) H T A N K A P U R . R D ( I J H T A N P U R . R D UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY Edited by Ahmed AbdelRaouf ElGeidie Contents Preface IX ) H Part 1 Laparoscopic Biliary-Pancreatic Surgery 1 T A Chapter 1 Transcylindrical Cholecystectomy for N the Treatment of Cholelithiasis and Its Complications Cholecystectomy KUnder Local Anesthesia 3 E. Javier Grau Talens, Julio HoraciAo Cattáneo, Rafael Giraldo Rubio and PabloP Gustavo Mangione Castro U Chapter 2 Laparoscopic CholecysteRctomy in High Risk Patients 27 Abdulrahman Saleh Al-M.ulhim R D Chapter 3 Gallbladder Surgery, Choice of Technique: An Overview 37 E. Nilsson, M. Öma(n , M.M. Haapamäki and C.B. Sandzén I J Chapter 4 Laparoscopy-AHssisted Distal Pancreatectomy 53 Masahiko HirTota, Daisuke Hashimoto, Kazuya Sakata, Hideyuki Kuroki, YouAhei Tanaka, Takatoshi Ishiko, Yu Motomura, Shinji IshiNkawa, Yoshitaka Kiyota, Tetsumasa Arita, AtsushiP Inayoshi and Yasushi Yagi U Part 2 LapRaroscopic Liver Surgery 61 . R Chapter 5 Laparoscopic Liver Resection 63 D Robert M. Cannon and Joseph F. Buell Chapter 6 Hilar Glissonean Access in Laparoscopic Liver Resection 77 Akihiro Cho Chapter 7 Laparoscopic Liver Surgery 87 Steven A. White, Rajesh Y. Satchidanand and Derek M. Manas Part 3 Laparoscopic Appendectomy 113 Chapter 8 Laparoscopic Appendectomy 115 Konstantinos M. Konstantinidis and Kornilia A. Anastasakou VI Contents Chapter 9 Appendicitis and Appendicectomy 137 Sami M. Shimi Part 4 Laparoscopic Hernia Repair Surgery 155 Chapter 10 Laparoscopic Hernia Repair 157 Eva Deerenberg, Irene Mulder and Johan Lange Chapter 11 Laparoscopic Incisional Hernia Repair 181 Anita Kurmann and Guido Beldi Part 5 Laparoscopic Solid Organ Surgery 193 ) Chapter 12 Spleen Preserving Surgery and H Related Laparoscopic Techniques 195 T Lianxin Liu, Dalong Yin and Hongchi Jiang A N Chapter 13 Laparoscopic Gastropexy for the Treatment of Wandering Spleen With or WithKout Gastric Volvulus 205 Caroline Francois-Fiquet,Yohann ARenard, Claude Avisse, Hugues Ludot, MPohamed Belouadah and Marie-Laurence Poli-meroUl R Part 6 Miscellaneous Laparos.copic Procedures 223 R D Chapter 14 Laparoscopic Approach to Abdominal Sepsis 225 José Sebastião San(tos, Carlos A.M. Donadelli, I Rafael Kemp, AlbJerto Facury Gaspar and Wilson Salgado Jr. H T Chapter 15 Role of Endoscopy in Laparoscopic Procedures 237 A Mohamed O. Othman, Mihir Patel and Timothy Woodward N P U R . R D Part 1 Laparoscopic Biliary-Pancreatic Surgery ) H T A N K A P U R . R D ( I J H T A N P U R . R D ) H T A N K A P U R . R D ( I J H T A N P U R . R D 1 Transcylindrical Cholecystectomy for the Treatment of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia E. Javier Grau Talens, Julio Horacio Cattáneo, Rafael Giraldo Rubio and Pablo Gustavo Mangione Castro Siberia-Serena Hospital, Talarrubias (Badajoz) Extremadura University Spain 1. Introduction Cholecystectomy is the primary treatment of cholelithiasis. But the prevention of the formation and the dissolution of the stones were popular in the 80's . The clinical use of the chenodeoxycholic and after the ursodeoxycholic acid emerged in the 70's, when proved that this acids reduced biliary cholesterol saturation in bile. Important aspects were significant but reversible hepatotoxicity in 3%, diarrhea in 8%, abandonment of treatment in 15% and a similar proportion of abdominal pain. Probably, more important was the increase in total serum cholesterol and low density lipoprotein during treatment with chenodesoxycholic acid. In general, ursodeoxycholic acid appears to have fewer side effects, works faster and causes less liver damage. In patients with small cholesterol stones and floating radiolucent treated with ursodeoxycholic acid, for 6-12 months, partial or complete dissolution can be expected in 40-55% of cases. The direct dissolution of cholesterol gallstones using methyl tert-butyl ether (MBTE) requires the insertion of a percutaneous transhepatic catheter in the gallbladder. The MBTE (5-10 mL) should be infused in a manner that involves the calculi but does not flow into the common bile duct and duodenum. In 4-16 hours the stones are dissolved. The patient should stay overnight in the hospital. Side effects include pain and nausea; haemolysis and ) duodenitis are serious consequences of the spilling of the solvent in to the duodenum . H Transabdominal mechanical lithotripsy is another treatment modality, which leads to T fragmentation of the stones in selected cases in almost 100% of patients. A All of these treatments have in common the recurrence of stones (from 45% to 70% at 5 or 7 N years of follow-up), due to persistence of a place for the precipitation of cholesterol crystals (gallbladder) and bile prone to precipitate (lithogenic bileK). A report by Gilliland and Traverso in 1990 settled any doubts about the alternatives iAn the treatment of cholelithiasis (Gilliland & Traverso, 1990) These authors reviewed oPutcomes of 671 cholecystectomy patients during the years 1982-1987 and found no mortaUlity and 2.2% of complications. They