasis, e.g., an abnormal preoperative sonographic examination of the common bile duct. An intraoperative cholangiogram was considered highly suspicious based on the opinion of the surgeon. Group III patients were those with proven choledocholithiasis based on an intraoperative sonogram, milking of stones from the common bile duct with a grasping forceps, or an early postoperative cholangiogram showing an unequivocal filling defect (Figs. 13). Abnormal cholangiograms in selected patients were managed with a transcystic catheter instead of an LCBDE. The transcystic catheter provides a means for serial postoperative cholangiograms and the placement of a guidewire for a guidewire-assisted sphincterotomy should filling defects persist. The description of this technique has previously been reported by our group [4].

Results There were 11 patients in group I (one soft indicator for CBD stones[s]). All patients had the transcystic catheter placed. Postoperative cholangiograms revealed eight patients (73%) with normal cholangiograms while three (27%) had positive cholangiograms. Those patients with positive cholangiograms underwent successful guidewire-assisted sphincterotomy and stone extraction. The eight patients with the normal postoperative cholangiograms either had false-positive abnormalities at the time of the intraoperative cholangiogram or they passed their stones spontaneously.

There were 27 patients in group II (a highly suspicious abnormal intraoperative cholangiogram, two or more soft indicators or positive clinical parameters such as abnormal liver function studies or preoperative radiological findings of choledocholithiasis, e.g., positive preoperative sonogram). Nineteen of the patients in this group underwent immediate LCBDE with 100% stone recovery. The remaining eight patients in group II had the transcystic catheter placed. The reasons for using the transcystic catheter in lieu of performing immediate LCBDE in these eight patients were as follows: (1) equipment for LCBDE was not available for three; (2) two had severe underlying medical illness and a prolonged operative procedure was not felt to be in their best interest; and (3) the remaining three patients were managed in this manner because of the surgeons intraoperative decision. One patient had a dilated CBD and an equivocal small filling defect but had free flow of contrast into the duodenum. Because it was unclear whether this was truly a positive cholangiogram, a catheter was placed. In the second patient, IOC showed a dilated CBD and no flow of contrast in the duodenum; however, after nitroglycerin and glucagon administration, a small amount of contrast was identified in the duodenum without obvious evidence of a filling defect. Thus, the decision was made to place the transcystic catheter. The third patient had an IOC filling defect. The surgeon was not impressed with the filling defect enough to proceed with a LCBDE. However, the chol-

458 Table 1. Results (700 consecutive laparoscopic cholecystectomies 41 (+) intraoperative cholangiograms) Postoperative cholangiogram Group I II III Patient 11 27 3 Operative management No LCBDE, transcystic catheter 19 LCBDE, stone extraction 8 transcystic catheter Transcystic catheter (+) 3 () 8

3. Subjects the patient to prolonged general anesthesia. 4. Is associated with minor complications in 5.7% and major in 0.4% [1]. A negative common bile duct exploration at the time of a conventional cholecystectomy results in minimal morbidity as it can ordinarily be completed quickly and does not require sophisticated equipment. It is preferable to an additional procedure such as a postoperative ERCP with stone extraction. A negative exploration during laparoscopic cholecystectomy is another matter. A small-diameter choledochoscope, a second video system, a digital fluoroscopy system, a mechanism for balloon or mechanical dilatation of the cystic duct, an array of extraction baskets and balloons, and a lithotripsy system may be required, which adds considerable expense. In addition, LCBDE can be expected to add 1.5 to 3.5 h or more to the procedure time, depending upon surgeon experience [3]. This additional anesthesia time may be contraindicated for elderly or high-risk patients. This study suggests that, in contradistinction to a conventional CBDE, a surgeon is probably better to err on the side of not performing a LCBDE when there are equivocal indications. Questionable positive cholangiograms are not unusual during conventional or laparoscopic cholecystectomies. Levine et al. reported their series of abnormal operative cholangiograms and noted a 16% false-positive rate. The authors reviewed eight other series from the literature and noted a false-positive rate in those series to be between 8 and 41% with an average of 25% [7]. It would be unfortunate to subject patients to a time-consuming and expensive laparoscopic common bile duct exploration for a falsely positive cholangiogram. Another issue is the incidence of spontaneous stone passage. Roush et al. reported a series of patients with positive intraoperative cholangiograms who were treated by observation. Only 20% of these patients required treatment of retained common bile duct stones [9]. It is unlikely that all of the other 80% of patients had either asymptomatic common bile duct stones indefinitely or had falsely positive intraoperative cholangiograms. It is reasonable to speculate that some of these patients had spontaneous stone passage. In fact, the rate of spontaneous stone passage has been suggested by other authors to range from 38 to 66% [2, 5]. In this series, 22 patients were available to be evaluated for spontaneous stone passage because they had a transcystic catheter placed in lieu of immediate treatment of the common bile duct. Of these 22 patients, 14 had negative postoperative cholangiograms through the transcystic catheter. The three patients in group III with confirmed CBD stones definitely had spontaneous stone passage as indicated by negative postoperative cholangiograms. Three out of eight patients in group II (probable choledocholithiasis) had negative postoperative cholangiograms, indicating a high likelihood of spontaneous stone passage. Eight out of 11 patients in group I (possible choledocholithiasis) had normal postoperative cholangiograms because of either spontaneous stone passage or false-positive intraoperative cholangiograms. To summarize, 14 out of 22 (64%) of the patients who did not undergo immediate CBDE had normal postoperative cholangiograms.

