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January - March 2013
JSLS - JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS
VOLUME 17, NUMBER 1 PAGES 1-169
January–March 2013
Volume 17 Number 1
SCIENTIFIC PAPERS
Extraperitoneal Closure of Persistent Gastrocutaneous
Fistula in Children . . . . . . . . . . . . . . . . . . . . . . . . . 1
Stringel G, McBride W, Sweny A.
Single-Port Laparoscopic Right Hemicolectomy:
Intermediate Results . . . . . . . . . . . . . . . . . . . . . . . . 5
Hopping JR, Bardakcioglu O.
Vacation Appendicitis . . . . . . . . . . . . . . . . . . . . . . . 9
Redan J, Tempel MB, Harrison S, Zhu X.
Meta-analysis of Laparoscopic Versus Open Repair of
Perforated Peptic Ulcer . . . . . . . . . . . . . . . . . . . . . 15
Antoniou SA, Antoniou GA, Koch OO, Pointner R,
Granderath FA.
Open Versus Laparoscopic Hiatal Hernia Repair . . . . . . 23
Fullum TM, Oyetunji TA, Ortega G, Tran DD, Woods IM,
Obayomi-Davies O, Pessu O, Downing SR, Cornwell EE.
Costs and Clinical Outcomes of Conventional, Single-Port
and Micro-laparoscopic Cholecystectomy . . . . . . . . . . 30
Chekan E, Moore M, Hunter TD, Gunnarsson C.
Complications of Liver Resection: Laparoscopic Versus
Open Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 46
Slakey DP, Simms E, Drew B, Yazdi F, Roberts B.
Robotic Liver Resection: Experience with Three-Arm
Robotic and Single-Port Robotic Technique . . . . . . . . . 56
Kandil E, Noureldine, Saggi B, Buell JF.
Laparoscopic Appendectomy in Women Without
Identifiable Pathology Undergoing Laparoscopy for Chronic
Pelvic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Lal AK, Weaver AL, Hopkins MR, Famuyide AO.
A Pilot Feasibility, Multicenter Study of Patients After
Excision of Endometriosis . . . . . . . . . . . . . . . . . . . 88
Yeung P, Tu F, Bajzak K, Lamvu G, Gusovsky O,
Agnelli R, Peavey M, Winer W, Albee R, Sinervo K.
Robotic-Assisted Hysterectomy for the Management of
Severe Endometriosis: A Retrospective Review of
Short-Term Surgical Outcomes . . . . . . . . . . . . . . . . . 95
Bedaiwy MA, AbdelRahman MY, Chapman M, Frasure H,
Mahajan S, von Gruenigen VE, Hurd W, Zanotti K.
Perioperative Outcomes of Robotic Versus Laparoscopic
Hysterectomy for Benign Disease . . . . . . . . . . . . . . 100
Patzkowsky KE, As-Sanie S, Smorgick N, Song AH, Advincula AP.
Postoperative Patient Satisfaction After Laparoscopic
Supracervical Hysterectomy . . . . . . . . . . . . . . . . . . 107
Tchartchian G, Gardanids K, Bojahr B, deWilde RL.
Total Microlaparoscopic Radical Hysterectomy in Early
Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . 111
Fanfani F, Gallotta V, Fagottti A, Rossitto C, Piovano E,
Scambia G.
Comparison of Robotic, Laparoscopic, and Abdominal
Myomectomy in a Community Hospital . . . . . . . . . . . 116
Gobern JM, Rosemeyer CJ, Barter JF, Steren AJ.
Sleeve Gastrectomy as a Stand-alone Bariatric Procedure for
Severe, Morbid, and Super Obesity . . . . . . . . . . . . . . . 63
Eisenberg D, Bellatorre A, Bellatorre N.
Laparoscopic Ureteroneocystostomy for Ureteral Injuries
After Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . 121
Pompeo A, Molina WR, Sehrt D, Tobias-Machado M,
Mariano Costa RM, Pompeo ACL, Kim FJ.
Pancreaticojejunostomy Sleeve Reconstruction After
Pancreaticoduodenectomy in Laparoscopic and Open
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Lei Z, Zhifei W, Jun X, Chang L, Lishan X,
Yinghui G, Bo Z.
Laparoscopic Surgery for Kidney Orthotopic Transplant in
the Pig Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
He B, Musk GC, Mou L, Waneck GL, Delriviere L.
Laparoscopic Inguinal Exploration and Mesh Implantation
for Chronic Pelvic Pain . . . . . . . . . . . . . . . . . . . . . 74
Yong PJ, Williams C, Allaire C.
CASE REPORTS . . . . . . . . . . . . . . . . . . . . . 132
ISSN: 1086-8089
January - March 2013
JSLS, Journal of the Society of Laparoendoscopic Surgeons (ISSN #1086 –
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JSLS, Journal of the Society of Laparoendoscopic Surgeons publishes original
articles on basic science and technical topics in all the fields involved with
laparoendoscopic surgery. The journal seeks to advance understanding and
practice of minimally invasive, image-guided surgery by providing a forum
for all relevant disciplines and by promoting the exchange of information
and ideas across specialties.
The statements, opinions, conclusions and recommendations contained in
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© Copyright 2013 JSLS, Journal of the Society of Laparoendoscopic Surgeons.
i
Volume 17 Number 1
International
Advisory
Committee
Gerard B. Adhoute, MD
France
Bernard Dallemagne, MD
Belgium
Edvaldo Fahel, MD, PhD
Brazil
G. M. Filshie, MD
United Kingdom
Xianbo Fu, Prof.
China
JSLS Affiliates
The Society of
Laparoendoscopic
Surgeons
Paul Alan Wetter, MD
Chairman
Chinese Journal of
Minimally Invasive
Surgery
Xianbo Fu, Prof.
Executive Editor-in-Chief
The International Pelvic
Pain Society
Fred Marion Howard, MD
Chairman
Jorge Cueto Garcia, MD
Mexico
Achille Lucio Gaspari, MD
Italy
Staff
Hector E. Geninazzi, MD
Uruguay
Administrator of
Publications
Janice Gisele Muller
Yasuo Idezuki, MD
Japan
Senior Editorial Assistant
Patricia Fleck Kavic
Ming-Chien Kao, MD
Taiwan
Operations Officer
Janis Chinnock
Liselotte Mettler, Prof. Dr.
Med
Germany
Circulation Coordinator
Lauren Frede
Erich Mühe, MD
Germany
Sergio Roll, MD
Brazil
Copy Editor
Ann Conti Morcos
January - March 2013
Volume 17 Number 1
Editorial Board
Maurice E. Arregui, MD
Keith B. Isaacson, MD
St. Vincent Hospitals and Health
Center
Indianapolis, Indiana
Harvard Medical School
Newton-Wellesley Hospital
Newton, Massachusetts
Charles Bellows, MD
Volker R. Jacobs, MD, PhD,
MBA
Tulane University
Health Sciences Center
New Orleans, Louisiana
Maurice K. Chung, RPh, MD
Regional Center for Chronic
Pelvic Pain and Female Pelvic
Medicine
University of Toledo School of
Medicine
Toledo, Ohio
Sakti Das, MD
Univ.-Klinik f ür
Frauenheilkunde Paracelsus
Medizinische Universität
salzburg, Germany
Samir Johna, MD
Fontana Medical Center
Loma Linda University
School of Medicine
Loma Linda, California
William E. Kelley Jr., MD
University of California Davis
School of Medicine
Sacramento, California
The Richmond Surgical Group
Richmond, Virginia
Larry A. Demco, MD
Reproductive Specialty Center
Milwaukee, Wisconsin
University of Calgary
Calgary, Alberta, Canada
Charles H. Koh, MD
Jaime Landman, MD
Peachtree Surgical and Bariatrics
Atlanta, Georgia
Columbia University School of
Medicine
New York, New York
Edward L. Felix, MD
Karl A. LeBlanc, MD, MBA
Titus D. Duncan, MD
California Institute of Minimally
Invasive Surgery
Fresno, California
Minimally Invasive Surgery Institute
Baton Rouge, Louisiana
Morris E. Franklin Jr., MD
Texas Endosurgery Institute
San Antonio, Texas
University of Pittsburgh Medical
Center
Pittsburgh, Pennsylvania
Michel Gagner, MD
Farr Nezhat, MD
Florida International University
Mt. Sinai Medical Center
Miami Beach, Florida
W. Peter Geis, MD
Northwest Hospital Center
Baltimore, Maryland
Herbert A. Goldfarb, MD
New York University School of
Medicine
New York, New York
Harrith M. Hasson, MD
Louis A. Weiss Memorial
Hospital
Chicago, Illinois
B. Todd Heniford, MD
Carolinas Medical Center
Charlotte, North Carolina
James D. Luketich, MD
St. Luke’s-Roosevelt Hospital
Center
University Hospital of Columbia
University, College of Physicians
and Surgeons
New York, New York
Douglas E. Ott, MD, MBA
Mercer University
Macon, Georgia
EDITOR-IN-CHIEF
Michael S. Kavic, MD
Department of Surgery
Northeastern Ohio Universities
College of Medicine
Rootstown, Ohio
Department of Surgery
University of Pittsburgh
School of Medicine
Pittsburgh, Pennsylvania
MANAGING EDITOR
Paul Alan Wetter, MD
University of Miami
School of Medicine
Miami, Florida
ASSOCIATE EDITORS
Camran Nezhat, MD
Stanford University
School of Medicine
Stanford, California
Richard M. Satava, MD
University of Washington Medical Center
Seattle, Washington
ASSISTANT EDITORS
Raymond J. Lanzafame, MD, MBA
Rochester, New York
Elspeth M. McDougall, MD, MHPE
University of California
Irvine Medical Center
Orange, California
Francis J. Podbielski, MD
University of Massachusetts
Worcester, Massachusetts
Gustavo Stringel, MD, MBA
New York Medical College
Westchester Medical Center
Valhalla, New York
James C. Rosser Jr., MD
Morehouse School of Medicine
Atlanta, Georgia
Steven D. Wexner, MD
Cleveland Clinic Florida
Weston, Florida
Howard N. Winfield, MD
DCH Regional Health System
West Alabama Urology Associates
Tuscaloosa, Alabama
ii
TABLE
January–March 2013
GUIDELINES
FOR
CONTENTS
Volume 17 Number 1
AUTHORS
. . . . . . . . . . vi
SCIENTIFIC PAPERS
Extraperitoneal Closure of Persistent
Gastrocutaneous Fistula in Children . . . . . . . . 1
Stringel G, McBride W, Sweny A.
Extraperitoneal closure of gastrocutaneous fistula can
be safe and effective. This approach can allow for
rapid resumption of feeding and a shortened length of
stay.
Single-Port Laparoscopic Right Hemicolectomy:
Intermediate Results . . . . . . . . . . . . . . . . . . . . 5
Hopping JR, Bardakcioglu O.
Single-port right hemicolectomy may be safely performed in patients who are candidates for conventional laparoscopic hemicolectomy with similar efficacy, safety, and oncologic outcomes.
Vacation Appendicitis . . . . . . . . . . . . . . . . . . . 9
Redan J, Tempel MB, Harrison S, Zhu X.
This study suggests that developing appendicitis while
on vacation to Walt Disney World, Florida is associated
with a higher incidence of perforated appendicitis.
Meta-analysis of Laparoscopic Versus Open
Repair of Perforated Peptic Ulcer . . . . . . . . . 15
Antoniou SA, Antoniou GA, Koch OO, Pointner R,
Granderath FA.
A meta-analysis of four randomized trials comparing
laparoscopic versus open repair of perforated ulcer did
not demonstrate significant superiority of the laparoscopic or open approach.
Open Versus Laparoscopic Hiatal Hernia
Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Fullum TM, Oyetunji TA, Ortega G, Tran DD,
Woods IM, Obayomi-Davies O, Pessu O,
Downing SR, Cornwell EE.
Laparoscopic repair of paraesophageal hiatal hernia
where only a portion of the stomach is in the chest, is
associated with a lower mortality rate than open repair.
iii
OF
Costs and Clinical Outcomes of Conventional,
Single-Port and Micro-laparoscopic
Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . 30
Chekan E, Moore M, Hunter TD, Gunnarsson C.
Cost for single-port cholecystectomy in the outpatient
setting was found to be greater than the cost for microlaparoscopic or conventional laparoscopic cholecystectomy.
Complications of Liver Resection:
Laparoscopic Versus Open Procedures . . . . 46
Slakey DP, Simms E, Drew B, Yazdi F, Roberts B.
Complications appear to be lower in laparoscopic
cases versus open cases for anterolateral and posterosuperior hepatic segment surgery.
Robotic Liver Resection: Experience with ThreeArm Robotic and Single-Port Robotic
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Kandil E, Noureldine, Saggi B, Buell JF.
Robotic liver surgery was found to offer advantages
not inherent in conventional laparoscopic liver resection.
Sleeve Gastrectomy as a Stand-alone Bariatric
Procedure for Severe, Morbid, and Super
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Eisenberg D, Bellatorre A, Bellatorre N.
Laparoscopic sleeve gastrectomy was found to be a
safe and effective stand-alone procedure for severe,
morbid, and super obese patients in a high-risk veteran
population.
Pancreaticojejunostomy Sleeve Reconstruction
After Pancreaticoduodenectomy in Laparoscopic
and Open Surgery . . . . . . . . . . . . . . . . . . . . . 68
Lei Z, Zhifei W, Jun X, Chang L, Lishan X,
Yinghui G, Bo Z.
This report suggests that sleeve-joint pancreaticojejunostomy reduces the rate of postoperative pancreatic
fistula.
January–March 2013
Laparoscopic Inguinal Exploration and Mesh
Implantation for Chronic Pelvic Pain . . . . . . 74
Yong PJ, Williams C, Allaire C.
In selected female patients with chronic pelvic pain,
laparoscopic inguinal exploration with mesh implantation resulted in a moderate improvement of symptoms.
Laparoscopic Appendectomy in Women
Without Identifiable Pathology Undergoing
Laparoscopy for Chronic Pelvic Pain . . . . . . 82
Lal AK, Weaver AL, Hopkins MR, Famuyide AO.
Laparoscopic appendectomy is suggested to be effective therapy for women with chronic pelvic pain of
unknown etiology.
Volume 17 Number 1
Postoperative Patient Satisfaction After
Laparoscopic Supracervical Hysterectomy . . . 107
Tchartchian G, Gardanids K, Bojahr B, deWilde RL.
This study demonstrates a high degree of postoperative patient satisfaction after laparoscopic supracervical hysterectomy.
Total Microlaparoscopic Radical Hysterectomy
in Early Cervical Cancer . . . . . . . . . . . . . . . 111
Fanfani F, Gallotta V, Fagottti A, Rossitto C,
Piovano E, Scambia G.
This report suggests that microlaparoscopy has a role
in the management of early cervical cancer with results
comparable with standard laparoscopy.
A Pilot Feasibility, Multicenter Study of Patients
After Excision of Endometriosis . . . . . . . . . . 88
Yeung P, Tu F, Bajzak K, Lamvu G, Gusovsky O,
Agnelli R, Peavey M, Winer W, Albee R, Sinervo K.
A multicenter prospective study evaluating the management of endometriosis comparing excision versus
ablation is needed using primary outcomes other than
chronic pelvic pain.
Comparison of Robotic, Laparoscopic, and
Abdominal Myomectomy in a Community
Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Gobern JM, Rosemeyer CJ, Barter JF, Steren AJ.
Laparoscopic and robotic-assisted laparoscopic myomectomies demonstrated shorter hospital stays, less
blood loss, and fewer transfusions than abdominal
myomectomies. Robotic myomectomy offers a minimally invasive alternative for management of symptomatic myoma in a community hospital setting.
Robotic-Assisted Hysterectomy for the
Management of Severe Endometriosis:
A Retrospective Review of Short-Term Surgical
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Bedaiwy MA, AbdelRahman MY, Chapman M,
Frasure H, Mahajan S, von Gruenigen VE, Hurd W,
Zanotti K.
Robotic-assisted laparoscopic surgery appears to be
safe and feasible for definitive management of patients
with severe endometriosis.
Laparoscopic Ureteroneocystostomy for
Ureteral Injuries After Hysterectomy . . . . . 121
Pompeo A, Molina WR, Sehrt D, Tobias-Machado M,
Mariano Costa RM, Pompeo ACL, Kim FJ.
This report suggests that laparoscopic ureteral reimplantation offers an alternative surgical approach to
open surgery after distal ureteral injuries.
Perioperative Outcomes of Robotic Versus
Laparoscopic Hysterectomy for Benign
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Patzkowsky KE, As-Sanie S, Smorgick N, Song AH,
Advincula AP.
Robotic assistance appears to enable the successful
completion of complex hysterectomies with perioperative outcomes equivalent to laparoscopy.
Laparoscopic Surgery for Kidney Orthotopic
Transplant in the Pig Model . . . . . . . . . . . . 126
He B, Musk GC, Mou L, Waneck GL, Delriviere L.
The authors report that a laparoscopic technique could
facilitate orthotopic kidney transplantation in selected
patients.
iv
January–March 2013
CASE REPORTS
Laparoscopic Excision of Splenic Artery
Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Kim Y, Johna S.
Endovascular management of splenic artery aneurysm
is the most applied therapy for this condition; however, laparoscopic intervention should be considered
as an alternative option.
Transvaginal Liver Surgery Using a Tethered
Magnet and a Laparoscopic Rein . . . . . . . . . 135
Tsin DA, Dominguez G, Davila F, Alonso-Rivera JM,
Safro B, Tinelli A.
Hybrid transvaginal endoscopic surgery can be facilitated with additional instruments, techniques, and a
flexible endoscope. Magnets are an aid to exposure
using a laparoscopic rein.
Gallstone-Related Abdominal Abscess 8 Years
After Laparoscopic Cholecystectomy . . . . . . . 139
Dobradin A, Jugmohan S, Dabul L.
An unusual collection of fluid in the perihepatic space
needs to be investigated for abscess in patients with a
remote history of cholecystectomy.
Laparoscopic Completion Cholecystectomy and
Common Bile Duct Exploration for Retained
Gallbladder After Single-Incision
Cholecystectomy . . . . . . . . . . . . . . . . . . . . . 143
Kroh M, Chalikonda S, Chand B, Walsh M.
This report details laparoscopic remnant cholecystectomy and transcystic common duct exploration after
previous single-port cholecystectomy.
Catastrophic Bleeding From a Marginal Ulcer
After Gastric Bypass . . . . . . . . . . . . . . . . . . . 148
Sidani S, Akkary E, Bell R.
The authors describe a case of life-threatening hemorrhagic marginal ulcer eroding into the splenic artery
that required surgical intervention.
v
Volume 17 Number 1
Endoclip Closure of a Colonic Perforation
Following Colonoscopic Leiomyoma
Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Velchuru VR, Zawadzki M, Levin AL, Bouchard CM,
Marecik S, Prasad LM, Park JJ.
This report suggests that iatrogenic colon perforations
in a prepped colon can be managed with endoclip
closure.
Robotic Repair of Uterine Dehiscence . . . . . 156
LaRosa MF, McCarthy S, Richter C, Azodi M.
A pediatric robot and 5-mm trocars were used to effect
a repair of a cesarean scar dehiscence, also known as
a cesarean scar defect.
Laparoscopic Removal of Abdominal Cerclage at
19 Weeks’ Gestation . . . . . . . . . . . . . . . . . . . 161
Carter JF, Savage A, Soper DE.
The authors discuss laparoscopic removal of an abdominal cerclage in a female patient who presented at
19 weeks with ruptured membranes.
Single-Incision Laparoscopic Adnexectomy in a
Patient with Previous Laparotomies . . . . . . 164
Sesti F, Boccia C, Sorrenti G, Baffa A, Piccione E.
Single-incision laparoscopic surgery appears to be feasible in obese patients who have undergone previous
midline laparotomies.
Small Bowel Injury During Laparoendoscopic
Single-Site Surgery for Simple
Nephrectomy . . . . . . . . . . . . . . . . . . . . . . . . 167
Joshi SS, Sundaram C.
The authors conclude that single-site surgery is not
without risk of serious complications and must be
performed in selected cases by experienced surgeons.
EDITORIAL POLICY
JSLS, Journal of the Society of Laparoendoscopic Surgeons publishes
original articles on basic science and technical topics in all the fields
involved with laparoendoscopic surgery. The journal seeks to advance
our understandings and practice of minimally invasive, image-guided
surgery by providing a forum for all relevant disciplines and by promoting the exchange of information and ideas across specialties.
JSLS is a peer-reviewed journal that employs a rapid review process for
all submitted manuscripts so that significant scientific findings appear
with minimal delay. All submitted manuscripts are initially reviewed by
a JSLS editor. Manuscripts considered appropriate for publication are
sent to expert reviewers for peer review. JSLS uses a “blinded” review
process. The identities of authors and peer reviewers are kept confidential. All materials accepted for publication are copyedited and returned to
the author for approval of significant recommended editorial changes.
The editor reserves the right to make minor changes for clarity and
accuracy without seeking author approval.
JSLS, Journal of the Society of Laparoendoscopic Surgeons has joined many
other medical journals endorsing the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals,” including the statements related
to “Protection of Patients’ Rights to Privacy,” established by editors in the
United States, Canada, and the United Kingdom.1 JSLS also endorses the
revised CONSORT statement2 and the AMA Guidelines for web sites.3
Papers are invited in the following categories:
• Clinical and experimental surgery
• Operative technique
• Review articles
• Case reports
• Laparoendoscopic education
• Letters to the editor
The journal, at the discretion of the editor, will also publish:
• Editorials
• Commentaries
• Articles concerning emerging technology
• Information (news) and events
Online Only Publication: JSLS reserves the right to publish manuscripts online and not in a hardcopy format. Authors who wish to have
their work published with color figures or who cannot provide high
resolution figures may request online only publication.
MANUSCRIPT SUBMISSION
Please review the complete Guidelines for Authors before submitting. Manuscripts that do not adhere to the Guidelines may be
rejected or returned to the author for correction before going
through the review process. Authors must also follow the Ethical
Policies and Procedures. Completion of the copyright transfer
agreement is required in order to have your manuscript reviewed.
Submit online at www.editorialmanager.com/jsls
MANUSCRIPT FORMAT
• All manuscripts must be typewritten in English with American
spelling and submitted in an editable Microsoft Word OR rich text
format document (PDFs and other document types are not acceptable.)
• Authors whose primary language is not English should have their
papers checked for linguistic accuracy by a person skilled in the
English language and medical terminology.
• For style, consult the American Medical Association Manual of
Style4 and/or the Uniform Requirements for Manuscripts Submitted
to Biomedical Journals.1
• Manuscripts should not exceed 4500 words, including references,
tables, and figures.
• Do not include a running header or footer.
• Be concise and avoid medical jargon. Keep abbreviations and
acronyms within the text to a minimum and spelled out, in parentheses, when first used.
• Use Systéme International (SI) measurements only.
• Use generic names for drugs.
• Text should avoid sexual and racial bias and use gender inclusive
language when possible.
• All persons listed as authors must meet the criteria for authorship
outlined in the American Medical Association Manual of Style4 and/or
Uniform Requirements for Manuscripts Submitted to Biomedical Journals.1 Authorship requires substantial participation in the work,
with the ability to take public responsibility for the content. Substantial
contribution must be made in all three of following areas: conception
and design or analysis and interpretation of data; drafting of the
manuscript or its critical revision for important intellectual content; and
approving the version of the manuscript to be published.4
Title Page
Please include the following:
• Title with no more than 75 characters. Do not use abbreviations.
Avoid acronyms.
• Date on which the manuscript was submitted.
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tables, figures, and illustrations.
Author’s Contact Information in Byline Order
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ship designations or honorary designations.
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state, and country.
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authors. Designate one author as the corresponding author.
Disclosure of Conflicts of Interest and Sources of Financial
Support (Also see Ethical Policies and Procedures)
Authors must state any financial interest they have in any commercial
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vi
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References
The latest version of this document is available on the SLS web site at www.sls.org/pubs/JSLS/JSLSauthors.html
1.
2.
3.
4.
5.
International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. JAMA. 1993;269:2282–2286 or Ann Intern
Med. 1988;108:258 –265 or Br Med J. 1988;296:4011– 405.
Moher D, Schulz K, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. JAMA
2001;285:1987–1991 or http://www.consort-statement.org/
Winker MA, Flanagan A, Chi-Lum B, et al. Guidelines for medical and health information sites on the internet. JAMA. 2000;283:1600 –1606.
Iverson C, Flanagin A, Fontanarosa PB, et al. American Medical Association Manual of Style. 9th ed. Baltimore, MD: William & Wilkins; 1988.
41st World Medical Assembly. Declaration of Helsinki; recommendations guiding physicians in biomedical research involving human subjects. Bull Pan Am Health
Organ. 1990;24:606 – 609.
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References:
1. The American Physiological Society. Ethical policies and procedures.
Available at: http://www.the-aps.org/publications/journals/apsethic.htm.
Accessed February 2008.
SCIENTIFIC PAPER
Extraperitoneal Closure of Persistent
Gastrocutaneous Fistula in Children
Gustavo Stringel, MD, MBA, Whitney McBride, MD, Allison Sweny, MD
ABSTRACT
Background and Objectives: Gastrostomy feeding in
children is well established for nutritional support. Gastrostomy tubes may be permanent or temporary. After
removal, spontaneous closure may occur, but persistence
of the tract requires surgical repair. Laparotomy with gastric repair and fascial closure is the standard technique for
treatment of a persistent gastrocutaneous fistula. We describe a technique of extraperitoneal excision of the fistulous tract and our results using this method.
Methods: We reviewed 21 cases of extraperitoneal gastrocutaneous fistula closure in which a Foley catheter
traction technique was used and were performed over the
last 8 y. The technique involves insertion of a small Foley
catheter with traction applied to the fistulous tract and
core excision with electrocautery. Closure of the tract
without fascial separation was accomplished and early
feedings were allowed.
Results: Ten males and 11 females underwent closure
with this technique. The duration of the gastrostomy
ranged from 1 y to 6 y, with a mean of 3.3 y. The time from
removal to surgical repair was 3 wk to 1 y, with a mean of
4.3 mo; 15 had gastrostomy alone, and 6 had gastrostomy
in combination with Nissen fundoplication. Open gastrostomy had been done in 10 patients and laparoscopic
gastrostomy in 11 patients. Half of the patients had an
ambulatory procedure. One patient developed a superficial wound infection, and there was 1 recurrence requiring intraperitoneal closure.
Conclusion: Extraperitoneal closure for gastrocutaneous
fistula is safe and effective. The technique allows for rapid
resumption of feeds and a shortened length of stay. Min-
Department of Pediatrics and Department of Surgery, NY Medical College, Maria
Fareri Children’s Hospital at Westchester County Medical Center, Valhalla, NY, USA
(all authors).
Address correspondence to: Gustavo Stringel, MD, MBA, NY Medical College,
Munger Pavilion Rm 321, Valhalla, NY 10595, Telephone: (914) 493-7620, Fax:
(914) 594-4933, E-Mail: [email protected]
DOI: 10.4293/108680812X13517013317590
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
imal morbidity occurs with this technique, and it is well
tolerated in the pediatric population.
Key Words: Gastrostomy, Gastrostomy closure, Gastrocutaneous fistula.
INTRODUCTION
Persistence of a gastrocutaneous fistula after removal of a
gastrostomy tube is a well-known sequela occurring in 5%
to 45% of patients.1– 4 These fistulas are managed expectantly for spontaneous closure in 1 to 3 mo after removal
of the feeding tube. A gastrocutaneous fistula that persists
requires surgical repair.3,4 The traditional operative technique widely used for treatment involves a layered closure. The fistula tract is excised, and the gastric wall is
separated from the fascia and the gastric defect is primarily repaired. The abdominal wall is closed in a layered
fashion. This procedure requires a period of bowel rest
with nasogastric decompression and a 2-d to 5-d hospital
stay. We describe an innovative approach that is performed entirely extraperitoneally, without the aid of endoscopy, and that can be performed in an ambulatory
setting.
MATERIALS AND METHODS
This was a retrospective study reviewing 21 patients over
an 8-y time span. The cases were performed by 2 pediatric
surgeons at a children’s hospital. This technique involves
inserting an 8 or 10 French Foley catheter into the
fistula tract; the stomach is then pulled up and the tract
exposed and excised using electrocautery. While under
traction, interrupted polyglycolic acid sutures are
placed to close the gastric and peritoneal defect without
fascial separation. The skin is subsequently closed with
interrupted nylon sutures (Figures 1 through 6). Patients were started on a diet 6 h postoperatively and
were discharged home on the same day unless a preexisting medical condition required additional hospitalization. The amount of time the gastrostomy tube had
been in place ranged from 1 y to 6 y. Indication for
gastrostomy placement included failure to thrive, se-
JSLS (2013)17:1– 4
1
Extraperitoneal Closure of Persistent Gastrocutaneous Fistula in Children, Stringel et al.
Figure 1. Gastrocutaneous fistula.
Figure 4. Fistulous tract excised and extraperitoneal suture placed.
Figure 2. Foley traction on the GCF tract.
Figure 5. Full thickness extraperitoneal closure.
Figure 3. Excision of the fistula tract.
Figure 6. Skin closure.
2
JSLS (2013)17:1– 4
tube; he had severe irritation around the stoma at the
time of closure. He was 1 of the initial patients in our
series.
vere mental retardation, genetic disorders, and congenital malformations as described in Table 1. An open
gastrostomy had been performed in 10 patients, while
the remaining had undergone laparoscopic placement.
Fifteen patients had a gastrostomy alone, and 6 had a
gastrostomy in combination with fundoplication. The
interval time from removal of the gastrostomy tube
to closure ranged from 3 wk to 1 y, with an average of
4.3 mo.
One patient, who was HIV/AIDS positive and immunocompromised, developed a superficial wound infection
that resolved with conservative management.
Eleven patients were ambulatory and were discharged on
a regular diet the day of surgery. Nine patients were
admitted for 2 to 3 d due to other comorbidities. One
patient remained hospitalized for 7 d secondary to other
medical comorbidities. All patients were started on a diet
on postoperative day 1. A few patients were observed to
have a small amount of leakage at the gastrocutaneous
fistula site postoperatively. This resolved spontaneously
after a short period of time.
RESULTS
All patients recovered uneventfully. There were 2 complications. One patient developed a recurrence of the
gastrocutaneous fistula requiring intraperitoneal layered closure. This patient had the initial extraperitoneal
closure 3 wk following removal of the gastrostomy
Table 1.
Patient Demographics
Sex
Age
Comorbiditya
Open Vs
Lapa
Duration
of GT
Interval to
Closure
NISSEN
Length of
Stay Days
Complication
M
8m
FTT
O
6y
3m
Y
0
None
F
5y
Esophageal perforation
O
5y
4 wks
N
0
None
F
19 m
FTT
L
3y
6m
Y
0
None
M
10 m
Trisomy 21, GERD
L
2y
2 wks
Y
0
Recurrence
F
3y
S/p renal transplant
O
1y
3 wks
N
2
None
M
2m
Kabuki syndrome
O
5y
2m
Y
7
None
M
1y
CPMR
O
7y
1y
N
2
None
F
22 m
Unknown
L
6y
3m
N
0
None
M
1 day
Long gap EA
O
2y
2m
N
0
None
M
5m
CPMR
L
2y
3m
N
2
None
F
2m
Cardiac disease
1y
6m
Y
3
None
M
4y
Small bowel transplant
O
6y
1y
N
2
None
F
3 wks
Tracheal mass
O
4y
2m
N
0
None
M
6 wks
Multiple medical problems
L
2y
2m
N
0
None
F
2m
Prader Willi syndrome
L
2y
6m
N
0
None
F
2m
Multiple medical problems
L
2y
6m
N
2
None
F
6y
HIV/AIDS
O
4y
1y
N
1
Wound
infection
M
3m
Trisomy 21, AV canal defect
L
3y
6m
N
2
None
M
5m
CPMR
L
4y
3m
Y
0
None
F
3m
Gastroschisis
O
15 m
2m
N
0
None
F
2y
FTT
L
1 year
3m
N
1
None
a
FTT (failure to thrive), O (open), L (Laparoscopic), EA (esophageal Atresia), GERD (Gastroesophageal reflux), CPMR (cerebral palsy
mental retardation).
JSLS (2013)17:1– 4
3
Extraperitoneal Closure of Persistent Gastrocutaneous Fistula in Children, Stringel et al.
DISCUSSION
Gastrostomy tubes are commonly used in the pediatric
population to manage enteral feeding. This can be temporary for short-term therapy or permanent. Gastrostomy
feeding tubes can provide a safe and physiologic method
of providing nutrition for patients with failure to thrive,
neurological disorders, and other conditions that impair
oral intake. If the underlying disease process can be corrected, gastrostomy tubes are removed and the tract allowed to close spontaneously. Previous studies1– 4 have
demonstrated failure of closure with subsequent gastrocutaneous fistula formation 5% to 45% of the time. Nonsurgical management is initially attempted with the application of silver nitrate and a pressure dressing. H2
blockers and proton pump inhibitors are also used at the
time of gastrostomy removal. Unfortunately, a number of
patients fail conservative therapy and surgical intervention
is indicated. The traditional layered closure technique
involves a hospital stay of an average of 3 d to 5 d and
requires nasogastric tube decompression and fasting for a
period of time postoperatively. While this technique has
proven to be quite successful in repairing the defect with
low recurrence rates, it involves substantial health care
costs and discomfort for patients and caregivers. More
recently, endoscopic techniques are being advocated with
placement of an endoclip to close the gastric defect in
conjunction with chemical cauterization to de-epithelialize the fistula tract.5 Fibrin tissue glue has also been used
with some success.6 Most the data available for the above-
4
mentioned techniques involves case studies or small-scale
reviews, and the success of complete closure is questionable. The extraperitoneal technique we describe has
lower morbidity, shorter hospital stay, and is more cost
effective than the traditional layered closure. Furthermore,
this approach is a simple technique that can be done
without the use of costly endoscopic equipment that may
not be readily available. Our data suggest that this technique is both safe and effective with low morbidity.
References:
1. Janik TA, Hendrickson RJ, Janick JS, Landholm AE. Analysis
of factors affecting the spontaneous closure of a gastrocutaneous
fistula. J Pediatr Surg. 2004;39:1197–1199.
2. Gordon JM, Langer JC. Gastrocutaneous fistula in children
after removal of gastrostomy tube: Incidence and predictive
factors. J Pediatr Surg. 1999;34:1345–1346.
3. Arnbjornsson E, Backman T, Berglund Y, Kullendorff CM. Closure
after gastrostomy button. Pediatr Surg Int. 2005;21:797–799.
4. El-Rifai N, Michaud L, Mention K, et al. Persistence of gastrocutaneous fistula after removal of gastrostomy tubes in children; prevalence
and associated factors. Endoscopy. 2004;36:700–704.
5. Teitelbaum JE, Gorcey SA, Fox VL. Combined endoscopic
cautery and clip closure of chronic gastrocutaneous fistula. Gastrointest Endosc. 2005;62:432– 435.
6. González-Ojeda A, Avalos-González J, Muciño-Hernández MI, et
al. Fibrin glue as adjuvant treatment for gastrocutaneous fistula after
gastrostomy tube removal. Endoscopy. 2004;36:337–341.
JSLS (2013)17:1– 4
SCIENTIFIC PAPER
Single-Port Laparoscopic Right Hemicolectomy:
Intermediate Results
Jacob R. Hopping, MD, Ovunc Bardakcioglu, MD
ABSTRACT
Background: Single-port laparoscopic colectomy was
first described in 2008 as a new technique for colorectal
surgery.1 No available reports have stated the intermediate- or long-term outcome. We report our intermediate results for the first 20 single-port laparoscopic right hemicolectomies performed by a single laparoscopically trained surgeon at
our institution.
Design: Between February 2009 and September 2010, 20
consecutive patients with an indication for right hemicolectomy who were candidates for laparoscopic surgery
underwent a single-port laparoscopic approach. The only
exclusion was a previous midline laparotomy. The patients were followed for outcomes after a median of 27
months (range: 15 to 35).
Results: The mean age was 65 years (range: 59 to 88). The
mean body mass index was 28 (range: 20 to 35). Seventyfive percent of patients had significant comorbidities, with
an American Society of Anesthesiologists class of III or IV.
The median estimated blood loss was 25 mL (range: 25 to
250). The mean number of lymph nodes was 13 (range: 0
to 29). There was one conversion to hand-assisted laparoscopic colectomy and one to open colectomy secondary
to bleeding. The mean hospital stay was 5 days (range: 3 to
7). Thirty-day postoperative complications included 1
wound infection, 1 patient with alcohol withdrawal, and 1
incidence of colitis caused by Clostridium difficile infection.
At a median follow-up of 27 months, there were no local
recurrences or distant metastases. One death occurred at
Department of Surgery, Saint Louis University, St. Louis, Missouri, USA.
Jacob R. Hopping has no disclosures. Ovunc Bardakcioglu is currently a proctor
with Intuitive Surgical and has received honoraria from Covidien and Niti Surgical
solutions.
Presented as a Poster at the meeting of the Society of Gastrointestinal and Endoscopic Surgeons, San Diego, California, USA, March 3–7, 2012
Address correspondence to: Ovunc Bardakcioglu, MD, FACS, Associate Professor
of Surgery Chief Division Colon and Rectal Surgery Department of Surgery, University of Nevada School of Medicine, 2040 W. Charleston Blvd, Ste 601, Las Vegas,
NV 89102, USA. E-mail: [email protected]
DOI: 10.4293/108680812X13517013316997
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
17 months from myocardial infarction. Two patients developed incisional hernias, with one requiring a laparoscopic hernia repair. One patient required a completion
proctocolectomy for a pathological diagnosis of hyperplastic polyposis syndrome.
Conclusions: Single-port laparoscopic right hemicolectomy has been safely performed in patients who are
candidates for conventional laparoscopic hemicolectomy. This small series indicates that intermediate-term
results are similar to conventional laparoscopic surgery
in efficacy, safety, and oncological outcomes. Larger
datasets are necessary to determine cost-effectiveness,
differences in postoperative outcomes, and patient satisfaction.
Key Words: Single-port laparoscopic colectomy, Singleincision laparoscopic colectomy, Long-term outcome, Intermediate term.
INTRODUCTION
Many small case series are now available that show
single-port laparoscopic (SPL) or single-incision laparoscopic (SIL) colectomy is a safe alternative to conventional laparoscopy. Single-incision techniques have
been described since 2008.1 There are many proposed
short-term benefits to laparoscopic colectomy, including less postoperative pain, quicker recovery, reduced
ileus, lower rate of wound infections/complications,
and rapid mobilization.2 Publications of long-term data
on conventional laparoscopic colectomy for adenocarcinoma have shown similar oncological outcomes and
no higher risks of port-site recurrence.2– 4 Similarly,
long-term data for conventional laparoscopic colectomy indicate that patient satisfaction, incisional hernia
rates, and rates of small bowel obstruction are not
statistically different from those in open surgery.5 Now
that short-term data for SIL for colon surgery exist
showing its efficacy and safety, long-term parameters
deserve focus. The primary aim of this study is to look
at our intermediate-term morbidity and mortality data,
including incisional hernia rate, which is considered to
be a particular concern for SIL surgery.
JSLS (2013)17:5– 8
5
Single-Port Laparoscopic Right Hemicolectomy: Intermediate Results, Hopping JR et al.
MATERIALS AND METHODS
Patient Selection
Patients were selected from the practice of a single laparoscopic colorectal surgeon at a university institution from
February 2009 through September 2010. Patient demographics are listed in Table 1. The only exclusion criterion
was a previous midline laparotomy. Patients were selected if they had an indication for laparoscopic right
hemicolectomy. Seven patients had a preprocedure pathological diagnosis of adenocarcinoma, 9 patients had adenomatous polyps, and 4 patients had unspecified polyps,
one of which was found to have hyperplastic polyposis
syndrome on pathological examination. All data were
collected retrospectively. All patients were told of the
alternative surgical approaches, including open surgery
and conventional laparoscopic surgery beforehand, and
all agreed to undergo SIL surgery.
Operative Technique
After induction of general endotracheal anesthesia, the
patient was placed in a beanbag and lithotomy position
using Allen Stirrups (Allen Medical, Acton, MA). A 4-cm
incision was made through the umbilicus, and a singleport access device (Gelpoint, Applied Medical, Ranch
Santa Margarita, CA) with one 12-mm and two 5-mm ports
was introduced through this incision. A 5-mm flexible tip
laparoscope (Olympus, Center Valley, PA), a straight
bowel grasper, and a bipolar vessel sealer with a monopolar tip (Ligasure Advance, Covidien, Mansfield, MA)
were used as instruments. The following description of
the “colonic rollover” approach was reported previously.6
After a careful examination of the peritoneal cavity, a
window in the small bowel mesentery was created 10 cm
Table 1.
Patient Demographics
Mean age (y)
66 (range: 45–88)
Sex (M:F)
18:2
Mean body mass index
28 (range: 20–35)
ASA class
I
1
II
4
III
13
VI
2
Preoperative diagnosis of cancer
6
7
proximal to the ileocecal valve and the small bowel divided using an endoscopic linear stapler (ETS45, Ethicon
Endosurgery, Blue Ash, OH). The mesenteric cut edge of
the small bowel was then serially divided with the vessel
sealer toward the root of the ileocolic pedicle. This step
was alternated with lateral mobilization of the cecum and
ascending colon. Constant traction of the mobilized colon
into the left upper quadrant allowed adequate tension and
visualization of the mesentery and the lateral attachments.
The duodenum was identified and dissected off the ileocolic pedicle, which was divided using the bipolar vessel
sealer. Further traction of the mobilized colon to the left
lower quadrant allowed division of the attachments of the
hepatic flexure and dissection of the omentum off the
transverse colon entering the lesser sac. The right branch
of the middle colic artery was similarly divided from a
supramesocolic approach. After complete mobilization
and intracorporeal vessel ligation, the colon was exteriorized, and a standard stapled side-to-side functional endto-end anastomosis was performed. The fascial defect was
closed using interrupted #1 Prolene sutures, and the skin
was closed with a subcuticular 4 – 0 Monocryl suture (Ethicon, Somerville, NJ).
RESULTS
In the 18 months of patient selection, 20 right hemicolectomies were performed using the previously described SIL
approach. The mean age was 65 years (range: 59 to 88).
Eighteen patients were male and two were female. The
average body mass index was 28 (range: 20 to 35). The
median American Society of Anesthesiologists (ASA) score
was III with a range of I to IV. Two cases were converted
because of bleeding and difficulty of safe ligation of the
ileocolic pedicle; one case was converted to a handassisted laparoscopic approach; and one was converted to
open. Median blood loss was 25 mL (18 of 20 patients),
with two cases reporting a 250-mL blood loss. The median
operative time was 156.5 minutes (range: 98 to 272),
which is consistent with those previously reported.7–9
There were no other intraoperative complications. Thirtyday postoperative complications included 1 case of alcohol withdrawal requiring a longer recovery and hospital
length of stay, 1 wound infection, and 1 case of colitis
caused by Clostridium difficile infection requiring appropriate antibiotic coverage (Table 2). Average hospital
length of stay was 5 days (range: 2 to 7). There were no
readmissions within a 30-day period.
Pathological diagnosis was confirmed in all cases. Three
patients had pathologically unspecified unresectable pol-
JSLS (2013)17:5– 8
case series reporting intermediate-term outcomes in SIL
colectomy.
Table 2.
Perioperative Data and Long-Term Complications
Average length of surgery (min)
161
Conversion (for bleeding)
1 to hand assisted
1 to open
Median blood loss (mL)
25 (range: 25–250)
Mean intravenous narcotic use (d)
2.1 (range: 1–5)
Median length of stay (d)
4.5 (range: 2–7)
Postoperative complications (30 day)
1 ETOH withdrawal
1 surgical site infection
1 C difficile colitis
Complications at follow up
4*
*One death at 17 months from myocardial infarction, 2 incisional
hernias, and 1 completion proctocolectomy for undiagnosed
familial polyposis.
yps preoperatively. Two of these were confirmed as villous adenoma, and the third was a T3 adenocarcinoma on
final pathology. Of the cases of adenocarcinoma, there
was 1 T1 lesion, 2 T2 lesions, and 5 T3 lesions. Three
patients had positive lymph nodes. The median lymph
node harvest was 13 (range: 0 to 29).
Intermediate follow-up was achieved with a mean of 27
months (range: 15 to 35). There was one death, the result
of a myocardial infarction at 17 months in a patient who
was ASA class IV and also had a significant history of
cardiovascular disease, including coronary artery bypass
graft, congestive heart failure, and atrial flutter. One patient with a postoperative diagnosis of hyperplastic polyposis syndrome and multiple new unresectable polyps in
the remaining colon and rectum on follow-up colonoscopy required a laparoscopic completion proctocolectomy. Two patients developed incisional hernias, one of
which required laparoscopic repair.
DISCUSSION
Short-term outcomes for SIL colon resection for benign
and malignant disease have been promising, showing hospital length of stay, time to oral intake, and intravenous pain
medication use that is not significantly different from conventional laparoscopic surgery.10 –13 The technique has been
used safely in patients who were candidates for conventional
laparoscopy. Most case series report similar to decreased
mean operating times.14 Currently, long-term data exist
exclusively for conventional laparoscopic colectomies. It
has been shown to be equal in safety, efficacy, and longterm oncological outcomes.2–5 Therefore, we present a
One of the leading criticisms of SIL surgery is a potentially
increased rate of hernia formation. On this issue here is
conflict in the literature: some authors believe that because of the decreased number of incisions, the hernia
rate should decrease as well.15 Data from long-term follow-up of single-incision cholecystectomies have not
shown an increase in hernias.16 Some data report rates as
low as 0.1%.17 One meta-analysis of 1100 SIL cholecystectomies did report a single umbilical hernia that was strangulated and required surgical intervention.18 It also reported that as a result of a mean follow-up time of only 72
hours to 24 months, the true hernia rate was likely underreported. Furthermore, incisional hernia rates of different
SPL procedures may not be comparable. The incision
needed for a SPL cholecystectomy is typically larger than
the 12-mm periumbilical port and gallbladder extraction
site used in conventional laparoscopic cholecystectomy.
The single-port extraction site in our case series is smaller
compared with conventional laparoscopy because of easier extraction of the colon after intracorporeal division of
the small bowel. Because of cosmetic reasons, the incision
was also made through the umbilicus, which is considered
a weak spot prone to hernia formation by many surgeons.
Therefore, technical details may play an important role to
consistently compare incisional hernia rates.
Two of our patients developed incisional hernias, leading
to an incisional hernia rate of 10%. We believe that, given
the small number of patients involved in this study, our
hernia rate may not accurately predict the risk of incisional
hernia in SIL colectomy.
Our median lymph node harvest was 13, similar to that
reported for conventional laparoscopy and open procedures.4 Many specimens harboring benign adenomas
were not fully examined by the pathologists for lymph
node counts, and secondary examination of the specimen
was not requested by the surgeon because of the benign
nature of the underlying polyp. The number of patients in
this study is too small, and follow-up of up to 35 months
is not adequate to comment on cancer recurrence or
port-site recurrence rates.
CONCLUSION
SPL for colorectal surgery has been established to be safe
and effective in the short term compared with conventional laparoscopy. In the hands of an experienced laparoscopic surgeon, SIL or SPL surgery could therefore be an
JSLS (2013)17:5– 8
7
Single-Port Laparoscopic Right Hemicolectomy: Intermediate Results, Hopping JR et al.
alternative to conventional laparoscopic surgery in patients who are otherwise candidates for a laparoscopic
procedure. Given our success with 20 patients, it would
appear that the intermediate- to long-term benefits are
likewise comparable, with no increase in morbidity or
mortality. Larger prospective case series and trials are
needed to evaluate differences in long-term postoperative
outcomes of SPL in colorectal surgery.
References:
1. Bucher P, Pugin F, Morel P. Single port access laparoscopic
right hemicolectomy. Int J Colorectal Dis. 2008;23:1013–1016.
2. Mehta PP, Griffin J, Ganta S, Rangraj M, Steichen F. Laparoscopic-assisted colon resections: Long-term results and survival.
JSLS. 2005;9:184 –188.
3. Fleshman J, Sargent DJ, Green E, et al. Laparoscopic colectomy
for cancer is not inferior to open surgery based on 5-year data from
the COST Study Group Trial. Ann Surg. 2007;246:655– 664.
4. Kojima M, Konisha F, Okada M, Nagai H. Laparoscopic
colectomy versus open colectomy for colorectal carcinoma: A
retrospective analysis of patients followed up for at least 4 years.
Surg Today. 2004;34:1020 –1024.
5. Thaler K, Dinnewitzer A, Mascha E, et al. Long-term outcome
and health related quality of life after laparoscopic and open colectomy for benign disease. Surg Endosc. 2003;17:1404 –1408.
6. Bardakcioglu O, Ahmed S. Single incision laparoscopic total
abdominal colectomy with ileorectal anastomosis for synchronous colon cancer. Tech Coloproctol. 2010;14:257–261.
7. Adair J, Gromski MA, Lim RB, Nagle DN. Single-incision
laparoscopic right colectomy: Experience with 17 consecutive
cases and comparison with multiport laparoscopic right colectomy. Dis Colon Rectum. 2010;53:1549 –1554.
9. Chen WT, Chang S, Chiang H, et al. Single-incision laparoscopic versus conventional laparoscopic right hemicolectomy: A
comparison of short-term surgical results. Surg Endosc. 2011;25:
1887–1892.