conclude that open cholecystectomy is a definitive treRatment for symptomatic cholelithiasis with minimal risk to the patient and a high degree o.f cure of the symptoms. R D ( I J H T A N P U R . R D 4 Updated Topics in Minimally Invasive Abdominal Surgery The first truly major surgery on the biliary tract was performed in 1867 in Indiana (USA). John S. Bobbs, professor of surgery at the Medical College of Indiana, operates a tumor in the right upper quadrant in a 30 year old woman, at home and under general anesthesia, resulting in the diagnosis of gallbladder hydrops which was evacuated and drained. It was the first cholecystostomy performed in the history. Fifteen years later, in 1882, Carl J. Langenbush of Berlin performed the first cholecystectomy by lithiasis, after exercising cholecystectomy in cadavers for several years. However, as more than a century later would happen with the laparoscopy and in the same Germany, Langenbush's communication in the German Congress of Surgery of three cases of cholecystectomy that evolved successfully, was received with apathy and without due consideration that the time reserved. ) 1.2 Development of mini-lap (small-incision) cholecystectomy H Minilaparotomy was used for several decades for the diagnosis of obstructive jaundice. T Through a small incision is valued, in addition to the aetiologyA, the operability by palpation of the gallbladder and hilum liver and usually Nthe diagnosis included a cholecistocholangiography. K In 1982 F. Dubois and B. Berthelot (Dubois & Berthelot, 1982) published the first paper on A the minilaparotomy for operations on the bile duct, performing the procedure in 1500 patients, including alongside cholecystectomy, Psome cases of choledochotomy, sphincterotomy and choledochoduodenostomy. AlUl these interventions were carried out with a transverse or oblique skin incision 3 to 6 cRm in length, but the duration of surgery, the authors say, was "twice that of a normal op.eration". Intervention was carried out with R the help of an autostatic (if no more than one assistant was available), a vaginal valve for D retraction of the liver, a malleable valve for retraction of the hepatic flexure of the colon and the positioning of two packs for the separa(tion of the colon and stomach, referenced with a I tape. J H The description of the intervention with this procedure and its duration arise a suspicion of some difficulty with exposure of Tthe structures and the easement of the procedure. A However, the authors describe: a minimization of cosmetic damage, solidness of the wall N closure an a reduction of pain and postoperative ileus. Moss, in 1983, published the firPst cases of cholecystectomy with stay less than 24 hours, and in 1986, 100 cases. Later, he oUperates 160 patients by midline laparotomy, with an incision that "barely allows the suRrgeon's hand”, which were discharged the day after surgery without receiving narcot.ics, tolerating food intake between 8 and 18 hours and only 3 R readmissions. The author concluded in 1996 that the benefits of laparoscopy may be more D related to the enthusiasm and expectations for the new technology that in the technique by itself (Moss, 1996). In 1985, Morton (Morton, 1985) performs a cost containment study of cholecystectomy with intraoperative cholangiography in 96 patients through an incision of 4 to 5 cm with a mean operating time of 45 minutes. The average stay was 2.5 days and analgesic requirements were lower than in the classical subcostal incision. The period of sick leave decreased significantly. Goco and Chambers in 1988 (Goco & Chambers, 1988) studied the impact of mini- cholecystectomy in the management of health expenditure, considering the reduction of hospital costs compared to traditional cholecystectomy. The authors conclude, by analyzing 450 interventions, that a 4-cm incision produces an average stay of 1.22 days and that the savings stay was 4.78 days per case. Rating the daily cost at $ 200 USA in 1988, it is easy to Transcylindrical Cholecystectomy for the Treatment of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 5 see the savings produced by minilaparotomy, especially if applied to the 600,000 cholecystectomies performed annually in the United States. Despite these and further studies, minilaparotomy was never popular. For example, out of seven standard textbooks: Norton al al., (Harris, 2008). Sabiston (Arendt & Pitt, 2004), Schwartz (Schwatz 1989), Doherty (Doherty, 2010), Maingot (Karam & Roslyn, 1997), Marlow & Sherlock (Dawnson, 1985). Morris & Malt (Britton & Bickerstaff, 1994), only the latter describes the technique of cholecystectomy by minilaparotomy. 