Clinical follow-up only 5 3 0 3

angiogram was felt to be highly suspicious when reviewed by the radiologist. Cholangiograms were performed at a later date in these eight patients. Five patients (three of whom had the catheter placed due to surgeons intraoperative decision) had persistent filling defects and three patients (43%) had normal cholangiograms. Those patients with positive cholangiograms had guidewire-assisted sphincterotomies with successful stone extraction. It was suspected that the three patients with normal cholangiograms had passed their stones spontaneously. There were three patients in group III, all of whom had proven choledocholithiasis. One patient had a CBD stone seen intraoperatively by ultrasound (Fig. 1). The second patient had a stone milked from the common duct with a forceps (Fig. 2). The third patient had a repeat cholangiogram performed on postoperative day 1 using the transcystic catheter placed intraoperatively primarily because of a disagreement between the surgeon and the radiologist as to whether or not there truly was a common bile duct stone. The cholangiogram was unequivocally positive (Fig. 3). Each of these patients subsequently had normal postoperative cholangiograms, strongly suggesting spontaneous CBD stone passage. These results are summarized in Table 1. Discussion Now that laparoscopic cholecystectomy has replaced conventional cholecystectomy as the usual recommended procedure for patients with symptomatic gallbladder disease, laparoscopic biliary tract surgeons have turned their attention to determining the best method for dealing with CBD stones during laparoscopic cholecystectomy. Some argue that all surgeons should be proficient with LCBDE so they can apply the same indications for CBDE as they did during the era of conventional cholecystectomy. However, we feel that LCBDE cannot be applied universally with the same expediency as CBDE during a conventional cholecystectomy for the following reasons: LCBDE: 1. Is technically difficult and requires specialized training. Because of the relative infrequency of choledocholithiasis detected during laparoscopic cholecystectomy (less than 10%), it is difficult for many surgeons to gain significant experience. 2. Is expensive because of the sophisticated equipment needs which cannot be justified by all institutions, especially in those where relatively few cholecystectomies are performed.

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Conclusion In this study the finding of a single soft indicator such as nonpassage of contrast into the duodenum, a dilated cystic duct, a dilated common duct, or an equivocal filling defect on operative cholangiography results in a low rate of stone recovery postoperatively. Such patients should not undergo LCBDE. Spontaneous stone passage occurred in at least 14% (3/22) and possibly as high as 64% (14/22) of the patients subjected to delayed treatment in this study. References
1. Berci G, Morgenstern L (1994) Laparoscopic management of common bile duct stones. A multi-institutional SAGES study. Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc 8: 11681174 2. Bergdahl L, Holmlund DE (1976) Retained bile duct stones. Acta Chir Scand 142: 145149

3. Fielding GA, ORourke NA (1993) Laparoscopic common bile duct exploration. Aust N Z J Surg 63: 113115 4. Fitzgibbons Jr RJ, Ryberg A, Ulualp KM, Nguyen NX, Litke BS, Camps J, McGinn TR, Jenkins J, Filipi CJ (1995) An alternative technique for treatment of choledocholithiasis found at laparoscopic cholecystectomy. Arch Surg 130: 638642 5. Hainsworth PJ, Rhodes M, Gompertz RH, Armstrong CP, Lennard TW (1994) Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy. Gut 35: 991995 6. Hunter JG (1992) Laparoscopic transcystic common bile duct exploration. Am J Surg 163: 5356 7. Levine SB, Lerner HJ, Leifer ED, Lindheim SR (1983) Intraoperative cholangiography. A review of indications and analysis of age-sex groups. Ann Surg 198: 692697 8. Petelin JB (1993) Laparoscopic approach to common duct pathology. Am J Surg 165: 487491 9. Roush TS, Traverso LW (1995) Management and long-term follow-up of patients with positive cholangiograms during laparoscopic cholecystectomy. Am J Surg 169: 484487