10. Waters JA, Guzman MJ, Fajardo AD, et al. Single-port laparoscopic right hemicolectomy: A safe alternative to conventional
laparoscopy. Dis Colon Rectum. 2010;53:1467–1472.
11. Waters J, Rapp BM, Guzman MJ, et al. Single-port laparoscopic right hemicolectomy: The first 100 resections. Dis Colon
Rectum. 2012;55:134 –139.
12. Champagne BJ, Lee EC, Leblanc F, Stein SL, Delaney CP.
Single-incision vs straight laparoscopic segmental colectomy: A
case-controlled study. Dis Colon Rectum. 2011;54:183–186.
13. Ross H, Steele S, Whiteford M, et al. Early multi-institution
experience with single-incision laparoscopic colectomy. Dis Colon Rectum. 2011;54:187–192.
14. Rijcken E, Mennigen R, Argyris I, Senninger N, Bruewer M.
Single-incision laparoscopic surgery for ileocolic resection in
Crohn’s disease. Dis Colon Rectum. 2012;55:140 –146.
15. Gaujoux S, Bretagnol F, Ferron M, Panis Y. Single-incision
laparoscopic colonic surgery. Colorectal Dis. 2011;13:1066 –
1071.
16. Phillips MS, Marks JM, Roberts K, et al. Intermediate results
of a prospective randomized controlled trial of traditional fourport laparoscopic cholecystectomy versus single incision laparoscopic cholecystectomy. Surg Endosc. 2012;26:1296 –1303.
17. Wong JSW, Cheung YS, Chong CCN, Lee KF, Wong J, Lai
PBS. Single-incision laparoscopic cholecystectomy: From four
wounds to one. Hong Kong Med J. 2011;17:465– 468.
18. Fransen S, Stassen L, Bouvy N. Single incision laparoscopic
cholecystectomy: A review on the complications. J Min Access
Surg. 2012;8:1–5.
8. Chambers WM, Bicsak M, Lamparellie M, Dixon AR. Singleincision laparoscopic surgery (SILS) in common colorectal surgery: A technique offering potential and not just cosmesis. Colorectal Dis. 2011;13:393–398.
8
JSLS (2013)17:5– 8
SCIENTIFIC PAPER
Vacation Appendicitis
Jay A. Redan, MD, Michael B. Tempel, MD,
Shannon Harrison, RN, MBA, CCRC, Xiang Zhu, MS
ABSTRACT
INTRODUCTION
Objective: When someone plans a vacation, one of the
last things taken into consideration is the possibility of
contracting an illness while away. Unfortunately, if people
develop abdominal pain while planning for a vacation,
they usually proceed with the vacation and do not consider getting medical attention for their pain. The purpose
of this study was to examine the effect of being on vacation and its association with ruptured appendicitis.
Appendicitis is one of the most common causes of abdominal pain and requires surgical treatment. Lifetime risk
of appendicitis ranges from 6% to 7%.1 Delayed presentation can lead to prolonged inflammation and subsequent rupture of the appendix. Increasing duration between the onset of inflammation and surgical intervention
increases the risk of perforation of the appendix. Retrospective chart reviews by Bicknell et al have shown that
rupture risk was ⬍2% when symptoms were present for
⬍36 hours. Thereafter, rupture risk rises to 5%.2 This leads
to prolonged hospitalization in addition to increased risk
of postoperative morbidity.
Methods: From January 1, 2007 to December 31, 2008,
the incidence of ruptured appendicitis cases at Florida
Hospital–Celebration Health, located 5 miles from Walt
Disney World, was compared with that of Florida Hospital–Orlando, approximately 30 miles away from Walt Disney World. We evaluated whether patients “on vacation”
versus residents of Orlando have an increased incidence
of ruptured appendicitis.
Results: Of patients treated for presumed appendicitis,
60.59% at Florida Hospital–Celebration Health had ruptured appendicitis during this time versus 20.42% at Florida Hospital–Orlando. Of those 266 patients seen at Florida Hospital–Celebration Health, 155 were on vacation
versus only 21 at Florida Hospital–Orlando.
Conclusion: Although there is not a direct cause and
effect, it is clear that there is a higher incidence of ruptured appendicitis in patients on vacation versus in the
regular community in the Orlando, Florida area.
Key Words: Appendicitis, Ruptured appendicitis.
Department of Surgery, Florida Hospital–Celebration Health, Celebration, Florida,
USA (all authors).
Presented as a poster at the American College of Surgeons, October 2011, San
Francisco, CA.
Address correspondence to: Jay A. Redan, MD, FACS, Director of Minimally Invasive General Surgery, Florida Hospital–Celebration Health, Associate Professor of
Surgery, University of Central Florida Medical School, 400 Celebration Place, Suite
A-140, Celebration, FL 34747. Telephone: 407-303-4602, Fax: 407-303-4602, E-mail:
[email protected]
DOI: 10.4293/108680812X13517013318355
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
Over 2 years, we analyzed patients who presented to our
facility and required emergency surgery for presumed
appendicitis. We divided our patients between those who
were visiting on vacation and those who lived as residents
in the area. Because of our location near Walt Disney
World, Universal Studios, and many other resorts and
hotels, we see a large number of patients on vacation with
their families; this includes both domestic and international visitors. Because of the factors associated with taking a vacation, such as time off of work, arranging flights
and hotels, saving money, and arranging children’s time
away from school, people experiencing abdominal pain
before their vacation may often delay treatment. Consequently, when they do present to the emergency department, pathology is often advanced, secondary to delay of
treatment. As stated previously, this can add to both postoperative morbidity and cost of hospital stay. Our hypothesis is that, simply because of our location, we see a
higher-than-average number of vacation emergencies versus emergencies in patients who live in the area. We
compared this with the incidence of appendicitis (perforated and nonperforated) to a local teaching hospital in
our health system, Florida Hospital–Orlando (FHO), a
large tertiary care teaching hospital with 938 beds.
MATERIALS AND METHODS
This is a retrospective chart review using patient data from
Florida Hospital–Celebration Health (FHCH), a small 112bed community hospital in Celebration, Florida, approxi-
JSLS (2013)17:9 –14
9
Vacation Appendicitis, Redan JA et al.
mately 5 miles from Walt Disney World. A request was
made and granted from our institutional review board to
conduct this chart review. The review uses data from
January 1, 2007 to December 31, 2008. The study population consists of patients undergoing emergent or urgent
surgery for presumed appendicitis. All patients in the
study were ⬎18 years (all patients ⬍18 were sent to FHO).
All appendectomies are performed laparoscopically at
FHCH. Data regarding laparoscopic versus open procedures were not available at FHO. The conversion rate to
open is ⬍1% among the experienced surgeons at FHCH.
Only “positive appendectomies” were included in this
study; however, negative appendectomies are unusual
because of the high-quality imaging studies now available
in most hospitals. These patients were analyzed with respect to age, sex, race, actual pathology, and length of
hospital stay. More importantly, we analyzed the patients
with respect to home geographic location indicated by zip
codes. FHCH has a service area of 30 zip codes. For the
purpose of this study and to allow for overlap of the
comparative hospital zip codes, we assumed that any
patient who came to FHCH whose home residence was
not in Florida was considered to be “on vacation.” This
obviously includes patients from other countries and
those from out-of-state. Finally, we compared these data
with those obtained over a similar period at FHO, the
flagship hospital for the Florida Hospital Health System. It
is a tertiary care and teaching hospital located in downtown Orlando with 938 beds.
In the multiple regression analysis, we adopted multiple
logistic regression models to analyze perforation rate. We
designated perforation as a dependent variable and coded
it as “1” for perforated and “0” for nonperforated. We
designated all other factors as independent variables, including (1) patient type (binary variable, “1” for on-vacation patients who live outside the service area and “0” for
resident patients who live in the service area); (2) campus
(binary variable, “1” for FHCH and “0” for FHO); (3) age
(continuous variable); (4) gender (binary variable, “1” for
male and “0” for female); (5) race (binary, “1” for white
and “0” for nonwhite; we grouped races into 2 categories
because some races had too few observations); and (6)
medical insurance status (binary variable, “1” for with
insurance and “0” for without insurance). We estimated
odds ratios of perforation versus nonperforation on the
condition of patient type with other independent variables
treated as adjustment factors.
To investigate the relationship of LOS with perforation, we
used multiple Poisson regression analysis. Poisson regression was applied because LOS was a count variable following a Poisson distribution (Figure 1). In the Poisson
regression analysis, we designated LOS as a dependent
variable and all other factors (perforation, age, gender,
race, patient type) as independent variables.
400
300
Frequency
200
100
0
In this retrospective study, in addition to vacationers (ie,
people visiting Orlando as nonresidents), there were also
other factors examined, such as age, gender, medical
insurance, and race, which might be associated with perforation development of appendicitis patients but not under control. This aggressive statistical analysis was performed to rule out the possibility that our high incidence
of ruptured appendicitis was not a result of chance. In
addition, hospital facility characteristics, such as location
and size, as a whole might somehow affect the pattern of
patients’ use of the emergency department and, hence,
result in different levels of perforation rate in different
patient populations. We first used univariate analysis,
which included frequency ␹2 test for percentage number
comparison, Student t test for age comparison, and Wilcoxon rank-sum test for length of stay (LOS) comparison,
to investigate the association of perforation with campuses, patient type (resident patient vs on-vacation patient), age, gender, medical insurance status, and race,
500
Stata version 10.0 (StataCorp, College Station, TX) was
used for all analyses. All data were presented as mean ⫾
Statistics
10
separately. Then we used multiple regression analysis to
further isolate and evaluate the effect of each factor on the
perforation rate with the rest factors under control.
0
2
4
6
8
10
12
LOS (day)
14
16
18
20
Figure 1. Frequency distribution of LOS ranging from 0 to 20
days.
JSLS (2013)17:9 –14
standard error unless otherwise specified, and the significance level for all tests was set at P ⬍ .05.
RESULTS
Following are the new results based on the data where
patients ⬍18 years are removed from both the FHCH and
FHO campuses. In addition, to unify the criteria that both
campuses used to distinguish on-vacation patients from
resident patients, we classified the patients who lived in
Florida as resident patients, and those who did not as
on-vacation patients.
If the patients ⬍18 years were excluded from this study
(ie, removed from both campuses), the total number of
patients included was 943, 439 (46.55%) of which were
from the FHCH campus and 504 (53.45%) from the FHO
campus. If the patients who lived in Florida were identified as resident patients, and the patients who lived outside as on-vacation patients, the total number of resident
patients versus the total number of on-vacation patients
was 767 (81.34%) versus 176 (18.66%).
Table 1 shows the results of the association of perforation
with age, race (as noted in the chart face sheet), and
campus.
The multiple Poisson regression analysis showed that LOS
was significantly positively associated with perforation, age,
gender, medical insurance status, and campus (Table 4).
According to the model, we predict that if other conditions
are held unchanged, patients with a perforated appendix
have a 68% longer LOS than patients with a nonperforated
appendix. With a patient age increase of 1 year, the LOS
increases by 2%; male patients have a 7% longer LOS than
female patients; patients with medical insurance have a
9% longer LOS than patients without medical insurance;
and patients at FHCH have a 13% longer LOS than at
Orlando campus. Race and patient type do not significantly affect LOS.
To avoid multicollinearity among independent variables,
we conducted Kendall ␶ test. We did not detect any high
collinearity (⬎0.8) among the independent variables that
we incorporated into our models, suggesting that the
structure of our models is valid.
From the period of January 2007 through December 2008,
439 patients were admitted to FHCH for presumed appendicitis. All patients were taken to the operating room. The
appendix was removed and sent for pathological analysis.
Final diagnoses were classified as acute appendicitis either with or without perforation.
In contrast, 504 patients were admitted to FHO with presumed appendicitis. Table 5 summarizes these data.
Table 6 further divides the totals from FHCH into those
patients within the service area (ie, 30 surrounding zip
codes) and those “on vacation.” As before, these patients were also grouped into acute versus perforated/
peritonitis.
Finally, Table 7 displays the admission data for each
campus as a function of percentage of acute and perforated appendicitis.
Table 1.
Comparison of Patient Populations between the Celebration Campus and the Orlando Campusa
Celebration
Orlando
Overall
Number of patients
439
504
943
On-vacation patients (%)
155 (35.31)
21 (4.17)
176 (18.66)
␹2
P Value
149.89
.000
Perforated (%)
266 (60.59)
113 (22.42)
483 (40.19)
142.22
.000
Male (%)
205 (46.70)
271 (53.77)
476 (50.48)
4.70
.030
Age (SD, min–max)
41.2 (15.4, 18–90)
38.7 (16.9, 18–97)
39.9 (16.2, 18–97)
–2.34b
.020
White (%)
436 (99.32)
404 (80.16)
840 (89.08)
88.51
.000
Medical insured (%)
384 (87.47)
381 (75.60)
765 (81.12)
21.61
.000
LOS (SD, min–max)
4.3 (6.5, 0–71)
2.9 (7.6, 0–147)
3.6 (7.1, 0–147)
–6.12c
.000
Patients ⬍18 years old were excluded, and patients who lived outside Florida State were identified as “on-vacation” patients.
Two-tailed t test.
c
Wilcoxon rank-sum test.
a
b
JSLS (2013)17:9 –14
11
Vacation Appendicitis, Redan JA et al.
Table 2.
Comparison of Patient Characteristics Between Those with Perforated Versus Nonperforated Appendixa
␹2
P Value
176 (18.66)
24.89
.000
173 (30.67)
439 (46.55)
142.22
.000
391 (69.33)
504 (53.45)
179 (47.23)
297 (52.67)
476 (50.48)
2.67
.102
43.2 (16.6, 18–91)
37.6 (15.6, 18–97)
39.9 (16.2, 18–97)
–5.26b
.000
White (%)
345 (91.03)
495 (87.77)
840 (89.08)
2.68
.115
Med. insured (%)
325 (85.75)
440 (78.01)
765 (81.12)
8.86
Perforated
Nonperforated
Overall
Number of patients
379
564
943
On-vacation patients (%)
100 (26.39)
76(13.48)
Celebration (%)
266 (70.18)
Orlando (%)
113 (29.82)
Male (%)
Age (SD, min–max)
LOS (SD, min–max)
5.1 (7.1, 0–71)
2.6 (6.9, 0–147)
.003
c
3.6 (7.1, 0–147)
.000
–9.60
Patients ⬍18 years old were excluded, and patients who lived outside Florida State were identified as “on-vacation” patients.
Two-tailed t test.
c
Wilcoxon rank-sum test.
a
b
Table 3.
Estimation of Odds Ratio of Perforated versus Nonperforated
Appendix in Relation to Age, Gender, Race, Medical Insurance
Status, Patient Type, and Campus Using a Multiple Logistic
Regression Modelab
Odds
Ratio
SE
Z
P
Value
Incidence
Rate
Ratio
SE
Perforation
1.59
0.06
12.03
Age
1.03
0.00
Gender
1.06
0.04
Medical
insurance
1.05
0.05
95% CI
Lower
Upper
Age
1.02
0.00
4.61
.000
1.01
1.03
Gender
0.96
0.14
–0.28
.781
0.72
1.28
Medical
insurance
1.15
0.23
0.69
.491
0.78
1.69
Race
0.49
0.12
–2.84
.005
0.30
0.80
Patient
type
1.02
0.20
0.09
.931
0.69
1.49
Campus
6.03
1.04
10.45
.000
4.30
8.44
Patients ⬍18 years old were excluded, and patients who lived
outside Florida were identified as “on-vacation” patients.
b
Pseudo R2 ⫽ 0.138, ␹2(6) ⫽ 175.9, P ⫽ .000.
a
DISCUSSION
Appendicitis is one of the most common conditions
requiring surgical intervention. Lifetime risk of appendicitis is estimated to be 6% to 7% overall. Although
simple acute appendicitis requires a relatively simple
operation with a short hospital stay (possibly even
same-day discharge), delays in treatment lead to perforation of the appendix with subsequent localized abscess and/or peritonitis.
12
Table 4.
Estimation of Effects of Perforation, Age, Gender, Medical
Insurance, Race, Patient Type and Campus on LOS Using the
Multiple Poisson Regression Modelab
z
P
Value
95% C.I.
Lower
Upper
.000
1.47
1.71
28.34
.000
1.03
1.03
1.62
.106
0.99
1.13
0.94
.347
0.95
1.16
Race
1.00
0.07
0.07
.943
0.88
1.14
Patient
type
0.99
0.05
–0.17
.868
0.91
1.08
Campus
1.17
0.05
3.75
.000
1.08
1.28
Patients ⬍18 years old were excluded, and patients who lived
outside Florida were identified as “on-vacation” patients.
b
Pseudo R2 ⫽ 0.162, ␹2(7) ⫽ 1194.36, P ⫽ .000.
a
It is our goal to study the effects of treatment delay—
namely, vacation time away from home— on the course
of appendicitis. Our small community hospital is located approximately 4 miles from the Walt Disney
World and Resorts complex, with an estimated 50 million visitors annually. In addition to the 4 theme parks
at Walt Disney World, Universal Studios, and Sea
World, there are other theme parks, themed hotels,
resorts, and local attractions.
JSLS (2013)17:9 –14
Table 5.
Patients Admitted with Presumel Appendicitis
Orlando total
504
Acute appendicitis with perforation
113
Celebration total
439
Acute appendicitis with perforation
266
Table 6.
Florida Hospital Celebration Health From Service Area vs On
Vaction and Acute Appendicitis vs Perforated Appendicitis
(n⫽439)
439
Appendicitis in service area
81
Appendicitis out of service area
92
Perforated appendicitis in service area
93
Perforated appendicitis out of service area
173
Of note, appendicitis is traditionally thought of as a disease of children. Our hospital policy directs us to send any
patients ⬍18 years to FHO for treatment. Pediatric surgical
patients at FHCH do not exist and may have skewed the
data; however, the average age of patients at our hospital
is 36.5 years.
Table 7.
Hospital and Appendix Pathology
Orlando
Perforated appendicitis
Celebration
Perforated appendicitis
Total No. Admissions
2007–2008 (%)
504
439
266 (60.59)
121 (21.18)
Perforated appendicitis out of
service area
157 (65.04)
CONCLUSIONS
Perforation is significantly associated with age, race, and
campus (FHCH vs FHO), and on-vacation patients have a
30% higher odds ratio of perforation rate than resident
patients.
113 (22.42)
Perforated appendicitis in service
area
During the period from 2007 to 2008, FHO admitted 504
patients with presumed appendicitis. Of those, 113 patients (22.42%) had perforation. During the same period,
FHCH admitted 439 patients with the same diagnosis of
presumed appendicitis. Of our 439 patients with presumed appendicitis, 266 (60.5%) had perforations at the
time of operation. Our patients with perforated appendicitis were further divided into those inside the service area
and those “on vacation.” It is interesting to note that 93
patients (21.18% of total) with perforated appendicitis
were in our service area. In addition, 173 patients (65.04%
of total) with perforated appendicitis were outside of our
service area. In other words, based only on vacationing
patients visiting our area, we had almost 3 times as many
appendiceal perforations as did our flagship hospital.
FHCH accepted a higher percentage of patients with perforations than did FHO, but this could not be explained by
the fact that FHCH had a larger percentage of on-vacation
patients compared with FHO.
Given the time and finances needed to organize time
away from home (as discussed previously), it is easy to
see how someone may dismiss the initial vague abdominal pain of appendicitis as a hassle rather than a condition
requiring surgical attention. Consequently, as time progresses and treatment is delayed, a simple procedure
transforms into a more complicated one as patients arrive
at their “vacation destination.”
Our goal was to compare our data regarding perforated
appendicitis with data from a large tertiary-care teaching
hospital and to show that, based simply on location, our
smaller hospital sees a proportionately larger number of
perforated appendicitis cases than a larger hospital with
more resources, a higher bed capacity, and a larger service
area.
Although factors such as age, gender, medical insurance
status, race, and patient type were taken into account, the
difference in perforation rates between campuses (ie,
“campus effect”) was still significant. This part of effect at
the campus level is still unclear, probably because of
some unobserved reasons.
The criteria used to classify on-vacation patients and resident patients at FHCH and FHO might not be the same
“ruler” to reflect all aspects of their patient populations.
This may have been problematic when all data were
pooled to evaluate the effect of patient type on perforation rate.
Of the patients with suspected appendicitis, 65.04% of the
visitor patients at FHCH had perforated appendicitis versus 22.42% at FHO. All comparisons were statistically
significant, P ⬍ .001 by ␹2 analysis. We concluded that
JSLS (2013)17:9 –14
13
Vacation Appendicitis, Redan JA et al.
developing appendicitis while on vacation is associated
with a statistically significantly higher incidence of perforated appendicitis in Orlando, Florida, P ⬍ .001. Although
there is no way to definitively prove cause and effect, we
believe that patients planning an expensive vacation tend
to “ignore” warning signs of a more serious illness than
when they are “at home” and not planning a vacation.
References:
1. Fischer JE, et al. Chapters 129 –230. In: Mastery of Surgery.
Fifth edition. Philadelphia: Lippincott Williams & Wilkins; 2007.
2. Bicknell NA, Aufses AH Jr, Rojas M, Bodian C. How time
affects the risk of rupture in appendicitis. J Am Coll Surg. 2006;
202(3):401– 406.
3. Bickell NA, Siu AL. Why do delays in treatment occur?
Lessons learned from ruptured appendicitis. Health Serv Res.
2001;36(1):1–5.
4. Sicard N, Tousignant P, Pineault R, Dubé S. Non-patient
factors related to rates of ruptured appendicitis. Br J Surg. 2007;
94:214 –221.
5. Eldar S, Nash E, Sabo E, et al. Delay of surgery in acute
appendicitis. Am J Surg. 1997;173:194 –198.
14
6. Deck KB, Pettitt BJ, Harrison MR. The length-time correlate
in appendicitis. JAMA. 1980;244:806 – 807.
7. Temple CL, Huchcroft SA, Temple WJ. The natural history of
appendicitis in adults. A prospective study. Ann Surg. 1995;221:
278 –281.
8. Penfold RB, Chisolm DJ, Nwomeh BC, Kelleher KJ. Geographic disparities in the risk of perforated appendicitis among
children in Ohio: 2001–2003. Int J Health Geogr. 2008;7:56.
9. Davies GM, Dasbach EJ, Teutsch S. The burden of appendicitis-related hospitalizations in the United States in 1997. Surg
Infect (Larchmt). 2004;5:160 –165.
10. Kraemer M, Franke C, Ohmann C, Yang Q; Acute Abdominal
Pain Study Group. Acute appendicitis in late adulthood: incidence, presentation, and outcome. Results of a prospective multicenter acute abdominal pain study and a review of the literature. Langenbecks Arch Surg. 2000;385(7):470 – 481.
11. Hansson LE, Laurell H, Gunnarsson U. Impact of time in the
development of acute appendicitis. Dig Surg. 2008;25(5):394 –
399.
12. Papaziogas B, Tsiaousis P, Koutelidakis I, Glakoustidis A,
Atmatzidis S, Atmatzidis K. Effect of time risk of perforation in
acute appendicitis. Acta Chir Belg. 2009;109(1):75– 80.
JSLS (2013)17:9 –14
SCIENTIFIC PAPER
Meta-analysis of Laparoscopic Versus Open Repair of
Perforated Peptic Ulcer
Stavros A. Antoniou, MD, George A. Antoniou, MD, PhD, Oliver O. Koch, MD,
Rudolph Pointner, MD, PhD, Frank A. Granderath, MD, PhD
ABSTRACT
INTRODUCTION
Background and Objectives: Laparoscopic treatment of
perforated peptic ulcer (PPU) has been introduced as an
alternative procedure to open surgery. It has been postulated that the minimally invasive approach involves less
operative stress and results in decreased morbidity and
mortality.
Laparoscopic repair of perforated peptic ulcer (PPU) was
first reported with the introduction of laparoscopy.1,2 Nevertheless, the use of the procedure in routine practice has
been rather limited during the 1990s, largely because of
the low incidence of PPU after identification of Helicobacter pylori as a prime factor, and because of the effectiveness of pharmacologic treatment in eradication of the
bacterium and prevention of ulcer recurrence.3 Nevertheless, several studies have reported the use of the laparoscopic approach in clinical practice. Minimally invasive
treatment of PPU involves entering the abdominal cavity
after establishing a pneumoperitoneum, closure of the
gastric defect, and lavage of the abdomen. Closure of the
defect is facilitated either by direct suturing with or without placement of an omental patch or by introduction of
biological glue with or without placement of a gelatin
sponge.4,5 The concept of sutured closure is the laparoscopic counterpart to the open technique, whereas nonsutured repair does not require laparoscopic suturing
skills and has the advantage of shorter operative time.6
Methods: We conducted a meta-analysis of randomized
trials to test this hypothesis. Medline, EMBASE, and the
Cochrane Central Register of Randomized Trials databases
were searched, with no date or language restrictions.
Results: Our literature search identified 4 randomized trials,
with a cumulative number of 289 patients, that compared the
laparoscopic approach with open sutured repair of perforated ulcer. Analysis of outcomes did not favor either
approach in terms of morbidity, mortality, and reoperation
rate, although odds ratios seemed to consistently support
the laparoscopic approach. Results did not determine the
comparative efficiency and safety of laparoscopic or open
approach for PPU.
Conclusion: In view of an increased interest in the laparoscopic approach, further randomized trials are considered essential to determine the relative effectiveness of
laparoscopic and open repair of PPU.
Key Words: Peptic ulcer disease, Perforated peptic ulcer, Gastric ulcer, Duodenal ulcer, Laparoscopy, Metaanalysis.
Center for Minimally Invasive Surgery, Hospital Neuwerk, Mönchengladbach, Germany (Drs. S. Antoniou, Granderath).
Department of Vascular and Endovascular Surgery, Manchester Royal Infirmary,
Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
(Dr. G. Antoniou).
Department of General Surgery, Hospital Zell am See, Zell am See, Austria (Drs.
Koch, Pointner).
Address correspondence to: Stavros A. Antoniou, Souniou 11, 19001 Keratea
Attikis, Athens, Greece. Telephone: (⫹49) 163-851-8279, Fax: (⫹30) 229-906-8845,
E-mail: [email protected]
The decreasing incidence of PPU has diminished the use of
the laparoscopic treatment of this condition.7 Clinical data
mostly report retrospective studies, whereas prospective trials are primarily uncontrolled,8 thereby providing a low level
of evidence. In view of experimental data demonstrating the
efficacy of pneumoperitoneum compared with laparotomy
in experimental models of intra-abdominal sepsis,9 the laparoscopic approach to PPU is of considerable interest.
The present study reviews the current literature to identify
the highest-quality studies and performs a comparative
analysis of the clinical outcomes in laparoscopic and open
sutured treatment of peptic ulcer perforation. A metaanalysis of randomized controlled trials was undertaken to
examine the relative risks of morbidity and mortality for
both the laparoscopic and open approaches.
MATERIALS AND METHODS
Study Protocol and Eligibility Criteria
DOI: 10.4293/108680812X13517013317752
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
An ad hoc study protocol was designed to address inclusion
criteria and methods of analysis. Randomized controlled tri-
JSLS (2013)17:15–22
15
Meta-analysis of Laparoscopic Versus Open Repair of Perforated Peptic Ulcer, Antoniou SA et al.
als providing operative outcome data of laparoscopic sutured and open sutured repair of PPU were considered for
inclusion. The primary outcome measure of the present
meta-analysis was the relative risk of in-hospital mortality,
whereas secondary outcome measures included operative
morbidity, duration of surgery, postoperative pain, and
length of in-hospital stay. Data sources were searched
with no language or date restrictions. Only published
material was included, whereas study abstracts presented in medical congresses and indexed in peerreviewed journals were evaluated for content.
Data Sources and Study Selection
The electronic databases of the National Library of Medicine
(Medline; provider Ovid, from 1966 to July 2012), Excerpta
Medica (EMBASE; provider Elsevier, from 1980 to July 2012),
and the Cochrane Central Register of Controlled Trials were
searched to identify relevant articles. The following search
terms were used: “laparoscopy (MeSH)” AND “repair OR
closure” AND “gastric OR duodenal” AND “ulcer (MeSH).”
Study abstracts were reviewed and full-text articles on pertinent subjects were obtained. A second-level search included
the reference lists of eligible studies and the bibliography of
all relevant systematic reviews. Study eligibility was assessed
independently by 2 authors in an unblinded manner. Disagreements between reviewers were resolved by consensus.
The last search was run on July 14, 2012.
Data Collection and Indexing
Data were independently retrieved by the 2 reviewers upon
selection of studies to include in this work. For this purpose,
an electronic database was developed using Microsoft Excel
(Microsoft Corp, Redmond, WA) and refined accordingly.
Data items extracted from each study included author, year
of publication, country of origin, period of treatment, number of participating centers, number of included patients,
number of patients who received treatment, number of patients for whom operative and postoperative data were available, number of patients in each treatment arm, inclusion
criteria, exclusion criteria, randomization method, blinded
method (if applicable), number of patients who were evaluated after treatment, male-to-female ratio, mean age, mean
American Society of Anesthesiologists score, mean Boey
score, type of surgery (simple repair with or without omental
patch), and mean size of perforation. Outcome measures
extracted from each study included duration of surgery,
conversion rate, visual analog score (VAS) at 24, 48, and 72
hours after surgery, diet toleration time, absolute number of
major complications, absolute number of minor complications, and duration of in-hospital stay. Major complications
16
included suture line leakage, peritoneal abscess/collection,
pancreatitis, fascial dehiscence, pneumonia or respiratory
failure, and severe cardiac and cerebrovascular events.
Wound infection or wound abscess, urinary tract infection,
prolonged ileus, and incisional hernia were considered minor complications. If data were not reported, or were insufficient, the authors were contacted by e-mail, provided with
information on the study, and invited to provide additional
information. VAS at 48 and 72 hours after surgery were only
provided by one study. A meta-analytical model for the
continuous variables of duration of hospital stay and time to
tolerate oral diet could not be applied because respective
mean values were not provided.
Quality Assessment and Methods of Analysis
The Jadad score was calculated for each study to assess
methodologic quality of the included trials. This 5-point
scoring system takes a number of criteria into account,
such as the randomization process, the blind assessment
of investigated treatments, and reporting of dropouts.10 A
Jadad score of 1 to 2 was considered poor quality, a score
of 2 to 3 was considered fair, and a score of 4 to 5
indicated good methodologic quality.
Study-specific estimates were combined using randomeffects or fixed-effects models as appropriate. Weighted
mean differences with 95% confidence intervals were calculated to assess the size of the effect of each type of
procedure on continuous variables. Pooled odds ratios
with 95% CI were calculated to measure the effect of each
type of procedure on categoric variables. Heterogeneity
among trials was assessed using Cochrane’s Q-statistic, a
null hypothesis test with a value of P⬍.05 to indicate the
presence of significant heterogeneity. Publication bias
was assessed using Egger regression intercept. Statistical
analysis was performed using Comprehensive Meta Analysis Version 2.0 (Biostat, Englewood, NJ). Statistical expertise was provided by one of the study authors. The
present meta-analysis conformed to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement standards, a methodologic protocol based on essential criteria for transparent reporting.11
RESULTS
Search Results and Selection of Studies
The electronic search of the databases returned 290 results
(Figure 1). On the basis of the abstracts, 271 records were
discarded because they were either confirmed retrospec-
JSLS (2013)17:15–22
tive studies or they did not report whether they were
prospective or retrospective (n⫽42); case series (n⫽58);
case reports (n⫽22); letters, comments, or editorials
(n⫽32); reviews (n⫽38); animal studies (n⫽6); or studies
with unrelated subjects (n⫽73). Nineteen prospective
studies with a control arm were identified and their full
texts retrieved. Four randomized controlled trials fulfilling
the eligibility criteria were identified and included in the
meta-analysis.12–15 Manual search of the reference lists
reported in the included studies and relevant systematic
reviews did not identify any further eligible studies.
Characteristics of Included Studies
Table 1 reports the characteristics of the included randomized trials. All 4 studies were randomized controlled
trials published in the English language between 1996 and
2009. One was a multicentric study with 9 participating
centers.15 Three articles originated from China and one
from the Netherlands, whereas 2 studies were designed by
the same author team and reported on different study
groups in distinct periods.12,13 One study focused its results on biochemical evaluation of stress-associated factors rather than on clinical outcomes.13 Nevertheless, this
study was included in the analysis because it provided
data on duration of surgery. Of 289 patients, 151 were
included in the laparoscopic sutured repair arm and 138 in
the open sutured repair arm. One study also compared the
outcome of laparoscopic and open sutureless techniques,
although respective data on treatments were excluded
Figure 1. Flow chart of search history.
Table 1.
Characteristics of Randomized Trials
Author
Year of
Country
Publication
No. of
Period of
Participating Treatment
Centers
Lau, et al.12
1996
China
1
August 1992–
Clinical diagnosis of 1.
September 1994 PPU
2.
3.
4.
Lau et al.13
1998
China
1
September
1995–July 1996
Age between 17
and 69 years
Siu et al.14
2002
China
1
January 1994–
June 1997
1. Clinical diagnosis 1. Bleeding ulcer
3
of PPU
2. Prior abdominal surgery
2. Age ⬎16 years
3. Gastric outlet
obstruction
March 1999–
July 2005
Clinical diagnosis of 1. Prior upper abdominal
PPU
surgery
Bertleff et al.15 2009
The
9
Netherlands
Inclusion Criteria
Exclusion Criteria
Jadad
Score
Complicated ulcer
3
Bleeding ulcer
Prior abdominal surgery
Severe cardiopulmonary
disease
1. Bleeding ulcer
2. Immunosuppression
2
3
2. Pregnancy
JSLS (2013)17:15–22
17
Meta-analysis of Laparoscopic Versus Open Repair of Perforated Peptic Ulcer, Antoniou SA et al.
from this analysis.12 The main inclusion criteria entailed
patients with the clinical diagnosis of PPU, whereas patients with bleeding ulcers and prior surgery in the upper
abdomen were excluded by 3 studies. Male patients were
predominant in the 3 studies that reported gender distribution, with an overall ratio of 1.5:1. The mean age was 54
years in the 2 studies reporting relevant data. In 3 studies,
an omental patch was sutured on the repair site,12–14
whereas in 1 study, this was not included as a routine step
for both laparoscopic and open procedures.15 Data on
VAS, time to tolerate oral diet, and length of in-hospital
stay could not be analyzed because several studies failed
to report respective mean values or absolute numbers.
quality, with a Jadad score of 3, and 1 study was poor
quality, reaching a Jadad score of only 2. All reported
results adhered to the intention-to-treat concept in all
studies. Data collected from patients who underwent conversion to open surgery were analyzed as data of the
laparoscopic cohort.
A blinded approach was not applied in any of the studies,
and one study did not specify any method of randomization.13 Hereby, 3 studies were considered to be of fair
There were 3 deaths in the laparoscopic group and 8
deaths in the open group, giving rates of 2% and 6%,
respectively (OR 0.36, 95% CI 0.10 –1.32, P⫽.124). There
Synthesis of Results and Outcome
Table 2 illustrates demographic data of the study populations, and Table 3 summarizes outcome measures.
Mortality
Table 2.
Demographic and Operative Data of the Studied Patient Populations
Author
No. of
Patients
(Lap/Open)
Age (Lap/
Open)
Male-toFemale
Ratio
ASA Score
(Lap/Open)
Boey Score
(Lap/Open)
Size of Perforation
(mm) (Lap/Open)
Omental
Patch
Conversion
Rate
Lau et al.12
45 (24/21)
52 (52/53)
4.6:1
NR
0.27 (0.29/0.24)
NR (6 mm/5 mm)
Yes
25% (6/24)
13
Lau et al.
22 (12/10)
NR
NR
NR
NR
NR
Yes
25% (3/12)
Siu et al.14
121 (63/58)
55 (54/56)
4.3:1
1.72 (1.7/1.7)
0.28 (0.24/0.33)
5.0 (5.2/4.7)
Yes
14% (9/63)
101 (52/49)
NR (66/59)*
1.5:1
NR (1.0/1.5)*
NR
NR (10.0/7.0)*
Mixed
cases
8% (4/52)
15
Bertleff et al.
NR, not reported; ASA, American Society of Anesthesiologists; lap, laparoscopic.
Numerical data are reported as mean values, unless otherwise indicated.
*Median values.
Table 3.
Summary Data of Outcome Measures
Author
Lau et al.12
13
Lau et al.
14
Siu et al.
Operative VAS† (Lap/
Time (Min) Open)
(Lap/Open)
Days After
Surgery to
Tolerate Oral
Diet (Lap/
Open)
Minor
Complications,
(Lap/Open), n
(%)
Major
Reoperation, Duration of In- Mortality
Complications (Lap/Open), Hospital Stay
(Lap/Open),
(Lap/Open), n n (%)
(d) (Lap/Open) n (%)
(%)
87 (113/57) NR (4/5)*
NR (4/4)*
2/4 (8/19)
2/1 (8/5)
0/1 (0/5)
NR (5/5)*
0/1 (0/5)
NR (96/35)* NR
NR
NR
NR
NR
NR
NR
47 (42/52)
4.9 (3.5/6.4) NR (4/5)*
Bertleff et al.15 NR (75/50)* (3.8/5.2)*
NR
7/14 (11/24)
3/8 (5/14)
5/1 (8/5)
NR (6/7)
1/3 (2/5)
NR
NR
NR
NR (6.5/8)*
2/4 (4/8)
n, absolute number; NR, not reported; lap, laparoscopic.
Numerical data are reported as mean values, unless otherwise indicated.
*Median values.
†
24 hours after surgery.
18
*
JSLS (2013)17:15–22
was no evidence of between-study heterogeneity (P⫽.945)
(Figure 2).
Operative Time
Mean duration of surgery was 62 minutes for the laparoscopic group and 53 minutes for the open group
(weighted mean difference 0.38, 95% CI 1.22–1.99, P⫽
.639). There was significant evidence of between-study heterogeneity (P⬍.001) (Figure 3).
Major Complications
Incidence of major complications was 6% in the laparoscopic group and 11% in the open surgery group (OR
0.47, 95% CI 0.14 –1.58, P⫽.225). The level of betweenstudy heterogeneity was low (P⫽.223) (Figure 4).
Reoperation
One percent of patients of the laparoscopic group and 8%
of patients of the open group underwent repeated surgery
(OR 2.02, 95% CI 0.33–12.36, P⫽.446). Between-study
heterogeneity was low (P⫽.151) (Figure 5).
DISCUSSION
The present meta-analysis does not support favorable
outcomes for minimally invasive treatment of PPU over its
open surgery counterpart, as reported in the currently
studied variables. Several limitations have to be taken into
account to evaluate these results. Our literature search
identified only 4 randomized trials. Three of these studies
were of fair methodologic quality, whereas the rest failed
to provide adequate data for statistical evaluation. The
Figure 2. Forest plot of mortality for laparoscopic and open repair of perforated ulcer.
Figure 3. Forest plot of operative time for laparoscopic and open repair of perforated ulcer.
JSLS (2013)17:15–22
19
Meta-analysis of Laparoscopic Versus Open Repair of Perforated Peptic Ulcer, Antoniou SA et al.
Figure 4. Forest plot of major complications for laparoscopic and open repair of perforated ulcer.
Figure 5. Forest plot of rate of reoperation for laparoscopic and open repair of perforated ulcer.
cumulative study population was low, and the strength of
the analysis was therefore limited.
The set of available data demonstrated homogeneous results for the outcome variables of mortality, complications,
and reoperation rate. All studies adhered to the intentionto-treat principle, thereby rendering the outcome for laparoscopic repair more reliable. Statistical significance could
not be reached for any of these variables, although odd
ratios were consistently in favor of the laparoscopic repair,
suggesting a potential type II statistical error. Similarly, the
laparoscopic approach resulted in a lower rate of minor
complications (10% vs 23%, data not shown). These results are consistent with a meta-analytical approach of
nonrandomized trials, which may reflect the standard
health care delivery setting.8
20
Early evidence from prospective studies demonstrated
longer operating times for laparoscopic repair of PPU.
Two randomized studies provided relevant data, which
were contradictory, however. Longer duration of surgery
was reported by Lau et al12 in their trial conducted between 1992 and 1994, whereas a significantly reduced
mean operating time was demonstrated in a more recent
study by Siu et al,14 which introduced substantial heterogeneity into the analysis. It has been suggested that acquaintance with the laparoscopic concept and laparoscopic suturing skills may result in a reduction in the
duration of surgery over time.8 A prospective analysis of
more than 100 cases of laparoscopic treatment of PPU
performed by surgical trainees has reported an acceptable
mean operating time of 65 minutes, although most the
JSLS (2013)17:15–22
study population consisted of low-risk patients.16 Peritoneal lavage is a factor of prolonged duration of surgery,
although this has now been replaced with high-volume
irrigation systems.8,17
Open repair of PPU remains the gold-standard treatment.
It is simple and effective and provides long-term regression of the disease when combined with eradication of H
pylori and recess of nonsteroidal anti-inflammatory medication.18,19 In these patients, mortality is frequently associated with underlying sepsis and inflammatory response,
which correlates with patient risk factors rather than surgical complications.20 Considering the mitigated inflammatory reaction after elective laparoscopic procedures or
laparoscopy for perforated appendicitis,21,22 a minimally
invasive approach to this emergency condition seems
appealing. Outcomes of 3 randomized trials on in-hospital
mortality were consistently favorable of the laparoscopic
approach, although statistical significance could not be
reached. The maximum relative weight was provided by
the study by Bertleff et al,15 which reported a higher
peritonitis index for the laparoscopic cohort. Although
there is evidence suggesting a decreased amount of operative stress in patients with peritonitis undergoing laparoscopic surgery, the true benefit of laparoscopic repair in
specific patients remains to be identified. Centers with
adequate experience and a community-based evaluation
of laparoscopic repair of PPU have recognized old age,
poor anesthesiologic status, and delayed presentation as
predictive factors for mortality.23–25 Comparative data on
laparoscopic and open repair of PPU in patients stratified
according to risk factors as ASA score and Boey score are
still unavailable.
Systemic and procedure-related complications are a matter of concern in septic patients undergoing upper abdominal surgery. The theoretic advantage of laparoscopic
treatment in terms of morbidity cannot be confirmed in the
present analysis. The largest available randomized trial,
which enrolled more than 100 patients, demonstrated a
lower morbidity rate for the laparoscopic approach (5% vs
14%), but the data were not statistically significant.14 This
finding correlates with a cumulative evaluation of prospective and retrospective studies in 2005.8 Because half of the
studies included in this analysis were published before 2000,
when laparoscopy experience was still limited, evaluation of
surgery-related morbidity in the modern era of laparoscopy
is a field for future investigation. Suture-site leakage is still an
issue, and concerns have been raised regarding laparoscopic
suturing of friable ulcer edges. An analysis of risk factors
found that 84% of patients with a history of symptoms lasting
longer than 9 hours developed leakage after laparoscopic
Figure 6. Absolute numbers of prospective studies on laparoscopic treatment of PPU published from 1990 to 2010.
repair.26 Nevertheless, high-quality comparative data of laparoscopic and open repair with regard to suture failure and
intra-abdominal abscess are not available.
Although the laparoscopic approach to PPU may offer
significant advantages over open repair with regard to
postoperative morbidity and mortality, the evidence of its
efficacy is still inconclusive. A population-based study
from China reported an increase in the frequency of laparoscopic repair of PPU.27 Interestingly, our literature review has retrieved a decreasing number of published
prospective trials from 1996 to date (Figure 6). In view of
the low incidence of ulcer perforation, interinstitutional
collaboration is strongly recommended to evaluate the
effect of laparoscopic repair of PPU on the setting of a
randomized study.
Current evidence does not clearly demonstrate the advantages of laparoscopic versus open repair of PPU for any of
the examined outcome measures. Growing interest in the
laparoscopic approach may encourage the design of additional randomized trials to analyze its efficacy compared
with the open approach.
References:
1. Nathanson LK, Easter WT, Cushieri A. Laparoscopic repair/
peritoneal toilet of perforated duodenal ulcer. Surg Endosc.
1990;4:232–233.
2. Mouret P, François Y, Vignal J, Barth X, Lombard-Platet R.
Laparoscopic treatment of perforated peptic ulcer. Br J Surg.
1990;77:1006.
3. Coghlan JG, Gilligan D, Humphries H, et al. Campylobacter
pylori and recurrence of duodenal ulcers—a 12-month follow-up
study. Lancet. 1987;2:1109 –1111.
JSLS (2013)17:15–22
21
Meta-analysis of Laparoscopic Versus Open Repair of Perforated Peptic Ulcer, Antoniou SA et al.
4. Bhogal RH, Athwal R, Durkin D, Deakin M, Cheruvu CN.
Comparison between open and laparoscopic repair of perforated peptic ulcer disease. World J Surg. 2008;32:2371–2374.
16. Siu WT, Chau CH, Law BK, Tang CN, Ha PY, Li MK. Routine
use of laparoscopic repair for perforated peptic ulcer. Br J Surg.
2004;91:481– 484.
5. Ates M, Sevil S, Bakircioglu E, Colak C. Laparoscopic repair
of peptic ulcer perforation without omental patch versus conventional open repair. J Laparoendosc Adv Surg Tech. 2007;17:
615– 619.
17. Lagoo S, McMahon RL, Kahikara M, Pappas TN, Eubanks S.
The sixth decision regarding perforated duodenal ulcer. JSLS.
2002;6:359 –368.
6. Lau WY, Leung KL, Zhu XL, Lam YH, Chung SC, Li AK.
Laparoscopic repair of perforated peptic ulcer. Br J Surg. 1995;
82:814 – 816.
18. Ng EK, Lam YH, Sung JJ, et al. Eradication of Helicobacter
pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: Randomized controlled trial. Ann Surg.
2000;231:153–158.
7. Bashinskaya B, Nahed BV, Redjal N, Kahle KT, Walcott BP.
Trends in peptic ulcer disease and the identification of Helicobacter pylori as a causative organism: Population-based estimates from the US nationwide inpatient sample. J Glob Infect
Dis. 2011;3:366 –370.
19. Tomtitchong P, Siribumrungwong B, Vilaichone RK, Kasetsuwan P, Matsukura N, Chaiyakunapruk N. Systematic review
and meta-analysis: Helicobacter pylori eradication therapy after
simple closure of perforated duodenal ulcer. Helicobacter. 2012;
17:148 –152.
8. Lunevicius R, Morkevicius M. Systematic review comparing
laparoscopic and open repair for perforated peptic ulcer. Br J
Surg. 2005;92:1195–1207.
20. Boey J, Choi SK, Poon A, Alagaratnam TT. Risk stratification
in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg. 1987;205:22–26.
9. Karantonis FF, Nikiteas N, Perrea D, et al. Evaluation of the
effects of laparotomy and laparoscopy on the immune system in
intra-abdominal sepsis–a review. J Invest Surg. 2008;21:330 –339.
21. Sammour T, Kahokehr A, Chan S, Booth RJ, Hill AG. The
humoral response after laparoscopic versus open colorectal surgery: A meta-analysis. J Surg Res. 2010;164:28 –37.
10. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of
reports of randomized clinical trials: Is blinding necessary? Control Clin Trials. 1996;17:1–12.
22. Schietroma M, Piccione F, Carlei F, et al. Peritonitis from
perforated appendicitis: stress response after laparoscopic or
open treatment. Am Surg. 2012;78:582–590.
11. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of
studies that evaluate healthcare interventions: Explanation and
elaboration. BMJ. 2009;339:b2700.
23. Druart ML, Van Hee R, Etienne J, et al. Laparoscopic repair
of perforated duodenal ulcer. A prospective multicenter clinical
trial. Surg Endosc. 1997;11:1017–1020.
12. Lau WY, Leung KL, Kwong KH, et al. A randomized study
comparing laparoscopic versus open repair of perforated peptic
ulcer using suture or sutureless technique. Ann Surg. 1996;224:
131–138.
13. Lau JY, Lo SY, Ng EK, Lee DW, Lam YH, Chung SC. A
randomized comparison of acute phase response and endotoxemia in patients with perforated peptic ulcers receiving laparoscopic or open patch repair. Am J Surg. 1998;175:325–327.
14. Siu WT, Leong HT, Law BK, et al. Laparoscopic repair for
perforated peptic ulcer: A randomized controlled trial. Ann Surg.
2002;235:313–319.
15. Bertleff MJ, Halm JA, Bemelman WA, et al. Randomized
clinical trial of laparoscopic versus open repair of the perforated peptic ulcer: the LAMA Trial. World J Surg. 2009;33:
1368 –1373.
22
24. Wong DC, Siu WT, Wong SK, Tai YP, Li MK. Routine laparoscopic single-stitch omental patch repair for perforated peptic
ulcer: Experience from 338 cases. Surg Endosc. 2009;23:457–
458.
25. Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi
H, Fujimori K. Community-based evaluation of laparoscopic
versus open simple closure of perforated peptic ulcers. World
J Surg. 2011;35:2485–2492.
26. Lunevicius R, Morkevicius M. Risk factors influencing the
early outcome results after laparoscopic repair of perforated
duodenal ulcer and their predictive value. Langenbecks Arch
Surg. 2005;390:413– 420.
27. Lam CM, Yuen AW, Chik B, Wai AC, Fan ST. Laparoscopic
surgery for common surgical emergencies: A population-based
study. Surg Endosc. 2005;19:774 –779.