1.3 Laparoscopic cholecystectomy – Eric Mühe Laparoscopy has not only caused a revolution in the treatment of cholelithiasis, but that has changed an old surgical proverb: "a large incision, a great surgeon." It seems reasonable to assert that "a smaller incision, less abdominal wall trauma and bette)r aesthetic results." The era of minimally invasive surgery began and laparoscopy has beeHn extended to almost all abdominal surgical operation and almost any procedure Thas been performed by laparoscopic approach, including resections and all types of gasAtrointestinal suture. Interestingly, laparoscopic cholecystectomy was not well recNeived by the German Surgical Society when E. Mühe reported the first operation in 198 6. On September 12, 1985, Mühe K selected with great care the first patient to perform the first laparoscopic cholecystectomy, A almost five years after the first laparoscopic appendectomy by Semm. Like him, Mühe P performed the pneumoperitoneum with the Veress needle, inserted the trocar and U introduced his own "galloscope" through the umbilicus. Two hours later he concluded R successfully the first laparoscopic cholecystectomy (Litynski, 1996). His presentation at the . congress was not published and only a sumRmary appeared in Langenbecks Archiv für Chirurgie 1986 (Mühe, 1986). However, with Dsubsequent amendments Mühe concluded that inserting the laparoscope (galloscope) as close as possible to the gallbladder the ( "cumbersome" pneumoperitoneum couJlId be avoided. After several cholecystectomies without gas, trying to simplify and adHapt the technique to be used by most surgeons, he realized that the optical instrument Twas not necessary, "with or without galloscope, the magic surgical approach could bAe the same". Soon operated through sheath of the galloscope without the optical insNtrument with the advantages of minimal incision: - The abdominal musclulatuPre is not cut - Little postoperative pain Uthat disappears in two or three days - short Immobilization(eRven elderly patients need to be in bed only the day of operation) - Short hospital stay (4.-5 days) R - Quick return to work (50-75% earlier than with traditional surgery) D This outlined the bases of minimally invasive surgery. Sadly, Mühe didn´t publish the evolution of his technique for cholecystectomy in any international journal and we haven´t hat notice of it until 1996 with the Litynski´s. book. Many reasons can be considered to explain the success of laparoscopic cholecystectomy: 1. It is obvious that the ports, about 1 cm, scattered in the upper abdomen and a umbilical opening for the introduction of optic, produce a minimal aesthetic disorder. 2. The trauma to the abdominal wall caused by an incision about 15 cm is large and has a well-known impact on the respiratory physiology, a greater possibility of formation of adhesions, hernias and, above all, pain. 3. The acceptance by the patient has been quick, because it was publicized with all of the above advantages. The charisma of laparoscopic technology is undeniable, its elegance, too. 6 Updated Topics in Minimally Invasive Abdominal Surgery 4. The commercial pressure has been relentless. Technological research has been overturned in the design and implementation of increasingly sophisticated and safer instruments. Sponsoring of the learning of the technique to the interested surgeons was a strategic objective. 5. Finally, the health financier had an opportunity to reduce hospital stays. Given all the above mentioned facts it is obvious that the introduction of the technique is an undeniable fact and that, at present, nobody doubt that laparoscopy is the technique of choice for cholecystectomy. However, the advantages of laparoscopic cholecystectomy have been put in evidence, deliberately, with the open cholecystectomy with a generous wound of about 15 cm. But what if the comparison is made against a technique that uses an incision of 5 cm or smaller? It is possible that the above mentioned advantages were less obvious and that the assessment had to be made over other aspects than a)esthetics, postoperative pain, parietal trauma, hospital stay, re-employment, etc., entering Ht he field of cost, security and benefits to the patient. T A 2. Laparoscopic vs. small-incision cholecystectomyN K A review in 1993 (Olsen, 1993) concluded that there are no good studies comparing A conventional cholecystectomy by minilaparotomy or by laparoscopy. However, it was P apparent that the small incision was better than the big one and that the length of the U incision appears to be associated with hospital stay and return to the workplace. The R ultimate goal is to achieve a safe surgery with the maximum benefit for the patient, and the . keys are: knowledge of anatomy, good surgicalR view and a proper exposure. This last key to safety, exposure, is a limiting factor for miniDlaparotomy, which leads the question of how small an incision can still provide a expos ure to perform the cholecystectomy safely. For ( Olsen, the answer is the laparoscopy, whiIch allows for smaller incision, but it is noteworthy J that the sum of the incisones made forH the insertion of four trocars is about 4 cm and two- dimensional view. An incision oTf this size can provide adequate exposure for cholecystectomy under direct three-Adimensional vision. An overview of the Cochrane HNepato-Biliary Group reviews in January 2010 (Keus et al., 2010) revealed the evidence toP date of the revisions that assess