JSLS (2013)17:15–22
SCIENTIFIC PAPER
Open versus Laparoscopic Hiatal Hernia Repair
Terrence M. Fullum, MD, Tolulope A. Oyetunji, MD, MPH, Gezzer Ortega, MD, MPH,
Daniel D. Tran, MD, Ian M. Woods, BS, Olusola Obayomi-Davies, BS, Orighomisan Pessu, BS,
Stephanie R. Downing, MD, Edward E. Cornwell, MD
ABSTRACT
INTRODUCTION
Background: The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair.
However, its adoption as the preferred surgical approach
and the risks associated with paraesophageal hiatal hernia
repair have not been reviewed in a large database.
Paraesophageal hiatal hernia (PHH) accounts for 5% of all
hiatal hernias and occurs with increasing incidence in elderly
patients.1– 4 Controversies exist regarding its management.5– 8
Historically, surgical repair has been advocated in all patients
with PHH (symptomatic patients and incidental diagnoses).
Elective PHH repair has been advocated in patients with
mild symptoms for 2 reasons: to prevent potentially lethal
complications, such as strangulation, incarceration, perforation, and volvulus, as detailed in the studies by Skinner and
Hill,9,10 and to avoid the significant operative morbidity and
mortality associated with emergent PHH repair.11–14 In recent
years, physicians proposing conservative and nonsurgical
management have scrutinized this dogma.
Method: The Nationwide Inpatient Sample dataset was
queried from 1998 to 2005 for patients who underwent
repair of a complicated (the entire stomach moves into the
chest cavity) versus uncomplicated (only the upper part of
the stomach protrudes into the chest) paraesophageal
hiatal hernia via the laparoscopic, open abdominal, or
open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities
while looking for independent risk factors for mortality.
Results: In total, 23,514 patients met the inclusion criteria.
By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs.
Length of stay was significantly reduced for all patients after
laparoscopic repair (P ⬍ .001). Age ⱖ60 years and nonwhite
ethnicity were associated with significantly higher odds of
death. Laparoscopic repair and obesity were associated with
lower odds of death in the uncomplicated group.
Conclusion: Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic
ethnicity increased the odds of death.
Key Words: Paraesophageal hiatal hernia repair, Preoperative risk factors, Laparoscopy.
Division of Minimally Invasive and Bariatric Surgery, Department of Surgery,
Howard University College of Medicine, Washington, DC, USA (Drs. Fullum, Tran).
Department of Surgery, Howard University College of Medicine, Washington, DC,
USA (Drs. Oyetunji, Ortega, Downing, Cornwell).
Howard University College of Medicine, Washington, DC, USA (Drs. Woods,
Obayomi-Davies, Pessu).
Address correspondence to: Terrence M. Fullum, MD, Howard University College
of Medicine, 2041 Georgia Avenue, NW, Washington, DC 20060. Telephone:
202-865-1286, Fax: 202-865-3063, E-mail: [email protected].
DOI: 10.4293/108680812X13517013316951
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
Proponents of nonsurgical management suggest that previous beliefs about the natural history and the worsening
progression of mildly symptomatic PHH are rare in modern
medicine, thus negating the need for elective surgery.15,16
Stylopoulos et al,17 using a complex decision analysis, concluded that watchful waiting is a better alternative to elective
surgery in mildly symptomatic patients. In addition, a plethora of common comorbid conditions in affected elderly patients caused many surgeons to view surgical intervention as
high risk in mildly symptomatic elderly patients.2,15,17,18 Additional controversy exists regarding the choice of surgical
approach.1,5,6 Before the advent of minimally invasive techniques, open surgeries via transabdominal and transthoracic
entry were the indicated management of PHH. Since its
introduction in 1992, laparoscopic PHH repair (LPHHR) has
emerged at the forefront of PHH treatment.19 A large dataset
of patients across the United States treated with different
approaches allows for evaluation of perioperative outcomes
and has adequate power to determine factors influencing
hospital outcome.16,20,21
We hypothesize that mortality is lower after laparoscopic
repair than after open repair. To test this hypothesis, the
Nationwide Inpatient Sample (NIS) was used to (1) determine whether there is a difference in mortality between
the 2 approaches and (2) identify risk factors that may be
associated with poor in-hospital outcomes after PHH repair.
JSLS (2013)17:23–29
23
Open versus Laparoscopic Hiatal Hernia Repair, Fullum TM et al.
METHODS
Table 1.
ICD-9 Codes Used for Patient Selection
Overview
The NIS is the largest all-payer inpatient care database that is
publicly available in the United States. It contains data from
5 to 8 million hospital stays from approximately 1000 hospitals sampled to approximate a 20% stratified sample of US
community hospitals. The NIS is drawn from states participating in the Healthcare Cost and Utilization Project, and
weights are provided to calculate national estimates.22 Researchers and policy makers use the NIS to identify, track,
and analyze national trends in health care use, access,
charges, quality, and outcomes. The large sample size of the
NIS enables analyses of rare conditions such as congenital
anomalies, uncommon treatments such as organ transplantation, and special patient populations such as the uninsured. Data available within the NIS include patient and
hospital demographics, payer information, treatment and
concomitant diagnoses, inpatient procedures, inpatient mortality, and length of stay.
Patient Selection
The NIS dataset was queried for patients who underwent
open or laparoscopic repair of a complicated or uncomplicated PHH between 1998 and 2005. Open repair included
both the transthoracic and transabdominal approaches. Patients were identified according to the relevant International
Classification of Diseases, Ninth Revision (ICD-9) diagnosis
and procedure codes (Table 1). ICD-9 codes 553.3 and
552.3 were used to identify patients with uncomplicated
PHH and complicated (ie, incarcerated, irreducible, strangulated, or obstructed) PHH, respectively. ICD-9 codes 53.70,
53.72, and 53.75 were used to identify patients who underwent open abdominal PHH repair, whereas ICD-9 codes
53.80 and 53.84 identified patients who underwent open
thoracic PHH repair. Patients who underwent LPHHR were
identified using ICD-9 codes 53.71, 53.83, and 54.21. Obese
and morbidly obese patients were identified with ICD-9
codes 278.0 and 278.01.
Code
Description
555.3
Diaphragmatic hernia: paraesophageal hiatal hernia
555.2
Diaphragmatic hernia with obstruction:
paraesophageal specified as incarcerated,
irreducible, strangulated, or causing obstruction
53.70
Repair of diaphragmatic hernia, abdominal
approach
53.72
Other and open repair of diaphragmatic hernia,
abdominal approach
53.75
Repair of diaphragmatic hernia, abdominal
approach, not otherwise specified
53.80
Repair of diaphragmatic hernia with thoracic
approach, not otherwise specified
53.84
Other and open repair of diaphragmatic hernia,
with thoracic approach
53.71
Laparoscopic repair of diaphragmatic hernia,
abdominal approach
52.21
Laparoscopy, peritoneoscopy
52.83
Laparoscopic repair of diaphragmatic hernia, with
thoracic approach
278.00
Obesity, unspecified
278.01
Morbid obesity
logistic regression models, adjusting for age, sex, race, obesity, Charlson score, surgical approach, and complication
status. A P value ⬍ .05 was considered statistically significant. The Charlson score is a comorbidity index that predicts
the 10-year mortality for a patient who may have any one or
a combination of 22 select comorbid conditions.
RESULTS
Statistical Analysis
A total of 23,514 patients met the inclusion criteria. Patient
demographics are shown in Table 1. In univariate analysis, mean (median) age was 56 (57) years. A majority of
the patients were women (64%) and white (62%). AfricanAmerican and Hispanic patients each represented approximately 4% of the patient population. Seventeen percent
of patients were obese.
Statistical analysis was performed with STATA 10.0 statistical
software (StataCorp, College Station, TX). Bivariate analysis
of categorical data was performed using the ␹2 test. Analysis
of continuous data was performed using the t test. Bivariate
analysis compared length of stay (LOS) and mortality by
surgical approach to treat complicated and uncomplicated
hernias. Multivariate analysis was performed using multiple
When we compared surgical approaches (Table 2) we
found that 55% of the repairs were performed via the open
abdominal approach, 35% by laparoscopy, and 10% by
the open thoracic approach. There was no significant
difference in odds of death between the open thoracic
and open abdominal approaches. In addition, Hispanic
ethnicity and age ⬎60 years (Figure 1) were associated
24
JSLS (2013)17:23–29
Table 2.
Patient Demographics
Overall Patient Demographics
Patient Demographics by Surgical Approach and Year
Variable
N
%
All patients
23,514
In-hospital mortality
393
1.67
Open
Abdominal
13,011
55.33
Laparoscopic
8281
35.22
Open thoracic
2222
9.45
15,119
64
Open Abdominal (%)
Laparoscopic (%)
Open Thoracic (%)
Approach
Gender
Female
Male
Age (y)
8668 (57.3)
5114 (34)
1307 (8.6)
4321 (51.7)
3124 (37.38)
912 (10.9)
56.15 (Mean)
57 (Median)
58
54
57
⬍60
16,796
71
8604
6604
1588
⬎60
6700
28
4394
1673
633
Ethnicity
White
14,575
62
7953 (54.5)
5254 (36.05)
1368 (9.39)
Black
942
4.04
578 ( 61.36)
271 (28.77)
93 (9.87)
Hispanic
Obesity
899
3.82
455 (50.61)
324 (36.04)
120 (13.35)
3891
16.55
2742 (70.47)
922 (23.70)
227 (5.83)
19,921
84.72
10258 (51.49)
7859 (39.45)
1804 (9.06)
137 (1.34)
45 (0.57)
22 (1.22)
3593
15.28
2753 (76.62)
422 (11.75)
418 (11.63)
158 (5.75)
16 (3.79)
15 (3.6)
5.99 (Mean)
4 (Median)
6.91
3.81
8.75
Hernia status
Uncomplicated
Mortality
Complicated
Mortality
LOS
with significantly increased odds of death (Table 3). Male
sex and obesity status did not influence odds of death.
Mortality rate in the uncomplicated group was 1.02%.
Fifty-one percent of uncomplicated hernias were repaired
by the open abdominal approach (P ⬍ .001). Mortality
with the laparoscopic approach (0.57%) was significantly
less (P ⬍ .001) in the uncomplicated group compared
with the open abdominal approach (1.34%) and the open
thoracic approach (1.22%). In the uncomplicated hernia
group, laparoscopic repair was associated with a 49%
reduction in odds of death compared with the open abdominal approach (odds ratio [OR], 0.51 [95% confidence
interval [CI], 0.34 – 0.75]; P ⫽ .001).
Complicated hernias were present in 15% of the patients.
The overall in-hospital mortality rate was 1.67%. Mortality
in the complicated group was 5.26%. Seventy-seven percent of complicated hernias were repaired using the open
abdominal approach (P ⬍ .001). On multivariate analysis,
complicated hernia status was associated with a 2-fold
increase in odds of death (OR, 2.02 [95% CI, 1.52–2.67];
P ⬍ .001) in the entire patient population (Figure 2). In
the complicated hernia group, laparoscopic repair was
associated with a 41% reduction in odds of death compared with open repair, but the reduction was not statistically significant (OR, 0.59 [95% CI, 0.30 –1.19]; P ⫽ .142).
African-American ethnicity and age ⬎80 years were associated with increased odds of death.
Compared with the open abdominal approach, LOS was
significantly reduced for all patients who had laparoscopic
repair and was increased for patients undergoing trans-
JSLS (2013)17:23–29
25
Open versus Laparoscopic Hiatal Hernia Repair, Fullum TM et al.
Figure 1. Mortality by age group: laparoscopic versus open, P ⫽ .000.
Table 3.
Risk Factors Associated with Poor Outcomes in Uncomplicated Versus Complicated Cases of PHH
Risk Factors
Uncomplicated
Complicated
Odds Ratio
P Value
(95% CI)
Odds Ratio
P Value
(95% CI)
Laparoscopic
0.509
.001
0.34–0.75
0.594
.142
0.29–1.19
Open thoracic
1.065
.816
0.62–1.83
0.966
.917
0.51–1.82
ⱖ40 to ⬍60
1.823
.212
0.71–4.68
0.816
.82
0.14–4.69
ⱖ60 to ⬍70
2.847
.042
1.04–7.82
2.78
.189
0.60–12.78
ⱖ70 to ⬍80
6.977
.000
2.79–17.37
4.07
.065
0.91–18.12
ⱖ80 to ⬍90
19.04
.000
7.57–47.88
11.477
.001
2.65–49.65
61.64
.000
22.37–169.84
14.999
.001
3.22–69.73
African American
1.77
.163
0.79–3.93
2.12
.048
1.00–4.46
Hispanic
2.65
.002
1.42–4.91
1.86
.104
0.88–3.93
0.899
.560
0.63–1.28
1.29
.183
0.89–1.87
0.52
.116
0.23–1.17
0.39
.367
0.05–2.99
Approach (reference open abdominal)
Age (y) (reference ⬍40)
⬎90
Race (reference white)
Sex (reference female)
Male
Obesity
thoracic repair (Table 4). Patients with complicated hernias remained in the hospital 3.8 days longer (P ⬍ .001)
than patients with uncomplicated hernias. Obesity and
age ⬍60 years were associated with shorter hospital stays.
Insured patients, male sex, and African-American and Hispanic ethnicities were associated with increased LOS.
26
DISCUSSION
Hiatal hernias occur partly because of gradual enlargement of the diaphragmatic hiatus. They are generally classified as sliding hiatal hernias (type I), which result from
the fixed location of the gastroesophageal junction (GEJ)
JSLS (2013)17:23–29
Figure 2. Multivariate analysis: likelihood of death for PHH repair, 1.0 ⫽ comparison.
above the hiatus, or as paraesophageal hiatal hernias
(type II), in which the fundus of the stomach has herniated through the crural defect but the GEJ remains in its
natural anatomic position. Mixed hiatal hernias (type III)
are a mixture of type I and type II, in which there is
migration of the GEJ into the chest and herniation of a
portion of the fundus. Short esophagus (type IV) is caused
by foreshortening as a result of esophagitis from gastroesophageal reflux. Type III-IV surgical correction of PHH
improves symptoms and averts potentially lethal complications associated with PHH. However, significant operative morbidity and mortality have been reported in PHH
repair.5,6,17 The analysis showed that surgical approach,
age ⬎60 years, complicated hernia status, and ethnicity
are independent risk factors for increased odds of inhospital mortality and increased LOS. Male sex and obesity did not affect the risk of in-hospital mortality.
repairs. Although there was a clear advantage in mortality
rates with LPHHR, it was not possible to identify specific
patient circumstances that might have affected mortality
given the nature of the collected data in this study. Observable differences (eg, comorbid conditions, geographical variables, complications) that could affect outcome
were adjusted using multivariate analysis. LPHHR was
found to significantly reduce the odds of death, by 48%.
This finding largely agrees with previous studies comparing the open and laparoscopic approaches. Once a hernia
became complicated, the overall mortality rate was lower
with the laparoscopic approach, but the mortality difference compared with the open repair group was not significant. Therefore, the mortality advantage of LPHHR was
lost once the hernia became complicated. This finding
supports the opinion that early laparoscopic intervention
in asymptomatic patients may be beneficial.
Surgical Approach
Age
PHH repair was most commonly performed via the open
abdominal approach. However, numerous studies have
demonstrated the safety, efficacy, and durability of
LPHHR, but its acceptance as the procedure of choice has
not been universal, and no randomized controlled trials
comparing the open versus laparoscopic approach exist.1,3,7,13,14,23–30 Proponents of the open approach argue
that LPHHR is associated with a high recurrence rate and
intraoperative and postoperative complications, and they
tout open PHH repair’s comparable, if not superior, results.31–33 Among the 389 patients with in-hospital mortality, 85% had undergone open repair compared with 15%
who had undergone laparoscopic repair. In complicated
hernia cases, 92% of patients who died had open hernia
On average, PHH was diagnosed in patients between ages
60 and 70 years.34 Advanced age was considered an increased operative risk because of the multiple comorbidities in the elderly population. In this study, 46% of patients
undergoing PHH repair were older than 60 years. On
multivariate analysis, patients aged 60 years or older had
a 3-fold increase in the odds of death. These odds increased exponentially every decade thereafter. In patients
aged 60 years and older, ⬍27% of repairs were performed
laparoscopically despite the demonstrated safety and efficacy of LPHHR in elderly patients.3,35 Furthermore, nonelective PHH repair has been identified as an independent
risk factor, with as high as a 7-fold increase in mortality
specifically in elderly patients.8,36 Given these findings, 2
JSLS (2013)17:23–29
27
Open versus Laparoscopic Hiatal Hernia Repair, Fullum TM et al.
issues require attention. First, a significant percentage of
the elderly patients who underwent open repairs were
predisposed to a higher morbidity and mortality. Second,
in light of a significant increase in mortality associated
with nonelective PHH repair, the benefit of “watchful
waiting” for the asymptomatic uncomplicated hernia versus early elective repair deserves a reassessment. In this
study, the overall mortality in patients older than 60 years
was 26%. This translated to a 48-fold increase in mortality
compared with that in individuals younger than 60 years.
We theorized that with a patient’s advancing age, a previously uncomplicated hernia will likely become complicated, thus requiring urgent or emergent repair. Therefore, “watchful waiting” may prove a costly gamble for
physician and patient alike, exchanging the lower risk of
an early elective laparoscopic repair for the potentially
time-dependent accumulating risk of significant morbidity
and mortality.
Complicated Hernia Status
and there was an associated significant half-day increase in
LOS. Although there is a general perception that obese individuals are at increased risk of adverse outcomes with operative intervention, once appropriate comorbidities are adjusted for, there is no difference in outcome.
Study Limitations
There are limitations to this study. Our assessment was
limited to in-hospital morbidity and mortality. Patients
who had adverse outcomes after discharge were not reported and thus could not be included in the study.
Because of the nature of the collected data, specific clinical aspects of patients that might have contributed to
poor outcomes were not able to be identified. Not all
symptomatic hernias were complicated, and not all complicated hernias were symptomatic. Finally, there was no
accounting for differences in patient management, the
complex nature of the repair, and socioeconomic variables.
PHHs found to be incarcerated, strangulated, or obstructed were classified as complicated hernias. These
hernias made up 15.4% of all identified cases. The mortality rate in this group was 5.3%. With advancing age, the
percentage of patients with complicated hernias increases,
reaching 51% in the category of patients aged 90 years and
older. Compared with uncomplicated hernias, complicated hernias resulted in a 2-fold increase in the odds of
in-hospital mortality and increased LOS by 3 days. In the
complicated hernia group, 88.3% of patients received
open paraesophageal hiatal hernia repair compared with
60.6% of patients in the uncomplicated group.
CONCLUSION
Ethnicity
1. Lal DR, Pellegrini CA, Oelschlager BK. Laparoscopic repair of
paraesophageal hernia. Surg Clin North Am. 2005;85:105–118, x.
It is unclear why African-American and Hispanic patients
had significantly increased odds of death compared with
white patients. The exact nature of the problem is beyond
the scope of this study. However, 29% of hernias in AfricanAmerican patients were repaired laparoscopically compared
with 36% in white and Hispanic patients. In addition, it did
not appear that African-American or Hispanic patients had
significant differences in mortality from complicated hernias.
Obesity and Sex
It was unclear why obesity had a protective role in patients
with PHH. Even though obese patients had a significantly
reduced LOS compared with nonobese patients, the reduction in mortality odds was not significant. In addition, male
sex did not appear to increase the risk of mortality in PHHR,
28
Surgical approach, age, complicated hernia status, and
ethnicity are independent risk factors for mortality in patients undergoing PHHR. Watchful waiting, particularly
for patients older than 60 years, may delay intervention
when the hernia is uncomplicated or asymptomatic. Once
the hernia becomes complicated, urgent surgical intervention subjects the patient to increased morbidity and mortality. It would be prudent to consider early elective
LPHHR to maximize safety and reduce hospital LOS.
References:
2. Kercher KW, Matthews BD, Ponsky JL, et al. Minimally
invasive management of paraesophageal herniation in the highrisk surgical patient. Am J Surg. 2001;182:510 –514.
3. Gangopadhyay N, Perrone JM, Soper NJ, et al. Outcomes of
laparoscopic paraesophageal hernia repair in elderly and highrisk patients. Surgery. 2006;140:491– 498.
4. Landreneau RJ, Johnson JA, Marshall JB, Hazelrigg SR, Boley
TM, Curtis JJ. Clinical spectrum of paraesophageal herniation.
Dig Dis Sci. 1992;37:537–544.
5. Draaisma WA, Gooszen HG, Tournoij E, Broeders IA. Controversies in paraesophageal hernia repair: a review of literature.
Surg Endosc. 2005;19:1300 –1308.
6. Davis SS Jr. Current controversies in paraesophageal hernia
repair. Surg Clin North Am. 2008;88:959 –978, vi.
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7. Ferri LE, Feldman LS, Stanbridge D, Mayrand S, Stein L,
Fried GM. Should laparoscopic paraesophageal hernia repair
be abandoned in favor of the open approach? Surg Endosc.
2005;19:4 – 8.
8. Hallissey MT, Ratliff DA, Temple JG. Paraoesophageal
hiatus hernia: surgery for all ages. Ann R Coll Surg Engl.
1992;74:23–25.
9. Skinner DB, Belsey RH. Surgical management of esophageal
reflux and hiatus hernia. Long-term results with 1,030 patients.
J Thorac Cardiovasc Surg. 1967;53:33–54.
10. Hill LD. Incarcerated paraesophageal hernia. A surgical
emergency. Am J Surg. 1973;126:286 –291.
11. Sihvo EI, Salo JA, Rasanen JV, Rantanen TK. Fatal complications of adult paraesophageal hernia: a population-based study.
J Thorac Cardiovasc Surg. 2009;137:419 – 424.
12. Chang CC, Tseng CL, Chang YC. A surgical emergency due
to an incarcerated paraesophageal hernia. Am J Emerg Med.
2009;27:134.e1– e3.
13. Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair
of giant paraesophageal hernia: 100 consecutive cases. Ann
Surg. 2000;232:608 – 618.
14. Schauer PR, Ikramuddin S, McLaughlin RH, et al. Comparison of laparoscopic versus open repair of paraesophageal hernia. Am J Surg. 1998;176:659 – 665.
22. HCUP NIS Database Documentation. Healthcare Cost and
Utilization Project (HCUP). February 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://
www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp.
Accessed August 12, 2010.
23. Andujar JJ, Papasavas PK, Birdas T, et al. Laparoscopic repair of
large paraesophageal hernia is associated with a low incidence of
recurrence and reoperation. Surg Endosc. 2004;18:444 – 447.
24. Edye MB, Canin-Endres J, Gattorno F, Salky BA. Durability of
laparoscopic repair of paraesophageal hernia. Ann Surg. 1998;
228:528 –535.
25. Nason KS, Luketich JD, Qureshi I, et al. Laparoscopic repair of
giant paraesophageal hernia results in long-term patient satisfaction
and a durable repair. J Gastrointest Surg. 2008;12:2066 –2075.
26. Willekes CL, Edoga JK, Frezza EE. Laparoscopic repair of
paraesophageal hernia. Ann Surg. 1997;225:31–38.
27. Parameswaran R, Ali A, Velmurugan S, Adjepong SE, Sigurdsson A. Laparoscopic repair of large paraesophageal hiatus hernia: quality of life and durability. Surg Endosc. 2006;20:1221–1224.
28. Mattar SG, Bowers SP, Galloway KD, Hunter JG, Smith CD.
Long-term outcome of laparoscopic repair of paraesophageal
hernia. Surg Endosc. 2002;16:745–749.
29. Bawahab M, Mitchell P, Church N, Debru E. Management of
acute paraesophageal hernia. Surg Endosc. 2009;23:255–259.
15. Treacy PJ, Jamieson GG. An approach to the management of
para-oesophageal hiatus hernias. Aust N Z J Surg. 1987;57:813–
817.
30. Pierre AF, Luketich JD, Fernando HC, et al. Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive
patients. Ann Thorac Surg. 2002;74:1909 –1915.
16. Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach. Presentation and results of operation. J Thorac
Cardiovasc Surg. 1993;105:253–258.
31. Low DE, Unger T. Open repair of paraesophageal hernia:
reassessment of subjective and objective outcomes. Ann Thorac
Surg. 2005;80:287–294.
17. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal
hernias: operation or observation? Ann Surg. 2002;236:492–
500.
32. Trus TL, Bax T, Richardson WS, et al. Complications of
laparoscopic paraesophageal hernia repair. J Gastrointest Surg.
1997;1:221–227.
18. Larusson HJ, Zingg U, Hahnloser D, Delport K, Seifert B,
Oertli D. Predictive factors for morbidity and mortality in patients
undergoing laparoscopic paraesophageal hernia repair: age,
ASA score and operation type influence morbidity. World J Surg.
2009;33:980 –985.
33. Dahlberg PS, Deschamps C, Miller DL, Allen MS, Nichols FC,
Pairolero PC. Laparoscopic repair of large paraesophageal hiatal
hernia. Ann Thorac Surg. 2001;72:1125–1129.
19. Cuschieri A, Shimi S, Nathanson LK. Laparoscopic reduction,
crural repair, and fundoplication of large hiatal hernia. Am J
Surg. 1992;163:425– 430.
20. Ellis FH Jr, Crozier RE, Shea JA. Paraesophageal hiatus hernia. Arch Surg. 1986;121:416 – 420.
21. Pearson FG, Cooper JD, Ilves R, Todd TR, Jamieson WR.
Massive hiatal hernia with incarceration: a report of 53 cases.
Ann Thorac Surg. 1983;35:45–51.
34. Williamson WA, Ellis FH Jr, Streitz JM Jr, Shahian DM. Paraesophageal hiatal hernia: is an antireflux procedure necessary?
Ann Thorac Surg. 1993;56:447– 451.
35. Coelho JC, Campos AC, Costa MA, Soares RV, Faucz RA.
Complications of laparoscopic fundoplication in the elderly.
Surg Laparosc Endosc Percutan Tech. 2003;13:6 –10.
36. Poulose BK, Gosen C, Marks JM, et al. Inpatient mortality
analysis of paraesophageal hernia repair in octogenarians. J
Gastrointest Surg. 2008;12:1888 –1892.
JSLS (2013)17:23–29
29
SCIENTIFIC PAPER
Costs and Clinical Outcomes of Conventional Single
Port and Micro-laparoscopic Cholecystectomy
Edward Chekan, MD, Matthew Moore, MHA, Tina D. Hunter, PhD, Candace Gunnarsson, EdD
ABSTRACT
Background and Objective: This study compares hospital costs and clinical outcomes for conventional laparoscopic, single-port, and mini-laparoscopic cholecystectomy from US hospitals.
Methods: Eligible patients were aged ⱖ18 years and
undergoing laparoscopic cholecystectomy with records in
the Premier Hospital Database from 2009 through the
second quarter of 2010. Patients were categorized into 3
groups— conventional laparoscopic, single port, or minilaparoscopic— based on the International Classification
of Diseases, Ninth Revision and Current Procedural Terminology codes and hospital charge descriptions for surgical tools used. A procedure was considered mini-laparoscopic if no single-port surgery products were identified
in the charge master descriptions and the patient record
showed that at least 1 product measuring ⬍5 mm was
used, not more than 1 product measuring ⬎5 mm was
used, and the measurements of the other products identified equaled 5 mm. Summary statistics were generated
for all 3 groups. Multivariable analyses were performed on
hospital costs and clinical outcomes. Models were adjusted for demographics, patient severity, comorbid conditions, and hospital characteristics.
Results: In the outpatient setting, for single-port surgery,
hospital costs were approximately $834 more than those
for mini-laparoscopic surgery and $964 more than those
for conventional laparoscopic surgery (P ⬍ .0001). AdEthicon Endo-Surgery, Inc., Cincinnati, OH, USA (Dr. Chekan, Moore).
S2 Statistical Solutions, Inc., Cincinnati, OH, USA (Drs. Hunter, Gunnarsson).
Dr. Chekan is an employee of Ethicon Endo-Surgery, Inc. Mr. Moore was an
employee of Ethicon Endo-Surgery at the time of the research. Dr. Gunnarsson is
President and Dr. Hunter is an employee of S2 Statistical Solutions, Inc. which is a
paid consultant to Ethicon Endo-Surgery, Inc.
This research was funded by Ethicon Endo-Surgery, Inc. which is a manufacturer of
minimally invasive surgical equipment and manufactures and sells products that
are used in the procedures analyzed in this study.
Address correspondence to: Candace L. Gunnarsson, EdD, S2 Statistical Solutions,
11176 Main St, Cincinnati, OH 45241, USA. Telephone: (513) 247-0561, Fax: (866)
247-0524, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317635
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
30
verse events were significantly higher (P ⬍ .0001) for
single-port surgery compared with mini-laparoscopic surgery (95% confidence interval for odds ratio, 1.38 –2.68)
and single-port surgery versus conventional surgery (95%
confidence interval for odds ratio, 1.37–2.35). Mini-laparoscopic surgery hospital costs were significantly (P ⬍
.0001) lower than the costs for conventional surgery by
$211, and there were no significant differences in adverse
events.
Conclusions: These findings should inform practice patterns, treatment guidelines, and payor policy in managing
cholecystectomy patients.
Key Words: Abdominal, Cholecystectomy, Laparoscopic.
INTRODUCTION
Cholecystectomy is one of the most frequently performed
abdominal surgery procedures in the United States, with
⬎750,000 cholecystectomies performed laparoscopically
each year.1,2 Laparoscopic cholecystectomy evolved from
surgical attempts to improve patient outcomes, including
postoperative morbidity, cosmetic results, hospital length
of stay, and duration of convalescence.3–5 Continued attempts to improve these outcomes have led to the development of alternatives to conventional laparoscopic cholecystectomy (CLC), including micro- or mini-laparoscopic
cholecystectomy (MLC) and, more recently, single-port cholecystectomy surgery (SPS).6 However, understanding the
effect of these emerging techniques on clinical and economic outcomes is critical to guiding practice patterns, clinical guidelines, and payor decisions.
SPS is a technical departure from CLC in that it uses a
single, transabdominal incision rather than multiple incisions for trocar insertion.7,8 This procedure is typically
performed with several trocars spaced closely together or
with a multi-instrument port.7–9
MLC is performed by use of percutaneous instrumentation
or trocars that are significantly smaller in size than those
used in conventional laparoscopic procedures. The procedure was primarily developed to reduce incisional pain.
JSLS (2013)17:30 – 45
Studies have reported improvements in cosmetic outcome, pulmonary function, and overall satisfaction.10 –14
One small study did report that up to 38% of patients (5 of
13) required conversion from MLC to CLC.10
The purpose of this article is a cost comparison of cholecystectomy approaches including conventional, singleport, and mini-laparoscopic surgeries. We performed our
analysis using the Premier Hospital Database as a source
of cost from the hospital perspective.
METHODS
A protocol describing the analysis objectives, criteria for
patient selection, data elements of interest, and statistical
methods was submitted to the New England Institutional
Review Board, and exemption was obtained (No. 11–240).
Data Source
The Premier Hospital Database, which contains clinical
and utilization information on patients receiving care in
442 hospitals and ambulatory surgery centers across the
United States during the period of interest, was used.
Specifically, this database contains complete patient billing, hospital cost, and coding histories from more than 25
million inpatient discharges and 175 million hospital outpatient visits.15 Data for 2009 through the second quarter
of 2010 were used and anonymized with regard to patient
identifiers.
Patients and Procedures
Eligible patients were those aged ⱖ18 years undergoing
an outpatient laparoscopic cholecystectomy. International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes for identifying the
laparoscopic cholecystectomy, diagnosis codes for identifying patient comorbid conditions, and all adverse
events are listed in Appendices A, B, and C, respectively.
Eligible patients with procedure codes identifying a laparoscopic cholecystectomy were then subdivided into 3
mutually exclusive groups: CLC, SPS, or MLC. Hospital
charge descriptions for the surgical tools used were text
mined to identify SPS procedures. The distinction between MLC and CLC was based on the size of the surgical
instrument. MLC was defined by records of no SPS products identified in the charge master descriptions, record of
at least 1 product ⬍5 mm used; not more than 1 product
⬎5 mm used, and any other products identified equaled 5
mm. Procedures that were not identified as SPS or MLC
were considered CLC procedures.
Statistical Analyses
Initial counts, percentages, means, and standard deviations for demographics, comorbid conditions, hospital
characteristics, safety, and cost outcomes were summarized for CLC, SPS, and MLC by use of descriptive statistics
for patients in the outpatient setting. Safety outcomes of
interest were selected from adverse events occurring during or up to 30 days after surgery. Cost outcomes were
total hospital costs per patient, both fixed and variable.
Because the sample size for the SPS group was very
limited in the inpatient setting, univariate and multivariable analyses were performed on outpatient procedures
only. Furthermore, by examining patients in the outpatient setting only, it was possible to analyze a more homogeneous patient population.
Multivariable logistic regression analyses were run for
binary outcomes, such as adverse events. Ordinary least
squares regressions were used for the continuous outcome of hospital costs. For all models, the following
explanatory variables were included: age, sex, race, marital status, insurance type, comorbid conditions (e.g., diabetes), census region of the hospital, rural versus urban
hospitals, teaching versus nonteaching hospitals, and
number of hospital beds. By use of these explanatory
variables, multivariable models were estimated to isolate
the effects of SPS versus CLC, SPS versus MLC, and MLC
versus CLC on hospital costs. To eliminate cost outliers,
both the upper 0.5% and lower 0.5% of costs were set to
missing values. In addition to the trimming of outliers, a
natural-log transformation of the costs was used as the
dependent variable in multivariate models. Smearing estimates were then used to avoid the introduction of bias
when we converted back to the untransformed dollar
scale.16 All analyses were performed with SAS software,
version 9.2 (SAS Institute, Cary, NC, USA).
RESULTS
There were a total of 193,014 eligible laparoscopic cholecystectomy procedures identified in the database from the
period from the first quarter of 2009 through the second
quarter of 2010. A patient attrition diagram is shown in
Figure 1. The majority of all procedures (59%, 116,823 of
196,628) were performed in the outpatient setting, with
98% (114,356) of these patients undergoing a CLC. For the
remaining 2% of outpatient procedures (2,467), 527 SPS
procedures and 1,940 MLC procedures were identified. As
summarized in Table 1, characteristics of eligible outpatient procedures show that there were substantially more
JSLS (2013)17:30 – 45
31
Costs and Clinical Outcomes of Conventional Single Port and Micro Laparoscopic Cholecystectomy, Chekan E et al.
Table 1.
Patient Characteristics
SPS
(n ⫽ 527)
(%)
MLC
(n ⫽ 1,940)
(%)
CLC
(n ⫽ 114,356)
(%)
18–40 yr
282 (53.5)
751 (38.7)
43,452 (38.0)
41–50 yr
113 (21.4)
411 (21.2)
23,364 (20.4)
51–60 yr
76 (14.4)
361 (18.6)
21,703 (19.0)
61–70 yr
35 (6.6)
258 (13.3)
15,413 (13.5)
71–80 yr
17 (3.2)
124 (6.4)
8,068 (7.1)
⬎80 yr
4 (0.8)
35 (1.8)
2,356 (2.1)
Female
445 (84.4)
1,443 (74.4)
86,757 (75.9)
Male
82 (15.6)
497 (25.6)
27,599 (24.1)
108 (20.5)
582 (30.0)
35,410 (31.0)
Age
Gender
Insurance
Government
Managed care
331 (62.8)
1,090 (56.2)
56,228 (49.2)
Other
88 (16.7)
268 (13.8)
22,718 (19.9)
418 (79.3)
1,318 (67.9)
81,096 (70.9)
Race
White
Figure 1. Patient attrition is shown from all data from the first
quarter (Q1) of 2009 to the second quarter (Q2) of 2010 to the
subset used in our analysis. The analysis included patients with
International Classification of Diseases, Ninth Revision (ICD-9)
code 51.23 or Current Procedural Terminology (CPT) code
47562, 47563, or 47564 whose gender was known, who were
aged ⱖ18 years, and who underwent outpatient visits.
women than men, with rates for both dropping off after
age 50 years. Regarding insurance, more patients had
managed care than government or other sources of insurance. In the outpatient setting, the 3 procedure groups
(SPS, MLC, and CLC) appear to be very well balanced
overall in terms of patient demographics.
The distribution of patient comorbidities is shown in
Table 2 and suggests a lower percentage of comorbidities
overall in the SPS population, with the rates of many of the
32
African American
22 (4.2)
109 (5.6)
8,358 (7.3)
Hispanic
27 (5.1)
172 (8.9)
7,509 (6.6)
Other
60 (11.4)
341 (17.6)
17,307 (15.1)
Invalid code
0 (0.0)
0 (0.0)
86 (0.1)
conditions as low as half of the rates in the other cohorts.
Hypertension was the most common comorbid condition
across all 3 groups.
Unadjusted Analysis
The cholecystectomies studied were performed in 428
hospitals. Most procedures, as well as most patients,
derived from urban, nonteaching, moderate- to largesized hospitals in the South.15 As noted earlier for the
overall patient population, hospital characteristics were
well balanced across all 3 surgical cohorts (CLC, MLC,
and SPS).
All adverse events are reported in Table 3. Events are
subdivided into 5 categories: procedure related, systemic, other events, death, and bleeding. The most
common complications were in the category of other
events and included abdominal rigidity/tenderness, digestive system complications, gastroparesis paralytic ileus, nausea and vomiting, operative complications, and
JSLS (2013)17:30 – 45
Table 2.
Comorbid Conditions
SPS (n ⫽ 527) (%)
MLC (n ⫽ 1,940) (%)
CLC (n ⫽ 114,356) (%)
Cardiomyopathy
2 (0.4)
15 (0.8)
778 (0.7)
Cerebrovascular accident
1 (0.2)
11 (0.6)
548 (0.5)
Chronic obstructive pulmonary disease
14 (2.7)
73 (3.8)
4,232 (3.7)
Diabetes
23 (4.4)
170 (8.8)
9,904 (8.7)
Ischemic heart disease, including myocardial infarction
17 (3.2)
131 (6.8)
7,108 (6.2)
Hypertensive heart disease without heart failure
2 (0.4)
8 (0.4)
566 (0.5)
Heart failure
8 (1.5)
40 (2.1)
2,145 (1.9)
Hypertension
86 (16.3)
414 (21.3)
24,664 (21.6)
Chronic liver disease/disorders
14 (2.7)
75 (3.9)
6,425 (5.6)
Transient ischemic attack
1 (0.2)
16 (0.8)
754 (0.7)
Table 3.
Adverse Events
SPS (n ⫽ 527) (%)
MLC (n ⫽ 1,940) (%)
CLC (n ⫽ 114,356) (%)
Bile duct fistula
0 (0.0)
0 (0.0)
7 (0.0)
Bile duct obstruction
2 (0.4)
2 (0.1)
195 (0.2)
Bile duct perforation
0 (0.0)
0 (0.0)
6 (0.0)
Cerebrovascular accident
0 (0.0)
1 (0.1)
43 (0.0)
Acute myocardial infarction
0 (0.0)
2 (0.1)
37 (0.0)
Procedure related
Systemic adverse events
Transient ischemic attack
0 (0.0)
2 (0.1)
46 (0.0)
Other embolism
0 (0.0)
3 (0.2)
120 (0.1)
Pneumothorax
0 (0.0)
0 (0.0)
16 (0.0)
Pulmonary embolism
1 (0.2)
3 (0.2)
95 (0.1)
Abdominal rigidity/tenderness
0 (0.0)
0 (0.0)
114 (0.1)
Digestive system complications
8 (1.5)
15 (0.8)
735 (0.6)
Gastroparesis paralytic ileus
4 (0.8)
7 (0.4)
438 (0.4)
Other adverse events
Nausea and vomiting
45 (8.5)
86 (4.4)
4,874 (4.3)
Operative complication
19 (3.6)
30 (1.6)
2,006 (1.8)
Peritonitis (not specified)
1 (0.2)
3 (0.2)
103 (0.1)
Death during procedure
0 (0.0)
0 (0.0)
2 (0.0)
Death after procedure
0 (0.0)
2 (0.1)
35 (0.0)
0 (0.0)
0 (0.0)
9 (0.0)
Death
Hemorrhage/bleeding
Minor bleeding
Major bleeding
Any one or more adverse event
0 (0.0)
0 (0.0)
20 (0.0)
62 (11.8)
123 (6.3)
7,307 (6.4)
JSLS (2013)17:30 – 45
33
Costs and Clinical Outcomes of Conventional Single Port and Micro Laparoscopic Cholecystectomy, Chekan E et al.
peritonitis. The overall adverse event rate was higher
for SPS (12%) than for MLC (6%) and CLC (6%), with
most of the events in all 3 groups falling into the “other
events” category. The procedure-related systemic
events, death and bleeding, were very infrequent
(⬍0.5%) for all 3 groups.
Table 4 shows the unadjusted means and medians for
hospital costs, as well as median surgery time, for
each group. In the outpatient setting, CLC (median,
$3,600.37) costs slightly more than MLC (median,
$3,357.01) but less than SPS (median, $4,367.93). It is
essential to adjust for a number of potential confounders in multivariable regression analyses, including patient demographics, comorbid conditions, and hospital
characteristics.
Adjusted Analysis
The results of adjusted analyses of costs and complication
rates are shown in Table 5. After we adjusted for the
aforementioned variables, adjusted mean hospital costs
remained significantly higher (P ⬍ .0001) for SPS versus
MLC ($4,680.40 vs $3,846.19) and SPS versus CLC
($5,313.96 vs $4,350.29). When we compared MLC versus
CLC, cost differences were lower but still significant (P ⬍
.0001), with MLC at $4,137.23 versus CLC at $4,349.06.
Results of the multivariable logistic regressions for the
likelihood of patients having an adverse event showed
significant (P ⬍ .0001) odds ratios of 1.92 (95% confidence
interval, 1.38 –2.68) for SPS compared with MLC and 1.80
(95% confidence interval, 1.37–2.35) for SPS compared
with CLC. However, when MLC was compared with CLC,
the difference was not significant.
DISCUSSION
This retrospective analysis of a large, nationally representative database of hospitals and procedures found that
patients undergoing SPS had higher adverse event rates
than those undergoing MLC or CLC. The analysis also
showed that SPS was associated with higher adjusted
hospital outpatient costs than CLC but that MLC, when
performed in this setting, was the least expensive. These
findings are somewhat consistent with a recent review of
SPS, which also raised concerns about the safety of the
procedure, and a recent meta-analysis of primarily MLC
procedures, which found similar rates of adverse events
compared with patients undergoing CLC.17,18
Clinical Implications
Innovations in the surgical approach to performing cholecystectomy represent an important potential pathway
to improving patient outcomes. The development and
diffusion of laparoscopic cholecystectomy to the United
States that began more than 20 years ago heralded a
reduction in postoperative mortality rates and days of
convalescence for patients who would have otherwise
been treated with open cholecystectomy.2 This pattern
of innovation continues with both SPS and MLC. However, continued improvements in patient outcomes can
only be ensured with careful attention to the comparative effectiveness of these procedures relative to CLC,
which constitutes most cholecystectomies currently
performed in developed countries.19
Adverse event rates in patients undergoing cholecystectomy
in outpatient hospital centers were highest in patients treated
with SPS compared with MLC and CLC and were comparable
between patients treated with MLC and those treated with
CLC. This difference appears to be driven by higher rates of
bile duct obstruction, digestive system complications, gastroparesis, paralytic ileus, postoperative nausea and vomiting,
and operative complications in the SPS population. The
incidence of serious adverse events, including bile duct injury, thromboembolic events (including stroke and myocardial infarction), and hemorrhage, was low across all proce-
Table 4.
Unadjusted Utilization and Cost Outcomes
SPS (n ⫽ 527)
MLC (n ⫽ 1,940)
CLC (n ⫽ 114,356)
Surgery time (median, h)
1.60
1.26
1.35
Anesthesia time (median, h)
1.57
1.50
1.47
No. of readmissions (30 days after surgery) (%)
20 (3.8)
71 (3.7)
3,200 (2.8)
Median
4,367.93
3,357.01
3,600.37
Mean
4,573.74
3,814.35
3,964.67
SD
1,664.17
1,992.26
1,967.81
Total hospital costs ($)
34
JSLS (2013)17:30 – 45
Table 5.
Multivariable Cost and Adverse Event Findingsa
LSb Mean
95% CIb for LS Mean
SPS
$4,680.40
$4,480.96–$4,888.73
MLC
$3,846.19
$3,722.38–$3,974.11
ORb
95% CI for OR
P Value
SPS/MLC outpatients (n ⫽ 2,535)
Total hospital costs ($)
⬍ .0001
Adverse events (any adverse event/none)
SPS vs MLC
1.92
1.38–2.68
.0001
SPS/CLC outpatients (n ⫽ 114,883)
Total hospital costs ($)
SPS
$5,313.96
$5,119.09–$5,516.25
CLC
$4,350.29
$4,276.75–$4,425.09
⬍ .0001
Adverse events (any adverse event/none)
SPS vs CLC
1.80
1.37–2.35
⬍ .0001
MLC/CLC outpatients (n ⫽ 116,296)
Total hospital costs ($)
MLC
$4,137.23
$4,037.97–$4,238.93
CLC
$4,349.06
$4,275.54–$4,423.85
⬍ .0001
Adverse events (any adverse event/none)
MLC vs CLC
1.01
0.84–1.21
.9333
a
All models are adjusted for patient demographics, comorbid conditions, patient severity, and hospital characteristics.
CI⫽confidence interval; LS⫽least square; OR⫽odds ratio.
b
dures and did not appear to be substantially different in
patients undergoing SPS.
Economic Implications
Adjusted hospital outpatient costs were highest in patients
undergoing SPS: SPS cost 18% more than MLC and 18%
more than CLC, with a difference of $834 and $964, respectively (Table 5). The analyses also showed that MLC
was associated with the lowest hospital costs. It is likely
that the differences in adverse event rates detailed earlier
contributed to the cost differences.
Because otherwise healthy patients with reliable home
support can leave the hospital within 6 hours of undergoing cholecystectomy, outpatient models of cholecystectomy are increasingly used.20 The sources of variation in
costs of cholecystectomy procedures performed in an
outpatient setting should be explored further in future
studies, but these findings of statistically significant differences between the cost of SPS and the cost of MLC or CLC
may have important implications with regard to the cost of
the procedure to the hospital or outpatient facility. With
approximately 750,000 laparoscopic cholecystectomies
performed in the United States each year, any differences
in procedure-related costs or savings could be significant
and realizable.1,2
Limitations
This analysis was limited by the lack of more detailed
information about patients and procedures. For instance,
it would have been of interest to examine the influence of
additional patient characteristics, such as weight or body
mass index, and more procedure-related details. In the
future, this may be possible as clinically rich datasets
become available from greater use of electronic medical
records in hospital settings, thereby facilitating analyses in
these directions.
The analyses of adverse event rates and the specific types
of complications constituting these rates in patients undergoing SPS were also limited by a small sample size,
particularly compared with the number of patients in the
database who underwent MLC or CLC. Surgeon experience is a well-established predictor of the overall inci-
JSLS (2013)17:30 – 45
35
Costs and Clinical Outcomes of Conventional Single Port and Micro Laparoscopic Cholecystectomy, Chekan E et al.
dence of laparoscopic complications, and we were unable
to adjust for this important variable.21,22 The available data
will likely become more robust over time as procedure
volume increases.
Even without access to the additional clinical detail available in electronic medical records, the Premier Hospital
Database provides a strong basis for this analysis, given
the very large numbers of patients and procedures that it
provides, as well as the nationwide scope it represents.15
Thus the cost of each procedure was based on costs
across the Premier network. This analysis found MLC to
have a statistically lower cost to the hospital in comparison with CLC. The reasons for these differences were not
ascertained, and further study to understand these differences would be of interest.
CONCLUSION
The analysis of a large, nationally representative hospital
claims database provides evidence that, in the outpatient
setting, SPS costs approximately 18% more than MLC and
CLC. Mini-laparoscopic surgery costs approximately 5%
less than traditional laparoscopy. Although additional
studies may be useful, these findings could help shape
practice patterns, treatment guidelines, and payor policy
in the management of patients requiring cholecystectomy.
References:
1. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary
complications after laparoscopic cholecystectomy detected by
ERCP: experience at a large tertiary referral center. Gastrointest
Endosc. 2007;65:247–252.
2. Vollmer CM Jr, Callery MP. Biliary injury following laparoscopic cholecystectomy: why still a problem? Gastroenterology.
2007;133:1039 –1041.
3. Schirmer BD, Edge SB, Dix J, Hyser MJ, Hanks JB, Jones RS.
Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg. 1991;213:665– 676; discussion
677.
7. Hodgett SE, Hernandez JM, Morton CA, Ross SB, Albrink M,
Rosemurgy AS. Laparoendoscopic single site (LESS) cholecystectomy. J Gastrointest Surg. 2009;13:188 –192.
8. Philipp SR, Miedema BW, Thaler K. Single-incision laparoscopic cholecystectomy using conventional instruments: early
experience in comparison with the gold standard. J Am Coll
Surg. 2009;209:632– 637.
9. Ponsky TA. Single port laparoscopic cholecystectomy in adults
and children: tools and techniques. J Am Coll Surg. 2009;209:e1–e6.
10. Bisgaard T, Klarskov B, Trap R, Kehlet H, Rosenberg J. Pain
after microlaparoscopic cholecystectomy. A randomized doubleblind controlled study. Surg Endosc. 2000;14:340 –344.
11. Bisgaard T, Klarskov B, Trap R, Kehlet H, Rosenberg J.
Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial. Surg Endosc.
2002;16:458 – 464.
12. Hosono S, Osaka H. Minilaparoscopic versus conventional
laparoscopic cholecystectomy: a meta-analysis of randomized
controlled trials. J Laparoendosc Adv Surg Tech A. 2007;17:191–
199.
13. Novitsky YW, Kercher KW, Czerniach DR, et al. Advantages
of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial. Arch Surg. 2005;
140:1178 –1183.
14. Schwenk W, Neudecker J, Mall J, Bohm B, Muller JM. Prospective randomized blinded trial of pulmonary function, pain,
and cosmetic results after laparoscopic vs. microlaparoscopic
cholecystectomy. Surg Endosc. 2000;14:345–348.
15. Premier Research Services—Premier I. Available at: http://
www.premier-inc.com/prs. Accessed September 3, 2011.
16. Duan N. Smearing estimate: a nonparametric retransformation method. J Am Stat Assoc. 1983;78:605– 610.
17. Allemann P, Schafer M, Demartines N. Critical appraisal of
single port access cholecystectomy. Br J Surg. 2010;97:1476 –1480.
18. Thakur V, Schlachta CM, Jayaraman S. Minilaparoscopic versus conventional laparoscopic cholecystectomy a systematic review and meta-analysis. Ann Surg. 2011;253:244 –258.
4. Wiesen SM, Unger SW, Barkin JS, Edelman DS, Scott JS,
Unger HM. Laparoscopic cholecystectomy: the procedure of
choice for acute cholecystitis. Am J Gastroenterol. 1993;88:334 –
337.
19. Visser BC, Parks RW, Garden OJ. Open cholecystectomy in
the laparoendoscopic era. Am J Surg. 2008;195:108 –114.
5. Wilson RG, Macintyre IM, Nixon SJ, Saunders JH, Varma JS,
King PM. Laparoscopic cholecystectomy as a safe and effective
treatment for severe acute cholecystitis. BMJ. 1992;305:394 –396.
21. Csikesz NG, Singla A, Murphy MM, Tseng JF, Shah SA.
Surgeon volume metrics in laparoscopic cholecystectomy. Dig
Dis Sci. 2010;55:2398 –2405.
6. McCormack D, Saldinger P, Cocieru A, House S, Zuccala K.
Micro-laparoscopic cholecystectomy: an alternative to singleport surgery. J Gastrointest Surg. 2011;15:758 –761.
22. Moore MJ, Bennett CL. The learning curve for laparoscopic
cholecystectomy. The Southern Surgeons Club. Am J Surg. 1995;
170:55–59.
36
20. Curet MJ, Contreras M, Weber DM, Albrecht R. Laparoscopic
cholecystectomy. Surg Endosc. 2002;16:453– 457.
JSLS (2013)17:30 – 45
Appendix A.
Procedure Codes for Laparoscopic Cholecystectomy
Description
ICD-9a code
51.23
Laparoscopic cholecystectomy
51.24
Laparoscopic partial cholecystectomy
CPTa code
47562
Laparoscopic cholecystectomy
47563
Laparoscopic cholecystectomy with cholangiography
47564
Laparoscopic cholecystectomy with exploration of common duct
a
CPT⫽Current Procedural Terminology; ICD-9⫽International Classification of Diseases, Ninth Revision.
Appendix B.
Diagnosis Codes for Comorbid Conditions
Event
Transient ischemic attack
Cerebrovascular accident
Diabetes
ICD-9a Code
Description
435.8
Other specified transient cerebral ischemia
435.9
Unspecified transient cerebral ischemia
430
Subarachnoid hemorrhage
431
Intracerebral hemorrhage
432
Nontraumatic extradural hemorrhage
432.1
Subdural hemorrhage
432.9
Unspecified intracranial hemorrhage
433.01
Occlusion and stenosis, basilar artery, with cerebral infarction
433.11
Occlusion and stenosis, carotid artery, with cerebral infarction
433.21
Occlusion and stenosis, vertebral artery, with cerebral infarction
433.31
Occlusion and stenosis, multiple and bilateral precerebral arteries, with
cerebral infarction
433.81
Occlusion and stenosis, other specified precerebral artery, with cerebral
infarction
433.91
Occlusion and stenosis, unspecified precerebral artery, with cerebral infarction
434.01
Cerebral thrombosis, with cerebral infarction
434.11
Cerebral embolism, with cerebral infarction
434.91
Cerebral artery occlusion, unspecified, with cerebral infarction
997.02
Iatrogenic cerebrovascular infarction or hemorrhage
249
Secondary diabetes mellitus
249.01
Secondary diabetes mellitus without mention of complication, uncontrolled
249.1
Secondary diabetes mellitus with ketoacidosis
249.11
Secondary diabetes mellitus with ketoacidosis, uncontrolled
249.2
Secondary diabetes mellitus with hyperosmolarity
249.21
Secondary diabetes mellitus with hyperosmolarity, uncontrolled
249.3
Secondary diabetes mellitus with other coma
249.31
Secondary diabetes mellitus with other coma, uncontrolled
249.4
Secondary diabetes mellitus with renal manifestations
JSLS (2013)17:30 – 45
37
Costs and Clinical Outcomes of Conventional Single Port and Micro Laparoscopic Cholecystectomy, Chekan E et al.
Appendix B. (continued)
Diagnosis Codes for Comorbid Conditions
Event
38
ICD-9a Code
Description
249.41
Secondary diabetes mellitus with renal manifestations, uncontrolled
249.5
Secondary diabetes mellitus with ophthalmic manifestations
249.51
Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled
249.6
Secondary diabetes mellitus with neurological manifestations
249.61
Secondary diabetes mellitus with neurological manifestations, uncontrolled
249.7
Secondary diabetes mellitus with peripheral circulatory disorders
249.71
Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled
249.8
Secondary diabetes mellitus with other specified manifestations
249.81
Secondary diabetes mellitus with other specified manifestations, uncontrolled
249.9
Secondary diabetes mellitus with unspecified complication
249.91
Secondary diabetes mellitus with unspecified complication, uncontrolled
250
Diabetes mellitus
250.01
Diabetes mellitus without mention of complication, type I (juvenile type), not
stated as uncontrolled
250.02
Diabetes mellitus without mention of complication, type II or unspecified
type, uncontrolled
250.03
Diabetes mellitus without mention of complication, type I (juvenile type),
uncontrolled
250.1
Diabetes with ketoacidosis, type II or unspecified type, not stated as
uncontrolled
250.11
Diabetes with ketoacidosis, type I (juvenile type), not stated as uncontrolled
250.12
Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
250.13
Diabetes with ketoacidosis, type I (juvenile type), uncontrolled
250.2
Diabetes with hyperosmolarity
250.21
Diabetes with hyperosmolarity, type I (juvenile type), not stated as
uncontrolled
250.22
Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled
250.23
Diabetes with hyperosmolarity, type I (juvenile type), uncontrolled
250.3
Diabetes with other coma
250.31
Diabetes with other coma, type I (juvenile type), not stated as uncontrolled
250.32
Diabetes with other coma, type II or unspecified type, uncontrolled
250.33
Diabetes with other coma, type I (juvenile type), uncontrolled
250.4
Diabetes with renal manifestations
250.41
Diabetes with renal manifestations, type I (juvenile type), not stated as
uncontrolled
250.42
Diabetes with renal manifestations, type II or unspecified type, uncontrolled
250.43
Diabetes with renal manifestations, type I (juvenile type), uncontrolled
250.5
Diabetes with ophthalmic manifestations
250.51
Diabetes with ophthalmic manifestations, type I (juvenile type), not stated as
uncontrolled
250.52
Diabetes with ophthalmic manifestations, type II or unspecified type,
uncontrolled
JSLS (2013)17:30 – 45
Appendix B. (continued)
Diagnosis Codes for Comorbid Conditions
Event
Chronic obstructive pulmonary
disease
ICD-9a Code
Description
250.53
Diabetes with ophthalmic manifestations, type I (juvenile type), uncontrolled
250.6
Diabetes with neurological manifestations, type II or unspecified type, not
stated as uncontrolled
250.61
Diabetes with neurological manifestations, type I (juvenile type), not stated as
uncontrolled
250.62
Diabetes with neurological manifestations, type II or unspecified type,
uncontrolled
250.63
Diabetes with neurological manifestations, type I (juvenile type), uncontrolled
250.7
Diabetes with peripheral circulatory disorders
250.71
Diabetes with peripheral circulatory disorders, type I (juvenile type), not
stated as uncontrolled
250.72
Diabetes with peripheral circulatory disorders, type II or unspecified type,
uncontrolled
250.73
Diabetes with peripheral circulatory disorders, type I (juvenile type),
uncontrolled
250.8
Diabetes with other specified manifestations
250.81
Diabetes with other specified manifestations, type I (juvenile type), not stated
as uncontrolled
250.82
Diabetes with other specified manifestations, type II or unspecified type,
uncontrolled
250.83
Diabetes with other specified manifestations, type I (juvenile type),
uncontrolled
250.9
Diabetes with unspecified complication
250.91
Diabetes with unspecified complication, type I (juvenile type), not stated as
uncontrolled
250.92
Diabetes with unspecified complication, type II or unspecified type,
uncontrolled
250.93
Diabetes with unspecified complication, type I (juvenile type), uncontrolled
491.1
Mucopurulent chronic bronchitis
491.2
Obstructive chronic bronchitis
491.21
Obstructive chronic bronchitis with (acute) exacerbation
491.22
Obstructive chronic bronchitis with acute bronchitis
491.8
Other chronic bronchitis
491.9
Unspecified chronic bronchitis
492
Emphysema
492.0
Emphysematous bleb
492.8
Other emphysema
493.2
Chronic obstructive asthma
493.20
Chronic obstructive asthma, unspecified
493.21
Chronic obstructive asthma with status asthmaticus
493.22
Chronic obstructive asthma with (acute) exacerbation
494
Bronchiectasis
494.0
Bronchiectasis without acute exacerbation
JSLS (2013)17:30 – 45
39
Costs and Clinical Outcomes of Conventional Single Port and Micro Laparoscopic Cholecystectomy, Chekan E et al.
Appendix B. (continued)
Diagnosis Codes for Comorbid Conditions
Event
Chronic liver disease/disorders
Hypertension
Ischemic heart disease, including
myocardial infarction
40
ICD-9a Code
Description
494.1
Bronchiectasis with acute exacerbation
496
Chronic airway obstruction, not elsewhere classified
571.x
Chronic liver disease and cirrhosis
571.4x
Chronic hepatitis
572.x
Liver abscess and sequelae of chronic liver disease
573.x
Other disorders of liver
401
Essential hypertension
401.0
Malignant essential hypertension
401.1
Benign essential hypertension
401.9
Unspecified essential hypertension
405
Secondary hypertension
405.0
Malignant secondary hypertension
405.01
Malignant renovascular hypertension
405.09
Other malignant secondary hypertension
405.1
Benign secondary hypertension
405.11
Benign renovascular hypertension
405.19
Other benign secondary hypertension
405.9
Unspecified secondary hypertension
405.91
Unspecified renovascular hypertension
405.99
Other unspecified secondary hypertension
410
Acute myocardial infarction
410.0
Acute myocardial infarction of anterolateral wall
410.01
Acute myocardial infarction of anterolateral wall, initial episode of care
410.02
Acute myocardial infarction of anterolateral wall, subsequent episode of care
410.1
Acute myocardial infarction of other anterior wall
410.10
Acute myocardial infarction of other anterior wall, episode of care unspecified
410.11
Acute myocardial infarction of other anterior wall, initial episode of care
410.12
Acute myocardial infarction of other anterior wall, subsequent episode of care
410.2
Acute myocardial infarction of inferolateral wall
410.20
Acute myocardial infarction of inferolateral wall, episode of care unspecified
410.21
Acute myocardial infarction of inferolateral wall, initial episode of care
410.22
Acute myocardial infarction of inferolateral wall, subsequent episode of care
410.3
Acute myocardial infarction of inferoposterior wall
410.30
Acute myocardial infarction of inferoposterior wall, episode of care
unspecified
410.31
Acute myocardial infarction of inferoposterior wall, initial episode of care
410.32
Acute myocardial infarction of inferoposterior wall, subsequent episode of
care
410.4
Acute myocardial infarction of other inferior wall
410.40
Acute myocardial infarction of other inferior wall, episode of care unspecified
JSLS (2013)17:30 – 45
Appendix B. (continued)
Diagnosis Codes for Comorbid Conditions
Event
ICD-9a Code
Description
410.41
Acute myocardial infarction of other inferior wall, initial episode of care
410.42
Acute myocardial infarction of other inferior wall, subsequent episode of care
410.5
Acute myocardial infarction of other lateral wall
410.50
Acute myocardial infarction of other lateral wall, episode of care unspecified
410.51
Acute myocardial infarction of other lateral wall, initial episode of care
410.52
Acute myocardial infarction of other lateral wall, subsequent episode of care
410.6
Acute myocardial infarction of posterior wall infarction
410.61
Acute posterior wall infarction, initial episode of care
410.62
Acute posterior wall infarction, subsequent episode of care
410.7
Subendocardial infarction
410.70
Subendocardial infarction, episode of care unspecified
410.71
Subendocardial infarction, initial episode of care
410.72
Subendocardial infarction, subsequent episode of care
410.8
Acute myocardial infarction of other specified sites
410.80
Acute myocardial infarction of other specified sites, episode of care
unspecified
410.81
Acute myocardial infarction of other specified sites, initial episode of care
410.82
Acute myocardial infarction of other specified sites, subsequent episode of
care
410.9
Acute myocardial infarction of unspecified site
410.90
Acute myocardial infarction of unspecified site, episode of care unspecified
410.91
Acute myocardial infarction of unspecified site, initial episode of care
410.92
Acute myocardial infarction of unspecified site, subsequent episode of care
411
Other acute and subacute forms of ischemic heart disease
411.0
Postmyocardial infarction syndrome
411.1
Intermediate coronary syndrome
411.8
Other acute and subacute forms of ischemic heart disease
411.81
Acute coronary occlusion without myocardial infarction
411.89
Other acute and subacute forms of ischemic heart disease, other
412
Old myocardial infarction
413
Angina pectoris
413.0
Angina decubitus
413.1
Prinzmetal angina
413.9
Other and unspecified angina pectoris
414
Other forms of chronic ischemic heart disease
414.0
Coronary atherosclerosis
414.00
Coronary atherosclerosis of unspecified type of vessel, native or graft
414.01
Coronary atherosclerosis of native coronary artery
414.02
Coronary atherosclerosis of autologous vein bypass graft
414.03
Coronary atherosclerosis of nonautologous biological bypass graft
JSLS (2013)17:30 – 45
41
Costs and Clinical Outcomes of Conventional Single Port and Micro Laparoscopic Cholecystectomy, Chekan E et al.
Appendix B. (continued)
Diagnosis Codes for Comorbid Conditions
Event
Heart failure
42
ICD-9a Code
Description
414.04
Coronary atherosclerosis of artery bypass graft
414.05
Coronary atherosclerosis of unspecified bypass graft
414.06
Coronary atherosclerosis of native coronary artery of transplanted heart
414.07
Coronary atherosclerosis of bypass graft transplanted heart
414.1
Aneurysm and dissection of heart
414.10
Aneurysm of heart (wall)
414.11
Aneurysm of coronary vessels
414.12
Dissection of coronary artery
414.19
Other aneurysm of heart
414.2
Chronic total occlusion of coronary artery
414.3
Coronary atherosclerosis due to lipid rich plaque
414.8
Other specified forms of chronic ischemic heart disease
414.9
Chronic ischemic heart disease, unspecified
398.91
Rheumatic heart failure (congestive)
402.01
Benign hypertensive heart disease without heart failure
402.11
Benign hypertensive heart disease with heart failure
402.91
Unspecified hypertensive heart disease with heart failure
404.01
Hypertensive heart and chronic kidney disease, malignant, with heart failure
and with chronic kidney disease stage I through stage IV, or unspecified
404.03
Hypertensive heart and chronic kidney disease, malignant, with heart failure
and with chronic kidney disease stage V or end stage renal disease
404.11
Hypertensive heart and chronic kidney disease, benign, with heart failure and
with chronic kidney disease stage I through stage IV, or unspecified
404.13
Hypertensive heart and chronic kidney disease, benign, with heart failure and
chronic kidney disease stage V or end stage renal disease
404.91
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and with chronic kidney disease stage I through stage IV, or unspecified
404.93
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and chronic kidney disease stage V or end stage renal disease
428
Heart failure
428.0
Congestive heart failure, unspecified
428.1
Left heart failure
428.2
Systolic heart failure
428.21
Acute systolic heart failure
428.22
Chronic systolic heart failure
428.23
Acute on chronic systolic heart failure
428.3
Diastolic heart failure
428.31
Acute diastolic heart failure
428.32
Chronic diastolic heart failure
428.33
Acute on chronic diastolic heart failure
428.4
Combined systolic and diastolic heart failure
428.41
Acute combined systolic and diastolic heart failure
JSLS (2013)17:30 – 45
Appendix B. (continued)
Diagnosis Codes for Comorbid Conditions
Event
Cardiomyopathy
Hypertensive heart disease without
heart failure
ICD-9a Code
Description
428.42
Chronic combined systolic and diastolic heart failure
428.43
Acute on chronic combined systolic and diastolic heart failure
428.9
Heart failure, unspecified
425
Cardiomyopathy
425.0
Endomyocardial fibrosis
425.1
Hypertrophic cardiomyopathy
425.2
Obscure cardiomyopathy of Africa
425.3
Endocardial fibroelastosis
425.4
Other primary cardiomyopathies
425.5
Alcoholic cardiomyopathy
425.7
Nutritional and metabolic cardiomyopathy
425.8
Cardiomyopathy in other diseases classified elsewhere
425.9
Secondary cardiomyopathy, unspecified
402
Hypertensive heart disease
402.0
Malignant hypertensive heart disease
402.1
Benign hypertensive heart disease
402.10
Benign hypertensive heart disease without heart failure
402.9
Unspecified hypertensive heart disease
404
Hypertensive heart and chronic kidney disease
404.02
Hypertensive heart and chronic kidney disease, malignant, without heart
failure and with chronic kidney disease stage V or end stage renal disease
404.1
Benign hypertensive heart and renal disease
404.12
Hypertensive heart and chronic kidney disease, benign, without heart failure
and with chronic kidney disease stage V or end stage renal disease
404.9
Unspecified hypertensive heart and renal disease
404.90
Hypertensive heart and chronic kidney disease, unspecified, without heart
failure and with chronic kidney disease stage I through stage IV, or
unspecified
404.92
Hypertensive heart and chronic kidney disease, unspecified, without heart
failure and with chronic kidney disease stage V or end stage renal disease
a
ICD-9⫽International Classification of Diseases, Ninth Revision.
JSLS (2013)17:30 – 45
43
Costs and Clinical Outcomes of Conventional Single Port and Micro Laparoscopic Cholecystectomy, Chekan E et al.
Appendix C.
Diagnosis Codes for Adverse Events
Event
Transient ischemic attack
Cerebrovascular accident
Acute myocardial infarction
Pneumothorax
Pulmonary embolism
Other embolism
44
ICD-9a Code
Description
435.8
Other specified transient cerebral ischemia
435.9
Unspecified transient cerebral ischemia
430
Subarachnoid hemorrhage
431
Intracerebral hemorrhage
432.0
Nontraumatic extradural hemorrhage
432.1
Subdural hemorrhage
432.9
Unspecified intracranial hemorrhage
433.01
Occlusion and stenosis, basilar artery, with cerebral infarction
433.11
Occlusion and stenosis, carotid artery, with cerebral infarction
433.21
Occlusion and stenosis, vertebral artery, with cerebral infarction
433.31
Occlusion and stenosis, multiple and bilateral precerebral arteries, with cerebral
infarction
433.81
Occlusion and stenosis, other specified precerebral artery, with cerebral infarction
433.91
Occlusion and stenosis, unspecified precerebral artery, with cerebral infarction
434.01
Cerebral thrombosis, with cerebral infarction
434.11
Cerebral embolism, with cerebral infarction
434.91
Cerebral artery occlusion, unspecified, with cerebral infarction
997.02
Iatrogenic cerebrovascular infarction or hemorrhage
410.01
Acute myocardial infarction, anterolateral wall
410.11
Acute myocardial infarction, other anterior wall
410.21
Acute myocardial infarction, inferolateral wall
410.31
Acute myocardial infarction, inferoposterior wall
410.41
Acute myocardial infarction, other inferior wall
410.51
Acute myocardial infarction, other lateral wall
410.61
Acute myocardial infarction, true posterior wall
410.71
Acute myocardial infarction, subendocardial (NSTEMIa)
410.81
Acute myocardial infarction, other sites
410.91
Acute myocardial infarction, unspecified site
512.0
Spontaneous tension pneumothorax
512.1
Iatrogenic pneumothorax
512.8
Other spontaneous pneumothorax
415.1
Pulmonary embolism and infarction
415.11
Iatrogenic pulmonary embolism and infarction
415.12
Septic pulmonary embolism
415.19
Other pulmonary embolism and infarction
453.4
Acute venous embolism and thrombosis of deep vessels of lower extremity
453.41
Acute venous embolism and thrombosis of deep vessels of proximal lower
extremity
453.42
Acute venous embolism and thrombosis of deep vessels of distal lower extremity
JSLS (2013)17:30 – 45
Appendix C. (continued)
Diagnosis Codes for Adverse Events
Event
Operative complication
Other adverse events
ICD-9a Code
Description
453.8
Acute venous embolism and thrombosis of other specified veins
453.9
Other venous embolism and thrombosis of unspecified site
997.1
Cardiac complications
997.2
Peripheral vascular complications
997.3
Respiratory complications
997.31
Ventilator associated pneumonia
997.39
Other respiratory complications
997.4
Digestive system
997.5
Urinary tract
997.7
Vascular complications of other vessels
998
Other complications of procedures
998.x
Other complications of procedures
998.xx
Other complications of procedures
997.4
Digestive system complications
789.4x
Abdominal rigidity/tenderness
789.6x
Abdominal rigidity/tenderness
536.2
Nausea and vomiting nausea
564.3
Nausea and vomiting nausea
787.0x
Nausea and vomiting nausea
536.3
Gastroparesis paralytic ileus
560.1
Gastroparesis paralytic ileus
567.9
Peritonitis not specified
567.8x
Peritonitis not specified
576.2
Bile duct obstruction
576.3
Bile duct perforation
576.4
Bile duct fistula
a
ICD-9⫽International Classification of Diseases, Ninth Revision; NSTEMI⫽non–ST-segment elevation myocardial infarction.
JSLS (2013)17:30 – 45
45
SCIENTIFIC PAPER
Complications of Liver Resection: Laparoscopic
Versus Open Procedures
Douglas P. Slakey, MD, MPH, Eric Simms, MD, Barbara Drew, MD,
Farshid Yazdi, MD, Brett Roberts, MD
ABSTRACT
INTRODUCTION
Background and Objective: Minimally invasive surgery
for liver resection remains controversial. This study was
designed to compare open versus laparoscopic surgical
approaches to liver resection.
Laparoscopic approaches to liver resection have found
acceptance among institutions where surgeons have the
requisite experience. Improved techniques and technologic advances have permitted better control of intrahepatic blood vessels and bile ducts, improving the safety
and feasibility of laparoscopic liver resection.1–5 Several
studies have described laparoscopic liver resections as
safe and have shown some advantages over open liver
resections, especially in terms of decreased postoperative
pain, less intraoperative blood loss, reduced recovery
time, and shorter hospital stay.6
Methods: We performed a single-center retrospective
chart review.
Results: We compared 45 laparoscopic liver resections
with 17 open cases having equivalent resections based on
anatomy and diagnosis. The overall complication rate was
25.8%. More open resection patients had complications
(52.9% vs 15.5%, P ⬍ .008). The conversion rate was
11.1%. The mean blood loss was 667.1 ⫾ 1450 mL in open
cases versus 47.8 ⫾ 89 mL in laparoscopic cases (P ⬍
.0001). Measures of intravenous narcotic use, intensive
care unit length of stay, and hospital length of stay all
favored the laparoscopic group. Patients were more likely
to have complications or morbidity in the open resection
group than in the laparoscopic group for both the anterolateral (P ⬍ .085) and posterosuperior (P ⬍ .002) resection
subgroups.
Conclusion: In this series comparing laparoscopic and
open liver resections, there were fewer complications,
more rapid recovery, and lower morbidity in the laparoscopic group, even for those resections involving the
posterosuperior segments of the liver.
Key Words: Liver resection, Laparoscopic, LigaSure.
Department of Surgery, Tulane University School of Medicine, New Orleans, LA,
USA (all authors).
Address correspondence to: Douglas P. Slakey, MD, MPH, Department of Surgery,
Tulane University School of Medicine, 1430 Tulane Ave, SL-22, New Orleans, LA
70112-2699, USA. Telephone: (504) 988-2317, Fax: (504)988-1874 E-mail:
[email protected]
DOI: 10.4293/108680812X13517013317716
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
46
When one is evaluating the safety of surgical methods, the
intraoperative and postoperative morbidity and mortality
rates are considered the primary metrics of efficacy and
safety.7 Measures of outcome, such as blood loss, duration
of hospital stay, and duration of postoperative ileus, are
also important when one is determining the efficacy and
cost-effectiveness of procedures. Postoperative morbidity
for liver resection is predominantly associated with hemorrhage from the cut edge, ascites (especially in cirrhotic
patients or patients with cysts), and intra-abdominal fluid
collection or abscess, with reported rates of 11% to 34%.8
Morbidity and mortality rates are increased with major
resections and the presence of cirrhosis.9
Most published studies and reviews describing the safety
and efficacy of laparoscopic liver resection are narrowly
focused on a homogeneous type of procedure (e.g., left
lobectomy) or specific diagnosis (e.g., hepatocellular carcinoma). To date, few studies have compared all-indication open and laparoscopic liver resections with respect to
complications, morbidity, and outcome. The goal of this
study was to assess the safety and efficacy of laparoscopic
liver resection by comparing the outcomes of laparoscopic liver resections versus open procedures with
equivalent resections based on anatomy and indication.
METHODS
The study design was a single-center retrospective chart
review, and institutional review board approval was obtained. We compared 45 consecutive laparoscopic liver
resections with 17 open resections with similar indications
JSLS (2013)17:46 –55
and anatomy of resection. The 17 open cases were chosen
because they closely matched the parameters recorded for
the laparoscopic cases; all cases were performed within
the same period, and no matched open cases were excluded. All resections were performed by 1 of 2 senior
hepatobiliary staff surgeons, each of whom performed
both laparoscopic and open resections, using similar techniques. Cases in which biopsy was the only procedure
were not included in this study. Demographic information, operative details, and postoperative outcome data
were analyzed. Results are expressed as mean ⫾ standard
deviation. Statistical analyses included the odds ratio and
relative risk with 95% confidence intervals, and results
were verified by use of an online statistics calculator from
the Centre for Evidence Based Medicine.10 Cases converted from laparoscopic to open were included in the
laparoscopic group for intent-to-treat analysis.
Surgical Technique
In patients receiving laparoscopic liver resection, both
pure laparoscopic and hand-assisted techniques were
grouped together. Only 2 of the 45 laparoscopic cases
involved a hand-assisted technique, 1 for a large symptomatic cyst in the right lobe of the liver and the other for
a large hemangioma in the left lobe. Ultrasonography with
duplex was used in all cases, with the Aloka 7.5-MHz
flexible linear laparoscopic transducer (Hitachi Aloka
Medical, Ltd., Willingford, CT, USA) for laparoscopic cases
and the Philips 15– 6L intraoperative linear array transducer (Andover, MA, USA) for the open cases. For laparoscopic resections, supraumbilical trocars were placed
first by use of the Hasson technique, and additional trocars were placed as needed based on individual anatomy.
Laparoscopic resections used either three or four 10-mm
to 1-mm trocars so that ultrasonography probes and staplers could be inserted through any trocar. For the 2
resections that used hand-assisted techniques, the Applied
Medical GelPort (Rancho Santa Margarita, CA, USA) was
placed in an incision in the right upper quadrant, with
some variation based on anatomy and position of the
masses. For right or left hemihepatectomy or left lateral
lobectomy, the portal pedicles were most often divided
within the liver parenchyma by use of a linear stapler.
Similarly, hepatic veins were identified as the parenchymal dissection progressed cephalad, with dissection only
as much as necessary to allow a linear stapler to be safely
positioned and fired. Parenchymal dissection was primarily completed with the LigaSure Atlas 10-mm vessel sealing device during laparoscopic cases and the LigaSure
Max (Covidien, Mansfield, MA, USA) device during open
procedures. Cholecystectomy and cholangiography were
performed when indicated. The Pringle maneuver was
only rarely used to aid in bleeding control and was never
performed for ⬎20 minutes. In laparoscopic cases, once a
transected surgical specimen was detached, it was inserted into an Endobag (Cardinal Health, Dublin, Ott,
USA) and extracted through either an enlarged epigastric
port incision or a hand-port incision if present. Hemostasis
was achieved by use of an argon beam coagulator and
sometimes titanium clips and/or fibrin glue sealant. After
irrigation of the surgical field, pneumoperitoneum was
evacuated for 5 minutes in laparoscopic cases and then
reinsufflated to inspect for hemostasis. Blake-type closed
suction drains were used in ⬍20% of cases (not different
for open or laparoscopic). The nomenclature of Strasberg11 was used to describe the types of resections. Anterolateral procedures were defined as resections involving liver segments II, III, IVa (the anterior part of segment
IV), V, and VI. Posterosuperior procedures were defined
as resections involving segments IVb (the posterior part of
segment IV), VII, and VIII. No caudate resections were
performed.
RESULTS
A total of 62 liver resections are included in this cohort (45
laparoscopic and 17 open). Patient demographics, indications for resection, and tumor characteristics are summarized in Table 1. No significant differences were noted
between the open and laparoscopic resection groups with
respect to patient age, sex, severity of underlying liver
disease, preoperative diagnosis, or indication for resection. The size, number, and location of the resected lesions were also similar. There were no significant differences between the open and laparoscopic groups with
respect to operative procedures (Table 2). Conversion to
an open approach was required in 5 of 45 laparoscopic
cases (11.1%) because of inadequate visualization of the
liver (n ⫽ 3) or an insufficient resection margin (n ⫽ 2).
No conversion was performed for bleeding.
The indication for resection was hepatocellular carcinoma
in 17 patients (27.0%), metastatic colon cancer in 8
(12.9%), symptomatic hepatic cyst in 8 (12.9%), hemangioma in 6 (9.6%), focal nodular hyperplasia in 14 (22.6%),
hepatic adenoma in 3 (4.8%), other malignant lesion in 4
(6.5%), and other nonmalignant lesion in 2 (3.2%). Table
1 shows the number of laparoscopic and open cases for
each indication. The “other” malignant lesions were carcinoid tumor (n ⫽ 1), sclerosing malignant epithelial neoplasm (n ⫽ 1), and cholangiocarcinoma (n ⫽ 2). The
JSLS (2013)17:46 –55
47
Complications of Liver Resection: Laparoscopic Versus Open Procedures, Slakey DP et al.
Table 1.
Characteristics of Patients Who Underwent Laparoscopic and Open Resection of Hepatic Lesions
Total (N ⫽ 62)
Laparoscopic Group (n ⫽ 45)
Open Group (n ⫽ 17)
53.1 ⫾ 13.4
53.5 ⫾ 13.9
52.4 ⫾ 12.5
Demographic factors
Age, yr
Sex (male/female)
28/29 (45.2%/46.8%)
19/26 (42.2%/57.8%)
12/5 (70.6%/29.4%)
Liver disease (normal/CLDa/Ca)
31/17/20
22/16/16
7/5/6
17
12
5
Indications for liver resection, n
Hepatocellular carcinoma
Colorectal metastasis to liver
8
5
3
Symptomatic cyst
8
7
1
Hemangioma
6
4
2
Focal nodular hyperplasia
14
10
4
Hepatic adenoma
3
3
0
Malignant lesion—other
4
3
1
Nonmalignant lesion—other
2
1
1
Size (cm)
7.3 ⫾ 3.6
6.4 ⫾ 3.6
10.5 ⫾ 3.8
Number (single/multiple)
35/27
26/19
6/11
20/5/28/9
16/3/20/6
4/2/8/3
Tumor characteristics
Location
(ALa/PSa/both/indeterminate)
a
AL⫽anterolateral segments; C⫽cirrhosis; CLD⫽chronic liver disease; PS⫽posterosuperior segments.
Table 2.
Liver Resection Types
No. of Resections/Procedures
Total No.
Laparoscopic Group
Open Group
Right hemihepatectomy (segments V, VI, VII, VIII)
2
0
2
Left hemihepatectomy (segments II, III, IV)
4
3
1
Right posterior sectionectomy (segments VII, VIII, IVb)
0
0
0
2
1
1
Major resections
Minor resections
Left lateral sectionectomy (segments II, III)
Right trisegmentectomy (segments V, VI, VII)
1
0
1
Bisegmentectomy (segments VII, VIII)
1
1
0
Segment 3
1
1
0
Segment 4a
1
1
0
Segment 6
1
1
0
49
37
12
Segmentectomy
Nonanatomic
48
JSLS (2013)17:46 –55
“other” nonmalignant lesions were a focus of mucinous
epithelial metaplasia (n ⫽ 1) and fibrosis suspicious for
schistosomiasis (n ⫽ 1).
The open resection group showed a significantly increased risk of having at least 1 complication (P ⫽ .007)
(Table 3). In addition, the open resection group showed
significantly increased lengths of both intensive care unit
stay and hospital stay (P ⫽ .05 and P ⫽ .01, respectively).
There was no significant difference in the need for intravenous narcotic pain medication, the length of postoperative ileus (expressed as time to initiation of oral intake),
and 30-day or 1-year mortality rate between the open and
laparoscopic resection groups. The amount of blood loss
was greater in the open group than in the laparoscopic
group (median, 988 mL vs 95 mL; P ⫽ .0001). Overall,
intraoperative bleeding was limited except in 3 open resection patients who required intraoperative blood transfusion. Postoperative transfusion was required in 6 patients (5 from the open group and 1 from the laparoscopic
group). The overall complication rate was 25.8%, and
complications included pleural effusion (2 patients),
wound infection (2 patients), incisional hernia (4 patients), hematoma requiring drainage (1 patient), abscess
requiring drainage (1 patient), upper gastrointestinal
bleed (2 patients), bile duct stricture (1 patient), common
bile duct obstruction (1 patient), bile leak (1 patient),
ascites requiring drainage (5 patients), and retained drain
requiring a procedure (1 patient). The complication rate in
the laparoscopic group was 15.5%. The complication rate
in open cases was 52.9%.
Twenty patients (32.2%) underwent resections of the anterolateral segments of the liver, and 33 patients (53.2%)
underwent resections of the posterosuperior segments of
the liver or resections of both the anterolateral and posterosuperior segments. Nine patients (14.5%) had resections that could not be categorized as anterolateral or
posterosuperior. Laparoscopic and open complications
and outcomes in each liver resection group are shown in
Table 4. The open posterosuperior resection group had
significantly more complications than the laparoscopic
posterosuperior resection group (P ⫽ .002).
DISCUSSION
The indications and techniques for laparoscopic liver surgery have expanded during the past decade and today
include major resections such as right and left hemihepatectomy. However, laparoscopic liver resection has remained limited for nonanatomic resections of the anterolateral and posterosuperior segments. This is because of
concerns regarding the risks of bleeding and of jeopardizing oncologic principles by not achieving adequate margins, as well as difficulty in replicating the basic maneuvers of open liver resection (i.e., mobilization of the liver
and maintaining vascular control) laparoscopically.8 Starting in the late 1990s, published series showed that laparoscopic resection of select hepatic lesions not only is safe
but also often has a better postoperative outcome than
similar open procedures.1,3,5,9 Biertho et al.12 confirmed
the safety of the laparoscopic approach for resection of
minor hepatic lesions in a review of 186 laparoscopic liver
resections between 1991 and 2001, showing a morbidity
rate of 16%. More recent series have shown increasing
rates of laparoscopy for resection of nonmalignant lesions, especially in the noncirrhotic liver.5,13–16 Most series
report that the laparoscopic approach to malignant hepatic lesions has been more narrow if these lesions often
occur in patients with less hepatic reserve, such as patients with chronic liver disease, cirrhosis, or chemotherapy.13 Despite this, the suitability and safety of benign and
malignant lesion laparoscopic liver resection have been
shown in a 2007 meta-analysis of 8 studies, which showed
lower operative blood loss, fewer complications, and a
shorter duration of hospital stay in the laparoscopic
groups.17 There are no randomized clinical trials comparing laparoscopic with open hepatic resection.18
The overall complication rate in our study was 25.8%,
which corresponds to rates described in the literature.1
Interestingly, the complication rate in the laparoscopic
group was only 15.5%, significantly lower than that in the
open cases. The incidences of pleural effusion and incisional infection were higher in the open group. Intraoperative bleeding was limited except in 3 open resection
patients in whom a transfusion was required (4.8%). The
incidence of significant bleeding in patients included in
this study was lower than that for recent series in the
literature.13,19 –21 Lesions adjacent to or invading large hepatic veins are recognized to be at increased risk of bleeding.22 The major risk factors for significant or uncontrolled
bleeding are the size and location of the lesion. Though
difficult to quantify, expertise and available technology
are recognized as major factors in maintaining vascular
control.20,23 The role of pneumoperitoneum in homeostasis and meticulous dissection enabled by laparoscopic
magnification are also considered important factors contributing to decreased blood loss in laparoscopic procedures. Magnification may render laparoscopic dissection
of large hepatic veins safer than in open laparotomy.13,15
The use of vascular staples (with endoscopic linear staplers) for homeostasis and the use of the LigaSure device
JSLS (2013)17:46 –55
49
Complications of Liver Resection: Laparoscopic Versus Open Procedures, Slakey DP et al.
Table 3.
Complications
Total
Laparoscopic
Group
Open Group
ORa
Relative 95% CIa
Risk
Cases with complications, n
(male, female)
16 (11, 5)
7 (4, 3)
9 (7, 2)
6.11
.007
Mortality at 30 d, n (male,
female)
1 (1, 0)
0
1 (1, 0)
5.63
.86
Mortality at 12 m, n (male,
female)
3 (2, 1)
0
3 (2, 1)
19.29
.06
Blood loss, mean (male,
female); range (mL)
427.4 (676.3, 240.8);
0–5000
95.0 (115.0, 88.4);
0–350
988.0 (1050.4, 850.0);
10–5000
(SD, 969.09)
(SD, 88.75)
(SD, 1450.5)
IV pain medications ⬎5 d
10 (7, 3)
5 (3, 2)
5 (4, 1)
3.33
.17
ICUa stay ⬎5 d
8 (5, 3)
3 (2, 1)
5 (3, 2)
5.83
.05
P
Value
.0001
Measures of outcome, n
(male, female)
a
Hospital stay ⬎10 d
9 (8, 1)
3 (2, 1)
6 (6, 0)
7.64
.01
Postoperative ileus ⬎4 d
4 (3, 1)
1 (0, 1)
3 (3, 0)
9.43
.10
Pleural effusion
2 (1, 1)
0
2 (1, 1)
12.0
.23
Incisional infection
2 (2, 0)
0
2 (2, 0)
12.0
.23
Incisional hernia
4 (1, 3)
1 (0, 1)
3 (1, 2)
9.43
.10
Hematoma requiring
drainage
1 (1, 0)
0
1 (1, 0)
5.63
.86
Abscess requiring
drainage
1 (1, 0)
0
1 (1, 0)
5.63
.86
Upper GIa bleed
requiring EGD/epia
2 (2, 0)
1 (1, 0)
1 (1, 0)
2.75
.94
Bile duct stricture
requiring ERCPa
1 (1, 0)
0
1 (1, 0)
5.63
.86
CBDa obstruction
1 (1, 0)
0
1 (1, 0)
5.63
.86
Bile leak
1 (0, 1)
1 (0, 1)
0
0
.61
Ascites requiring
drainage
5 (4, 1)
3 (2, 1)
2 (2, 0)
1.86
.89
Retained drain requiring
procedure
1 (1, 0)
1 (1, 0)
0
0
.61
Total No. of specific
complications (male,
female)
Having a complication in
open group vs laparoscopic
group
5.29
1.83–15.34
.003
Having [me]1 measure of
poor outcome in open
group vs laparoscopic
group
3.67
1.48–9.07
.008
a
CBD⫽common bile duct; CI⫽confidence interval; EGD/epi⫽esophagogastroduodenoscopy/episode; ERCP⫽endoscopic retrograde
cholangiopancreatography; GI⫽gastrointestinal; ICU⫽ intensive care unit; IV⫽intravenous; OR⫽odds ratio.
50
JSLS (2013)17:46 –55
Table 4.
Intraoperative and Postoperative Results by Location of Resection
Anterolateral Group
Posterosuperior (PS
and AL⫹PS)a
Other Resection Cases
Lapa
Lap
Open
Lap
Open
Open
a
Conversion, n
3
NA
2
NA
0
NA
Blood loss requiring transfusion
4 U, n (male, female)
0
0
0
0
0
1 (1, 0)
Mortality within 30 d after operation, n
(male, female)
0
0
0
1 (1, 0)
0
0
Mortality within 12 m, n (male, female)
IVa pain medication
5 d, n (male, female)
ICUa stay 5 d, n (male, female)
Hospital stay 10 d, n (male, female)
0
2 (1, 1)
0
1 (1, 0)
0
0
4 (2, 2)
2 (2, 0)
1 (1, 0)
2 (1, 1)
0
1 (1, 0)
2 (1, 1)
1 (1, 0)
1 (1, 0)
4 (2, 2)
0
0
2 (1, 1)
2 (2, 0)
1 (1, 0)
2 (2, 0)
1 (1, 0)
1 (1, 0)
1 (0, 1)
2 (2, 0)
0
1 (1, 0)
0
0
Pleural effusion
0
0
0
2 (1, 1)
0
0
Incisional infection
0
0
0
1 (1, 0)
0
1 (1, 0)
Incisional hernia
0
1 (0, 1)
1 (0, 1)
1 (0, 1)
0
1 (1, 0)
Hematoma requiring drainage
0
0
0
1 (1, 0)
0
0
Postoperative ileus
4 d, n (male, female)
Complications, n (male, female)
Abscess requiring drainage
0
0
0
1 (1, 0)
0
0
Upper GIa bleed requiring EGD/epia
1 (1, 0)
1 (1, 0)
0
0
0
0
Bile duct stricture requiring ERCPa
0
0
0
1 (1, 0)
0
0
CBDa obstruction
0
0
0
1 (1, 0)
0
0
Bile leak requiring drainage
1 (0, 1)
0
0
0
0
0
Ascites requiring drainage
1 (1, 0)
1 (1, 0)
2 (1, 1)
1 (1, 0)
0
0
Retained drain requiring procedure
Total complications (n ⫽ 21)
0
0
0
1 (1, 0)
0
0
3 (2, 1)
3 (2, 1)
3 (1, 2)
10 (8, 2)
0
2 (2, 1)
a
AL⫽anterolateral segments; CBD⫽common bile duct; ERCP⫽endoscopic retrograde cholangiopancreatography; EGD/
epi⫽esophagogastroduodenoscopy/episode; GI⫽gastrointestinal; ICU⫽ intensive care unit; IV⫽intravenous; Lap⫽laparoscopic; NA⫽not
applicable; PS⫽posterosuperior segments.
to advance toward large vascular structures in the
deeper parenchyma may also decrease the risk of
bleeding.13,22,23
As hepatobiliary surgical teams gain experience with laparoscopic techniques, a significant percentage of liver resections may be accomplished laparoscopically. At our
center, greater than two-thirds of the liver resections are
performed by a laparoscopic approach. In this study only
11.1% of cases in the laparoscopic group required conversion to open resection. The reasons for conversion
were unsatisfactory visualization and an inadequate mar-
gin of resection. The latter is likely because of the inability
of the surgeon to palpate lesions with a laparoscopic
approach, resulting in difficulty identifying an optimal
margin.18,24,25 The conversion rate in this study was low
relative to that reported in the literature.15,20,26,27 One relative contraindication to the laparoscopic approach in our
experience has been previous upper abdominal surgery
and the resultant adhesions.
Despite the increasing use of laparoscopy for hepatic
procedures, the surgical techniques have been largely
limited to patients who have lesions confined to the an-
JSLS (2013)17:46 –55
51
Complications of Liver Resection: Laparoscopic Versus Open Procedures, Slakey DP et al.
terolateral segments of the liver.18 This is primarily because laparoscopic liver resection of the posterosuperior
segments is associated with poorer access and visualization compared with open resection.18,28 To a large degree,
lesions located in the posterosuperior segments of the
liver are still considered relative contraindications to laparoscopy.13,15,18,29 Of note, the posterosuperior group in
our study had a greater number of tumors that involved
⬎1 segment, as well as a greater proportion of deepseated tumors requiring longer and more complicated
procedures, than anterolateral cases. This may contribute
to the greater number of complications and poor measures of outcome in the posterosuperior groups relative to
the anterolateral groups. Interestingly, our study shows a
significantly greater proportion of complications and
poor measures of outcome in the open posterosuperior
resection group than in the laparoscopic group. This
observation may be tempered by the fact that most of
the open posterosuperior resection recipients had a
greater number of lesions overall (9 of 10 open posterosuperior resection patients had ⱖ2 lesions). Another potential limitation of the study is the smaller
number of open cases. This indicates the value of developing a multicenter outcomes database as opposed
to relying on single-center studies.
Although the demographic differences between the
groups in this study were not statistically significant, a
greater proportion of women underwent laparoscopic
liver resections (57.8%) and a greater number of men
underwent open resections (70.6%). Sex was not considered an indication or contraindication for either surgical
approach. It is not clear from this analysis why more male
patients had open resections, although it is possible that
body habitus played a role. In larger male patients, some
resections may not be amenable to resection given current
limitations of laparoscopic instruments. Studies have
noted that male sex is an independent risk factor for liver
failure after hepatectomy, although other hepatic resection complications associated with sex have not been
elucidated.30 In our study, when the open and laparoscopic resection groups are stratified by sex, some of the
differences in complications and measures of poor outcome between the open and laparoscopic resections do
show statistical significance. Nonetheless, male patients
undergoing open hepatic resection in this study show a
significantly greater proportion of poor measures of outcome (most notably longer hospital stay) than those undergoing laparoscopic resection. Laparoscopic and open
complications and outcomes stratified by sex are shown in
Table 5.
52
For patients in whom hepatic reserve was a consideration,
such as patients with chronic liver disease or cirrhosis, nonanatomic resections or tumorectomies are preferred as opposed to anatomic lobectomies. Nonanatomic resections in
these segments can be considered major liver resections
because of challenges with exposure, as well as the transection line, which is often curved.13,20 One series by Dagher et
al.13 noted that nonanatomic resections in the posterosuperior segments are more difficult than other major resections
(right hemihepatectomy, left hemihepatectomy, left lateral
segmentectomy). They noted that nonanatomic resections in
these segments resulted in more profuse bleeding, greater
transfusion requirements, and more frequent conversion.
Other series have recommended the hand-assisted laparoscopic technique for resection in these segments to improve
exposure and assist in transection.18,31 The hand-assisted
technique allows for digital palpation that is usually not
possible in laparoscopy, as well as manual control of bleeding. The hand-assisted technique does have several drawbacks including being generally more invasive, having a
greater risk of air leakage, and causing operator fatigue.32
Laparoscopic liver surgery is being used with increasing
frequency by abdominal surgery programs worldwide.1 In
the past 3 years, an increasing percentage of left lateral
segmentectomies have been performed by laparoscopy.13
A greater number of left and right hemihepatectomies are
also being performed laparoscopically in select centers.13
In our study 1 of the 2 left lateral sectionectomies and 3 of
the 4 left hemihepatectomies were performed laparoscopically. Our analysis shows that laparoscopic liver resection can be considered as safe as open liver resection
for most patients with lesions located in both the anterolateral and posterosuperior segments of the liver if performed by surgeons with the requisite expertise and experience in laparoscopy. Because laparoscopic liver
resection is still in its nascency, further technologic innovations will be required before the laparoscopic approach
can be considered the standard for the surgical resection
of hepatic lesions.32 The expansion of the use of laparoscopy for liver resection is limited by the necessity of
specialized surgical training, as well as fear of loss of
vascular control, but the scope of the laparoscopic approach will continue to expand to be considered suitable
for any resection of hepatic tumors.33 The lower operative
and postoperative blood loss, shortened intensive care
unit stay and overall hospital stay, shortened duration of
postoperative ileus, and smaller incidence of complications and postoperative morbidities have significant ramifications in terms of reducing overall morbidity and
health care costs.
JSLS (2013)17:46 –55
Table 5.