the effect of differents techniques of cholecystectomyU: open, small-incision, or laparoscopic. A total of 5246 patients in 56 randomized trials areR included. Total complications of laparoscopic cholecystectomy and small-incision weRr.e similar (17%), hospital stay and convalescence were not significantly differentD, small-incision cholecystectomy operative time was shortest (16.4 minutes) and is less costly. In our study of 1998 (Grau-Talens et al., 1998) small-incision cholecystectomy was $ 1003 U.S less costly than laparoscopic. The effects of anesthesia and surgery on lung function have been well studied (Lindell & Hendenstierna 1976). There is a reduction in FVC (Forced Vital Capacity) and FEV1 (Forced Expiratory Volume in one second) to 75% of baseline for a separate incision without cutting the muscles, while reducing down to 40-55% in the subcostal incisions and midline laparotomy. An incision that spares the muscular section can prevent postoperative pulmonary complications. The restrictive pattern of lung dysfunction in postoperative abdominal surgery is influenced by several factors and is not well understood. The size, location and direction of the incision are responsible for the alteration of mechanical ventilation, by themselves and the pain. Kind of anesthetic agent and diaphragmatic dysfunction are also involved (Craig 1981). Transcylindrical Cholecystectomy for the Treatment of Cholelithiasis and Its Complications: Cholecystectomy Under Local Anesthesia 7 In some studies, laparoscopic cholecystectomy has shown lower spirometric reductions when compared to open cholecystectomy (Frazee et al., 1991) and to mini-lap (McMahon et al., 1994) although the latter with incisions between 5 and 10 cm. Presumably, a reduction in the length of the incision could be rewarded by a smaller reduction in the impairment of lung physiology, ie, an incision of 4.5 cm, uniform to all layers of the abdominal wall could improve postoperative spirometric results as happened in our study (Grau-Talens et al.,1998) wich shows that the reduction of spirometrics values were similar in laparoscopic and small-incision cholecystectomy, ie over 20% of preoperative value for FVC and 25% for FEV1. The results obtained by keus et al. are similar to ours (Keus et al 2008). 3. Treatment options in biliary lithiasis complications ) 3.1 Acute cholecystitis H Early cholecystectomy is the best treatement for acute cholecystitis. Laparoscopic T cholecystectomy was a relative contraindication in acute cholecystitis, but now is the A preferred aproach for most patients. The first articles appearN in the early 90´s (Cooperman, 1990) (Yamashita et al., 2007). However, in our experience, cholecystectomy in this way was K not easy: the difficulties are related to the inflammatory process, with greater difficulty for A dissection and recognition of structures, the possibility of further contamination of the P cavity (not the surgical wound), the need for instruments to 10 mm in diameter, greater U difficulty in haemostasis and, of course, a greater proportion of conversions (35%) and R duration of the intervention. . With these preliminary considerations we begaRn to operate the acute cholecystitis by early transcylindrical cholecystectomy (within 72 hDours or more of admission), thinking that the abdominal wall injury should not be high(e r than laparoscopy, even using the cylinder of 5 I cm in diameter, that manipulation of Jthe gallbladder (gripping, aspiration, recovery of stones etc.) could be done in a simpler Hway than by laparoscopy, and that contamination of the surgical wound could be avoidedT by the protective and insulating effect of the cylinder. A We have only found an article of acute cholecystitis treated by minilaparotomy in the N context of a randomized study comparing minilaparotomy with conventional laparotomy P (Assalia et al., 1997). The authors show figures contrasting results in a very favourable way, U not only with traditional laparotomy, but with the laparoscopic approach. In this article the R average time (+ /-SD) of the intervention was 69.1 (+ / - 17.0) minutes and mean hospital . stay was 3.1 days. R D 3.2 Choledocholithiasis The choledochotomy was first performed in 1884 by Kummel and in 1889 by Thornton and Abbe, who made the first ideal suture of the choledochotomy. In the late nineteenth and early twentieth century the common bile duct exploration was guided by the subjective clinical impression of the surgeon, until the introduction of intraoperative cholangiography by Mirizzi in 1937. In the Massachusetts General Hospital (Bartlett & Waddell, 1958) were reviewed 1000 choledochotomy for suspected choledocholithiasis with a mortality of 1.8% (three times higher than simple cholecystectomy) and 16% global choledocholithiasis. In the presence of previous pancreatitis, stones were found at choledochotomy in 12% of the patients; in the presence of jaundice or a reliable history of jaundice, 35%; in the previous situation more palpable stone in 99%; with bile duct larger than 1 cm diameter, 58%;