Complications by Sex
Cases with complications, male, n
Total
Lapa
Group
Open
Group
ORa
11
4
7
5.25
Relative
Risk
95% CIa
P
Value
.08
Cases with complications, female, n
5
3
2
5.11
.36
Mortality at 30 d, male, n
1
0
1
3.46
.90
Mortality at 30 d, female, n
0
0
0
5.20
.64
Mortality at 12 m, male, n
2
0
2
7.60
.46
Mortality at 12 m, female, n
1
0
1
13.0
.55
IVa pain medications 5 d, male
7
3
4
2.67
.49
IV pain medications 5 d, female
3
2
1
3.0
.98
ICU stay 5 d, male
5
2
3
2.83
.57
ICU stay 5 d, female
3
1
2
16.67
.09
Measures of outcome, n
a
Hospital stay 10 d, male
8
2
6
8.5
.04
Hospital stay 10 d, female
1
1
0
2.5
.56
Postoperative ileus 4 d, male
3
0
3
12.67
.17
Postoperative ileus 4 d, female
1
1
0
2.5
.56
Pleural effusion, male
1
0
1
3.45
.90
Pleural effusion, female
1
0
1
13.0
.55
Incisional infection, male
2
0
2
7.6
.46
Total No. of specific complications
Incisional infection, female
0
0
0
5.2
.64
Incisional hernia, male
1
0
1
3.46
.90
Incisional hernia, female
3
1
2
16.67
.09
Hematoma requiring drainage, male
1
0
1
3.46
.90
Hematoma requiring drainage, female
0
0
0
5.2
.64
Abscess requiring drainage, male
1
0
1
3.46
.90
Abscess requiring drainage, female
0
0
0
5.2
.64
Upper GIa bleed requiring EGD/epia, male
2
1
1
1.64
.68
Upper GI bleed requiring EGD/epi, female
0
0
0
5.2
.64
Bile duct stricture requiring ERCPa, male
1
0
1
3.46
.90
Bile duct stricture requiring ERCP, female
0
0
0
5.2
.64
CBDa obstruction, male
1
0
1
3.46
.90
CBD obstruction, female
0
0
0
5.2
.64
Bile leak, male
0
0
0
1.58
.42
Bile leak, female
1
1
0
2.5
.56
Ascites requiring drainage, male
4
2
2
1.7
.96
Ascites requiring drainage, female
1
1
0
2.5
.56
Retained drain requiring procedure, male
1
1
0
0.75
.49
Retained drain requiring procedure, female
0
0
0
5.2
.64
JSLS (2013)17:46 –55
53
Complications of Liver Resection: Laparoscopic Versus Open Procedures, Slakey DP et al.
Table 5. (continued)
Complications by Sex
Relative
Risk
95% CIa
P
Value
Having a complication in open group vs lap
group, male
2.77
0.66–11.52
.28
Having a complication in open group vs lap
group, female
3.47
0.46–26.37
.52
Having [me]1 measure of poor outcome in
open group vs lap group, male
3.62
1.15–11.37
.05
Having [me]1 measure of poor outcome in
open group vs lap group, female
3.12
0.56–17.46
.40
Total
Lapa
Group
Open
Group
ORa
a
CBD⫽common bile duct; CI⫽confidence interval; EGD/epi⫽esophagogastroduodenoscopy/episode; ERCP⫽endoscopic retrograde cholangiopancreatography; GI⫽gastrointestinal; ICU⫽ intensive care unit; IV⫽intravenous; Lap⫽laparoscopic; OR⫽odds ratio.
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1. Troisi R, Montalti R, Smeets P, et al. The value of laparoscopic liver surgery for benign hepatic tumors. Surg Endosc.
2008;22:38 – 44.
2. Samama G, Chiche L, Brefort JL, Le Roux Y. Laparoscopic
anatomical hepatic resection. Report of four left lobectomies for
solid tumors. Surg Endosc. 1998;12(1):76 –78.
11. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary
Pancreat Surg. 1998;12:351–355.
12. Biertho L, Waage A, Gagner M. Laparoscopic hepatectomy.
Ann Chir. 2002;127(3):164 –170.
13. Dagher I, Proske JM, Carloni A, Richa H, Tranchart H, Franco
D. Laparoscopic liver resection: results for 70 patients. Surg
Endosc. 2007;21:619 – 624.
3. Rau HG, Buttler E, Meyer G, Schardey HM, Schildberg FW.
Laparoscopic liver resection compared with conventional partial
hepatectomy-a prospective analysis. Hepatogastroenterology.
1998;45:2333–2338.
14. Borzellino G, Ruzzenente A, Minicozzi AM, Giovinazzo F,
Pedrazzani C, Guglielmi A. Laparoscopic hepatic resection. Surg
Endosc. 2006;20:787–790.
4. Katkhouda N, Hurwitz M, Gugenheim J, et al. Laparoscopic
management of benign solid and cystic lesions of the liver. Ann
Surg. 1999;229(4):460 – 466.
15. Cherqui D, Husson E, Hammoud R, et al. Laparoscopic liver
resections: a feasibility study in 30 patients. Ann Surg. 2000;232:
753–762.
5. Descottes B, Glineur D, Lachachi F, et al. Laparoscopic liver
resection of benign liver tumors. Surg Endosc. 2003;17(1):23–30.
16. Rogula T, Gagner M. Current status of the laparoscopic
approach to liver resection. J Long Term Eff Med Implants.
2004;14:23–31.
6. Gagner M, Rheault M, Dubuc J. Laparoscopic partial hepatectomy for liver tumor. Surg Endosc. 1992;6:97–98.
7. Azagra JS, Goergen M, Gilbart E, Jacobs D. Laparoscopic
anatomical (hepatic) left lateral segmentectomy: technical aspects. Surg Endosc. 1996;10:758 –761.
8. Cherqui D, Chouillard E, Laurent A, Tayar C. Hépatectomies par abord coelioscopique. EMC Tech Med Chir. 2006;
3(40 –768):1– 8.
9. Morino M, Morra I, Rosso E, Miglietta C, Garrone C. Laparoscopic vs open hepatic resection: a comparative study. Surg
Endosc. 2003;17(12):1914 –1918.
10. KT Clearinghouse, Centre for Evidence-Based Medicine
(2000 –2012). Stats calculator. Available at: http://ktclearinghouse.ca/cebm/practise/ca/calculators/statscalc.
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May 29, 2012.
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17. Simillis C, Constantinides VA, Tekkis PP, et al. Laparoscopic versus open hepatic resections for benign and
malignant neoplasms-a meta-analysis. Surgery. 2007;141:203–
211.
18. Cho JY, Han HS, Yoon YS, Shin SH. Feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments of the liver, with a special reference to overcoming current limitations on tumor location. Surgery. 2008;
144:32–38.
19. Takayama T, Makuuchi M, Kubota K, et al. Randomized
comparison of ultrasonic vs clamp transection of the liver. Arch
Surg. 2001;136:922–928.
20. Vibert E, Perniceni T, Levard H, Denet C, Shahri NK, Gayet
B. Laparoscopic liver resection. Br J Surg. 2006;93:67–72.
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21. Wu CC, Ho WM, Cheng SB, et al. Perioperative parenteral
tranexamic acid in liver tumor resection: a prospective randomized trial toward a “blood transfusion”–free hepatectomy. Ann
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2003;138:763–769.
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assessment of the safety and benefit of laparoscopic liver resections. J Hepatobiliary Pancreat Surg. 2002;9:242–248.
30. Bachellier P, Rosso E, Pessaux P, et al. Risk factors for liver
failure and mortality after hepatectomy associated with portal
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24. John TG, Greig JD, Crosbie JL, Miles WF, Garden OJ. Superior staging of liver tumors with laparoscopy and laparoscopic
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31. Huang MT, Lee WJ, Wang W, Wei PL, Chen RJ. Handassisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe: initial experience. Ann Surg.
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25. Rahusen FD, Cuesta MA, Borgstein PJ, et al. Selection of
patients for resection of colorectal metastases to the liver using
diagnostic laparoscopy and laparoscopic ultrasonography. Ann
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26. Cherqui D, Laurent A, Tayar C, et al. Laparoscopic liver
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JSLS (2013)17:46 –55
55
SCIENTIFIC PAPER
Robotic Liver Resection: Initial Experience With
Three-Arm Robotic and Single-Port Robotic Technique
Emad Kandil, MD, Salem I. Noureldine, MD, Bob Saggi, MD, Joseph F. Buell, MD
ABSTRACT
INTRODUCTION
Background and Objective: Robotic-assisted surgery offers a solution to fundamental limitations of conventional
laparoscopic surgery, and its use is gaining wide popularity. However, the application of this technology has yet to
be established in hepatic surgery.
Over the past decade, minimally invasive liver surgery has
gained acceptance with proliferation worldwide. This was
a slow process, evolving from small peripheral resections
to formal hepatic lobectomies. Significant skepticism and
often vocal resistance were observed during this evolution. Not until several large series and a consensus statement were published did laparoscopic hepatic surgery
achieve a routine place in hepatic surgery.1– 4 Several subsequent studies have confirmed the oncologic equivalence of laparoscopic liver resection with open liver resection. In this setting, laparoscopic liver resection has
become the standard of care for left lateral sectionectomy.
Recent studies have confirmed the benefits of laparoscopic liver resection in patients undergoing repeat hepatectomy or as a bridge to subsequent liver transplantation.3,5 The benefits of laparoscopic liver resection, which
include shorter operative and recovery times, less blood
loss, and a lower incidence of postoperative adhesions,
make this technique highly desirable.2,4 –7
Methods: A retrospective analysis of our prospectively
collected liver surgery database was performed. Over a
6-month period, all consecutive patients who underwent
robotic-assisted hepatic resection for a liver neoplasm
were included. Demographics, operative time, and morbidity encountered were evaluated.
Results: A total of 7 robotic-assisted liver resections were
performed, including 2 robotic-assisted single-port access
liver resections with the da Vinci-Si Surgical System (Intuitive
Surgical Sunnyvalle, Calif.) USA. The mean age was 44.6
years (range, 21– 68 years); there were 5 male and 2 female
patients. The mean operative time (⫾ SD) was 61.4 ⫾ 26.7
minutes; the mean operative console time (⫾ SD) was
38.2 ⫾ 23 minutes. No conversions were required. The mean
blood loss was 100.7 mL (range, 10 –200 mL). The mean
hospital stay (⫾ SD) was 2 ⫾ 0.4 days. No postoperative morbidity related to the procedure or death was encountered.
Conclusion: Our initial experience with robotic liver resection confirms that this technique is both feasible and safe.
Robotic-assisted technology appears to improve the precision and ergonomics of single-access surgery while preserving the known benefits of laparoscopic surgery, including
cosmesis, minimal morbidity, and faster recovery.
Key Words: Robotic liver resection, Minimally invasive liver
surgery, Robotic hepatectomy, SILS, Single port, Single access.
Division of Endocrine and Oncological Surgery, Tulane Transplant Institute, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
(all authors).
This research and work was fully supported by Tulane University Medical Center.
Dr Buell is a consultant for both Ethicon and Coviden.
Address correspondence to: Joseph F. Buell, MD, Department of Surgery, Tulane
University School of Medicine, 1415 Tulane Ave, TW 35, New Orleans, LA, 70112
USA. Telephone: 504 988 0783, Fax: 504 988 7510, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317671
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
56
Despite the numerous benefits of laparoscopic liver resections, there are several inherent limitations to this technique. These include restricted instrument motion, 2-dimensional imaging, complex ergonomics, and unstable
operative exposure.8,9 Robotic-assisted technology appears to offer key solutions to these same fundamental
limitations of conventional laparoscopic surgery.10 –17 Unfortunately, as was witnessed with initial laparoscopic
liver resections, the application of robotic technology in
liver surgery has been controversial. To date, few large
series of robotic liver resection have been reported. This
study examines our group’s preliminary experience with
robotic-assisted liver resections.
METHODS
A retrospective review of our prospectively collected liver
surgery database was conducted to include all robotic-assisted liver resections performed between February and August 2011 at a tertiary care center. Demographics, operative
time, intraoperative blood loss, pathology, and postoperative
outcome were evaluated. Liver resections were defined according to the International Hepato-Pancreato-Biliary Asso-
JSLS (2013)17:56 – 62
ciation’s Couinaud classification.18 Resection for benign tumors was considered only for symptomatic lesions or for the
presence of uncertainty at preoperative biopsy or radiologic
evaluation. Resection of colorectal liver metastases was considered only in the absence of peritoneal carcinomatosis or
unresectable extrahepatic disease. In patients with hepatocellular cancers, only those with well-compensated cirrhosis
(Child-Pugh class A/B, low grade) with no signs of severe
portal hypertension (esophageal varices ⬎F2) were eligible
for robotic liver resections.
Surgical Technique
Patient and trocar positioning for robotic-assisted
laparoscopic liver resection. While under general anesthesia, the patient was placed in a supine position, and 4
trocars were inserted. A 12-mm trocar port for the robotic
camera was placed above the umbilicus by the Hassan technique. Two 8-mm robotic ports were placed at the left upper
quadrant and right upper quadrant, and a 12-mm trocar port
was placed at the midclavicular line lateral to the umbilicus
for the assistant.
Intraoperative ultrasonography was performed with a 7.5MHz, 10-mm SSD-1700 linear transducer (BK Medical,
Peabody, MA, USA) to examine the remaining liver for
undetectable lesions and obtain adequate surgical resection margins. The da Vinci-Si Surgical System (Intuitive
Surgical, Sunnyvalle, CA, USA) robot was brought into
position over the right shoulder of the patient and docked
after placement of the ports. The operator moved to the
robot console to control the robotic arms. The assisting
surgeon remained at the patient’s side to change robotic
instruments and performed clipping, stapling, and mobilization through the assistant 12-mm trocar. Figure 1 depicts the position of the trocars. A vascular reticulating
endoscopic stapler (Coviden, Norwalk, CT, USA) was used
to divide the ligamentum teres hepatis and to control the
main branches of the portal veins (Figure 2A). The endoscopic articulating stapler allowed safe control of the major
vessels from the hepatic parenchyma (Figure 2B). A Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH, USA)
was used to incise the capsule, to divide the parenchyma,
and to perform dissection (Figure 2C). A grasper was used
to retract the liver. An endoscopic suction device was used to
aid in the dissection of the blood vessels. Bile leaks and
hemostasis were completed with argon plasma coagulation
(Figure 2D).
Patient and trocar positioning for robotic-assisted
single-port access liver resection. While under gen-
Figure 1. Image of abdomen showing positioning of trocars.
eral anesthesia, the patient was placed in a supine position. An incision measuring approximately 3 cm was made
above the umbilicus. Dissection was performed down
through the fascia to the peritoneum. A single-port device
(Applied Medical, Rancho Santa Margarita, CA, USA) was
then placed once the abdomen was entered. The single
port included 3 small ports that were used for the placement of the robotic arms. The robotic arms were equipped
with a Harmonic scalpel, a Prograsper (Intuitive Surgical,
Sunnyvale, CA, USA), and a 12-mm camera. In addition, a
12-mm port was placed in the lower left quadrant for the
assistant.
The abdomen was then insufflated with 4 L of carbon
dioxide. Intraoperative ultrasonography was performed to
examine the remaining liver to search for undetectable
lesions and obtain adequate surgical resection margins.
The da Vinci-Si Surgical System robot was brought into
position and docked over the patient’s right shoulder after
port placements. The operator moved to the console to
control the robotic arms. The assisting surgeon remained
at the patient’s side to change robotic instruments and
perform clipping, stapling, and mobilization through the
assistant 12-mm trocar. Figure 3A depicts the position of
the trocars. Intraoperative ultrasonography was performed to examine the remaining liver to search for undetectable lesions and obtain adequate surgical resection
margins. The Harmonic scalpel was used to incise the
capsule and to perform dissection. The grasper was used
to retract the liver. The main branches of the portal veins
were controlled with the application of the endoscopic
articulating stapler by use of a white cartridge. The hepatic
surfaces were inspected for any evidence of bile leaks,
JSLS (2013)17:56 – 62
57
Robotic Liver Resection: Initial Experience With Three-Arm Robotic and Single-Port Robotic Technique, Kandil E et al.
Figure 2. A. The transected falciform ligament was used to expose the underside of the liver, with dissection of the inferior surface.
B. The endoscopic articulating stapler allowed safe control of the major vessels. C. The capsule was incised with the Harmonic scalpel.
D. Argon plasma coagulation.
and hemostasis was completed with argon plasma coagulation as needed. Figure 3B shows the surgical incision
used for the single-port device.
RESULTS
Seven of 29 liver resections (24%) were performed with
the da Vinci Si-Surgical System during the 6-month study
period. Table 1 depicts demographic information, indications for surgery, and characteristics of the lesions. The
mean age was 44.6 years (range, 21– 68 years), and 71.4%
of patients were men. The mean total operative time (⫾
SD) was 61.4 ⫾ 26.7 minutes; the mean operative console
time (⫾ SD) was 38.2 ⫾ 23 minutes. The mean blood loss
was 100.7 mL (range, 10 –200 mL). The mean hospital stay
(⫾ SD) was 2 ⫾ 0.4 days (Table 2). No postoperative
morbidity related to the procedure or death was encountered. Successful resection was established in all patients
58
without requiring a conversion to the traditional open
approach. No patients required a blood transfusion.
The latter 2 cases were performed by a robotic-assisted
single-port access technique. The mean estimated blood loss
(⫾ SD) was 22.5 ⫾ 10.6 mL. The mean robot docking time
(⫾ SD) was 7 ⫾ 1.7 minutes, the mean operative console
time (⫾ SD) was 33.5 ⫾ 12.0 minutes, and the mean total
operative time (⫾ SD) was 60.5 ⫾ 13.4 minutes.
DISCUSSION
Over the past decade, laparoscopic liver resection has
become an acceptable technique for the management of
benign tumors, colorectal metastases, and hepatocellular
cancers. Multiple studies have confirmed that laparoscopic
liver resection results in a shorter operative time, less blood
loss, and a shorter length of hospital stay. Despite consider-
JSLS (2013)17:56 – 62
control hemorrhage through the use of temporary digital
control or direct application of pressure.3,21,22 However, the
use of hand-assisted devices or hybrid incisions leads to a
greater interruption of the abdominal wall, diluting the potential benefits of minimally invasive surgery.
Robotic-assisted surgery is a new tool that provides a
novel way of controlling hemorrhage through stabilized
suture repair. Robotic surgery uniquely allows free articulation of the suturing arms, subsequently minimizing the
difficulties faced when one is performing conventional
laparoscopic liver surgery.10 –17 The da Vinci-Si Surgical
System provides surgeons with intuitive translation of the
instrument handle to the tip movement, eliminating the
mirror-image effect. In addition, a remotely controlled
camera provides improved visualization with high-quality
3-dimensional images and a stable camera platform with
scaling, tremor filtering, and coaxial alignment of the eyes
and EndoWrist, with a 360° range of motion, allowing
more precise operating techniques (Asheville, NC,
USA).5,23–26 Robotic-assisted laparoscopic liver resection is
a procedure in evolution. This operative platform potentially increases the diversity of laparoscopic liver resections able to be performed by a surgeon. The ease of
robotic suturing opens the surgeon’s ability to access the
biliary system and repair potential vascular injuries.
Figure 3. A. Positioning of single-access port. B. Abdomen
postoperatively.
able controversy, no increases in operative complications or
inferior oncologic outcomes were observed. These clinical
findings suggest that laparoscopic resection could be expanded to most hepatic resections, including cirrhotic patients and all malignancies.19,20
Unfortunately, conventional laparoscopic liver surgery
has several inherent limitations.15 These include challenging exposure, suboptimal visualization, and the complexity of vascular control during major hepatic hemorrhage.
Control of major vascular hemorrhage is one of the most
important issues in hepatic surgery. These challenges
made the use of hand-assisted devices and laparoscopicassisted open resection (hybrid) attractive options. These
devices and techniques afford several benefits, including the
ability to use the surgeon’s hand to stabilize, mobilize, and
However, significant criticism exists over the use of robotic-assisted surgery for liver resection. As was experienced
in the early application of laparoscopic liver surgery, significant concerns over safety and efficacy exist. Robotic
surgery does in fact separate the surgeon from having
direct contact with the patient. This results in significant
fear regarding hemorrhage and, in particular, concern
about delays in conversion inherent with the use of the
robot. Currently, robotic instrumentation has evolved and
has become diversified but still lacks a stapling platform or
a robotic argon coagulator, necessitating the addition of a
qualified surgical assistant. In robotic liver surgery, an
experienced assistant surgeon is required to suction, retract, and introduce the vascular stapler. As was seen with
the evolution of conventional laparoscopic liver resection,
a significant learning curve exists. Robotic liver surgery
requires significant experience with the robot both as an
assistant and on the console. Competency in robotic liver
surgery will require experience in robotic surgery and
open hepatic surgery, as well as advanced laparoscopic
liver resection. Despite all of these concerns, several small
series of robotic-assisted liver resections have been reported with limited conversion rates, reasonable blood
loss, and minimal postoperative morbidity, even for major
hepatectomy.14,27,28 However, when compared with con-
JSLS (2013)17:56 – 62
59
Robotic Liver Resection: Initial Experience With Three-Arm Robotic and Single-Port Robotic Technique, Kandil E et al.
Table 1.
Demographic Information, Indications for Surgery, and Characteristics of Lesions for 7 Patients in Cohort
Case
Sequence
Sex
Age,
yr
Body Mass
Index
Diagnosis
Tumor
Size, cm
Resection
Complications
Length of
Stay, d
1
Male
45
36.5
Hepatic adenoma
6
Left lobe
None
2
2
Male
58
32.1
Hepatoma
1.5
Bisegment 7 and 8
None
2
3
Male
21
26.4
Focal nodular hyperplasia
8
Left lateral
sectionectomy
None
1
4
Male
28
26.4
Hodgkin lymphoma
1
Dx wedge segment 2
Atelectasis
1
5
Male
28
26.4
Hodgkin lymphoma
1
Dx wedge segment 3
None
1
6
Female
64
28.1
Adenoma (procedure
performed for suspected
metastases)
1.5
Single port: left lateral
segmentectomy
Delirium and
tremors
5
7
Female
68
40.4
Metastatic
adenocarcinoma
(colorectal mass)
1.4
Single port: left lateral
segmentectomy
None
2
Table 2.
Intraoperative Data for Patients in Cohort
Case Sequence
Estimated Blood
Loss, mL
Console Time,
min
Docking Time,
min
ORa Time,
min
1
200
10
60
90
2
200
6
65
86
3
200
7
55
79
4
10
6
10
26
5
50
6
11
28
6 (single-port access)
15
9
25
51
7 (single-port access)
30
11
42
70
a
OR⫽operating room.
ventional laparoscopic liver resection, the robotic approach appears to provide similar outcomes.29
An additional potential advantage of robotic-assisted technology is the ability to perform a hepatic resection
through the single-port access approach. There are significant data to support the use of single-port laparoscopy
because it has gained momentum in multiple disciplines,
including laparoscopic cholecystectomy, colectomy, and
nephrectomy.30 –33 The advantages of single-port laparoscopy have been reported as decreased morbidity, postoperative pain, shorter hospital stay, and faster recovery, in
addition to a cosmetic advantage.33 However, to date,
there have only been a few case reports using single-port
laparoscopic surgery for liver resections because of the
complexity of such procedures and the significant and
60
often cumbersome crisscrossing “sword fighting” of instruments during triangulation inside the abdominal cavity. These significant prerequisites restrain the enthusiasm
of many surgeons, making single-port laparoscopic liver
resections a rather limited field.31
The use of the robotic control through the single-access
port appears to limit the occurrence of crisscrossing, improving the ability to use this instrumentation, and allows
for a more meaningful use of 3 arms without the frustration or added difficulty with this approach. A recent study
from Japan confirmed that robotic single-port liver resection was feasible in a porcine model.34 This study subsequently concluded that single-port laparoscopic liver resection was technically feasible and safe. In our study we
elected to use the single-access approach in the last 2
JSLS (2013)17:56 – 62
procedures to minimize trauma and port-related complications, such as organ damage, adhesions, bleedings,
wound infections, and hernias.33,35
The potential benefits of robotic-assisted single-port access
surgery remain to be proven; however, potential therapeutic
benefits might include less postoperative pain, a shorter
hospital stay, and faster recovery, in addition to the cosmetic
advantage. The decrease in abdominal wall trauma could be
specifically useful for cirrhotic patients, provided that the
incision is made in the supraumbilical location to avoid
bleeding from large umbilical veins and to allow a secure
closure. The use of the GelPort (Ranchos Margarita, CA,
USA) device makes it possible to use large instruments, such
as standard laparoscopic ultrasonography probes, LigaSure
(Boulder, CO, USA) devices, and staplers. This facilitates the
procedure and helps minimize blood loss.
6. Morino M, Morra I, Rosso E, Miglietta C, Garrone C. Laparoscopic vs open hepatic resection: a comparative study. Surg
Endosc. 2003;17(12):1914 –1918.
7. Polignano FM, Quyn AJ, de Figueiredo RS, Henderson NA, Kulli C,
Tait IS. Laparoscopic versus open liver segmentectomy: prospective,
case-matched, intention-to-treat analysis of clinical outcomes and cost
effectiveness. Surg Endosc. 2008;22(12):2564–2570.
8. Cadiere GB, Himpens J, Germay O, et al. Feasibility of
robotic laparoscopic surgery: 146 cases. World J Surg. 2001;
25(11):1467–1477.
9. Cadière G, Himpens J, Vertruyen M, et al. Evaluation of
telesurgical (robotic) NISSEN fundoplication. Surg Endosc. 2001;
(9):918 –923.
10. Giulianotti PC, Coratti A, Angelini M, et al. Robotics in
general surgery: personal experience in a large community hospital. Arch Surg. 2003;138:777–784.
11. Vibert E, Denet C, Gayet B. Major digestive surgery using a
remote-controlled robot: the next revolution. Arch Surg. 2003;
138:1002–1006.
CONCLUSION
Our group has shown that robotic-assisted laparoscopic liver
resection is both feasible and safe. We also have reported the
first 2 cases of robotic-assisted single-port access liver resection. Our initial experience confirms that robotic liver resection can be practical in select cases. We found no higher
incidence of conversion, morbidity, or even death. Robotic
liver surgery allows potential advantages not otherwise inherent in conventional laparoscopic liver resection. A robotic
approach to single-port access appears technically feasible
and safe. Nevertheless, this remains a challenging procedure,
requiring both hepatobiliary and laparoscopic experience.
Additional experiences are mandatory to assess and examine
the safety of this emerging technique.
References:
1. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection—2,804 patients. Ann Surg. 2009;250(5):831–841.
2. Buell JF, Thomas MT, Rudich S, et al. Experience with more
than 500 minimally invasive hepatic procedures. Ann Surg. 2008;
248:475– 486.
3. Buell JF, Cherqui D, Geller DA, et al. The international
position on laparoscopic liver surgery: the Louisville Statement,
2008. Ann Surg. 2009;250(5):825– 830.
4. Cannon RM, Brock GN, Marvin MR, Buell JF. Laparoscopic
liver resection: an examination of our first 300 patients. J Am Coll
Surg. 2011;213(4):501–507.
5. Panaro F, Piardi T, Cag M, Cinqualbre J, Wolf P, Audet M.
Robotic liver resection as a bridge to liver transplantation. JSLS.
2011;15(1):86 – 89.
12. Choi SB, Park JS, Kim JK, et al. Early experiences of roboticassisted laparoscopic liver resection. Yonsei Med J. 2008;49:632–638.
13. Patriti A, Ceccarelli G, Bartoli A, Spaziani A, Lapalorcia LM,
Casciola L. Laparoscopic and robot-assisted one-stage resection
of colorectal cancer with synchronous liver metastases: a pilot
study. J Hepatobiliary Pancreat Surg. 2009;16(4):450 – 457.
14. Giulianotti PC, Coratti A, Sbrana F, et al. Robotic liver surgery: results for 70 resections. Surgery. 2011;149:29 –39.
15. Idrees K, Bartlett DL. Robotic liver surgery. Surg Clin North
Am. 2010;90:761–774.
16. Chan OC, Tang CN, Lai EC, Yang GP, Li MK. Robotic hepatobiliary and pancreatic surgery: a cohort study. J Hepatobiliary
Pancreat Sci. 2011;18(4):471– 480.
17. Lai EC, Tang CN, Yang GP, Li MK. Multimodality laparoscopic liver resection for hepatic malignancy—from conventional total laparoscopic approach to robot-assisted laparoscopic
approach. Int J Surg. 2011;9:324 –328.
18. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary
Pancreat Surg. 2005;12(5):351–355.
19. Topal B, Fieuws S, Aerts R, Vandeweyer H, Penninckx F.
Laparoscopic versus open liver resection of hepatic neoplasms:
comparative analysis of short-term results. Surg Endosc. 2008;
22(10):2208 –2213.
20. Vibert E, Perniceni T, Levard H, Denet C, Shahri NK, Gayet
B. Laparoscopic liver resection. Br J Surg. 2006;93(1):67–72.
21. Cuschieri A. Laparoscopic hand-assisted hepatic surgery.
Semin Laparosc Surg. 2001;8:104 –113.
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22. Koffron AJ, Auffenberg G, Kung R, Abecassis M. Evaluation
of 300 minimally invasive liver resections at a single institution:
less is more. Ann Surg. 2007;246:385–392; discussion 92–94.
23. Vidovszky TJ, Smith W, Ghosh J, Ali MR. Robotic cholecystectomy: learning curve, advantages, and limitations. J Surg Res.
2006;136:172–178.
24. D’Annibale A, Morpurgo E, Fiscon V, et al. Robotic and
laparoscopic surgery for treatment of colorectal diseases. Dis
Colon Rectum. 2004;47(12):2162–2168.
25. Camarillo DB, Krummel TM, Salisbury JK Jr. Robotic technology in surgery: past, present, and future. Am J Surg. 2004;
188:2S–15S.
26. Hashizume M, Tsugawa K. Robotic surgery and cancer: the
present state, problems and future vision. Jpn J Clin Oncol.
2004;34(5):227–237.
27. Choi GH, Choi SH, Kim SH, et al. Robotic liver resection:
technique and results of 30 consecutive procedures. Surg Endosc. 2012;26(8):2247–2258.
28. Lai EC, Tang CN, Li MK. Robot-assisted laparoscopic hemihepatectomy: technique and surgical outcomes. Int J Surg. 2012;
10(1):11–15.
29. Berber E, Akyildiz HY, Aucejo F, Gunasekaran G,
Chalikonda S, Fung J. Robotic versus laparoscopic resection of
liver tumours. HPB (Oxford). 2010;12(8):583–586.
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Extending the limitations of liver surgery: outcomes of initial
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32. Aikawa M, Miyazawa M, Okamoto K, et al. Single-port laparoscopic hepatectomy: technique, safety, and feasibility in a
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33. Gaujoux S, Kingham TP, Jarnagin WR, D’Angelica MI, Allen
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single-incision cholecystectomy and hepatectomy using singlechannel GelPort access. J Hepatobiliary Pancreat Sci. 2011;
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JSLS (2013)17:56 – 62
SCIENTIFIC PAPER
Sleeve Gastrectomy as a Stand-alone Bariatric
Operation for Severe, Morbid, and Super Obesity
Dan Eisenberg, MD, MS, Anna Bellatorre, MA, Nina Bellatorre, RN, MS
ABSTRACT
Background: The laparoscopic sleeve gastrectomy (LSG)
is emerging as an effective bariatric operation and is especially attractive in high-risk populations. In this study
we examine the efficacy of LSG as a stand-alone operation
in the veteran population.
Methods: This is a retrospective review of consecutive
patients who underwent LSG as a stand-alone procedure
at the Palo Alto Veterans Affairs medical center with a
minimum 12-month follow-up.
Results: Of 205 patients undergoing bariatric surgery, 71
patients had a sleeve gastrectomy, 40 of whom had the
operation performed at least 12 months previously. Thirtysix (90%) were available for 1-year follow-up, with a mean
follow-up duration of 22 months (range: 12– 42), a mean
body mass index of 48.3 kg/m2, and an 83% male population. Mean percent excess weight loss was 61% at an
average of 22 months, with no significant difference between severely obese, morbidly obese, and super obese
cohorts. Diabetes remission was seen in 56% of patients,
hypertension remission in 51.6%, and obstructive sleep
apnea remission in 46.4%, and gastroesophageal reflux
disease improved or did not change in 83%. Medication
use significantly decreased after surgery.
Conclusion: LSG is safe and effective as a stand-alone
bariatric operation in the high-risk veteran population. It
is effective in severely obese, morbidly obese, and super
obese patients. LSG induces remission or improvement in
comorbidities of nearly all patients, translating to a decrease in medication use.
Department of Surgery, Stanford School of Medicine, Stanford, CA, USA (Dr.
Eisenberg).
Department of Surgery, Palo Alto VA Health Care System, Palo Alto, CA, USA (Drs.
Eisenberg, N. Bellatorre).
Department of Sociology, Univeristy of Nebraska-Lincoln, Lincoln, NE, USA (Dr. A.
Bellatorre).
Address correspondence to: Dan Eisenberg, MD, MS, Department of Surgery,
Stanford School of Medicine, Palo Alto VA HCS, 3801 Miranda Avenue, Palo Alto,
CA 94304. Telephone: 650-852-3461. E-mail: [email protected]
DOI: 10.4293/108680812X13517013317077
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
Key Words: Obesity, Sleeve gastrectomy, Bariatric surgery, Veterans, Diabetes, Hypertension, Obstructive sleep
apnea, Gastroesphageal reflux.
INTRODUCTION
The problem of obesity in the United States has reached
epidemic proportions. It has increased over the past few
decades, and it is now estimated that ⬎30% of American
adults are obese, and nearly two-thirds are either overweight or obese.1,2 The prevalence of severe and morbid
obesity (corresponding to a body mass index [BMI] ⬎35
kg/m2 and 40 kg/m2, respectively) has increased as well.
Bariatric surgery, meanwhile, has emerged as the only
effective and durable treatment of morbid obesity. Bariatric surgery consistently induces durable weight loss and
reliably causes improvement or remission of comorbid
diseases, such as diabetes mellitus and hypertension
(HTN).3–10 The prevalence of obesity is especially high in
the veteran population, and veterans are an especially
high-risk bariatric surgical group.11–13
Laparoscopic sleeve gastrectomy (LSG), first described as
a modification of the biliopancreatic diversion-duodenal
switch (BPD-DS), is emerging as a popular operation for
the treatment of morbid obesity, with acceptable morbidity and long-term weight loss compared with the laparoscopic Roux-en-Y gastric bypass (LRYGB) and adjustable
gastric band (AGB).14 –16 The advantages of this procedure
include lack of an intestinal bypass, thus avoiding gastrointestinal anastomoses, metabolic derangements, and internal hernias, shorter operating times, and no implantation of a foreign body.17 LSG has a favorable complication
profile,17–19 making it an especially attractive procedure
for higher-risk patients. It has been shown that male
gender, advanced age, higher BMI, and the presence of
multiple comorbidities are associated with higher risk of
morbidity and mortality after bariatric surgery.20,23 The
bariatric patient presenting to our Veterans Medical Center
is typically male, older, heavier, and has more comorbidities than the bariatric cohort in the general population,
representing a higher-risk bariatric surgical group.12 In this
study, we examined the efficacy of LSG as a single stand-
JSLS (2013)17:63– 67
63
Sleeve Gastrectomy as a Stand-Alone Bariatric Operation for Severe, Morbid, and Super Obesity, Eisenberg D et al.
alone bariatric operation in the veteran population, and
compared outcomes among severely obese, morbidly
obese, and super obese patients.
METHODS
After obtaining institutional review board approval, we
reviewed the medical records of consecutive patients who
underwent bariatric surgery at the Palo Alto Veterans
Affairs (VA) Health Care System. All patients were followed before and after surgery by a dedicated multidisciplinary bariatric team including a bariatrician, bariatric
surgeon, dietitian, psychologist, and exercise physiologist.
Data for patients who had an LSG and a minimum of 12
months of follow-up were collected. These included patient demographic characteristics, weight, height, and comorbid conditions. After surgery, patients were followed
after 2 weeks, 2 months, 6 months, 12 months, and at least
annually thereafter.
Surgical Procedure
All operations were performed laparoscopically under
general anesthesia, with the patient in the supine position.
We used a 5-port technique with the bed in the reverseTrendelenburg position. The division of the vascular supply to the greater curvature of the stomach was begun 6
cm proximal to the pylorus and continued to the angle of
His, using the LigaSure device (Covidien, Norwalk, CT).
The gastrectomy was performed using an Echelon Flex
stapler (Ethicon, Somerville, NJ). The sleeve volume was
calibrated to an intralumenal 36-Fr endoscope. The green
staple load (4.1/60 mm) was used for the first 3 staple
firings, followed by gold staple loads (3.8/60 mm) to
complete the sleeve. SeamGuard (W.L. Gore, Flagstaff,
AZ) buttressing strips were used to reinforce the staple
line. The proximal resection line was performed 1 cm to
the left of the angle of His. An endoscopic air-leak test was
routinely performed at the conclusion of the operation,
and an upper gastrointestinal contrast study was performed on the first postoperative day before introduction
of oral liquid nutrition. All patients were discharged on a
standard liquid diet.
RESULTS
Of the 205 patients who underwent bariatric surgery, 71
patients had an LSG, of whom 40 had the operation
performed at least 12 months previously. Thirty-six (90%)
were available for 1-year follow-up, with a mean follow-up duration of 22 months (range: 12– 42). Thirty of
the patients (83%) were male and had a mean age of 53
years at the time of surgery. Patients with type 2 diabetes
represented 50% of the cohort, 84% had HTN, 78% had
obstructive sleep apnea, and 67.5% carried a diagnosis of
gastroesophageal reflux disease (GERD) (Table 1). Overall, patients had a mean of 5.2 preoperative comorbid
conditions, a mean calculated age-modified, Charlson comorbidity index score of 3, and were taking an average of
6.2 medications.
The mean BMI was 48.3 kg/m2: 25% were severely obese
(BMI 35–39 kg/m2), 31% were morbidly obese (BMI
40 – 49 kg/m2), and 44% were super obese (BMI ⬎50
kg/m2).
Early postoperative complications included urinary tract
infection (2.8%), urinary retention (8.4%), prolonged nausea (8.4%), and refractory HTN in 2.8%. There was 1
postoperative staple-line leak (2.8%) identified 8 months
after surgery in the distal sleeve and treated with partial
gastrectomy. One patient had intraoperative bleeding
from a splenic capsular tear that required conversion to
Table 1.
Patient Characteristics
Total
BMI 35–39
kg/m2
BMI 40–49
kg/m2
BMI 50⫹
kg/m2
N
36
9 (25%)
11 (31%)
16 (44%)
M/F (%)
83/17
88/12
55/45
94/6
Age (y)
53
57
51
52
Preoperative
BMI (kg/m2)
48.3
38.0
43.7
56.3
No.
comorbidities
5.2
5.0
5.7
5.0
DM (%)
18 (50)
5
6
7
HTN (%)
31 (84)
8
11
12
Statistical Analysis
OSA (%)
28 (78)
6
11
14
Group comparisons were performed using multiple regression and linear regression analyses, using Stata 11.0
software (StataCorp, College Station, TX); portions of the
means were compared using the ␹2 test.
GERD (%)
24 (67.5)
5
9
10
64
M ⫽ male; F ⫽ female; BMI ⫽ body mass index; DM ⫽ diabetes
mellitus; HTN ⫽ hypertension; OSA ⫽ obstructive sleep apnea;
GERD ⫽ gastroesophageal reflux disease.
JSLS (2013)17:63– 67
open for control. All other operations were completed
laparoscopically. There was no perioperative mortality.
GERD, GERD symptoms worsened in 17% after LSG, improved in 25%, and did not change in the majority (58%).
The mean percent excess weight loss (%EWL) for the
entire group was 61% at a mean follow-up of 22 months
(Table 2). Although the mean %EWL was highest for the
cohort with a BMI of 35 to 39 kg/m2 (71%), this was not
statistically significant (morbidly obese cohort 60% EWL,
super obese cohort 56% EWL; P⫽.113).
DISCUSSION
Total medication usage decreased from a mean of 6.2 to
3.8 (P⫽.002). Reduction of medication usage postoperatively correlated strongly with a preoperative diagnosis of
diabetes. In addition, a negative relationship between
percentage of excess weight loss and a previous diagnosis
of diabetes was identified. The presence of a previous
diagnosis of diabetes was the strongest single negative
predictor of %EWL. This finding is associated with a predicted 17.1-point reduction in the percentage of EWL
for patients with a previous diagnosis of diabetes relative to patients without diabetes (95% CI⫽2.16 –32. 03%;
P⫽.026).
Of the diabetic patients undergoing LSG, 56% had complete remission of diabetes (100% of patients had improvement or remission) (Table 3). The super obese
cohort had the largest percentage of diabetes remission
(71.4%). HTN resolved in 51.6% of the patients, whereas
46.4% of the patients with obstructive sleep apnea had
complete resolution. Of the 24 patients with a diagnosis of
Table 2.
Percent Excess Weight Loss for Each Weight Classification
%EWL
Total
BMI 35–39
kg/m2
BMI 40–49
kg/m2
BMI 50⫹
kg/m2
P
Value
61%
71%
60%
56%
.113
%EWL ⫽ percent excess weight loss.
Table 3.
Postoperative Remission of Comorbidities
Remission (%)
Improvement or
Remission (%)
DM
56.0
100
HTN
51.6
87
OSA
46.4
100
DM ⫽ diabetes mellitus; HTN ⫽ hypertension; OSA ⫽ obstructive sleep apnea.
LSG is increasing in popularity, and, despite limited longterm data, it is accepted as a safe and effective bariatric
operation and is especially attractive for the higher-risk
patient.21 The higher-risk patient is characterized by male
gender, increased age, and the presence of comorbidities
such as diabetes and HTN.22,23 We found the use of LSG as
a stand-alone bariatric procedure to be highly effective in
the US veteran population. This is especially significant
because the prevalence of obesity among American veterans is especially high. Three in 4 male veterans are
overweight or obese, and the prevalence of overweight
and obesity among veterans who use VA outpatient facilities is higher than in the general population.32 This veteran population is often a challenging bariatric surgical
group, representing a mostly male older cohort, with multiple comorbidities, compared with the general bariatric
population.13 Older age and male gender— both characteristics of the veteran bariatric surgical patient—are associated with adverse outcomes after bariatric surgery.23 In
addition, the bariatric patients at the Palo Alto VA center
described in this study were referred to our surgical center
from great distances, averaging more than 300 miles, posing
specific challenges for postoperative follow-up and treatment of late complications. Nonetheless, with a mean follow-up of 22 months in this study, we have shown %EWL
that compares favorably with multiple published results in
the nonveteran population undergoing LSG.16,17,24 Residing a
large distance from the medical and surgical center is typical
of VA patients but less common in the general population.
For this reason, it is valuable to identify a durable and
effective operation that has low early and late morbidity for
veteran patients who may not be able to easily access their
bariatric surgical team because of geographic limitations.
This makes the LSF as a stand-alone operation especially
attractive in this patient population.
Unlike the patients described in this study, large series of
LSG as a stand-alone procedure in the literature typically
describe a population that is mostly female and younger
with a lower BMI than the average veteran bariatric population.33 To our knowledge, this is the first study to
describe LSG as a stand-alone operation in veterans. Our
reported mean EWL compares favorably with published
results but is slightly less than the %EWL documented in
the general population. This may be a result of the demographic characteristics of the veteran patients, as described previously.
JSLS (2013)17:63– 67
65
Sleeve Gastrectomy as a Stand-Alone Bariatric Operation for Severe, Morbid, and Super Obesity, Eisenberg D et al.
We found that the preoperative obesity classification, patient gender, patient age, and presence of other preoperative comorbidities, other than diabetes, had no statistically significant effect on %EWL. The efficacy of LSG as a
stand-alone weight loss operation in the veteran population was seen in all BMI ranges. In comparing the results
in patients with severe obesity, morbid obesity, and super
obesity, we found that LSG as a stand-alone procedure
was most effective in the cohort with a BMI of 35 to 39
kg/m2, but this was not statistically significant. However,
we did note that more patients in this group were able to
achieve a normal BMI after LSG than patients in other
groups. This suggests that in addition to the morbidly and
super obese groups, the LSG is a very effective standalone operation for the severely obese population. All but
one of the patients with BMI ⬎50 kg/m2 were satisfied
with total weight loss after a minimum of 1 year. Despite
a high satisfaction rate overall, it appears that it may be
difficult for the super obese population to reach a BMI
⬍30 kg/m2 with LSG alone. Chopra et al25 found similar
results 24 months after surgery, with a greater %EWL in
the cohort of patients with a BMI ⬍50 kg/m2 compared
with those with BMI ⬎50 kg/m2, although their results
were not statistically significant. In this study, we also
showed that there is no significant difference between the
morbidly obese and the severely obese.
We found that LSG alone also resulted in significant improvement in obesity-related comorbid conditions, in a
manner similar to that seen with the general population
undergoing LSG, and compares favorably with patients
undergoing LRYGB.26 Nearly all patients with diabetes,
HTN, or obstructive sleep apnea saw improvement in
their comorbidities, and a large proportion had complete
remission. This was seen in all weight categories. Casella
et al27 demonstrated that duration of diabetes for ⬎10
years before surgery predicts lower rates of complete
remission postoperatively. It is possible that we saw this
effect in our study population because only 56% had
complete remission of type 2 diabetes. Interestingly, 50%
of the diabetic patients in this study were taking injectable
insulin preoperatively, but in this relatively small cohort it
did not correlate with lack of remission postoperatively.
There is disagreement in the literature with respect to the
effect of LSG on GERD symptoms.25,28,29 In the present
study, we found that a minority of patients had exacerbation of GERD symptoms, whereas most of the patients had
no change in GERD symptoms.
Overall improvement in comorbidities translated to a significant decrease in total medication requirements after
66
surgery in all weight groups. LSG has previously been
shown to decrease diabetes and HTN medication requirements after surgery.30 In this study, we demonstrated a
decrease in all medications, although we excluded vitamin supplements.
There were no mortalities, and there was a favorable
complication profile. We had a single leak in the postoperative period, also comparing favorably with published
results.24 Interestingly, our leak presented several months
after surgery and was identified in the distal portion of the
gastric sleeve. This is in contrast to most reported leaks
that are identified in the proximal stomach and often take
a long time to heal.31 Because of the location in this
specific case, we treated the leak by partial gastrectomy
and drainage. Other complications appeared in the immediate postoperative period and were easily treated with
nonoperative measures.
CONCLUSION
LSG is safe and effective as a stand-alone bariatric
treatment in members of the high-risk veteran population group who are severely, morbidly, and super
obese. In addition, LSG induces remission or improvement in comorbidities of nearly all patients and in all
obesity categories, translating to a decrease in medication use.
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67
SCIENTIFIC PAPER
Pancreaticojejunostomy Sleeve Reconstruction
After Pancreaticoduodenectomy in Laparoscopic
and Open Surgery
Zhao Lei, MS, Wang Zhifei, MD, Xu Jun, MD, Liu Chang, MD,
Xu Lishan, MD, Guan Yinghui, MD, Zhai Bo, MS
ABSTRACT
Introduction: Laparoscopic procedures for pancreatic
surgery have been significantly improved recently; however, only a limited number of successful laparoscopic or
laparoscopy-assisted pancreaticoduodenectomy (PD) have
been reported. The limitations could be attributed to the
complexity of the reconstruction procedures under laparoscopic observation and the high incidence of complications. Postoperative pancreatic fistula (POPF) has been
regarded traditionally as the most frequent major complication and is a potentially serious and life-threatening
event. It remains the single most important cause of morbidity after PD and contributes significantly to prolonged
mortality. Several modified methods of pancreas anastomosis were introduced to prevent POPF. However, few
methods with a satisfactory leakage rate have yet to be
seen. Collating principle of theoretical mechanics, we introduce a new method of reconstruction by performing an
asymmetric sleeving-joint pancreaticojejunostomy (SJPJ).
The aim of this study is to summarize the results of a new
technique that is designed to decrease the POPF.
Methods: From January 2004 to December 2010, SJPJ was
performed on 86 patients undergoing PD by 1 surgeon: a
laparoscopic reconstruction was completed in 9 cases, a
hand-assisted laparoscopic reconstruction in 2 cases, and
an open SJPJ reconstruction in 75 cases.
Discussion: We used SJPJ, an asymmetric pancreaticojejunostomy (PJ). The time of operation ranged from 300
minutes to 640 minutes. Postoperatively there were no
major morbidities and no deaths. Although POPF was
Department of General Surgery, Fourth Affiliated Hospital of Harbin Medical
University, Harbin City, Heilongjiang Province, China (all authors).
Drs. Lei and Zhifei contributed equally to this work and should be considered
co–first authors.
This work was supported by a grant from the Ministry of Education of China [Grant
No. W2012RQ06].
Address correspondence to: Jun Xu, Department of General Surgery, Fourth
Affiliated Hospital of Harbin Medical University, No. 37, Yiyuan Street, NanGang District, Harbin City, Heilongjiang Prov, 150001, China. Telephone:
008613796001434. E-mail: [email protected]
DOI: 10.4293/10860812X13517013318238
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
68
observed in the laparoscopic SJPJ group with pancreatic
adenocarcinoma, 3 patients developed POPF in the open
SJPJ group with ampullary adenocarcinoma (n⫽1) and
pancreatic adenocarcinoma (n⫽2). The POPF rate was
9.30% in the open SJPJ group and 9.10% in the laparoscopic SJPJ group. The SJPJ procedure facilitates PJ, both
laparoscopically and in open surgery. It is safe, effective,
and feasible in experience hands.
Key Words: Laparoscopic, Pancreaticojejunostomy, Pancreaticoduodenectomy, Asymmetry.
INTRODUCTION
Pancreaticoduodenectomy (PD) is one of the most commonly performed procedures for the management of periampullary adenocarcinoma and cancer of the head of the
pancreas. Recently, laparoscopic surgery has evolved to
such an extent that even laparoscopic PD has been performed.1,2 Postoperative pancreatic fistula (POPF) has
been regarded traditionally as the most frequent major
complication and is a potentially serious life-threatening
event. It remains the single most important cause of morbidity after PD and also contributes significantly to prolonged mortality.3 Previous publications reported that the
incidence of pancreatic leakage ranged between 9.9% and
28.5%, and different definitions of PF were applied with
high statistical differences between them.4 To prevent
POPF, many methods have been attempted; pancreaticojejunostomy (PJ) is the most common technique used for
pancreatic reconstruction5 and also the most concerning.
Many modified methods of PJ were introduced in the
literature such as Blumgart’s anastomosis for PJ,6 PJ with
application of patch,7 and PengI.II-type binding PJ.8 However, few methods5 with a satisfactory leakage rate have
yet to be seen. The best technique in pancreatic anastomosis, especially under laparoscope, is still debated.5,8 We
introduce a new method of pancreatic reconstruction by
performing a sleeving-joint pancreaticojejunostomy (SJPJ)
during PD, which was applied both in laparoscopic and
open surgery.
JSLS (2013)17:68 –73
MATERIALS AND METHODS
Materials
From January 2004 to December 2010, data of 158 cases
undergoing PD (11 cases of laparoscopic PD, 147 cases of
open PD) by the same surgeon were retrospectively studied and were divided into 3 groups according to the
different reconstruction patterns for PJ: laparoscopic SJPJ
in 11 cases (group A), open SJPJ in 75 cases (group B), and
conventional end-to-end PJ in 72 cases (group C). The
primary indications for surgery were severe to moderate
unremitting abdominal pain, unrelieved or partially relieved with analgesics; severe unremitting icterus; and
significant weight loss. In group A, a totally laparoscopic
reconstruction was completed in 9 cases and a handassisted laparoscopic reconstruction in 2 cases. A stent
was placed in the pancreatic duct in some of the patients
(Table 1). All patients underwent routine hematological
and biochemical investigations and abdominal radiograph, ultrasonography computed tomography scan, and
magnetic resonance cholangiopancreatography. All patients were predicted to be fully resectable. PD was performed by the surgeon with experience of ⬎80 conventional open PD and ⬎100 complicated hepatobiliary and
pancreatic surgery operations.
Boulder, CO), respectively. An ancillary 5-mm trocar was
inserted 1.0 cm under the intersection of the right anterior
axillary line (AAL) and CM for laparoscopic grasping forceps. All of the positions of trocars were inserted as
illustrated in Figure 1. For open PD, the patients were
placed in the supine position.
Resecting Specimen
After a thorough exploration of the abdomen viscera and
systematic examination of any suspicious serosal lesion,
especially in the liver and stomach, the gastrocolic ligament was dissected and divided. The right half of the great
omentum was opened; a Kocher incision was made and
extended to 15.0 cm distal to the Treitz ligament for
completely mobilizing the duodenum. The superior mesenteric vein (SMV) was identified and dissected following
the middle colic vein below the pancreatic inferior margin
toward the junction of the SMV and portal vein. The dorsal
aspect of the pancreatic neck was then directly dissected
from the SMV and portal vein. The hepatoduodenal ligament was dissected, and the eighth and twelfth group
lymph nodes together with the surrounding soft tissue
were removed for a complete skeletonization. Distal gastrectomy was completed using Endo GIA (Covidien) after
dividing the right gastric gastroepiploic arteries and gastroduodenal artery with LigaSure. The common hepatic
General Considerations
The operation was performed under general anesthesia
with preoperative and intraoperative antibiotic cover. For
laparoscopic PD, the patient was placed in a supine position with both lower limbs abducted. The first 10-mm
trocar was inserted 1.0 cm under the umbilicus to allow
the laparoscope (Olympus, Tokyo, Japan), and a pneumoperitoneum was established with the pressure at 13
mm Hg. A 5-mm trocar and a 15-mm trocar were inserted
1.0 cm under the junction of the left and right medio
clavicular line (MCL) and costal margin (CM) for laparoscopic harmonic scalpel (UHS) and LigaSure (Covidien,
Table 1.
Data of Patients With and Without Stent in the Pancreatic Duct
Laparoscopic
SJPJ (n⫽11)
Open SJPJ
(n⫽75)
Open PJ
(n⫽72)
With stent (n)
10
47
45
POPF (n) (%)
1 (10.00)
0 (0)
5 (11.11)
Without stent (n)
1
28
27
POPF (n) (%)
0 (0)
3 (10.71)
10 (37.04)
Figure 1. Trocar placement and site of surgical incision for the
specimen delivery.
JSLS (2013)17:68 –73
69
Pancreaticojejunostomy Sleeve Reconstruction After Pancreaticoduodenectomy in Laparoscopic and Open Surgery, Lei Z et al.
duct was transected after cholecystectomy. The neck of
the pancreas was carefully divided using a laparoscopic
harmonic scalpel. The uncinate process of the pancreas
was separated and dissected along the SMV. The upper
portion of the jejunum was transected with Endo GIA. The
resection margins were tumor-free in all patients and confirmed by frozen section and histopathology.
Reconstruction
A modified reconstruction procedure was performed with
Child’s reconstruction. Laparoscopic SJPJ was performed
first. The remnant of the pancreas was dissected for a
distance of 2.0 cm from the cut edge. First, the anastomosis was constructed in an end-to-end fashion. The posterior wall consisted of interrupted 2 sutures with 5-0 absorbable monofilament incorporating the pancreatic capsule 2.0
cm distant to the pancreatic stump and seromuscular bites of
the jejunum. Tension should be maintained on the jejunum
specifically between sutures, for a tight connection between
the anastomosis part (Figure 2A). Second, the anterior jejunum wall was drawn to wrap over the pancreatic stump
with a 3.0-cm distance to the pancreatic stump; then the
seromuscular layer of the jejunum was sutured to the
pancreatic capsule. Thus, an asymmetry of 1.0 cm between 2 sides at the PJ site was made to form an additional
appropriate tension. One or 2 sutures were added to keep
a 0.3- to 0.5-cm distance between sutures (Figure 2B, C),
depending on the size of the pancreatic stump. Finally, a
binding technique was routinely added: a 4-0 nonabsorbable ligature was circled around the jejunum loop with the
pancreatic stump inside, 1.0 cm distant to the anastomosis,
after 2 string sutures were placed, connecting it to the jejunum serosa to prevent sliding. Then the circled ligature was
tied to form an appropriate tension until the wall where the
jejunum was bound appeared a little wrinkled (Figure 2D).
Cholangiojejunostomy (CHJ) and gastrojejunostomy
(GJ) were done on the same jejunal loop distal to the PJ.
CHJ was completed 10 cm distal to the stoma of pancreaticojejunostomosis with a 1-layer suture with 3.0
absorbable ligatures. GJ was completed 50.0 cm away
from the CHJ site with staples. Two drainage tubes were
Figure 2. The main steps of laparoscopic sleeving-joint pancreaticojejunostomy (SJPJ); (B) top view of laparoscopic SJPJ; (C) side view
of laparoscopic SJPJ.
Figure 3. (A) Sleeving-joint pancreaticojejunostomy (SJPJ) in total laparoscopic reconstruction; (B) SJPJ in hand-assisted laparoscopic
reconstruction.
70
JSLS (2013)17:68 –73
placed near the anastomosis site of PJ and CHJ, respectively.
RESULTS
The volume and the amylase level of the drain fluid were
measured daily postoperatively. The draining tube was
removed when the drain output was ⬍10 mL/day. POPF
was definite according to the definition of the International Study Group of Pancreatic Fistula in 20054: Output
via an operatively placed drain (or a subsequently placed
percutaneous drain) of any measurable volume of drain
fluid on or after postoperative day 3, with an amylase
content ⬎3 times the upper normal serum value.
The demographic data and the pathological findings of
the 3 groups are shown in Table 2. The final pathology
of the resected specimens was reviewed by 2 independent
pathologists. There were no significant differences in the
data between the 3 groups. The intraoperative data and
postoperative courses and complications of the 3 groups
of patients are presented in Table 3. The mean operative
time of laparoscopic SJPJ was 473.8 minutes (range: 300 –
640), which was significantly longer than that of both
open SJPJ and open PJ (P⬍.05). For all of the patients in
the 3 groups, 35 cases were found to have complications:
the total complication rate was 22.15% (35/158). Among
them, POPF was observed in 19 cases, with the rate of
12.03% (19/158), bile leakage was found in 3 cases, delayed gastic emptying occurred in 4 cases, and lung infection occurred in 2 cases.
Among the cases with the complication of POPF, 4 were
found in the laparoscopic and open SJPJ groups, with a
rate of 4.65% (4/86), whereas 15 were found in the open
PJ group, with a rate of 20.83% (15/72). In groups B and
C, the incidence rate of pancreatic leakage was significantly higher in the cases without the placement of stent
versus with stent placement (P⬍.05). For those with the
stent placement, POPF rate in the laparoscopic and open
SJPJ groups was both lower than that in the open PJ group
(P⬍.05), whereas there was no significant difference between the laparoscopic and open SJPJ groups. For those
without stent placement, the POPF rate was the lowest in
the open SJPJ group (P⬍.05), whereas in the laparoscopic
SJPJ group, the POPF rate was not taken into account
because there was only 1 case. All of the cases with POPF
were treated and cured with reliable irrigation and drainage. The mean duration of the postoperative hospital stay
for laparoscopic SJPJ was 18.14 days, significantly shorter
compared with 22.29 days for open SJPJ and 25.11 days
for open PJ. The difference between the 2 groups was
significant (P⬍.05).
Table 2.
Demographic Data and Pathological Findingsa
Laparoscopic SJPJ (n⫽11)
Open SJPJb (n⫽75)
Open PJb (n⫽72)
58.55⫾13.31
54.81⫾10.63
54.68⫾9.96
25.66⫾2.04
26.03⫾1.80
26.92⫾3.23
Male
6 (54.55)
33 (44.00)
35 (48.61)
Female
5 (45.45)
42 (56.00)
37 (51.39)
5 (45.45)
25 (33.33)
22 (30.56)
Age (y)
c
Body mass index
Gender [n (%)]
Final pathology [n (%)]
Pancreatic adenocarcinoma
Duodenal adenocarcinoma
3 (27.27)
23 (30.67)
16 (22.22)
Ampullary adenocarcinoma
1 (9.10)
18 (24.00)
17 (23.61)
Chronic pancreatitis and pancreatic lithiasis
1 (9.10)
—
—
Duodenal ulcer attack on the pancreatic papillae
1 (9.10)
6 (8.00)
2 (2.78)
Distal bile duct adenocarcinoma
—
3 (4.00)
6 (8.33)
Pancreatic pseudocyst
—
—
9 (12.50)
Data are presented as mean ⫾ SD.
SJPJ⫽sleeving-joint pancreaticojejunostomy; PJ⫽pancreaticojejunostomy.
c
Calculated as weight in kilograms divided by height in meters squared.
a
b
JSLS (2013)17:68 –73
71
Pancreaticojejunostomy Sleeve Reconstruction After Pancreaticoduodenectomy in Laparoscopic and Open Surgery, Lei Z et al.
Table 3.
Intraoperative and Postoperative Course and Complicationsa
Laparoscopic SJPJb (n⫽11)
Open SJPJb (n⫽75)
Open PJb (n⫽72)
Blood loss (mL)
1106⫾52.67
1103⫾56.14
1143⫾285.61
Operative time (min)
473.75⫾88.27
250.88⫾46.75
288.56⫾53.15
Pancreatic anastomotic leakage
1 (9.10)
3 (4.00)
15 (20.83)
Biliary leakage
0
0
0
Delayed gastric emptying
1 (9.10)
2 (2.67)
1 (1.39)
Lung infection
0
1 (1.33)
1 (1.39)
Intraperitoneal abscess
0
0
0
Postoperative hospital stay (days)
18.14⫾5.99
22.29⫾3.10
25.11⫾4.20
In-hospital mortality [n (%)]
0
0
0
Abdominal complications [n (%)]
Data are presented as mean ⫾ SD.
SJPJ⫽sleeving-joint pancreaticojejunostomy; PJ⫽pancreaticojejunostomy.
a
b
The follow-up ranged from 1 to 6 months. Icterus relief
was complete in 158 patients. Pain relief was complete in
155 patients (98.10%). In 3 patients (1.90%) with initial pain
relief, pain recurred after approximately 3 to 6 months but
was milder in intensity, was occasional, and could be relieved with oral analgesics. Exocrine function of the pancreas was normal in all patients. No deaths were reported
in all cases within 6 months.
DISCUSSION
POPF is one of the most common and serious complications of PD, and various attempts at PJ have been attempted to reduce its incidence.9 Our study showed a
lower rate of POPF with the novel SJPJ pattern than with
conventional PJ, taking the stent placement in the pancreatic duct as an independent factor.
The incidence of POPF is generally considered to be
related to several factors: placement of the stent inside the
pancreatic duct, the texture of the pancreatic stump, and
the pattern for anastomosis. PJ is a commonly used pattern. Still, various modified attempts have been tried,5–7,9
and some were reported to be effective and have been
applied. However, the length for connecting the pancreas and jejunum is no doubt an important factor, and
an appropriate longer length for the pancreatic stump
plugged into the jejunum should be an effective modification. Yet, little attention is paid to its modification.
This is understandable given the fact that a longer freeing
of the dorsal side for pancreatic stump is somehow hard to
achieve. However, the anterior side of the pancreatic
72
stump can be easily and safely for dissection to a longer
distance, which will result in the longer connection for PJ
anteriorly. In addition, the different length of jejunum
connecting the pancreatic stump will produce an asymmetry for the anastomosis part; as a result, the anterior
jejunum wall connecting the pancreatic stump will retract
slightly to form a tension that makes the connection between the posterior wall of the jejunum and the pancreatic
stump tighter.
In addition, we also applied a binding around the jejunum
loop with the pancreatic stump inside similar to binding PJ
by Peng’s procedure without destroying the mucosa of the
segment of jejunum contacting with the pancreatic stump.
The advantages of this binding procedure have already
been introduced.5 We merely combined the binding with
our asymmetry anastomosis as SJPJ. The binding technique may also have contributed to the lower POPF rate of
laparoscopic and open SJPJ, so there should have been a
comparative study taking the binding technique as a single factor to rule out its influences.
Before laparoscopic PD, we completed 58 cases of open
PD from January 2004 to November 2005. During that
time, 40 PJs and 18 SJPJs were performed. After the initial
experience, we performed more SJPJs than PJs. Specifically, since December 2005, SJPJs have been the only
procedure for laparoscopic PD at our center. In this retrospective study, we take the placement of the pancreatic stent as a single factor to rule out the influence of
pancreatic duct drainage. In all of the cases in the 3
groups, we abandoned the placement of the pancreatic
JSLS (2013)17:68 –73
duct stent only in the cases whose pancreatic ducts
could not be found and also with nearly normal pancreatic texture. For those with a stent in open PD, the
POPF rate of open SJPJ was lower than that in open PJ
(P⬍.05), whereas for those without stent placement,
the POPF rate of open SJPJ was lower than that in open
PJ (P⬍.05) too, which shows that SJPJ reduces the POPF
rate in open PD.
CONCLUSION
Laparoscopic PJ after PD was rarely reported because it is
technically demanding and there is a high risk of PF complication. The rates of POPF in laparoscopy were still unsatisfactory.10–12 On the basis of the data in our study, laparoscopic SJPJ
reduces the POPF rate. In addition, to our experience, it does
not add much to the technique’s difficulties. Our study suggests
that SJPJ is a safe and feasible new technique for PJ, but more
cases are needed to verify this validity.
References:
1. Tantia O, Jindal MK, Khanna S, Sen B. Laparoscopic lateral
pancreaticojejunostomy: our experience of 17 cases. Surg Endosc. 2004;18:1054 –1057.
2. Zureikat AH, Breaux JA, Steel JL, Hughes SJ. Can laparoscopic pancreaticoduodenectomy be safely implemented? J Gastrointest Surg. 2011;15:1151–1157.
3. Poon RT, Lo SH, Fong D, Fan ST, Wong J. Prevention of
pancreatic anastomotic leakage after pancreaticoduodenectomy.
Am J Surg. 2002;183:42–52.
5. Peng SY, Wang JW, Lau WY, et al. Conventional versus binding
pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg. 2007;245:692– 698.
6. Kleespies A, Rentsch M, Seeliger H, Albertsmeier M, Jauch
KW, Bruns CJ. Blumgart anastomosis for pancreaticojejunostomy
minimizes severe complications after pancreatic head resection.
Br J Surg. 2009;96:741–750.
7. Chirletti P, Caronna R, Fanello G, et al. Pancreaticojejunostomy with application of fibrinogen/thrombin-coated collagen
patch (TachoSil) in Roux-en-Y reconstruction after pancreaticoduodenectomy. J Gastrointest Surg. 2009;13:1396 –1398; author reply 1399 –1400.
8. Peng S, Mou Y, Cai X, Peng C. Binding pancreaticojejunostomy is a new technique to minimize leakage. Am J Surg.
2002;183:283–285.
9. Chen XP, Qiu FZ, Zhang ZW, Chen YF, Huang ZY, Zhang
WG. A new simple and safe technique of end-to-end invaginated
pancreaticojejunostomy with transpancreatic U-sutures— early
postoperative outcomes in consecutive 88 cases. Langenbecks
Arch Surg. 2009;394:739 –744.
10. Palanivelu C, Jani K, Senthilnathan P, Parthasarathi R, Rajapandian S, Madhankumar MV. Laparoscopic pancreaticoduodenectomy: technique and outcomes. J Am Coll Surg. 2007;205:
222–230.
11. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic pancreaticoduodenectomy for benign and malignant diseases. Surg Endosc. 2006;20:1045–1050.
12. Kendrick ML, Cusati D. Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience. Arch
Surg. 2010;145:19 –23.
4. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition.
Surgery. 2005;138:8 –13.
JSLS (2013)17:68 –73
73
SCIENTIFIC PAPER
Laparoscopic Inguinal Exploration and Mesh
Placement for Chronic Pelvic Pain
Paul J. Yong, MD, PhD, Christina Williams, MD, Catherine Allaire, MD
ABSTRACT
Background and Objective: Chronic pelvic pain affects
15% of women. Our objective was to evaluate empiric
laparoscopic inguinal exploration and mesh placement in
this population.
Methods: Retrospective cohort with follow-up questionnaire of women with lateralizing chronic pelvic pain (right
or left), ipsilateral inguinal tenderness on pelvic examination, no clinical hernia on abdominal examination, and
ipsilateral empiric laparoscopic inguinal exploration with
mesh placement (2003–2009). Primary outcome was pain
level at the last postoperative visit. Secondary outcomes
were pain level and SF-36 scores from the follow-up
questionnaire.
Results: Forty-eight cases met the study criteria. Surgery
was done empirically for all patients, with only 7 patients
(15%) found to have an ipsilateral patent processus vaginalis (shallow peritoneal dimple or a deeper defect (occult
hernia)). Of 43 cases informative for the primary outcome,
there was pain improvement in 15 patients (35%); pain
improvement then return of the pain in 18 patients (42%);
and pain unchanged in 9 patients (21%) and worse in 1
patient (2%). Improvement in pain was associated with a
positive Carnett’s test in the ipsilateral abdominal lower
quadrant (P ⫽ .024). Thirteen patients returned the questionnaire (27%), and the pain was now described as improved in 9 patients (69%), unchanged in 4 patients (31%),
and worse in none. Three SF-36 subscales showed improvement (physical functioning, social functioning, and
pain).
Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada (all authors).; Division of Reproductive Endocrinology and
Infertility, University of British Columbia, Vancouver, BC, Canada (Drs. Williams,
Allaire).; BC Women’s Center for Reproductive Health, Vancouver, BC, Canada (all
authors).
In memory of Rachael Bagnall, medical student and research assistant on this
project, who passed away before the study could be completed.
Address correspondence to: Dr. Paul Yong, BC Women’s Center for Reproductive
Health, D600 – 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada. Telephone:
(604) 875-2445, Fax: (604) 875-2569, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317310
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
74
Conclusion: In select women with chronic pelvic pain,
empiric laparoscopic inguinal exploration and mesh
placement results in moderate improvement in outcome.
A positive Carnett’s test in the ipsilateral abdominal lower
quadrant is a predictor of better outcome.
Key Words: Chronic pelvic pain, Laparoscopy, Inguinal,
Mesh.
INTRODUCTION
Chronic pelvic pain (at least 6 mo duration) affects up to
15% women, can have a devastating impact on quality-oflife, and can be of musculoskeletal, neuropathic, gastrointestinal, urologic, or gynecologic origin.1 One musculoskeletal cause of chronic pelvic pain is a hernia, which
may be inguinal, obturator, femoral, sciatic, ventral, Spigelian, or incisional.2 If an inguinal (indirect) hernia is present, surgical repair of such hernias is effective for treatment of chronic pelvic pain.3 One method of repair is
transabdominal preperitoneal (TAPP), involving laparoscopic exploration and placement of mesh at the inguinal
canal.4
However, most women with chronic pelvic pain will not
have a clinical hernia. Two abstracts have described empiric laparoscopic inguinal exploration and mesh placement in women with chronic pelvic pain but without a
clinical hernia.5,6 It is important to determine whether this
empiric treatment is indeed evidence-based, in particular
whether it is safe and effective in women with chronic
pelvic pain. In this retrospective study with follow-up
questionnaire, we review our experience with empiric
laparoscopic exploration and mesh placement in women
with lateralizing chronic pelvic pain (right or left), no
evidence of clinical hernia on abdominal examination,
and ipsilateral inguinal tenderness on pelvic examination.
MATERIALS AND METHODS
The BC Women’s Center for Reproductive Health is an
academic tertiary referral center affiliated with the University of British Columbia, which specializes in chronic pelvic pain and endometriosis and in reproductive endocri-
JSLS (2013)17:74 – 81
nology and infertility. Patients referred for chronic pelvic
pain or endometriosis, or both, are given an initial preoperative questionnaire that includes the 36-Item Short Form
Health Survey (SF-36) for quality-of-life.7 In addition to an
abdominal examination and ultrasound-guided pelvic examination, patients who exhibit lateralizing chronic pelvic
pain (right- or left-sided) are examined for inguinal tenderness. On pelvic examination, a single digit is placed
above the cervix, ventrally towards the pubic bone, then
laterally towards the inguinal canal and the internal ring.
During laparoscopy under low pressures, the examining
digit can be seen approaching the insertion of the round
ligament into the pelvic sidewall where it then dives
caudally into the internal ring and inguinal canal. If inguinal tenderness on pelvic examination is demonstrated
ipsilateral to the patient’s lateralizing chronic pelvic pain,
then the patient is offered ipsilateral laparoscopic inguinal
exploration and mesh placement in addition to other indicated procedures (e.g., excision of endometriosis).
Surgical technique (Figure 1): After laparoscopic entry,
use of 3 or 4 ports, and inspection for inguinal abnormalities, an incision is made ventral to where the round
ligament enters the pelvic sidewall, with attention to avoid
the inferior epigastric. The extraperitoneal space is explored until the round ligament is seen diving into the
Figure 1. Laparoscopic inguinal exploration and mesh. (A) Example of a patent processus vaginalis [arrow] lateral to insertion of the
round ligament into the pelvic sidewall. (B) Opening of extraperitoneal space near the round ligament insertion into the pelvic sidewall
where it dives into the internal ring [arrow], with accompanying fat [asterisk], which is removed prior to mesh placement. (C) Mesh
placement over the round ligament and internal ring. (D) Extraperitonealization of the mesh.
JSLS (2013)17:74 – 81
75
Laparoscopic Inguinal Exploration and Mesh Placement for Chronic Pelvic Pain, Yong PJ et al.
inguinal internal ring to the inguinal canal. Fat is removed
from around the ligament at its entry into the internal ring,
and then an approximately 3-cm x 4-cm piece of polypropylene mesh is placed over the round ligament and the
internal ring. The peritoneum is then sutured to extraperitonealize the mesh, usually incorporating a piece of mesh
in the suture to avoid mesh migration.
We performed a retrospective review of empiric laparoscopic inguinal exploration and mesh placement done by 2
surgeons (CW and CA) at the BC Women’s Center for Reproductive Health. Inclusion criteria were lateralizing
chronic pelvic pain, ipsilateral inguinal tenderness on pelvic
examination, and ipsilateral empiric laparoscopic inguinal
exploration and mesh placement (2003–2009). Exclusion criterion was the presence of a clinical hernia on abdominal
examination. Medical records were reviewed (preoperative
to postoperative), including the preoperative SF-36 and the
level of pain at the last postoperative visit. For the follow-up
questionnaire component of the study, patients were sent a
package by mail that included a consent form for the study
and a postoperative questionnaire containing another copy
of the SF-36 and a question about the current level of pain.
The study was approved by the research ethics boards of the
University of British Columbia and BC Women’s and Children’s Hospitals (H09 – 00025).
The primary (short-term) outcome was the level of pain at
the last postoperative visit, which was coded as follows: 1)
Improvement (complete or partial resolution); 2) Improvement then return of the pain; 3) No change; or 4)
Worse. The primary outcome was tested for an association
with the following predictor variables: age; BMI; nulliparity; side of the pain (right or left); duration of pain; pain
characteristics (cyclical or noncyclical); previous laparoscopy; other chronic pelvic pain diagnosis (endometriosis,
interstitial cystitis, irritable bowel syndrome, vulvodynia,
or psychiatric comorbidity); ipsilateral abdominal lower
quadrant tenderness; positive Carnett’s test in the ipsilateral abdominal lower quadrant indicative of abdominal
wall pain (positive Carnett test⫽worsening or no change
in tenderness with abdominal wall flexion/contraction);
laparoscopic diagnosis of a patent processus vaginalis at
the round ligament insertion into the sidewall, either a
shallow peritoneal dimple or a larger defect (occult hernia) (Figure 1)8; laparoscopic findings after exploration
of the ipsilateral inguinal internal ring; laparoscopic abnormality of the contralateral inguinal region; concurrent
excision of endometriosis classified as symptomatic, defined as ipsilateral to the pain and tender on physical
examination (i.e., tender in the ipsilateral cul-desac, uterosacral ligament, sidewall, or adnexa); concurrent excision
76
of endometriosis classified as incidental, defined as contralateral or nontender on physical examination; and other
concurrent procedures. Endometriosis was confirmed on
histology in all cases. In addition, we reviewed the intraoperative and postoperative complications, and the number of patients requiring reoperation for pelvic pain.
Secondary (long-term) outcomes were from the mailed follow-up postoperative questionnaire containing the SF-36
and a question about the current level of pain. The questionnaire asked whether the pain was currently improved,
unchanged, or worse. The SF-36 from the follow-up questionnaire (postoperative) was compared to the SF-36 from
the initial questionnaire (preoperative). The SF-36 was
scored as per the RAND SF-36 1.0 protocol, which derives 8
subscales based on 35 questions with 1 additional question
about health change over the last year (http://www.rand.
org/health/surveys_tools/mos/mos_core_36item.html)
(Table 1). Each subscale and the health change question
are scored from 0 –100, with a higher score indicating
better quality-of-life.7
Statistical analyses were carried out using SPSS 19.0. For
descriptive statistics, means are described as ⫾-1 standard
deviation. For tests of association between the primary
outcome and the predictor variables, the nonparametric
2-tailed Mann-Whitney and Spearman rank correlation
tests were utilized because of nonnormality and nondirectional hypotheses; for the change in SF-36 scores, the
parametric 1-tailed paired-sample t test was utilized. Linear regression modeling was performed using likelihood
ratio model building. ␣⫽0.05.
RESULTS
Forty-eight patients met the inclusion criteria. No patients
were excluded (i.e., none had a clinical hernia on abdominal examination). Characteristics of the 48 patients are
summarized in Table 1. Of note, 38 patients (79%) had
had a previous laparoscopy, and of these, almost all (n ⫽
35) had had a previous laparoscopy for the same pain.
The procedures performed at the previous laparoscopy
are also summarized in Table 1.
At the time of empiric laparoscopic inguinal exploration
and mesh placement, there was a laparoscopic diagnosis
of an ipsilateral patent processus vaginalis in 7 patients
(15%) (Table 1; Figure 1); in an additional 5 patients
(10%), there were laparoscopic findings after exploration
of the ipsilateral inguinal internal ring (Table 1). Empiric
JSLS (2013)17:74 – 81
Table 1.
Predictor Variables
Predictor Variable
Table 1. (Continued)
Predictor Variables
Study Sample
(n ⫽ 48)a
Predictor Variable
History
Study Sample
(n ⫽ 48)a
Surgical
Age
31.4 ⫾ 9.2
BMI
24.4 ⫾ 3.9
Nulliparity (%)
24 (51)
Side of Pain (%)
R⫽27 (56)
After Exploration: Ipsilateral Findings at 5 (10)
the Inguinal Internal Ringg (%)
L⫽18 (38)
Contralateral Inguinal Abnormalityh (%) 4 (8)
Bilateral ⫽3 (6)
Concurrent Excision
of Symptomatic
i
Endometriosis (%)
4 (8)
Concurrent Excision
of Incidental
j
Endometriosis (%)
13 (27)
Other Concurrent
Laparoscopic
k
Procedure (%)
8 (17)
Duration of Pain (%)
Before Exploration: Ipsilateral Patent
Processus Vaginalis at the Inguinal
Internal Ringf (%)
⬍1 year⫽8 (18)
1–5 years⫽16 (36)
⬎5 years⫽21 (47)
Pain Characteristicsb (%)
Cyclical⫽24 (57)
Previous Laparoscopyc (%)
38 (79)
Non-cyclical⫽18 (43)
At Least One Other Chronic Pelvic Pain 35 (73)
Diagnosisd (%)
Endometriosis
22 (46)
Interstitial cystitis
3 (6)
Irritable bowel syndrome
6 (13)
Vulvodynia
3 (6)
Psychiatric comorbidity
10 (21)
Othere
3 (6)
Initial SF-36 Score (from the Preoperative Questionnaire)
Physical functioning
68.2 ⫾ 27.0
Role functioning (physical)
33.1 ⫾ 36.1
Role functioning (emotional)
59.5 ⫾ 42.6
Energy/Fatigue
38.6 ⫾ 23.1
Emotional well-being
64.5 ⫾ 18.6
Social functioning
59.7 ⫾ 25.0
Pain
42.7 ⫾ 22.5
General health
58.2 ⫾ 20.7
Health change
35.8 ⫾ 28.7
Examination
Ipsilateral Abdominal Lower Quadrant
Tenderness (%)
38 (79)
Positive Carnett’s Test in the Ipsilateral
Abdominal Lower Quadrant (%)
13 (27)
7 (15)
a
Denominator depends on the number of informative cases for
each predictor variable.
b
Six patients had a previous hysterectomy.
c
Of the 38 patients with previous laparoscopy, 35 had the previous laparoscopy for the same pain involving the following
procedures: treatment of endometriosis (n⫽16), diagnostic procedure only (n⫽11), ovarian cystectomy (n⫽2), treatment of
endometriosis and ovarian cystectomy (n⫽1), empiric appendectomy (n⫽1), empiric appendectomy and paratubal cystectomy (n⫽1), salpingectomy (n⫽1), lysis of adhesions (n⫽1), and
hysterectomy (n⫽1).
d
Some patients had more than one other diagnosis.
e
History of pelvic fractures, previous PID requiring hysterectomy, and inflammatory bowel disease.
f
Before exploration, there was a patent processus vaginalis,
which appeared as a shallow dimple or larger defect (occult
hernia) at the peritoneum near the round ligament insertion into
the pelvic sidewall (where it later enters the ipsilateral inguinal
internal ring)f (Figure 1).
g
After exploration, there was evidence of an “inguinal hernia,” a
“small defect,” or “large amount of fat” at the ipsilateral inguinal
ring.
h
Findings at the contralateral (nonpainful, nontender side) inguinal region: 3 patients with a patent processus vaginalish; and
1 patient with a direct inguinal hernia.
i
Excision of endometriosis that was ipsilateral and tender on
physical exam (ie, tender in the ipsilateral cul-de-sac, uterosacral
ligament, sidewall, or adnexa). Endometriosis was confirmed on
histology.
j
Exicision of endometriosis that was either contralateral or nontender on physical examination. Endometriosis confirmed on
histology.
k
Included an ipsilateral ovarian suspension, ipsilateral salpingooophorectomy, ipsilateral lysis of adhesions, and empiric appendectomy, as well as procedures that were done for other indications
(contralateral ovarian cystectomy, contralateral salpingo-oophorectomy, contralateral salpingectomy of accessory fallopian tube, and
tubal ligation).
JSLS (2013)17:74 – 81
77
Laparoscopic Inguinal Exploration and Mesh Placement for Chronic Pelvic Pain, Yong PJ et al.
ipsilateral inguinal exploration and mesh placement was
done for all patients, regardless of whether these findings
were present or not. In addition, 4 patients (8%) had a
laparoscopic abnormality of the contralateral inguinal region (the side with no pain or tenderness; Table 1), which
was not explored or repaired. Four patients (8%) had a
concurrent excision of endometriosis classified as symptomatic, while 13 patients (27%) had concurrent excision
of endometriosis classified as incidental (Table 1).
Five patients did not return for a postoperative visit, and
therefore 43 patients were informative for the primary
outcome (pain level at the last postoperative visit). The
average time to the last postoperative visit was 12.6 ⫾ 14.2
mo (range ⱕ 1 to 58) from the date of surgery. For the
primary (short-term) outcome, there was pain improvement in 15 patients (35%) (complete resolution in 3 and
partial resolution in 12 patients), pain improvement then
return of the pain in 18 patients (42%), and pain unchanged in 9 patients (21%) and worse in 1 patient (2%).
The average time to return of the pain was 8.7⫾-9.8 mo
(range ⱕ 1 to 34) from the date of surgery, and triggers
were trauma (n ⫽ 3), sports (n ⫽ 2), pregnancy (n ⫽ 2),
bikini wax (n ⫽ 1), and unknown (n ⫽ 10).
The predictor variables are listed in Table 1. Neither a
concurrent surgical procedure (such as excision of endometriosis, whether classified as symptomatic or incidental), nor the presence of an ipsilateral patent processus vaginalis, was associated with the primary
outcome (Table 1). The only predictor variable significantly associated with the primary outcome was a
positive Carnett’s test in the ipsilateral abdominal lower
quadrant, with a positive Carnett’s test associated with
improvement of the pain at the last postoperative visit
(Spearman’s rho ⫽ 0.34, P ⫽ .024). Of the 11 patients with a
positive Carnett’s test informative for the primary outcome,
improvement occurred in 8 patients (73%) (complete resolution in 2 and partial resolution in 6 patients), improvement
then return of the pain in 2 patients, no change in 1 patient,
and worsening in no patients. Of the 32 patients with a
negative Carnett’s test, improvement occurred in 7 patients
(22%) (complete resolution in 1 and partial resolution in 6
patients), improvement then return of the pain in 16 patients,
no change in 8 patients, and worsening in 1 patient. None of
the other predictor variables in Table 1 had an association
with the primary outcome.
In addition, there was possible evidence of selection bias,
as patients who had a longer time to the last postoperative
visit had a trend towards more pain for the primary outcome
(Spearman’s rho⫽-.31, P ⫽ .045). However, when a linear
78
regression model was constructed with a positive Carnett’s
test and time to last postoperative visit as predictor variables
for the primary outcome, the time to last postoperative visit
fell out of the model (P ⫽ .14) with only the positive Carnett’s test remaining significant (P ⫽ .024).
There were no intraoperative complications, and the postoperative complications were mild and uncommon (10%):
hospitalization for postoperative pain (n ⫽ 2), bladder
infection (n ⫽ 1), endometritis (n ⫽ 1), and “slow recovery” (n ⫽ 1). Eight patients required reoperation for pain
(17%), which included repeat laparoscopy for mesh removal (n ⫽ 3), open groin exploration by a general
surgeon (n ⫽ 2), hysterectomy (n ⫽ 1), hysterectomy and
ipsilateral salpingo-oophorectomy (n ⫽ 1), and unknown
(n ⫽ 1). One patient requested mesh removal after a
motor vehicle accident resulted in return of the pain, and
no inguinal abnormality was noted during repeat laparoscopy. A second patient requested mesh removal after
return of the pain secondary to trauma, and again no
inguinal abnormality was noted. A third patient requested
mesh removal after the pain returned (unknown cause),
and the inguinal canal looked slightly inflamed and thickened with pathology showing mild chronic and foreign
body inflammation. None of these patients had significant
improvements in their pain after mesh removal (and one
patient requested repeat inguinal exploration and mesh
placement), although follow-up was limited. An additional 2
patients were referred to a general surgeon and underwent
open groin exploration. One of these patients had experienced no improvement after laparoscopic inguinal exploration and mesh placement, while the other patient had experienced improvement then return of the pain. After open
groin exploration, both patients had an initial improvement,
then return of the same pain within 3 mo.
For the secondary (long-term) outcomes, 13 patients
(27%) returned the questionnaire. The time between the
surgery and the date of the questionnaire was 73.2 ⫾ 30.6
mo (range ⫽ 23 to 102). There was no evidence of selection bias, as these 13 patients had a similar distribution for
the primary outcome (improvement in 4, improvement
then return of the pain in 5, no change in 3, and worse in
0) compared to the rest of the sample (P ⫽ .54), and
similar initial (preoperative) SF-36 subscale scores compared to the rest of the sample (P ⫽ .39 to 0.98). In these
13 patients who returned the follow-up questionnaire,
pain was now described as being improved in 9 patients
(69%), unchanged in 4 patients (31%), and worse in 0
patients. Three SF-36 subscales improved from the initial
questionnaire (preoperative) to the follow-up questionnaire
(postoperative): physical functioning (P ⫽ .032), social func-
JSLS (2013)17:74 – 81
tioning (P ⫽ .036), and pain (P ⫽ .035) (Table 2). The SF-36
question about health change also improved (P ⫽ .003)
(Table 2).
DISCUSSION
In this retrospective study with follow-up questionnaire,
we found that empiric laparoscopic inguinal exploration
and mesh placement in women with lateralizing chronic
pelvic pain (right or left), no clinical hernia on abdominal
examination, and ipsilateral inguinal tenderness on pelvic
examination, resulted in improvement in 35% and improvement with return of the pain in 42% at the time of the last
postoperative visit. Of the 27% of patients who returned a
questionnaire for long-term follow-up, 69% reported their
pain was improved, and several SF-36 subscales showed
improvement (physical functioning, social functioning, pain)
in addition to an improvement in health change over the last
year. Complications were uncommon and mild. Three patients with return of pain requested mesh removal, without
significant improvement in symptoms.
The primary outcome was not found to be associated with
the presence or absence of an ipsilateral patent processus
vaginalis. It should be emphasized that the surgery was
done empirically in all patients, regardless of whether the
ipsilateral inguinal region looked normal or whether there
was an ipsilateral patent processus vaginalis. The incidence of patent processus vaginalis in this study (15%) is
consistent with previous reports.8
In this study population, it is thought that the chronic
pelvic pain and inguinal tenderness may arise from incarcerated fat in the inguinal canal.5 The goal of the surgery
is to decompress the ilioinguinal nerve by removing the
fat and placing a mesh at the internal ring. There have
only been 2 reports of empiric laparoscopic inguinal exploration and mesh placement in women with chronic
pelvic pain, some of whom with inguinal tenderness on
pelvic examination. A review cited an abstract stating that
80% to 85% of women with chronic pelvic pain obtain
“significant”: or complete resolution of their pain with
laparoscopic inguinal exploration and mesh placement,
although sample size was not provided.5 In another abstract, Janicki et al.6 reported on 21 women with chronic
pelvic pain who underwent laparoscopic inguinal exploration and mesh placement, and found that 74% to 78%
had “great” improvement or complete resolution of their
pain at 6 mo to 12 mo. Hussain et al.9 also reported a high
cure rate (70%) for the same surgery for chronic groin pain
(n ⫽ 43), although their study sample was 93% male and
the majority had a dilated external ring on examination.
Our study had a more modest improvement rate, which
may be because three-fourths of our study sample had a
comorbid chronic pelvic pain diagnosis and half had pain
lasting more than 5 y (Table 1), suggesting many women
with chronic pain syndrome, central sensitization, and
hyperalgesia. In addition, we found 42% of patients had
an initial improvement then the pain returned after an
average of 8.7 mo. These patients may have experienced
a true recurrence due to failure of the procedure, or else
have had a temporary placebo effect of the laparoscopy.
In a randomized trial for laparoscopic excision of endometriosis, Abbott et al.10 found that about one-third of
patients will have pain improvement at 6 mo from a
placebo diagnostic laparoscopy.
Table 2.
Comparison of SF-36 Subscale Scores
SF-36
Initial Questionnaire
Follow-up Questionnaire
Paired Sample
(Preoperative)
(Postoperative)
t test
Physical functioning
66.0 ⫾ 33.0
84.2 ⫾ 16.6
2.06
.032
Role functioning (physical)
31.3 ⫾ 37.1
56.3 ⫾ 44.1
1.59
.07
Role functioning (emotional)
69.4 ⫾ 43.7
58.3 ⫾ 42.9
0.60
.28
Energy/Fatigue
39.7 ⫾ 28.1
47.1 ⫾ 23.2
0.92
.19
Emotional well-being
67.3 ⫾ 17.5
72.8 ⫾ 16.4
0.76
.23
Social functioning
58.3 ⫾ 29.4
76.0 ⫾ 17.2
1.99
.036
Pain
43.5 ⫾ 22.4
59.6 ⫾ 19.9
2.02
.035
General health
59.2 ⫾ 24.4
70.0 ⫾ 20.0
1.50
.08
Health change
29.2 ⫾ 20.9
58.3 ⫾ 19.5
3.39
.003
JSLS (2013)17:74 – 81
P-Value
79
Laparoscopic Inguinal Exploration and Mesh Placement for Chronic Pelvic Pain, Yong PJ et al.
Weaknesses of our study include a low response rate for
the follow-up questionnaire (27%) and the lack of a separate control group. However, the patients who returned
the follow-up questionnaire had a similar distribution for
the primary outcome and the initial (preoperative) SF-36
subscale scores compared to the patients who did not
return the questionnaire (see Results), suggesting a lack of
selection bias. In addition, it is not possible to formally
rule out a placebo effect of the surgery without a separate
placebo control group, which would be difficult for this
study (i.e., it would require a group assigned to diagnostic
laparoscopy only). Finally, a proportion of patients had
concurrent surgical procedures including excision of endometriosis (Table 1): 8% had a concurrent excision of
endometriosis classified as symptomatic and 27% had
concurrent excision of endometriosis classified as incidental. Although we believe there to be a rational basis
for this subdivision of endometriosis (as defined in the
Methods), we acknowledge that we cannot be certain
that incidental endometriosis was truly incidental and
unrelated to the patient’s pain. In addition, although
concurrent excision of endometriosis, whether symptomatic or incidental, was not associated with the primary outcome (see Results), we acknowledge that concurrent excision of endometriosis should still be
considered a confounder in this study.
Strengths of the study include a larger sample size than
previous studies, long follow-up for the group who returned the questionnaire (73 mo) compared to previous
studies, and the incorporation of a quality-of-life measure
(SF-36). In particular, the improvement in SF-36 scores for
physical functioning, social functioning, pain, and the
health change question were not only statistically significant but also clinically significant, being much larger than
the minimally clinically important difference of 3 to 5
points.7
The only predictor variable associated with improvement of the pain at the last postoperative visit (i.e., the
primary outcome) was the presence of a positive Carnett’s test in the ipsilateral abdominal lower quadrant. A
positive Carnett’s test is a manifestation of abdominal
wall pain, of which one cause is neuropathic such as
iatrogenic or spontaneous ilioinguinal injury.11,12 The
ilioinguinal nerve may provide sensation to an area
above the inguinal ligament in the abdominal lower
quadrant.12,13 Therefore, it is possible that our patients
with a positive Carnett’s test in the ipsilateral abdominal
lower quadrant may have some sort of ilioinguinal
neuropathy contributing to their pain. Laparoscopic exploration and mesh placement could decompress the
80
ilioinguinal nerve in the inguinal canal, and therefore
may improve this ilioinguinal pain. None of our patients
had a diagnostic ilioinguinal nerve block, which has
been used for diagnosis of entrapment prior to ilioinguinal neurolysis or nerve resection through an abdominal incision.12,14 In the future, a diagnostic ilioinguinal
block may also be useful to identify which women may
respond to empiric laparoscopic inguinal exploration
and mesh.
CONCLUSION
Our study found moderate improvement in pain and
quality-of-life after empiric laparoscopic inguinal exploration and mesh placement in women with lateralizing chronic pelvic pain, no clinical hernia on abdominal examination, and ipsilateral inguinal tenderness on
pelvic examination. Patients with a positive Carnett’s
test in the ipsilateral abdominal lower quadrant had the
best response. Future research should include a prospective study, ideally with randomization. For example, patients could be randomized to laparoscopic inguinal exploration and mesh placement, or to medical
management with neuromodulator medications and/or
hormonal suppression. We consider such a prospective
randomized study to be an important step before empiric laparoscopic exploration and mesh placement can
be widely accepted as a treatment modality for women
with chronic pelvic pain. In the meantime, empiric
laparoscopic inguinal exploration and mesh placement
appears to be, at a minimum, a safe treatment option
that may result in moderate improvement in select
women with lateralizing chronic pelvic pain, most notably those with ipsilateral inguinal tenderness on pelvic examination and a positive Carnett’s test in the
ipsilateral abdominal lower quadrant.
References:
1. Gomel V. Chronic pelvic pain: a challenge. J Minim Invasive
Gynecol. 2007;14:521–526.
2. Carter JE. Surgical treatment for chronic pelvic pain. JSLS.
1998;2:129 –139.
3. Perry CP, Echeverri JD. Hernias as a cause of chronic pelvic
pain in women. JSLS. 2006;10:212–215.
4. Reuben B, Neumayer L. Surgical management of inguinal
hernia. Adv Surg. 2006;40:299 –317.
5. Metzger DA. Hernias in women: uncommon or unrecognized? Laparoscopy Today. 2004;3(1):8 –10.
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6. Janicki TI, Onders R, Bloom BJ, Green AE. Occult inguinal
hernias in women with chronic pelvic pain. J Am Assoc Gynecol
Laparosc. 2001;8(3Suppl):S28.
11. Suleiman S, Johnston DE. The abdominal wall: an overlooked source of pain. Am Fam Physician. 2001;64:431– 438.
7. Hays RD, Morales LS. The RAND-36 measure of healthrelated quality of life. Ann Med. 2001;33:350 –357.
12. Hahn L. Treatment of ilioinguinal nerve entrapment – a
randomized controlled trial. Acta Obstet Gynecol Scand. 2011;
90(9):955–960.
8. van Wessem KJ, Simons MP, Plaisier PW, Lange JF. The
etiology of indirect inguinal hernias: congenital and/or acquired?
Hernia. 2003;7:76 –79.
13. Knockhaert DC, D’Heygere FG, Bobbaers HJ. Ilioinguinal
nerve entrapment: a little-known cause of iliac fossa pain. Postgrad Med J. 1989;65:632– 635.
9. Hussain A, Mahmood H, Singhal T, et al. Laparoscopic surgery for chronic groin pain in the general population: a prospective study. J Laparoendosc Adv Surg Tech A. 2008;18(6):809 –
813.
14. Lee CH, Dellon AL. Surgical management of groin pain of
neural origin. J Am Coll Surg. 2000;191:137–142.
10. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R.
Laparoscopic excision of endometriosis: a randomized, placebocontrolled trial. Fertil Steril. 2004;82(4):878 – 884.
JSLS (2013)17:74 – 81
81
SCIENTIFIC PAPER
Laparoscopic Appendectomy in Women Without
Identifiable Pathology Undergoing Laparoscopy for
Chronic Pelvic Pain
Ann K. Lal, MD, Amy L. Weaver, MS, Matthew R. Hopkins, MD, Abimbola O. Famuyide, MBBS
ABSTRACT
INTRODUCTION
Objectives: To assess the effectiveness of appendectomy
in women undergoing laparoscopy for chronic pelvic pain
without identifiable pathology.
Chronic pelvic pain is generally defined as pelvic pain that
persists for at least 6 months. It causes considerable functional impairment to patients and represents a clinical
challenge for gynecologists. Although chronic pelvic pain
is a common presentation in clinical gynecologic practice,
its prevalence is difficult to determine because its definition is ambiguous. Of randomly selected women aged 18
to 50 years, 15% have been reported to visit a gynecologist
because of pelvic pain,1,2 and approximately 10% of all
visits to a gynecologist are related to pelvic pain.3 The
pathophysiology underlying chronic pelvic pain is complex and may involve many organ systems, including the
gynecologic, gastrointestinal, genitourinary, musculoskeletal, neurologic, and psychiatric systems. Laparoscopic
surgery can reveal certain diagnoses, such as endometriosis, adhesions, uterine anomalies, or adnexal pathology.
However, a cause for pelvic pain may not be found in as
many as 61% of patients who undergo laparoscopy.1 Furthermore, the presence of visible pathology does not
necessarily correlate with the severity of the patient’s pain
or the histology.4
Methods: This retrospective cohort study included
women aged 15 to 50 years who underwent laparoscopic
surgery for chronic pelvic pain without identifiable pathology. The cohort was divided into 2 groups: women
who underwent appendectomy and women who had not
undergone appendectomy at laparoscopic surgery. Postoperative pain was assessed at 6-week follow-up and by
subsequent mailed questionnaire.
Results: Women who underwent appendectomy (n ⫽ 19)
were significantly more likely to report improvement in
pain at 6-week follow-up than women who did not undergo appendectomy (n ⫽ 76) (93% vs 16%; P ⬍ .001).
Thirty-six patients (38%) responded to the questionnaire
at a median of 4.2 years after surgery, when the median
change (improvement) in reported pain was greater in the
appendectomy group than in the nonappendectomy
group.
Conclusion: Appendectomy is effective therapy for patients with chronic pelvic pain of unknown etiology who
are undergoing laparoscopy.
Key Words: Appendectomy, Laparoscopy, Pelvic pain,
Chronic.
Department of Obstetrics and Gynecology, University of Illinois, Chicago, IL, USA
(Dr. Lal).
Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
(Ms. Weaver).
Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA (Drs.
Hopkins and Famuyide).
Presented at the 58th Annual Conference of the American College of Obstetricians
and Gynecologists, May 15–19, 2010, San Francisco, CA.
Address correspondence to: Abimbola O. Famuyide, MBBS, Department of Obstetrics and Gynecology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905.
E-mail: [email protected], [email protected].
DOI: 10.4293/108680812X13517013317031
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
82
Incidental appendectomy at the time of laparoscopic surgery has been reported as a good treatment option for
women with chronic pelvic pain, with improvement in
pain in as many as 97% of patients.5 This is not surprising
because histologic examination has revealed pathologies
in as many as 66% of grossly normal appendices.6
Although several studies have shown a beneficial effect of
laparoscopic appendectomy in the absence of gross pelvic
disease, these studies had major flaws in their design or
methodology.5–7 These flaws include the use of singlearm, uncontrolled studies5–7; inconsistent definitions of
chronic pelvic pain5–7; inclusion of children and men6;
lack of adjustment for confounders such as concomitant
surgery for endometriosis or other pelvic pathology5–7;
and inconsistent use of a validated pain scale.5–7 Thus,
questions remain about the internal and external validity
of these studies. The objective of this study was to assess the
effectiveness of laparoscopic appendectomy in women undergoing laparoscopy for chronic pelvic pain for which no
identifiable pathology was encountered.
JSLS (2013)17:82– 87
MATERIALS AND METHODS
This study was approved by the Mayo Clinic Institutional
Review Board. Study subjects were identified through
retrospective medical record review for all women aged
15 to 50 years who underwent diagnostic laparoscopic
surgery from January 1, 2001 to April 30, 2009 with a
surgical indication of chronic pelvic pain or pelvic pain
lasting 6 months or longer before surgery. Specific exclusion criteria were prior hysterectomy or bilateral oophorectomy, prior appendectomy, lack of documentation of the
presence or absence of the appendix during surgery, grossly
visible pathology (eg, endometriosis, adnexal masses, uterine leiomyomas), and abnormal histology. The remaining
patients composed the laparoscopy cohort of patients who
had no visible or histologic evidence of pelvic pathology.
From this cohort, 2 groups were identified: women who
underwent appendectomy and women who did not undergo appendectomy or any additional surgical procedures
beyond visual inspection.
In the first phase of this study, baseline demographic
information, including age, parity, location of pain, and
history of endometriosis, was abstracted from the preoperative visit notes in each patient’s medical record. The
operative note and pathology report from the surgery
were reviewed. The preoperative pain assessment was
accessed through surgical consultation notes, as documented in the electronic medical record. The patient’s
postoperative pain assessment was taken from the first
postoperative visit at 6 weeks or at the last episode of care
that also included a documented pelvic pain rating.
letter detailing the study, a Health Insurance Portability
and Accountability Act (HIPAA) form, and the questionnaire. Questionnaires were mailed with the expectation of
a response within 6 weeks. Nonresponders were sent a
second mailing after those 6 weeks, and nonresponders
after the second mailing were then contacted by telephone.
Comparisons between 2 groups (ie, appendectomy vs
nonappendectomy, responders vs nonresponders) were
evaluated using the 2-sample t test or Wilcoxon rank sum
test for continuous or ordinal variables and the ␹2 test or
Fisher exact test, as appropriate, for categorical variables.
Comparisons of preoperative versus postoperative pain
ratings within a group were evaluated using the Wilcoxon
signed rank test. All statistical analyses were 2-sided, and
P values ⬍ .05 were considered statistically significant.
Statistical analyses were performed using SAS version 9.2
software (SAS Institute Inc, Cary, NC).
Previous outcome studies have suggested that pelvic pain
improved in 80% to 97% of patients who underwent appendectomy at the time of laparoscopy.5–7 Using a 2-tailed
␹2 test with 2 groups of patients—16 in the appendectomy
group and 110 in the nonappendectomy group—to detect
improved pelvic pain from 90% in the appendectomy
group to 30% in the laparoscopy group, gives a power
90%. Logistic regression modeling was used to adjust for
age, body mass index, and other known confounders.
RESULTS
Medical Record Review
In the second phase of the study, a questionnaire was mailed
to all patients in the cohort during January 2010. The questionnaire asked patients to recall their pain both preoperatively and postoperatively using a validated 11-point numeric scale and the Pain Disability Index.8,9 They were asked
to rate their pain on a scale of 0 to 10, with 0 being “no pain”
and 10 being “the worst pain imaginable.” The Pain Disability Index asked patients to rate their preoperative and postoperative disability in 5 categories—family/home responsibilities, recreation, social activity, occupation, and sexual
behavior— on a scale of 0 (meaning no disability) to 10
(meaning the worst disability). In addition, the survey included questions regarding any additional procedures they
had undergone for chronic pelvic pain or any new medications they had been prescribed for chronic pelvic pain since
their initial laparoscopic surgery.
We identified 200 patients who underwent laparoscopy
for chronic pelvic pain during the study period. After
extensive review of the medical records, we found that 95
patients met the inclusion criteria and included them in
the analyses—76 in the nonappendectomy group and 19
in the appendectomy group. There was no statistical difference between the 2 groups in age, parity, and history of
endometriosis. There was, however, a statistically significant difference in the preoperative location of the pain,
with women in the appendectomy group more likely to
report right-sided pain than women in the nonappendectomy group (58% [11/19] vs 22% [17/76]; P ⫽ .002). Review of surgical pathology revealed abnormal pathology
in 2 (11%) of the 19 patients in the appendectomy group
(ie, mild acute appendicitis and chronic appendicitis).
The Survey Research Center at the Mayo Clinic administered the questionnaires. The initial contact included a
The 6-week postoperative follow-up assessment was
available for 14 of 19 patients (74%) in the appendectomy
JSLS (2013)17:82– 87
83
Laparoscopic Appendectomy in Women Without Identifiable Pathology Undergoing Laparoscopy for Chronic Pelvic Pain, Lal AK et al.
group and 51 of 76 patients (67%) in the nonappendectomy group. Improvement in pain was reported in 13 of
14 patients (93%) in the appendectomy group and 8 of 51
patients (16%) in the nonappendectomy group (P ⬍ .001)
(Table 1). Women who underwent appendectomy were 70
times more likely to report improvement in pain compared
with women who did not have appendectomy (odds ratio,
69.9; 95% confidence interval, 8.0 – 611.6; P ⬍ .001).
median (and mean) change was greater in the appendectomy group than in the nonappendectomy group, the
difference was not statistically significant.
Finally, the survey data did not show any significant differences in the need for narcotic pain medications, surgical procedures for pain, and chiropractic or physical therapy services after the initial laparoscopic procedure
(Table 4).
Survey Results
DISCUSSION
In the second phase of the study, a questionnaire was
mailed to all 95 patients. Of these, 36 (38%) completed
both the questionnaire and the HIPAA form, and their
responses were included in the data analysis. The median
duration from the initial laparoscopic surgery to the questionnaire response was 4.2 years (range, 0.9 –9.3). An
additional 10 patients who completed the questionnaire
but did not return the HIPAA form were categorized as
nonresponders and were excluded from the analysis. In
the appendectomy group, 8 of 19 patients (42%) responded, and in the nonappendectomy group, 28 of 76
(37%) responded. There were no significant differences in
baseline demographics between responders and nonresponders (data not shown).
This retrospective cohort study was performed to assess
the effectiveness of laparoscopic appendectomy on pelvic pain improvement in patients with no identifiable
pelvic pathology. At a 6-week postoperative follow-up
visit, 93% of patients who underwent appendectomy
had an improvement in pain. In addition, in a survey
completed after surgery, the patients in the appendectomy group reported a greater mean decrease in pain
than did the nonappendectomy group. The pain improvements that we found were similar to those of
other studies assessing the effectiveness of appendectomy, including a prospective study by AlSalilli and
Vilos,5 who found a 97% improvement in pain after
appendectomy. These numbers are consistent with the
results of previous studies and show promise in the
treatment of pelvic pain.
For all 6 pain and disability measures, preoperative pain
and disability data were not significantly different between the 2 groups. In the nonappendectomy group, the
range in median values for the 6 measures was 4.5 to 8.0
before surgery and 1.5 to 3.0 after surgery, with a range in
the median change of 1.0 to 4.0 (Table 2). In the appendectomy group, the range in median values was 6.0 to 8.0
before surgery and 0 to 2.0 after surgery, with a range in
the median change of 4.0 to 5.0 (Table 3). Although the
Previous studies have assessed appendectomy as a possible treatment for patients with chronic pelvic pain and
have shown improvement in pain, with rates from 89% to
97%.5,6,10 Despite undergoing extensive medical and radiologic evaluation, 97% of patients with recurrent right
lower quadrant pain reported immediate relief of pain and
Table 1.
Results from the First Phase of the Study: Pain Improvement at 6 Weeks after Laparoscopic Surgerya
Characteristic
Appendectomy Group
(N ⫽ 19)
Nonappendectomy Group
(N ⫽ 76)
P Value
Comparing the
2 Groups with
Follow-up
Follow-up
(n ⫽ 14)
No Follow-up
(n ⫽ 5)
Follow-up
(n ⫽ 51)
No Follow-up
(n ⫽ 25)
Age (y), mean (SD)
26.3 (8.3)
23 (4.1)
29.6 (8.5)
27.3 (7.8)
.21
Parity ⱖ1
3 (21)
2 (40)
24 (47)
9 (36)
.08
History of endometriosis
5 (36)
0
13 (25)
4 (16)
.45
Right-sided pain (documented locations)
10/12 (83)
1/4 (25)
11/29 (38)
6/13 (46)
.008
Improvement in pain at 6-week follow-up
assessment
13 (93)
—
8 (16)
—
⬍ .001
a
Values are expressed as number (%) unless indicated otherwise.
84
JSLS (2013)17:82– 87
Table 2.
Results from Survey Data: Pain Disability Index Scores Before and After Surgery for Patients in the Nonappendectomy Groupa
Life Activity and Pain
Categories
Patients Without Concurrent
Appendectomy (n ⫽ 28)
Before Surgery Mean (SD)
Median
Family/home responsibilities
Recreation
Social activity
Occupation
Sexual behavior
Pain
After Surgery Mean (SD)
Median
Before–After Difference Mean
(SD) Median
5.1 (2.8)
2.8 (2.9)
2.3 (2.8)
5
2
1.5
5.8 (3)
3 (2.9)
2.8 (3.4)
5.5
3
1.5
5.1 (3.2)
2.9 (3.2)
2.2 (2.7)
5.5
1.5
1
5 (3.5)
2.8 (3.3)
2.2 (3)
4.5
2
1
6.2 (2.9)
3.1 (3.2)
3.2 (3.4)
6.0
2.5
2.5
7.2 (2)
3.6 (3)
3.6 (3.2)
8
3
4
a
Mean changes were 1.0 to 4.0 for all categories assessed.
Table 3.
Results from Survey Data: Pain Disability Index Scores Before and After Surgery for Patients in the Appendectomy Group
Life Activity and Pain
Categories
Family/home responsibilities
Recreation
Social activity
Occupation
Sexual behavior
Pain
Patients with Concurrent
Appendectomy (n⫽8)
Before Surgery Mean (SD)
Median
After Surgery Mean (SD)
Median
Before–After Difference Mean (SD)
Median
5.5 (3.7)
1.1 (1.4)
4.4 (3.3)
6.5
0.5
4.5
6 (4.1)
1.4 (1.8)
4.6 (3.5)
7
0.5
4.5
4.9 (3.5)
1 (1.4)
3.9 (2.8)
6
0
4.5
5.1 (3.6)
1 (1.1)
4.1 (3.5)
6
1
4
6.6 (3.1)
2.3 (2.6)
4.4 (3.3)
7
1.5
5
7.3 (2.5)
2.5 (2.2)
4.8 (3.2)
8
2
5
89% reported no recurrence, with a median follow-up of
19 months.6 In 1 study, with an appendectomy rate of 60%
in patients with right-sided chronic pelvic pain, the pain
was relieved in 97%.5
Studies have evaluated the operative complication rate
and mortality rate and have found no increase in groups
of patients in whom appendectomy was performed.11,12 In
one study assessing laparoscopic appendectomy for sus-
JSLS (2013)17:82– 87
85
Laparoscopic Appendectomy in Women Without Identifiable Pathology Undergoing Laparoscopy for Chronic Pelvic Pain, Lal AK et al.
Table 4.
Results from Survey Data: Secondary Outcomesa
Outcome
Nonappendectomy Group (n ⫽ 28)
Appendectomy Group (n ⫽ 8)
25 (89)
6 (75)
3 (11)
2 (25)
Additional surgeryc
P Valueb
.30
No
Yes
d
Additional procedures
.56
Missing
0 (0)
1 (13)
No
23 (82)
7 (100)
Yes
5 (18)
0 (0)
⬎ .99
Narcotic pain medications
No
25 (89)
8 (100)
Yes
3 (11)
0 (0)
a
Values are expressed as number (%) unless indicated otherwise.
Fisher exact test.
c
Additional surgical procedures for pelvic pain.
d
Chiropractic or physical therapy services for pelvic pain.
b
pected acute appendicitis, the overall mortality rate was
0% and the general morbidity rate was 1%.13 In a study of
100 patients undergoing incidental appendectomy at the
time of pelvic laparoscopic surgery, no increase in morbidity associated with the additional procedure was
found.14 Similarly, our study found no complications in
the negative laparoscopy cohort. Because total complications with laparoscopy are low, a larger sample size is
needed to better assess whether appendectomy performed at the time of laparoscopic surgery contributes to
an increase in complications of gynecologic laparoscopic
surgery.
In our study, 2 of 19 patients had abnormal appendix at
the time of surgery (ie, mild acute appendicitis and
chronic appendicitis). Similarly, Drozgyik et al15 found
chronic appendicitis in 3.8% of their patients. Other studies have shown a higher percentage of abnormal histologic or gross appendices. One study of 356 patients
undergoing laparoscopic surgery found that 30.2% of the
appendix specimens had abnormal histology, including
lymphoid hyperplasia, endometriosis, and chronic and
acute appendicitis.11 Wie et al16 reported similar findings
in 34.9% of histologic abnormalities. In a study of 231
women with endometriosis, 115 women had pathologic
abnormalities in their appendix when it was removed at
the time of their surgery for chronic pelvic pain.17 These
abnormal histologic findings may contribute to chronic
pelvic pain, specifically right lower quadrant pain. Other
86
studies have shown long-term improvement of pain in
patients who underwent appendectomy, regardless of
whether abnormal pathology was present at the time the
appendix was removed.12
Our study serves to better elucidate the relationship between appendectomy and improvement of chronic pelvic
pain. Compared with prior studies, our study has several
strengths. First, it is a cohort study with specifically defined exclusion criteria. It is also a single-institution study,
providing a more consistent definition of chronic pelvic
pain and more standardized surgical practices and postoperative follow-up. We also used a validated assessment
of pain, with the 11-point numeric pain scale and the Pain
Disability Index.
One of the main limitations of our study is its retrospective
nature. In addition, we had a poor response rate in the
second phase of the study. Only 38% of the cohort responded to the survey, although there were no demographic or clinical differences between responders and
nonresponders. The inadequate response undermined efforts to quantify any differences between the groups in the
need for additional analgesic use and surgical interventions. Also, recall bias may have been a factor because the
survey was sent during a defined period, regardless of
when the patient’s surgery was performed. Although we
believe a well-designed, randomized controlled trial can
JSLS (2013)17:82– 87
address the design limitations of this study, enrollment
could be challenging.
This study has demonstrated in the short term the effectiveness of appendectomy in patients with chronic pelvic
pain, especially right-sided pelvic pain that has no obvious pelvic pathology. Long-term outcomes data from randomized clinical trials are needed to validate these findings.
References:
1. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC,
Steege JF. Chronic pelvic pain: prevalence, health-related quality
of life, and economic correlates. Obstet Gynecol. 1996;87(3):321–
327.
2. McVeigh E. The surgical management of pelvic pain. Curr
Obstet Gynaecol. 2005;15(5):291–297.
8. Fauconnier A, Dallongeville E, Huchon C, Ville Y, Falissard
B. Measurement of acute pelvic pain intensity in gynecology: a
comparison of five methods. Obstet Gynecol. 2009;113(2 Pt 1):
260 –269.
9. Pollard CA. Preliminary validity study of the pain disability
index. Percept Mot Skills. 1984;59(3):974.
10. Fayez JA, Toy NJ, Flanagan TM. The appendix as the cause
of chronic lower abdominal pain. Am J Obstet Gynecol. 1995;
172(1 Pt 1):122–123.
11. Lee JH, Choi JS, Jeon SW, et al. Laparoscopic incidental
appendectomy during laparoscopic surgery for ovarian endometrioma. Am J Obstet Gynecol. 2011;204(1):28.e1– e5.
12. Popovic D, Kovjanic J, Milostic D, et al. Long-term benefits
of laparoscopic appendectomy for chronic abdominal pain in
fertile women. Croat Med J. 2004;45(2):171–175.
3. Reiter RC. A profile of women with chronic pelvic pain. Clin
Obstet Gynecol. 1990;33(1):130 –136.
13. Nana AM, Ouandji CN, Simoens C, Smets D, Mendes da
Costa P. Laparoscopic appendectomies: results of a monocentric
prospective and non-randomized study. Hepatogastroenterology. 2007;54(76):1146 –1152.
4. El Bishry G, Tselos V, Pathi A. Correlation between laparoscopic and histological diagnosis in patients with endometriosis.
J Obstet Gynaecol. 2008;28(5):511–515.
14. Nezhat C, Nezhat F. Incidental appendectomy during videolaseroscopy. Am J Obstet Gynecol. 1991;165(3):559 –564.
5. AlSalilli M, Vilos GA. Prospective evaluation of laparoscopic
appendectomy in women with chronic right lower quadrant
pain. J Am Assoc Gynecol Laparosc. 1995;2(2):139 –142.
15. Drozgyik I, Vizer M, Szabo I. Significance of laparoscopy in
the management of chronic pelvic pain. Eur J Obstet Gynecol
Reprod Biol. 2007;133(2):223–226.
6. DeCou JM, Gauderer MW, Boyle JT, Green JA, Abrams RS.
Diagnostic laparoscopy with planned appendectomy: an integral
step in the evaluation of unexplained right lower quadrant pain.
Pediatr Surg Int. 2004;20(2):123–126..
16. Wie HJ, Lee JH, Kyung MS, Jung US, Choi JS. Is incidental
appendectomy necessary in women with ovarian endometrioma? Aust N Z J Obstet Gynaecol. 2008;48(1):107–111.
7. Agarwala N, Liu CY. Laparoscopic appendectomy. J Am
Assoc Gynecol Laparosc. 2003;10(2):166 –168.
17. Berker B, Lashay N, Davarpanah R, Marziali M, Nezhat CH,
Nezhat C. Laparoscopic appendectomy in patients with endometriosis. J Minim Invasive Gynecol. 2005;12(3):206 –209.
JSLS (2013)17:82– 87
87
SCIENTIFIC PAPER
A Pilot Feasibility Multicenter Study of Patients After
Excision of Endometriosis
Patrick Yeung Jr, MD, Frank Tu, MD, MPH, Krisztina Bajzak, MD, MPH, Georgine Lamvu, MD,
Olga Guzovsky, Rob Agnelli, MStats, Mary Peavey, MD, Wendy Winer, RN, Robert Albee Jr, MD,
Ken Sinervo, MD
ABSTRACT
Objective: To serve as a pilot feasibility study for a randomized study of excision versus ablation in the treatment
of endometriosis by (1) estimating the magnitude of
change in symptoms after excision only at multiple referral centers and (2) determining the proportion of women
willing to participate in a randomized trial.
Methods: We performed a multicenter prospective study
of women undergoing excision for endometriosis (Canadian Task Force class II-3) at Duke University Center for
Endometriosis Research & Treatment (currently the Saint
Louis University Center for Endometriosis), Center for
Endometriosis Care, Northshore University Health System,
Memorial University (Canada), and Florida Hospital. The
study comprised 100 female patients, aged 18 to 55 years,
with endometriosis-suspected pelvic pain. The intervention was laparoscopic excision only of the abnormal peritoneum suspicious for endometriosis. The main outcome
measures were quality of life, pelvic pain, dysmenorrhea,
dyspareunia, and bowel and bladder symptoms.
Results: The mean follow-up period was 8.5 months.
Excision of endometriosis showed a significant reduction
in all pain scores except bowel symptoms, as well as
significant improvement in quality of life. Of the patients,
84% were willing to participate in a randomized study.
Department of Obstetrics, Gynecology & Women’s Health, Saint Louis University, and
Saint Louis University Center for Endometriosis, St. Louis, MO, USA (Dr. Yeung).
Northshore University Health System, Evanston, IL, USA (Dr. Tu).
Memorial University, St. John’s, Newfoundland, Canada (Dr. Bajzak).
Florida Hospital, Orlando, FL, USA (Dr. Lamvu).
School of Medicine, Saint Louis University, St. Louis, MO, USA (Guzovsky).
SAS Institute, Cary, NC, USA (Mr. Agnelli).
Department of Obstetrics & Gynecology, Duke University, Durham, NC, USA (Dr.
Peavey).
Center for Endometriosis Care, Atlanta, GA, USA (Ms. Winer; Drs. Sinervo, Albee).
DOI: 10.4293/108680812X13517013317833
Address correspondence to: Paul Yeung, Jr, MD, Director, Center for Endometriosis, Minimally Invasive Gynecologic Surgery, 1031 Bellevue Ave, Ste 400, St. Louis,
MO 63117, E-mail: [email protected]
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
88
Conclusions: Quality of life is a needed primary outcome
for any randomized study comparing excision versus ablation. A multicenter comparative trial is feasible, although
quality assurance would have to be addressed. Patients
were willing to be randomized even at surgical referral
centers.
Key Words: Endometriosis, Excision, Ablation, Randomized study, Quality of life.
INTRODUCTION
The optimal technique for the surgical management of
peritoneal endometriosis is not clear. Two main categories
of surgical management exist and are referred to as ablation (where endometrial implants are destroyed with energy, which will include vaporization, without a specimen
being taken out of the body) and excision (where the
implant is completely removed from the body and sent to
the pathology department). There is little evidence from
randomized controlled trials (RCTs) to guide surgical management of endometriosis-associated pelvic pain. In the
classic RCT by Sutton et al.1 published in 1994, the
combination of laparoscopic ablation and laser uterosacral nerve ablation was compared with no surgical
treatment. There was a statistically significant improvement in the treatment group compared with no treatment at 6 months (62.5% vs 22.6%), and this benefit was
continued in more than 90% of patients for up to 1
year.2 In an RCT by Abbott et al.3 published in 2004,
immediate laparoscopic excision was compared with
delayed excision at 6 months, and patients were followed up for up to 12 months after the initial surgery.
Statistically, more patients had improvement of pain
after excision versus placebo (80% vs 32%) per the
protocol. Both these trials compared a surgical technique (or combination of techniques) with no treatment
(or delayed treatment), and the results of the techniques cannot be compared against each other.
There have only been 2 RCTs that directly compared
ablation and excision in the laparoscopic management of
endometriosis. A small trial of 24 women performed by
JSLS (2013)17:88 –94
Wright et al.4 in 2005 compared excision of endometriosis
versus ablation and found that both treatments reduced
overall symptom scores by roughly 30% at 6 months.
However, given the small numbers, the study was underpowered, and no conclusions can be drawn from this trial.
A second, more recent RCT performed by Healey et al.5 in
2010 was powered to compare laparoscopic excision versus ablation of endometriosis for the primary outcome of
pelvic pain. There was no statistically significant difference in improvement of pelvic pain using the visual analog scale (VAS) at 12 months when comparing excision
versus ablation (56.4% vs 48.4%). However, there were
trends in improvement for dyschezia and dyspareunia. An
overall assessment of pain symptoms, such as quality of
life (QOL), was not performed. The authors advised that
these results are only applicable to results achievable by a
generalist gynecologist and are not necessarily applicable
to a specialist.
In practice, there is a tendency for gynecologic surgeons
to want to perform ablation because it is considered easier. Theoretically, excision is advantageous because it
ensures that the entire lesion or pathologic tissue is removed, especially for deeply infiltrating endometriosis or
disease found over a vital organ or structure.
The purpose of this study was to collect data from several
referral sites, both academic and private, with experience
and expertise in treating endometriosis by excision. There
were 2 specific aims for the study, meant to be used as a
pilot feasibility study for a subsequent comparative RCT
that might give new information on whether excision or
ablation is the better technique for treating symptomatic
endometriosis. First, we aimed to obtain an estimate of the
proportion of symptomatic women being treated for endometriosis at surgical referral sites who would be willing
to participate in a randomized trial of laparoscopic excision versus ablation of endometriosis. Second, we aimed
to estimate the magnitude of change in pain symptoms
and global QOL in symptomatic women at least 6 months
after undergoing laparoscopic excision only of endometriosis at several different referral centers.
METHODS
Informed consent was obtained and documented for patients seen at 5 referral centers in North America (formerly
Duke University Center for Endometriosis Research &
Treatment in Durham, North Carolina [currently Saint
Louis University Center for Endometriosis in St. Louis,
Missouri]; Center for Endometriosis Care in Atlanta, Georgia; Northshore University Health System in Evanston,
Illinois; Florida Hospital in Orlando, Florida; and Memorial University in St. John’s, Newfoundland, Canada) that
specialize in the management of pelvic pain or endometriosis. A 2-page (front and back) questionnaire was then
administered by the site investigator and/or the nursing
staff. The study was approved by the institutional review
board at each of the institutions.
Questions from the survey included information on baseline demographics, severity and type of pain, previous
medical and surgical history, and openness to participating in a randomized trial comparing excision versus ablation on the surgical management of endometriosis. The
goal was to obtain information from approximately 20
consecutive patients per site, for a total of 100 patients.
Data on the number of patients per site, as well as operative data, were collected. A follow-up 2-page questionnaire, sent by mail or administered by a phone consultation, was completed starting at 6 months after the surgery.
Inclusion criteria were female patients, aged 18 to 55
years, with endometriosis-associated persistent pelvic
pain defined as all of the following: 3 months of chronic
pelvic pain (defined as average pain intensity ⬎5 of 10 for
⬎50% of that time), which must have been predominantly
localized to the pelvic region, bounded by the umbilicus
superiorly and the inguinal ligament and symphysis pubis
inferiorly, and could not be solely from the lumbar back or
the skin (thus excluding isolated lumbago and vulvodynia); pain despite 1 class of medical treatments (eg,
over-the-counter anti-inflammatories or hormonal suppression with oral contraceptives) for their endometriosis-associated pain; and at least 1 pelvic visceral pain
component (dysmenorrhea, dyspareunia, dyschezia, or
dysuria).
Exclusion criteria included prior bilateral salpingo-oophorectomy or post–natural menopause status, as well as
significant mental or chronic systemic illness that might
confound pain assessment or the ability to complete the
study.
The primary symptom outcomes measured were QOL
and pain—pelvic pain, dysmenorrhea, dyspareunia, and
bowel and bladder symptoms. Analysis of variance and
Fisher exact tests were used to compare the baseline
demographic data between the centers as appropriate.
VAS scores are a validated way to measure pain and were
used to measure overall pelvic pain, as well as the different types of visceral pain.6 Patients were asked on the
preoperative and postoperative questionnaire to rate their
pain by placing a mark on a 10-cm line, and the measured
distance to the mark (in millimeters) gave the VAS score.
JSLS (2013)17:88 –94
89
A Feasibility Multicenter Study of Patients After Excision of Endometriosis, Yeung P et al.
QOL was also assessed simply as an overall assessment of
symptoms, before and after surgery, by asking the patient
to rate it on a scale from 0 to 100. This way of measuring
QOL has been validated in previous studies.7 Paired t tests
were used to compare VAS scores and QOL scores when
a close-to-normal distribution could be assumed. When
the numbers were smaller or a normal distribution could
not be assumed, nonparametric tests were used as appropriate (eg, signed rank test or sign test).
Analysis of variance and Kruskal-Wallis (nonparametric)
tests were used to compare the change in VAS scores and in
QOL scores between the centers as appropriate. Fisher exact
tests were used to compare the rate of histologically proven
endometriosis by preoperative symptom between centers.
The other important outcome measured was the percentage of participants who would be willing to be randomized in a controlled study of excision versus ablation. This
was reported simply as a percentage of those surveyed
who responded yes to this question.
RESULTS
Consecutive patients seen at any of the 5 participating
centers and who met the inclusion criteria were invited to
be included in the study. There were a total of 100 patients
(Figure 1) who enrolled in the study and completed the
informed consent form, 90% (90 of 100) of whom underwent excision surgery. Of the 90 patients who underwent
surgery, 72.2% (65 of 90) had histologically confirmed
endometriosis and 61.1% (55 of 90) completed a postoperative questionnaire. The mean time after which the
follow-up questionnaire was completed was 8.5 months
(range, 6 –14 months).
Of particular interest, 84.0% (84 of 100) of the patients
who completed the initial questionnaire indicated that
they would be willing to participate in a randomized
trial of laparoscopic excision versus ablation of endometriosis.
There was no difference in the baseline demographics
of the patients seen at the 5 centers (Table 1), except
for previous medical therapy. Overall, more than 80%
of patients presenting to the 5 centers had previous
surgical interventions and more than 90% of patients
had previous hormonal therapy. Of the patients in
whom histologically proven endometriosis was found,
55 of 65 (84.6%) overall had received previous hormonal therapy or surgery.
When we compared VAS scores after surgery with those
before surgery in the patients who had confirmed endo-
Figure 1. Flowchart of recruited subjects at all centers.
*The 90 patients who underwent surgery were distributed across the 5 centers as follows: 50 from Center for Endometriosis Research
& Treatment, Duke University, Durham, North Carolina; 20 from Center for Endometriosis Care, Atlanta, Georgia; 11 from Northshore
University Health System, Evanston, Illinois; 5 from Florida Hospital, Orlando, Florida; and 4 from Memorial University, St. John’s,
Newfoundland, Canada.
90
JSLS (2013)17:88 –94
Table 1.
Baseline Demographics Overall and by Center
Overall (100)
DUa (59)
CEa (20)
NSa (13)
MUa (4)
FHa (4)
P Value
Age at presentation (y)
31.6
31.1
32
32.3
34.3
32.8
.91
Age at menstruation (y)
12.3
12.4
12.2
12.6
11.8
11.8
.78
Duration of pelvic pain (y)
9.3
9
11.6
8.2
9
7.2
.64
White
85/100 (85%)
50/57 (88%)
17/20 (85%)
10/13 (77%)
3/4 (75%)
5/5 (100%)
.31
History of infertility
31/95 (32.6%)
17/58 (29.3%)
4/20 (20%)
6/13 (46.2%)
2/4 (50%)
2/5 (40%)
.44
Previous medical treatment
87/95 (91.6%)
53/58 (91.4%)
14/20 (70%)
13/13 (100%)
3/4 (75%)
4/5 (80%)
.04
Previous surgery
78/95 (82.1%)
45/58 (77.6%)
18/20 (90%)
11/13 (84.6%)
1/4 (25%)
3/5 (60%)
.05
CE ⫽ Center for Endometriosis Care, Atlanta, GA; DU ⫽ Center for Endometriosis Research & Treatment, Duke University, Durham,
NC; FH ⫽ Florida Hospital, Orlando, FL; MU ⫽ Memorial University, St. John’s, Newfoundland, Canada; NS ⫽ Northshore University
Health System, Evanston, IL.
a
metriosis, there was a significant reduction in pain scores
for all symptoms except bowel symptoms (Table 2). Of
the symptoms that had significant reductions in pain by
VAS score, bladder pain showed the least (1.8 reduction)
and dyspareunia showed the most (2.9 reduction). Also of
note, the QOL scores were significantly improved after
excision surgery, with a mean improvement of 19.5 points
(P ⬍ .001). Comparisons were also made for the change in
symptoms and QOL scores with hormonal suppression
versus without hormonal suppression, and there were no
significant changes found for any of these comparisons
(Table 2). In addition, the change in VAS scores and the
change in QOL scores were compared between the centers,
and no significant differences were found. When looking at
the patients who underwent surgery and who did not have
histologically confirmed endometriosis, we found no improvement in QOL scores, although there was improvement
in pelvic pain (P ⬍ .01) and dyspareunia (P ⫽ .03).
Pain symptoms (chronic pelvic pain, dysmenorrhea, dyspareunia, bowel symptoms, bladder symptoms) when
present had a rate of histologically proven endometriosis
ranging from 71.6% to 74%, with chronic pelvic pain being
the least predictive and deep dyspareunia being the most
predictive (Table 3). These results were compared between centers, and no significant differences were found.
DISCUSSION
A particular strength of this study is that it describes
outcomes after excision for endometriosis from multiple
referral centers; as such, it is the first study known to
include data from multiple centers after excision. This
shows that a multicenter trial is feasible, even among
surgical referral sites. Most studies that have been pub-
lished on excision for the surgical management of endometriosis have been from a single surgeon or center.5,8,9
Patients were suspected to have endometriosis based on
the overall assessment of the surgeon from the clinical
history and examination findings. One of the benefits of
excision is the histologic confirmation of disease, and
more than 7 of 10 patients who underwent surgery in this
study for the suspicion of endometriosis had histologically
proven disease. Even more noteworthy is that of the
patients in whom histologically proven endometriosis was
found, a high percentage (84.6%) had received either
previous hormonal therapy or surgery by ablation as
“treatment” for presumed endometriosis, indicating that
these interventions are ineffective at suppressing or preventing disease. The data from this study further indicate
that the addition of hormonal suppression after excision
did not further reduce VAS scores for pain or benefit QOL
scores, when compared with patients without postoperative hormonal suppression.
In the RCT of excision versus ablation for endometriosis
by Healey et al.5 (2010), differences in pelvic pain were
not statistically significant, but there were trends for a
difference in bowel-related symptoms and dyspareunia.
In addition, as mentioned earlier, the results of their
study came from a single center and are likely only
applicable to generalist gynecologists. In our prospective multicenter study on excision for endometriosis,
there were significant reductions in pelvic pain, dysmenorrhea, dyspareunia, and bladder symptoms but
not bowel symptoms.
In contrast to the study by Healey et al.,5 where fewer than
one-third of patients who underwent surgery previously
JSLS (2013)17:88 –94
91
A Feasibility Multicenter Study of Patients After Excision of Endometriosis, Yeung P et al.
Table 2.
VAS and QOL Scores Before and After Surgery in Patients Who Had Confirmed Endometriosis
Preoperative
Postoperative
Change in Score
P Value
5.2 (n ⫽ 65)
2.4 (n ⫽ 43)
–2.6
⬍ .001a,b
Postoperative suppression
5.3 (n ⫽ 23)
2.8 (n ⫽ 24)
–2.5
.19c,d
No suppression
4.6 (n ⫽ 39)
2.5 (n ⫽ 37)
–2.1
7.5 (n ⫽ 65)
4.0 (n ⫽ 36)
–2.6
.002a,e
Postoperative suppression
7.5 (n ⫽ 23)
4.7 (n ⫽ 19)
–2.8
.32b,c
No suppression
7.1 (n ⫽ 38)
3.3 (n ⫽ 16)
–3.8
5.1 (n ⫽ 61)
2.0 (n ⫽ 41)
–3.0
⬍ .001a,f
Postoperative suppression
5.1 (n ⫽ 21)
3.0 (n ⫽ 22)
–2.1
.20c,e
No suppression
4.9 (n ⫽ 38)
1.0 (n ⫽ 18)
–3.9
Bowel symptoms
3.4 (n ⫽ 65)
2.0 (n ⫽ 42)
–0.3
.6a,b
Postoperative suppression
3.8 (n ⫽ 23)
2.5 (n ⫽ 23)
–1.3
.22c,e
No suppression
3.1 (n ⫽ 37)
1.5 (n ⫽ 18)
–1.6
2.6 (n ⫽ 65)
0.6 (n ⫽ 41)
–1.8
⬍ .001a,e
Postoperative suppression
2.5 (n ⫽ 23)
0.8 (n ⫽ 22)
–1.7
.11c,g
No suppression
2.5 (n ⫽ 37)
0.4 (n ⫽ 18)
–2.1
63.3 (n ⫽ 65)
83.3 (n ⫽ 43)
20.0
⬍ .001a,e
Postoperative suppression
60.8 (n ⫽ 23)
78.5 (n ⫽ 24)
17.7
.15b,c
No suppression
67.7 (n ⫽ 37)
89.3 (n ⫽ 18)
21.6
Pelvic pain
Dysmenorrhea
Dyspareunia
Bladder symptoms
QOL
a
Comparison of preoperative and postoperative scores for symptom.
t Test.
c
Comparison of changes in system with and without hormonal suppression.
d
Wilcoxon 2-sample test.
e
Sign test.
f
Signed rank test.
g
t Test with Satterwaite correction for unequal variances.
b
Table 3.
The Rate of Histologically-Confirmed Endometriosis by Preoperative Symptom
Symptom
Overall
DUa
CEa
NSa
MUa
FHa
Pelvic pain
58/81 (71.6%)
35/45 (77.8%)
14/19 (73.9%)
6/9 (66.7%)
2/3 (66.7%)
(0/5) 0%
Menstrual cramps
61/83 (73.5%)
37/46 (80.4%)
14/17 (82.4%)
7/11 (63.6%)
3/4 (75%)
(0/5) 0%
Pain with intercourse
57/77 (74.0%)
37/44 (84.1%)
12/17 (70.6%)
6/9 (66.7%)
2/3 (66.7%)
(0/4) 0%
Pain with bowel movements
39/54 (72.2%)
21/25 (84%)
11/15 (73.3%)
6/10 (60.0%)
1/1 (100%)
(0/3) 0%
Pain with full bladder
32/44 (72.7%)
18/25 (72%)
9/14 (64.3%)
3/6 (50.0%)
2/2 (100%)
(0/2) 0%
CE ⫽ Center for Endometriosis Care, Atlanta, GA; DU ⫽ Center for Endometriosis Research & Treatment, Duke University, Durham,
NC; FH ⫽ Florida Hospital, Orlando, FL; MU ⫽ Memorial University, St. John’s, Newfoundland, Canada; NS ⫽ Northshore University
Health System, Evanston, IL.
a
92
JSLS (2013)17:88 –94
received either hormonal or surgical treatment, patients in
our study received either hormonal or surgical treatment
in the vast majority of cases (⬎80%). One might predict
that patients having previous treatment might respond
with less benefit from another surgical intervention, yet
the rates of improvement in VAS scores were comparable
in both studies. Also of note is the finding that patients did
not have symptom improvement in QOL scores when no
endometriosis was found histologically.
A strength of this study is the inclusion of a single validated measure of QOL before and after excision surgery.
A scale of 0 to 100 for the QOL score is easy to use and has
been validated as an assessment tool.7 Most studies on the
surgical management of endometriosis use pelvic pain as
the primary outcome as measured by VAS scores.1,3,5 A
potential problem with using pelvic pain as the primary
outcome of a study on endometriosis is that some components of pain may improve after surgically treating
endometriosis whereas others may not, at least to the
same extent. A QOL assessment may be a better overall
measure of the clinical benefit of surgery for treating
endometriosis by translating multiple pain symptoms to a
single measure of their effect on daily functioning. In fact,
published reviews have recommended the inclusion of a
QOL assessment in trials that look at pain as an outcome.10,11 Our study showed a statistically significant improvement in QOL scores after excision at multiple centers. It is our recommendation that a QOL measure be
used as the primary symptom outcome measure for future
comparative trials on excision versus ablation in the surgical management of endometriosis. This study has produced an estimate of the benefit on QOL after excision to
be an increase of 20 points. There are no known studies
that have evaluated QOL after ablation.
Weaknesses of this study include the skewed actual
numbers of recruitment, with more than 58 of 100
patients coming from a single center and 78 of 100 from
2 centers. Perhaps more important is the lack of quality
assurance or some objective way to determine whether
adequate or complete excision of all areas of abnormal
peritoneum was achieved at each of the centers. In any
subsequent randomized comparative trial comparing excision and ablation, objective or third-party quality assurance
will need to be included for both techniques, especially if a
particular referral center favors a particular approach over
the other.
As reported in a recent study on complete excision of
endometriosis in teenagers, one of the most important
benefits of excision may not be symptom relief but may
be eradication of disease.12 Potential eradication of disease by excision might benefit future fertility, and this
benefit might need to be evaluated also in a comparative trial of excision versus ablation in the treatment of
endometriosis.
One of the aims of this study was to obtain an estimate of
the rate of patients presenting to referral centers for pelvic
pain or endometriosis (in particular, centers that specialize
in the excision of endometriosis) who would be willing to
be randomized to either excision or ablation of endometriosis at the time of surgery. The vast majority of patients
(84.0%) were willing to be randomized when asked this
question. This bodes well for the feasibility of a randomized comparative trial even at referral centers that specialize in a particular surgical approach to the treatment of
endometriosis.
The results of this study indicate that patients were overwhelmingly willing to be randomized to either excision or
ablation for endometriosis even at referral centers, that
QOL may be a better overall measure as a primary outcome when one is looking at the benefit of surgery for
endometriosis, and that a comparative RCT is feasible, as
well as needed, among multiple centers that specialize in
surgically treating endometriosis.
CONCLUSION
A multicenter prospective study evaluating surgical treatment for endometriosis is feasible. Another comparative
trial comparing excision versus ablation in the surgical
management of endometriosis is needed at multiple centers but also with primary outcomes other than simply
pelvic pain. Patients are willing to be randomized even at
referral centers that treat endometriosis.
References:
1. Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective,
randomized, double-blind, controlled trial of laser laparoscopy
in the treatment of pelvic pain associated with minimal, mild,
and moderate endometriosis [see comment]. Fertil Steril. 1994;
62(4):696 –700.
2. Sutton CJ, Pooley AS, Ewen SP, Haines P. Follow-up report
on a randomized controlled trial of laser laparoscopy in the
treatment of pelvic pain associated with minimal to moderate
endometriosis. Fertil Steril. 1997;68(6):1070 –1074.
3. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R.
Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial [see comment]. Fertil Steril. 2004;82(4):
878 – 884.
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A Feasibility Multicenter Study of Patients After Excision of Endometriosis, Yeung P et al.
4. Wright J, Lotfallah H, Jones K, Lovell D. A randomized trial
of excision versus ablation for mild endometriosis. Fertil Steril.
2005;83(6):1830 –1836.
5. Healey M, Ang WC, Cheng C. Surgical treatment of endometriosis: a prospective randomized double-blinded trial comparing excision and ablation. Fertil Steril. 2010;94(7):2536 –2540.
6. Fauconnier A, Dallongeville E, Huchon C, Ville Y, Falissard B.
Measurement of acute pelvic pain intensity in gynecology: a comparison of five methods. Obstet Gynecol. 2009;113(2, pt 1):260–269.
7. de Boer AG, van Lanschot JJ, Stalmeier PF, et al. Is a singleitem visual analogue scale as valid, reliable and responsive as
multi-item scales in measuring quality of life? Qual Life Res.
2004;13(2):311–320.
8. Albee RB Jr, Sinervo K, Fisher DT. Laparoscopic excision of
lesions suggestive of endometriosis or otherwise atypical in
appearance: relationship between visual findings and final histologic diagnosis. J Minim Invasive Gynecol. 2008;15(1):32–37.
94
9. Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation
and persistent or recurrent disease. Fertil Steril. 1991;56(4):628 –
634.
10. Neelakantan D, Omojole F, Clark TJ, Gupta JK, Khan KS.
Quality of life instruments in studies of chronic pelvic pain: a
systematic review. J Obstet Gynaecol. 2004;24(8):851–
858.
11. Turk DC, Dworkin RH, Revicki D, et al. Identifying important
outcome domains for chronic pain clinical trials: an IMMPACT survey
of people with pain. Pain. 2008;137(2):276–285.
12. Yeung P Jr, Sinervo K, Winer W, Albee RB Jr. Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary? Fertil Steril. 2011;95(6):1909–1912,
1912.e1.
JSLS (2013)17:88 –94
SCIENTIFIC PAPER
Robotic-Assisted Hysterectomy for the Management
of Severe Endometriosis: A Retrospective Review of
Short-Term Surgical Outcomes
Mohamed A. Bedaiwy, MD, PhD, Mohamed Y. Abdel Rahman, MD,
Mark Chapman, MD, Heidi Frasure, MS, Sangeeta Mahajan, MD, Vivian E. von Gruenigen, MD,
William Hurd, MD, Kristine Zanotti, MD
ABSTRACT
Key Words: Robotics, Endometriosis, Surgery.
Objectives: The primary objective was to examine the
safety and feasibility of robotic-assisted laparoscopy in a
cohort of women treated surgically for stage III and IV
endometriosis. The secondary objective was to explore
whether the stage of endometriosis affected surgical outcome.
INTRODUCTION
Methods: In this cohort study, 43 women with severe
endometriosis were treated with robot-assisted laparoscopic hysterectomy with unilateral or bilateral salpingooophorectomy for stage III (n ⫽ 19) or stage IV (n ⫽ 24)
disease.
Results: Histopathologic evaluation confirmed endometriosis in all patients, and fibroids were also shown in 12
patients. The median actual operative time was 145 min
(range, 67–325 min), and the median blood loss was 100
mL (range, 20 – 400 mL). All but one of the procedures
were completed successfully robotically. The length of
hospital stay was 1 d for 95% of patients (41 of 43), and 2
patients had prolonged stays of 4 d and 5 d, respectively.
One patient was readmitted for a vaginal cuff abscess; this
represented the only complication identified in this series.
Conclusions: Robot-assisted laparoscopic surgery appears to be a reasonably safe and feasible method for the
definitive surgical management of women with severe
endometriosis.
Department of Obstetrics and Gynecology, University Hospitals, Case Western
Reserve University, Cleveland, OH, USA (Drs. Bedaiwy, Abdel Rahman, Chapman,
Frasure, Mahajan, Hurd, Zanotti).
Summa Akron City Hospital, Akron, OH, USA (Dr. von Gruenigen).
Presented in part at the annual meeting of the Society of Gynecologic Surgeons,
San Antonio, TX, USA, April 10 –13, 2011.
Address correspondence to: Kristine Zanotti, MD, Director, University Hospitals
Center for Robotic Surgery, Gynecologic Oncology, University Hospitals Case
Medical Center and The Seidman Cancer Center, 11100 Euclid Ave, Cleveland,
OH 44106, USA, Telephone: 216 844 5011. Fax: 216 844 7631, E-mail: kristine.
[email protected]
DOI: 10.4293/108680812X13517013317275
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
Endometriosis is estimated to occur in 6% to 10% of
women of reproductive age,1 with a prevalence of 38%
(range, 20%–50%) in infertile women,2 and in 71% to 87%
of women with chronic pelvic pain.3 In the past, symptomatic moderate to severe endometriosis was most commonly treated by laparotomy with the removal of affected
tissue, with or without hysterectomy and bilateral salpingo-oophorectomy. More recently, many women with advanced endometriosis have been treated with a laparoscopic approach because it results in a shorter hospital
stay and recovery period compared with laparotomy.
However, conventional laparoscopy has inherent limitations for the treatment of advanced endometriosis because
of the adhesive nature of the disease, obliteration of the
surgical plans, variability of surgical skill levels, and normal mechanics of the human hand.
The use of a robotic system to assist with laparoscopy has
been shown to overcome some of the technical limitations
of laparoscopy while maintaining its minimally invasive
nature. The most widely used system for robotically assisted laparoscopy is the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Advantages of this
system include a steady 3-dimensional (3D) image and
articulating instrumentation that allow for 7 degrees of
movement, mimicking the human wrist. It also filters the
surgeon’s hand tremors at the console and eliminates the
fulcrum effect encountered in conventional laparoscopy.
Moreover, it allows movement downscaling, increasing
accuracy and precision. To date, only a small study has
been published that examines the feasibility of robotically
assisted laparoscopy for the management of advanced
endometriosis.4 The primary objective of this study is to
report our experience with the safety and feasibility of
robotic surgical treatment of advanced pelvic endometriosis. The secondary objective was to explore whether the
stage of endometriosis affected surgical outcome.
JSLS (2013)17:95–99
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Robotic-Assisted Hysterectomy for the Management of Severe Endometriosis, Bedaiwy MA et al.
MATERIALS AND METHODS
The institutional review board of the University Hospitals
Case Medical Center, Cleveland, Ohio, approved this retrospective chart review study. Our series consists of 43
patients who underwent robotically assisted laparoscopic
surgery for the treatment of advanced endometriosis between April 2008 and March 2010. All data were collected
directly from the patients’ charts by use of a standardized
data collection sheet. The electronic records of 422 patients who underwent robotic surgery during the study
period for gynecologic indications were evaluated. Patients with histologically confirmed endometriosis were
identified. Operative reports of this cohort were reviewed.
The extent of disease as dictated by the primary surgeon
was matched against the American Society for Reproductive Medicine (ASRM) classification of endometriosis for
staging.5 Patients with stage I and II endometriosis were
excluded (n ⫽ 11). Patients who underwent conservative
surgical management with uterine preservation were also
excluded (n ⫽ 7). There were no selection criteria to use
the robotic platform. This was based solely on surgeon
preference, scheduling, and availability.
Demographic and clinical characteristics were recorded,
and the patients were divided into 2 groups according to
the ASRM classification by endometriosis stage III or IV.5
Outcome variables included total operating room, actual
operative time, and postanesthesia care unit (PACU) time
(in minutes); estimated blood loss (in milliliters); and
uterine weight (in grams). Complications were determined by examination of the hospital chart and the postoperative visit notes within 6 mo after surgery.
Operative Technique
After induction of general anesthesia, the patient was
positioned in the dorsal lithotomy position with both arms
tucked by the patient’s side. A beanbag was adjusted to
keep the arms and the shoulders in place. Pneumoperitoneum was usually induced with a Veress needle. A 12-mm
trocar was placed 2 to 5 cm supraumbilically. Two 8-mm
robotic trocars were placed bilaterally, 10 cm lateral to and
at the level of the umbilicus. An accessory 10-mm trocar
was placed in the left lower quadrant. Monopolar scissors
were inserted through the right robotic trocar, and a
plasma kinetic dissecting forceps was inserted through the
left robotic trocar.
Oophorectomy was started by entering the retroperitoneal
space of the lateral pelvic sidewall with unipolar electrosurgery. The infundibulopelvic (IP) ligament was then
96
skeletonized. The ureter was identified. Subsequently, unipolar electrosurgery was used to create a window below
the IP ligament and above the ureter. The IP was then
coagulated 3 times and divided. Alternatively, the IP was
coagulated and cut if the ureter could be visualized easily.
This process was repeated on the contralateral side when
both ovaries were removed. Lysis of adhesions was then
performed to restore normal anatomy in patients with
extensive adhesions.
Unilateral lateral pelvic sidewall dissection and ureterolysis were performed in a total of 8 patients (3 with stage III
and 5 with stage IV disease) to resect deep infiltrating
lesions. Partial obliteration of the cul-de-sac was treated
with sharp dissection in only 3 patients with stage IV
disease. Careful dissection with and without the use of
electrocautery was used to preserve the integrity of the
ureter, pelvic vessels, and rectum. The hysterectomy portion of the procedure was then completed by a standard
approach according to the surgeon’s preference.
The Foley catheter was removed at the end of the procedure. A regular diet was started on the same day of the
operation, and patients were allowed to ambulate as soon
as possible. The patient was routinely discharged the
morning after surgery, unless the patient’s clinical condition required continued hospitalization. A routine postoperative visit was made 4 to 6 wk after the surgery and as
needed thereafter. Total operative time was defined as the
time elapsed from intubation to extubation in minutes.
Actual operative time was defined as the time elapsed
from skin incision to skin closure. The PACU time was
defined as the time from arriving to the PACU until discharge of the patient to the floor.
Statistical Analysis
Patient characteristics and surgical parameters for the entire cohort of patients were described. A secondary goal
was to compare these parameters among patients with
stage III and stage IV endometriosis. Patient demographic
and clinical characteristics were compared between stage
III and IV endometriosis patients by use of the MannWhitney U test for continuous variables and ␹2 tests for
categorical variables. The median total operating room,
actual operative, and PACU times were compared for
women with stage III and IV endometriosis by use of the
Mann-Whitney U test. P ⬍ .05 was considered statistically
significant. Data were analyzed with SPSS software, version 17.0 (SPSS, Chicago, IL, USA).
JSLS (2013)17:95–99
RESULTS
Patient Characteristics
Forty-three women underwent a robotic procedure for
advanced endometriosis (Table 1). Of these, 19 (44.2%)
had stage III and 24 (55.8%) had stage IV endometriosis.
The median patient age was 46 y (range, 32– 68 y), and the
mean body mass index was 28 kg/m2 (range, 20.2–50.2
kg/m2). Baseline characteristics were similar in both
groups.
Nine patients (20.9%) had previously undergone laparotomy for various indications. Along with the hysterectomy,
both ovaries were removed in 29 of 43 patients (67.5%). In
14 patients (32.5%), only 1 ovary was removed and the
contralateral ovary was preserved.
Intraoperative Outcomes
The median total operative time was 190 min (range,
97–368 min), including patient positioning, robot docking,
performing surgery, and performing closure of the port
sites. The median actual operative time was 145 min
(range, 67–325 min), and both total operating room time
and actual operative time were comparable between the 2
groups (Table 1). There was no difference between the 2
groups regarding estimated blood loss and uterine weight.
Pathologic evaluation confirmed the endometriosis diagnosis in all patients. There was 1 conversion to laparotomy because of the size and location of multiple fibroids
in a woman with a 14 wk–sized uterus. One patient also
required vaginal assistance to expedite completion of her
hysterectomy.
Postoperative Outcomes
There was no significant difference between groups in
PACU times, with a median of 80 min (range, 32–165 min)
for all patients. Narcotics were given postoperatively as
needed. All patients were sent home with oral oxycodone/
acetaminophene, 5/325 mg. Histopathologic confirmation
of the disease was established postoperatively. Concomitant fibroids were confirmed in 12 patients (27.9%). Almost all patients were discharged the day after surgery (41
of 43 [95%]); 1 patient who was converted to laparotomy
was discharged after 5 d, and another patient stayed for
3 d because of postoperative ileus that resolved spontaneously. One patient was readmitted on postoperative
day 11 with fever, chills, and lower abdominal pain. Computed tomography showed a vaginal cuff abscess. She
was treated with antibiotics, the abscess was drained vaginally under general anesthesia, and a Foley catheter was
Table 1.
Baseline Characteristics and Intraoperative Outcome Measures of Study Population
Patient/Clinical Demographics
Age [median (range)] (y)
2
BMIb [mean (SD)] (kg/m )
Overall (N ⫽ 43)
Stage III Endometriosis
(n ⫽ 19)
Stage IV Endometriosis
(n ⫽ 24)
P Valuea
46 (32–68)
49 (34–68)
43.5 (32–61)
.339
28 (20.2–50.2)
26.8 (21.3–45.4)
30.4 (20.2–50.2)
.695
Previous surgery
9 (20.9%)
3 (15.8%)
6 (25%)
.708
Total ORb time [median (range)] (min)
190 (97–368)
190 (97–290)
183 (138–368)
.934
Actual operative time [median (range)] (min)
145 (67–325)
145 (67–234)
146.5 (102–325)
.882
Uterine weight [median (range)] (g)
121.3 (48–570)
105 (52–376)
125.1 (48–570)
.839
EBLb [median (range)] (mL)
100 (20–400)
100 (25–325)
100 (20–400)
.503
Complications intraoperatively
2 (4%)
1 (5.2%)
1 (4.2%)
.999
PACU time [median (range)] (min)
80 (32–165)
87.5 (32–135)
80.0 (32–165)
.752
1d
41 (95.3%)
19 (100%)
22 (91.7%)
.495
⬎1 d
2 (4.7%)
0
2 (8.3%)
1 (2%)
0
Hospital stay
Complications postoperatively
1 (4.2%)
.999
Comparison of stage III and stage IV endometriosis with Mann-Whitney U or ␹ test.
BMI ⫽ body mass index; EBL ⫽ estimated blood loss; OR ⫽ operating room.
a
2
b
JSLS (2013)17:95–99
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Robotic-Assisted Hysterectomy for the Management of Severe Endometriosis, Bedaiwy MA et al.
placed into the abscess cavity. She remained afebrile and
was discharged after 4 d. The Foley catheter was removed
after 7 d.
DISCUSSION
Our study represents the largest cohort of patients with
advanced endometriosis managed with definitive surgery
by robotic laparoscopy reported in the literature. In this
study of 43 patients with stage III and IV endometriosis,
intraoperative complication rates were low and only 1
patient required conversion to laparotomy. Moreover,
only 1 minor and 1 major postoperative complication
occurred, manifesting as a self-limited ileus and a vaginal
cuff abscess, respectively. Together these data suggest
both the feasibility and safety of this surgical modality for
the definitive treatment of severe endometriosis.
There are very few randomized trials evaluating the different surgical approaches to pelvic endometriosis.
Whereas Nezhat et al.4 observed no benefit of robotic over
conventional laparoscopy for the surgical treatment of
stage I or II endometriosis, we speculate that such comparisons are unlikely to be equivocal for more severe
manifestations of endometriosis. A 10% rate of conversion
to laparotomy has been reported in patients with severe
endometriosis managed with conventional laparoscopy
when performed by high-volume, experienced laparoscopic surgeons.6 In our series there were no conversions
to laparotomy because of an intraoperative complication;
moreover, a 2% overall conversion rate (1 of 50) compares
favorably with that reported with conventional laparoscopy. Furthermore, as the complexity of pelvic dissection
necessary for the surgical management of severe pelvic
endometriosis increases, the advantages provided by the
robotic platform become more indispensible. Isolated reports have documented its use in patients with severe
endometriosis involving the urinary and gastrointestinal
systems.7,8 These reports encourage further exploration of
robotic surgery in this population of patients.
Among its inherent characteristics, the 3D technology of
robotic surgery is of particular importance in the surgical
management of severe endometriosis. The robotic platform improves the depth of perception and facilitates the
resection of deep infiltrating lesions. In addition, the robotic system improves dexterity, filters the surgeon’s
tremor, and improves intuitive movements.9,10 These features enable the surgeon to execute complicated surgical
steps such as re-creation of an obliterated cul-de-sac,
lateral pelvic wall dissection and resection of densely
adherent endometriomas, ureterolysis, and enterolysis.
98
Moreover, the 7 df and 3D visual image permit easier
handling of the tissue.10,11
Robotic surgery has several disadvantages compared with
traditional laparotomy. These include increased cost; the
lack of tactile feedback to the surgeon; the presence of
bulky robotic arms, as well as long and thick cords; the
inability to move the surgical table once the robot arms
are attached; and a limited range of motion with respect to
operating in different quadrants in the same case.4 A major
potential limitation of robotic surgery is the absence of
tactile (also called “haptic”) feedback. This is of particular
importance when the dissection is close to delicate structures, such as the ureter, blood vessels, and rectum. This
could lead to an inability to determine the strength needed
for suturing without breaking the suture or possible injury
to adjacent structures. It is especially true in early cases
performed by inexperienced surgeons, and its effect will
decrease but not disappear with experience. In addition,
visual cues from the 3D image may dampen this limitation.12
This study has several limitations. First, it is a retrospective
study and, as such, has inherent weaknesses. Ideally, a
prospective randomized trial with laparotomy or laparoscopy without robotic assistance as a control group will be
of interest when analyzing the perioperative outcomes.
The study is also limited by the lack of a control group. In
addition, it is limited by the lack of long-term outcomes
including recurrence of endometriosis. Given the fact that
the long-term objective of most patients with pelvic pain
due to endometriosis is pain relief, a study with the longterm goal of pain relief is needed. However, most our
patients were followed up for up to 1 y after surgery
without recurrence of symptoms.
The ASRM scoring system did not correlate well with
either perioperative or postoperative outcome measures
in our cohort of patients. Although the ASRM system’s
limitations in predicting clinically relevant outcomes in
patients with endometriosis, such as pelvic pain and fertility, are well described, the scoring system was developed to describe the extent and location of anatomic
distortion in patients with endometriosis. Anatomic findings, such as cul-de-sac obliteration, adhesions to the
broad ligament and pelvic sidewall, and deep peritoneal
implants, are anticipated to add to the complexity of
definitive surgery for endometriosis. We regard our finding that the operative time was not significantly correlated
with ASRM stage as a significant negative finding. Although these data may suggest limitations in either the
functionality or the reproducibility of the ASRM system (or
JSLS (2013)17:95–99
both), one may also surmise that these findings further
attest to the ability of the robotic technique to manage
distorted pelvic anatomy with greater ease. Because of
these questions, long-term prospective studies on the definitive surgical management of severe endometriosis are
of great interest. However, investigators will also be challenged to prospectively define meaningful and reproducible inclusion criteria for these studies.
CONCLUSION
In this retrospective cohort of 43 patients with stage III
and IV endometriosis, we found robotic-assisted laparoscopy to be both safe and feasible. Moreover, we speculate
that the unique features of the robotic platform may offer
advantages over conventional laparoscopy in patients
with more severe forms of endometriosis and allow more
women with this condition the opportunity for surgical
management by a minimally invasive approach. A prospective study is essential to more fully evaluate the relative merits of the robotic platform in the surgical treatment
of severe endometriosis.
4. Nezhat C, Lewis M, Kotikela S, et al. Robotic versus standard
laparoscopy for the treatment of endometriosis. Fertil Steril.
2010;94:2758 –2760.
5. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997;67(5):817– 821.
6. Marchal F, Rauch P, Vandromme J, et al. Telerobotic-assisted
laparoscopic hysterectomy for benign and oncologic pathologies: initial clinical experience with 30 patients. Surg Endosc.
2005;19(6):826 – 831.
7. Frick AC, Barakat EE, Stein RJ, Mora M, Falcone T. Roboticassisted laparoscopic management of ureteral endometriosis.
JSLS. 2011;15(3):396 –399.
8. Averbach M, Popoutchi P, Marques OW Jr, Abdalla RZ,
Podgaec S, Abrao MS. Robotic rectosigmoidectomy—pioneer
case report in Brazil. Current scene in colorectal robotic surgery.
Arq Gastroenterol. 2010;47(1):116 –118.
9. Falcone T, Goldberg JM. Robotic surgery. Clin Obstet Gynecol. 2003;46(1):37– 43.
10. Bedaiwy MA, Barakat EM, Falcone T. Robotic tubal anastomosis: technical aspects. JSLS. 2011;15(1):10 –15.
11. Frick AC, Falcone T. Robotics in gynecologic surgery. Minerva Ginecol. 2009;61(3):187–199.
References:
1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364(9447):
1789 –1799.
2. Balasch J, Creus M, Fábregues F, et al. Visible and nonvisible endometriosis at laparoscopy in fertile and infertile
women and in patients with chronic pelvic pain: a prospective
study. Hum Reprod. 1996;11(2):387–391.
12. Barakat EE, Bedaiwy MA, Zimberg S, Nutter B, Nosseir M,
Falcone T. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol.
2011;117(2 Pt 1):256 –265.
3. Leibson CL, Good AE, Hass SL, et al. Incidence and characterization of diagnosed endometriosis in a geographically defined population. Fertil Steril. 2004;82(2):314 –321.
JSLS (2013)17:95–99
99
SCIENTIFIC PAPER
Perioperative Outcomes of Robotic Versus
Laparoscopic Hysterectomy for Benign Disease
Kristin E. Patzkowsky, MD†, Sawsan As-Sanie, MD, MPH, Noam Smorgick, MD, MSc,
Arleen H. Song, MD, MPH‡, Arnold P. Advincula, MD
ABSTRACT
Key Words: Hysterectomy, Laparoscopy, Robotic surgery.
Background and Objectives: We compared the perioperative outcomes of hysterectomy performed by robotic
(RH) versus laparoscopic (LH) routes for benign indications using the Dindo-Clavien scale for classification of the
surgical complications.
Methods: Retrospective chart review of all patients who
underwent robotic (n⫽288) and laparoscopic (n⫽257)
hysterectomies by minimally invasive surgeons at the University of Michigan from March 2001 until June 2010.
Results: Age, body mass index, operative time, and estimated blood loss were not statistically different between
groups. The RH subgroup had a larger uterine weight (LH
186.4⫾130.6 g vs RH 234.9⫾193.9 g, P⫽.001), higher
prevalence of severe adhesions (13.2% vs 23.3%, respectively, P⫽.003), and stage III–IV endometriosis (4.7% vs
15.3%, respectively, P⬍.05). There were no differences in
the rates of Dindo-Clavien grade I, grade II, and grade III
surgical complications between the RH and LH groups
(9.7%, 13.2%, and 3.1%, respectively, in the RH group vs
6.2%, 9.3%, and 5.8%, respectively, in the LH group,
P⬎.05). However, the rates of urinary tract infection were
higher in the RH group (LH 2.7% vs RH 6.9%, P⫽.02),
whereas the conversion to laparotomy rate was higher in
the LH group (LH 6.2% vs RH 1.7%, P⫽.007).
Conclusions: Perioperative outcomes for laparoscopic
and robotic hysterectomy for benign indications appear to
be equivalent.
University of Michigan Health Center, Ann Arbor, MI, USA (Drs. As-Sanie, Smorgick, Advincula).
Montefiore Medical Center, Centennial Women’s Center, Bronx, NY, USA (Dr.
Patzkowsky) Celebration Hospital, Celebration, FL, USA (Dr. Song).
Dr. Advincula is a consultant for Intuitive Surgical, Cooper Surgical, and Ethicon
Women’s Health & Urology.
Presented at the 39th Annual Meeting of the American Association of Gynecologic
Laparoscopists, Las Vegas, Nevada, November 2010. Recipient of “Robotic Technology Award” for the best abstract on robotic technology at this meeting.
Address correspondence to: Kristin Patzkowsky, MD, Montefiore Medical Center,
Centennial Women’s Center, 3332 Rochambeau Ave, Bronx, NY 10467. Telephone:
718-920-6311. Email: [email protected]
DOI: 10.4293/108680812X13517013317914
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
100
INTRODUCTION
Interest in minimally invasive gynecological surgery has
grown tremendously over the past 20 years. Numerous
studies have demonstrated the benefits of laparoscopy
over laparotomy, including decreased blood loss, shorter
length of hospital stay, decreased pain, earlier return to
routine activities, and improved cosmesis.1,2 Despite these
advantages, the percentage of gynecological hysterectomies performed laparoscopically has remained relatively
stagnant at 12% to 14% nationally.3–5 Some of the proposed reasons for its lack of widespread implementation
are the need for specialized training, its steep learning
curve, longer operative time, 2-D view, limited degrees of
instrument motion, and tremor amplification. The da Vinci
surgical system (Intuitive Surgical, Sunnyvale, CA) has
improved on these shortcomings intrinsic to laparoscopy
and has been rapidly incorporated into clinical practice.
Feasibility studies have shown success in performing robotic hysterectomy, myomectomy, sacrocolpopexy, gynecologic cancer staging, and tubal reanastomsis.6 –10 Similar
to those about laparoscopy, studies have shown improved
surgical outcomes (decreased blood loss, shorter length of
stay, decreased pain, and earlier return to activities) with
robotic surgery when compared with an abdominal
route.11–14 Although there are clear benefits of both robotic
and laparoscopic surgery over laparotomy, few studies have
directly compared perioperative outcomes of robotic and
laparoscopic hysterectomy for benign indications. In a recent
review of the literature, Sarlos and Kots15 concluded that
most clinical outcomes such as blood loss, complications,
and hospital stay were comparable for the robotic and the
laparoscopic hysterectomy. However, despite the paucity of
supportive data, robotic surgery has been rapidly adopted
into gynecological practice and has grown at a rate that has
far exceeded that seen with laparoscopy.
The purpose of this study is to compare perioperative
outcomes in all consecutive patients undergoing laparoscopic and robotic hysterectomy for benign indication at
one academic center.
JSLS (2013)17:100 –106
MATERIALS AND METHODS
After institutional review board approval, consecutive
cases of laparoscopic and robotic hysterectomy for benign
indications were collected by search of billing codes and
retrospectively reviewed by electronic medical record.
Included were all laparoscopic and robotic hysterectomies performed from March 1, 2001 until June 30, 2010, by
the faculty of the Minimally Invasive Gynecology Division
at the University of Michigan Health System. All 3 surgeons were fellowship trained in minimally invasive gynecological surgery and were proficient in laparoscopic
hysterectomy but had newly incorporated robotic surgery
during the study period. The University of Michigan is a
teaching hospital, and residents and/or fellows participated in all procedures at various levels as deemed appropriate by the faculty surgeon. Data regarding the extent of trainee involvement were not collected and are not
part of this study. The surgical approach was determined
preoperatively according to the surgeon’s and patient’s
preferences, based on the specific patient’s characteristics.
Women with a preoperative diagnosis of malignancy and
those who underwent concomitant procedures for treatment of urinary incontinence and/or pelvic organ prolapse
were excluded from the study. Only patients with American
Association of Gynecologic Laparoscopists (AAGL) type IVE
total hysterectomy and type III laparoscopic supracervical
hysterectomy were included.16
A systematic chart review using standardized case report
forms was conducted. Demographic and patient variables
collected were age, parity, body mass index, race, medical
and surgical history, preoperative symptoms, previous
treatment(s), and primary indication for surgery. Recorded
surgical variables were surgical route, surgical procedure,
operating time (intubation to exit from the operating
room), revised American Fertility Society endometriosis
score,17 Diamond adhesion index score,18 culdotomy
technique, estimated blood loss, final pathological diagnosis, specimen weight, and length of hospital stay. No
charts were excluded because ⬍1% of all charts were
missing data for uterine weight and operative time only.
All patients were scheduled for postoperative follow-up
within 4 to 8 weeks from surgery. Patients’ attendance at
this visit and duration of postoperative follow-up were
obtained from the medical records.
The medical records were reviewed for intraoperative and
postoperative complications occurring for 12 weeks after
hysterectomy. However, complications clearly related to
surgery such as cuff dehiscence were included regardless
of the time of occurrence. The postoperative complications were classified into severity grades according to the
Dindo-Clavien scale.19 This classification is based on the
type of therapy needed to correct the complication and
was found to be reproducible and applicable to various
surgical fields, including gynecology.20 Grade I complication includes any deviation from the normal postoperative course without the need for pharmacological
treatment or surgical, endoscopic, and radiological interventions. Grade II complications include blood
transfusions or total parenteral nutrition or other intervention that requires pharmacological treatment with
drugs other than such allowed for grade I complications. Grade III complications require surgical, endoscopic, or radiological intervention.
Surgical Procedures
Total hysterectomy was performed according to the AAGL
type IVE, laparoscopically directed removal of the entire
uterus, and supracervical hysterectomy was performed
according to AAGL laparoscopic supracervical hysterectomy type III; occlusion and division of uterine arteries were
performed laparoscopically.16 All patients were given prophylactic antibiotics at the start of surgery. The ZUMI or the
RUMI uterine manipulators backloaded with a KOH colpotomy ring (all by Cooper Surgical, Trumbull, CT) were
used. The uterine arteries were controlled with the use of
electrosurgical instruments.
The da Vinci robotic surgical platform was used in all
cases of robotic hysterectomy. The monopolar shears
and the Gyrus PK dissecting forceps (Gyrus ACMI, Norwalk, OH) were placed in the right and left robotic
arms, respectively, for the hysterectomy procedure, and
the tenaculum or Prograsp forceps were sometimes
used in the fourth robotic arm (all by Intuitive Surgical,
Sunnyvale, CA). Culdotomy or amputation of the uterine corpus was performed using the monopolar scissors
at 30 W coagulation current. The vaginal cuff was
closed with a series of figure-eight stitches using a
0-Vicryl suture (Ethicon, Cincinnati, OH) with intracorporeal knot-tying.
The laparoscopic hysterectomy was performed using the
Gyrus PK cutting forceps. Culdotomy or amputation of the
uterine corpus was performed using the monopolar J-hook
(range: 30 –50 W cut current), bipolar spatula (Gyrus
ACMI), or Harmonic scalpel (Ethicon). The Endostich device (Covidien, Mansfield, MA) was used for vaginal cuff
closure using a series of 0-Vicryl interrupted or figureeight sutures and extracorporeal knot-tying. The uterosa-
JSLS (2013)17:100 –106
101
Perioperative Outcomes of Robotic Versus Laparoscopic Hysterectomy for Benign Disease, Patzkowsky KE et al.
cral ligaments were incorporated in the angle closures of
both surgical approaches.
Statistical analyses were performed using the SPSS software, version 17.0 (IBM, Armonk, NY). Two-tailed statistical significance was set at .05. A normal distribution of
the data was determined using the Kolmogorov-Smirnov
test. The Student t test was used for comparison of means
for normally distributed data, whereas the Mann-Whitney
U test was used for comparison of non-normally distributed data. The ␹2 and the Fisher exact test were used
when appropriate for comparison of proportions.
RESULTS
A total of 545 patients underwent hysterectomy for benign
disease during the study period; 257 were performed
laparoscopically (LH) and 288 were performed robotically
(RH). Among all patients, 98% had documented follow-up
after surgery, with 83% of patients followed for ⱖ4 weeks
and 60% followed for ⱖ6 weeks.
Patients’ demographics are compared in Table 1. There
were no statistically significant differences in mean age,
body mass index, and prevalence of diabetes or hypertension between the 2 groups. There was a higher prev-
Table 1.
Comparison of Patient Demographics Between the
Laparoscopic (LH) and Robotic (RH) Cohorts
a
Age (y)
b
LH
(n⫽257)
RH
(n⫽288)
P
Value
42.3⫾6.9
43.2⫾7.1
.1
Parity
2 (0–5)
2 (0–6)
.8
BMIa,c (kg/m2)
29.1⫾6.7
30.3⫾8.6
.08
White
212 (82.5)
213 (74.0)
Black
32 (12.5)
37 (12.8)
Asian
5 (1.9)
8 (2.8)
Other
Race (%)
8 (3.1)
30 (10.4)
15 (5.8)
16 (5.6)
Hypertension (%)
38 (14.8)
47 (16.3)
Previous laparotomy (%)
90 (35.0)
151 (52.4)
ⱖ2
38 (14.8)
75 (26.0)
Expressed as mean ⫾ standard deviation.
Expressed as median (range).
c
BMI ⫽ body mass index.
102
The surgical complications classified according to the
Dindo-Clavien scale in the 2 groups are compared in
Table 3. Although grade I and grade II complications
were seemingly more prevalent in the robotic group
(grade I, LH 6.2% vs RH 9.7% and grade II, LH 9.3% vs
13.2%), whereas grade III complications were more prevalent in the laparoscopic group (LH 5.8% vs RH 3.1%),
these differences did not reach statistical significance
(P⬎.1). There were no cases of grade IV or grade IV
complications in either group.
The various perioperative complications in the 2 groups
are compared in Table 4. The incidence of viscus injury
.6
.5
.002
ⱖ1
b
Operative characteristics for each group are summarized
in Table 2. The rates of total hysterectomy and concomitant adnexectomy were similar in both groups, as were
the estimated blood loss and operative time. Intraoperatively confirmed stage III–IV endometriosis and the
incidence of severe adhesions (defined as a Diamond
adhesion score ⬎11) were more common in women
undergoing robotic hysterectomy. The mean uterine
weight was also greater in the robotic cohort (LH
186.4⫾130.6 g, 95% confidence interval 170.0 –202.8 g vs
RH 234.9⫾193.9 g, 95% confidence interval 212.3–257.7 g,
P⫽.001). The conversion to laparotomy rates were significantly higher in the laparoscopic cohort (LH 6.2% vs RH
1.7%, P⫽.007).
.03
Diabetes (%)
a
alence of higher-order (ⱖ2) laparotomies in the robotic
cohort (LH 14.8% vs RH 26.0%, P⬍.05). In both cohorts,
the most common indications for surgery were chronic
pelvic pain and symptomatic uterine fibroids, followed by
abnormal uterine bleeding (P⬎.05) (Figure 1).
Figure 1. Primary indications for hysterectomy in the laparoscopic (LH) and robotic (RH) cohorts. CPP ⫽ chronic pelvic
pain. “Others” refers to adnexal masses, endometrial hyperplasia, and cervical dysplasia.
JSLS (2013)17:100 –106
Table 2.
Comparison of Intraoperative Surgical Characteristics Between
the Laparoscopic (LH) and Robotic (RH) Cohorts
LH
(n⫽257)
RH
(n⫽288)
P
Value
Total hysterectomy (%)
185 (72.0)
213 (74.0)
.6
Concomitant
USO/BSOa (%)
102 (39.7)
109 (37.8)
.3
Stage III/IV
endometriosis (%)
12 (4.7)
44 (15.3)
.001
Severe adhesionsb (%)
34 (13.2)
67 (23.3)
.003
Table 4.
Comparison of Perioperative Complications Between the
Laparoscopic (LH) and Robotic (RH) Cohorts
LH
(n⫽244)
RH
(n⫽255)
P
Value
Viscus injurya (%)
3 (1.2)
5 (1.7)
.4
Blood transfusion (%)
3 (1.2)
1 (0.3)
.3
Vesicovaginal fistula (%)
1 (0.4)
0
.9
Vaginal cuff complicationsb (%)
6 (2.3)
14 (4.9)
.09
Vaginal cuff dehiscence (%)
5 (1.9)
1 (0.3)
.08
Thrombotic event (%)
2 (0.8)
0
.2
Pneumonia (%)
0
2 (0.7)
.3
Urinary tract infection (%)
7 (2.7)
20 (6.9)
.02
Uterine weightc (g)
186.4⫾130.6
234.9⫾193.9
.001
Estimated blood lossc
(mL)
100.9⫾136.4
99.4⫾166.5
.9
228.1⫾60.1
231.0⫾64.2
.9
Urinary retention (%)
11 (4.3)
31 (10.8)
.003
.007
Ileus (%)
0
2 (0.7)
.3
Wound complicationsc (%)
5 (1.9)
9 (3.1)
.3
Reoperation (%)
13 (5.1)
5 (1.7)
.03
c
Operative time (min)
Conversion to
laparotomy (%)
16 (6.2)
5 (1.7)
USO ⫽ unilateral salpingo-oophorectomy; BSO ⫽ bilateral salpingo-oophorectomy.
b
Defined as Diamond adhesion score ⱖ11.
c
Expressed as mean ⫾ standard deviation.
a
Table 3.
Comparison of Postoperative Surgical Complications Between
the Laparoscopic (LH) and Robotic (RH) Cohorts According to
the Dindo-Clavien Scale
Gradea
LH (n⫽257)
RH (n⫽288)
P Value
I (%)
16 (6.2)
28 (9.7)
.2
II (%)
24 (9.3)
38 (13.2)
.2
III (%)
.1
15 (5.8)
9 (3.1)
IIIa (%)
1 (0.4)
4 (1.4)
IIIb (%)
14 (5.4)
5 (1.7)
a
There were no cases of grade IV or grade V complications in
either group.
(bowel, bladder, ureter) was low in both groups (LH
1.2% vs RH 1.7%, P⫽.4). Overall, there were 4 bladder
injuries, 3 of which were recognized and repaired intraoperatively, and 2 bowel injuries, 1 of which was
recognized and repaired intraoperatively. One patient
who underwent robotic hysterectomy sustained a combined bladder and bowel injury diagnosed 14 days
postoperatively after presenting with fever and pelvic
abscess. There were 2 ureteral injuries in the LH group
and 1 in the RH group. All 3 cases were managed
conservatively with either temporary ureteral stenting
or percutaneous nephrostomy.
a
Bowel, bladder, and ureteral injury.
Vaginal cuff abscess, cuff cellulitis, and cuff hematoma.
c
Wound infection and wound hematoma.
b
There were fewer patients with vaginal cuff dehiscence in
the RH cohort (0.5%) than in the LH cohort (2.7%), but this
difference did not reach statistical significance (P⫽.07)
(Table 4). All patients reported coitus immediately preceding cuff dehiscence. However, not all episodes were
associated with the first coitus after the hysterectomy. Five
of the 6 patients with cuff dehiscence presented within 3
months after their surgery, and the sixth patient presented
on the 29th postoperative day. There was no significant
relationship between vaginal cuff dehiscence and age,
body mass index, menopausal status, diabetes, tobacco
use, estimated blood loss, or type of energy used for
culdotomy (data not shown).
The rates of other vaginal cuff complications (ie, cellulitis,
abscess, and hematoma) were similar in the 2 groups (LH
2.3% vs RH 4.9%, P⫽.09) (Table 4). Vaginal cuff abscess
occurred in 1.2% of LH patients versus 2.4% of RH patients
(P⫽.2). The incidence of cuff abscess increased with the
severity of endometriosis, with a 1.1% incidence in patients
without endometriosis, 2.6% incidence in patients with stage
I–II endometriosis, and 9.3% incidence in patients with stage
III–IV endometriosis (P⫽.01). There was no association between vaginal cuff abscess and body mass index, diabetes,
tobacco use, operative time, estimated blood loss, or the
need for morcellation (data not shown).
JSLS (2013)17:100 –106
103
Perioperative Outcomes of Robotic Versus Laparoscopic Hysterectomy for Benign Disease, Patzkowsky KE et al.
There was a significantly higher rate of urinary tract infection and urinary retention in the RH cohort than in the LH
cohort (Table 4). Urinary retention was not associated
with age, body mass index, presence of diabetes, smoking
status, previous cesarean sections, previous abdominal
surgeries, uterine weight, intra-abdominal adhesions, or
estimated blood loss (data not shown).
Overall, the need for reoperation was statistically greater
in the LH cohort (Table 4). The indications for reoperation in the laparoscopic cohort included vaginal cuff dehiscence (n⫽5), significant vaginal cuff bleeding (n⫽2),
vaginal cuff abscess (n⫽2), cystoscopic repair of ureteral
injury (n⫽1), vesicovaginal fistula (n⫽1), prolapsed fallopian tube through the vaginal cuff (n⫽1), and trocar site
hematoma (n⫽1). In the RH cohort, 5 patients underwent
reoperation for vaginal cuff abscess (n⫽2), vaginal cuff
bleeding (n⫽1), cuff dehiscence (n⫽1), and repair of
bladder and bowel injury (n⫽1).
DISCUSSION
This series directly compares perioperative outcomes of
LH with RH for benign indications. Our data suggest
that more complex surgeries are being performed robotically, as indicated by the higher prevalence of stage
III–IV endometriosis, high-order (ⱖ2) previous laparotomies, severe adhesions, and a larger mean uterine
weight. Despite the greater complexity of surgery, surgical outcomes including surgical complications, estimated blood loss, and operative time are similar between RH and LH groups, and the overall complication
rate is acceptably low. Because this is a retrospective
study, the difference in complexity of cases between
the 2 groups reflects the surgeons’ preference to perform complex hysterectomies via the robotic route. A
randomized study would be better designed to compare
the outcome of the 2 surgical approaches for cases of
similar complexity.
Another drawback of our study is the different distribution of the LH and RH cases over the ⬃10-year study
period, with more LH cases performed in the earlier
years and more RH cases performed in later years. This
may introduce a bias in the occurrence of surgical
complication in the laparoscopic groups because it
could be assumed that the surgeons gained additional
surgical experience during the 10 years of the study.
However, this bias may be offset by the surgeons being
novice robotic surgeons when this technique was introduced.
104
Previous studies reporting surgical complications of laparoscopic and robotic hysterectomy classified these complications into major and minor categories. In these studies, the rate of major complications varied widely, from
⬍1% to 20%. This wide range is probably because of the
absence of a standard definition of a major or minor
complication as well as extreme variability in the follow-up time for reporting of complications, ranging from
1 day to ⬎6 weeks.11–15 In the current study, the DindoClavien scale was used to classify the surgical complications. This system grades surgical complications according
to the treatments required19 and has been shown to be
reproducible and fairly easy to use.20 Using the DindoClavien scale, there were no statistically significant differences in surgical complications between the 2 groups, and
the rates of grade III complications were low in both
groups, indicating that both surgeries can be performed
safely. Nevertheless, our study may still be underpowered
to detect differences in rare postoperative complications
such as viscus injury. Further studies and meta-analyses
could provide additional data on the occurrence of these
rare complications.
Postoperative vaginal cuff abscess was an infrequent complication in both the LH and RH groups and was directly
related to the presence and severity of endometriosis. We
postulate that this relationship is a consequence of greater
tissue dissection, greater use of electrosurgery, more tissue necrosis, and possibly a less hemostatic surgical bed
associated with both the laparoscopic and the robotic
approach to an obliterated cul-de-sac.
Previous studies have consistently shown the incidence of
cuff dehiscence complicating total LH and RH to be higher
than the vaginal and abdominal routes.21–23 The incidence
of cuff dehiscence after total laparoscopic hysterectomy
was found to be as high as 4.9% in a large retrospective
study from 2007.24 However, the data from this large study
were recently reanalyzed and showed the 10-year cumulative incidence of dehiscence after total LH to be 1.35%.25
In the current study, the incidence of cuff dehiscence after
total laparoscopic hysterectomy was higher when compared with RH. This difference approached, but did not
reach, statistical significance (P⫽.07), possibly because
the sample size was underpowered to detect this relatively
rare complication.
Operative cost is another important consideration when
comparing LH with RH. Two previous studies26,27 estimated that the added cost of robotic hysterectomy over
laparoscopic hysterectomy is in the range of $2600. This
factor needs to be considered when determining the ap-
JSLS (2013)17:100 –106
propriate route of surgery, especially because operative
outcomes for these 2 routes appear to be similar.
Our study is limited by its retrospective and nonrandomized design, leading to possible inaccurate or incomplete
data collection, which may result in an underestimation of
surgical complications. The nonrandomized retrospective
design is also known to be associated with possible selection case bias, where more difficult cases may have been
chosen for a robotic approach according to surgeon preference. Another limitation of our study is the long duration of
the study period, during which some surgical and postoperative management practices may have changed. Conversely,
collecting data over a long period enabled us to include a
relatively large number of patients.
CONCLUSION
Perioperative outcomes for LH and RH for benign indications are equivalent. These findings are similar to a
recent Cochrane Review that concluded limited evidence showed that robotic surgery did not benefit
women with benign gynecological disease as far as
effectiveness or safety.28 Our study suggested that some
outcomes trend toward improvement with a robotic
route, including a lower incidence of vaginal cuff dehiscence and a lower rate of conversion to laparotomy.
Future studies using a randomized study design may
further investigate the operative outcomes of the robotic and laparoscopic routes.
References:
1. Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry
R. Methods of hysterectomy: systematic review and meta-analysis of randomized controlled trials. BMJ. 2005;330:1478 –1486.
2. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach
to hysterectomy for benign gynaecological disease. Cohcrane
Database Syst Rev. 2009;8:CD003677.
3. Farquhar CM, Steiner CA. Hysterectomy rates in the United
States 1990 –1997. Obstet Gynecol. 2002;99:229 –234.
4. Jacoby VL, Autry A, Jacobson G, Domush R, Nkagawa A,
Jacoby A. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol.
2009;114:1041–1048.
7. Daneshgari F, Kefer JC, Moore C, Kaouk J. Robotic abdominal sacrocolpopexy/sacrouteropexy repair of advanced female
pelvic organ prolapse (POP): utilizing POP-quantification based
staging and outcomes. BJU Int. 2007;100:875– 879.
8. Degueldre M, Vandromme J, Huong PT, Cadiere GB. Robotically assisted laparoscopic microsurgical tubal reanastomosis: a feasibility study. Fertil Steril. 2000;74:1020 –1023.
9. Marchal F, Rauch P, VAndromme J, et al. Telerobotic-assisted
laparoscopic hysterectomy for benign and oncologic pathologies:
initial clinical experience with 30 patients. Surg Endosc. 2005;19:
826 – 831.
10. Reynolds RK, Advincula AP. Robot-assisted laparoscopic
hysterectomy: technique and initial experience. Am J Surg. 2006;
191:555–560.
11. Boggess JF. A comparative study of three surgical methods
for hysterectomy with staging for endometrial cancer; robotic
assistance, laparoscopy, laparotomy. Am J Obstet Gynecol. 2008;
199:360.e1–9.
12. Boggess JF, Gehrig PA, Cantrell L, et al. A case-control study
of robotic assisted type III radical hysterectomy with pelvic
lymph-node dissection compared with open radical hysterectomy. Am J Obstet Gynecol. 2008;199:357.e1–7.
13. Magrina JF, Kho RM, Weaver AL, Motero RP, Magtibay PM.
Robotic radical hysterectomy: comparison with laparoscopy and
laparotomy. Gynecol Oncol. 2008;109:86 –91.
14. Shashoua AR, Gill D, Locher SR. Robotic-assisted total laparoscopic hysterectomy versus conventional total laparoscopic
hysterectomy. JSLS. 2009;13(3):364 –369.
15. Sarlos D, Kots LA. Robotic versus laparoscopic hysterectomy: a review of recent comparative studies. Curr Opin Obstet
Gynecol. 2011;23:283–288.
16. Olive DL, Parker WH, Cooper JM, Levine RL. The AAGL
classification system for laparoscopic hysterectomy. J Am Assoc
Gynecol Laparosc. 2000;7:9 –15.
17. The American Fertility Society. Revised American Fertility
Society classification of endometriosis: 1985. Fertil Steril. 1985;
43:351–352.
18. Diamond MP, Daniell JF, Johns DA, et al. Postoperative
adhesion development after operative laparoscopy: evaluation
at early second-look procedures. Operative Laparoscopy Study
Group Fertil Steril. 1991;55:700 –704.
5. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG.
Hysterectomy rates in the United States, 2003. Obstet Gynecol.
2007;110:1091–1095.
19. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of
6336 patients and results of a survey. Ann Surg. 2004;240:205–
213.
6. Advincula AP, Song AH, Burke W, Reynolds RK. Preliminary
experience with robot-assisted laparoscopic myomectomy. J Am
Assoc Gynecol Laparosc. 2004;11:511–518.
20. Clavien PA, Barkun J, de Oliveira ML, et al. The ClavienDindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–196.
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21. Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190
laparoscopic hysterectomies for benign disease from 1990 to
2006: evaluation of complications compared with vaginal and
abdominal procedures. BJOG. 2009;116:492–500.
22. Garry R, Fountain J, Mason S, et al. The eVALuate study: two
parallel randomized trials, one comparing laparoscopic with
abdominal hysterectomy, the other comparing laparoscopic with
vaginal hysterectomy. BMJ. 2004;328:129.
23. Makinen J, Johansson J, Tomas C, et al. Morbidity of 10,110
hysterectomies by type of approach. Hum Reprod. 2001;16:
1473–1478.
24. Hur HC, Guido RS, Mansuria SM, Hacker MR, Sanfilippo JS,
Lee TT. Incidence and patient characteristics of vaginal cuff
dehiscence after different modes of hysterectomies. J Minim
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25. Hur HC, Donnellan N, Mansuria S, Barber RE, Guido R, Lee
T. Vaginal cuff dehiscence after different modes of hysterectomy.
Obstet Gynecol. 2011;118:794 – 801.
26. Sarlos D, Kots L, Stevanovic N, Schaer G. Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome
and cost analyses of a matched case-control study. Eur J Obstet
Gynecol Reprod Biol. 2010;150:92–96.
27. Pasic RP, Rizzo JA, Fang H, et al. Comparing robot-assisted
with conventional laparoscopic hysterectomy: impact on cost
and clinical outcomes. J Minim Invasive Gynecol. 2010;17:730 –
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JSLS (2013)17:100 –106
SCIENTIFIC PAPER
Postoperative Patient Satisfaction After Laparoscopic
Supracervical Hysterectomy
Garri Tchartchian, MD, Konstantinos Gardanis, MD, Bernd Bojahr, Rudy Leon de Wilde
ABSTRACT
INTRODUCTION
Background and Objectives: The aim of this study was
to evaluate postoperative patient satisfaction in women
after laparoscopic supracervical hysterectomy (LASH).
Hysterectomy is one of the most commonly performed
surgical procedures in gynecology. Supracervical hysterectomy has been rediscovered as a minimally invasive
alternative to all methods of total hysterectomy. In the
1940s, supracervical hysterectomy, which was then performed by laparotomy, was largely replaced by total hysterectomy. This was the result of advances in medical
technology and the emerging use of antibiotics, and to
prevent the occurrence of cervical stump carcinoma and
the development of prolapse as adverse events after supracervical hysterectomy. The major changes in technique
introduced were extrafascial removal of the entire uterus
with anchoring of the anterior and posterior vaginal cuff at
the corners to the uterosacral ligaments.1 In this prelaparoscopic era, total hysterectomy dominated with its 2
approaches: vaginal (VH) and abdominal (AH). Reich2
first performed laparoscopic hysterectomy in 1989. During
the past 2 decades, the laparoscopic approach to hysterectomy has evolved. Currently, 3 types of laparoscopic
hysterectomy (LH) are practiced: laparoscopically assisted
vaginal hysterectomy (LAVH), where VH is preceded by
laparoscopy; total LH (TLH), where the vaginal vault is
sutured laparoscopically; and laparoscopic supracervical
hysterectomy (LASH).
Methods: A retrospective study by a mailed questionnaire
among 2334 women who underwent hysterectomy via
LASH at the MIC-Klinik, Berlin, between 1998 and 2004
was conducted. Indications for LASH were uterus myomatosus, adenomyosis uteri, disorders of bleeding, and
genital descensus. The LASH operation technique was
standardized and remained consistent throughout the observation period. Pearson’s test for metric variables, Spearman’s rank correlation test for ordinal data, Mann-Whitney
U test, and Kruskal-Wallis test were used.
Results: Of the 2334 questionnaires mailed, 1553 were
returned and 1431 (61.3%) of those could be analyzed.
Almost 94% (93.9%) of the women were highly satisfied
with the outcome, 5.6% reported medium satisfaction, and
0.5% were not satisfied. There was no significant difference in patient satisfaction with regard to the different
indication for LASH.
Conclusion: This study demonstrates high postoperative
patient satisfaction after LASH. The rate of highly satisfied
women might be increased by carefully choosing the right
indications for LASH and improving operation techniques.
This is important for widening acceptance of this innovative new operation standard.
Key Words: LASH, Hysterectomy, Satisfaction.
Klinik für Minimal Invasive Chirurgie, Berlin-Zehlendorf, Germany (Dr. Tchartchian, Dr. Bojahr)
Universitätsfrauenklinik Tübingen, Tübingen, Germany (Dr. Gardanis)
Pius-Hospital, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische
Onkologie, Oldenburg, Germany (Dr. de Wilde)
Address correspondence to: Garri Tchartchian, Klinik für Minimal Invasive Chirurgie, Kurstraße 11, 14129 Berlin-Zehlendorf, Germany. Telephone: 0049-30-80988155,
Fax: 0049-30-80988188, E-mail: [email protected]
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the
Society of Laparoendoscopic Surgeons, Inc.
Advantages of LASH are less morbidity, faster reconvalescence, shorter hospital stay, and subsequent reduced economic burden. Further, supracervical hysterectomy preserves the anatomy of the cervix and surrounding structures.
Numerous authors note that the cervix should not be removed without indication because this might result in genital descensus, bladder and bowel alterations, or sexual
disorders.3– 6
The leading argument against supracervical hysterectomy
is the possibility of cervical stump carcinoma development. Although the risk of cervical stump carcinoma is
low (0.11 to 1.9%),7,8 postoperative preventive cancer
screening is obligatory, and women with conspicuous
Papanicolaou test results should be excluded from LASH.
Beyond medical and economical reasons, patient satisfaction plays an important role with regard to the acceptance
and widening of a new operation technique. The aim of
JSLS (2013)17:107–110
107
Postoperative Patient Satisfaction After Laparoscopic Supracervical Hysterectomy, Tchartchian G et al.
this study was to evaluate postoperative patient satisfaction in women after LASH. To our knowledge, this issue
has been evaluated only in small cohorts.
MATERIALS AND METHODS
Patient satisfaction of women who underwent hysterectomy via LASH at the MIC-Klinik, Berlin, between 1998
and 2004 was evaluated in a retrospective study by mailed
questionnaire. Indications for LASH were uterus myomatosus, adenomyosis uteri, disorders of bleeding, and genital descensus. In the case of genital descensus, LASH was
performed in combination with cervicosacropexy or with
suspension with modified McCall suture. Benignity was
clarified by colposcopy and cytology. No woman had
endometriosis. In the case of abnormal bleeding and suspect sonographic findings, dilation and curettage was performed. Preoperative counseling emphasized the need for
continued cervical screening and a possibility of cyclical
bleeding in the future.
The LASH operation technique standardized and remained consistent throughout the observation period.9
Patients are placed in the dorsal lithotomy position with
the bladder drained before operation. A uterine manipulator is not used. With sufficient pulling of the forceps to
the other side, it is not necessary for safety reasons to use
a manipulator. With this method, our intraoperative complication rate remains as low as with use of a manipulator.
Pneumoperitoneum is established via the Veress needle
through the umbilicus, and a 5-mm port is inserted followed by two 5-mm lower quadrant ports, lateral to the
inferior epigastric arteries. The round ligaments and the
uterine tubes are coagulated and transected bilaterally.
After creation of a bladder flap, the parametria are dissected and the uterine arteries secured with a bipolar
device. The uterus is amputated using a monopolar hook.
Hemostasis is performed by bipolar coagulation of the
cervical stump, including the epithelium lining the endocervical canal. The cervical stump is covered with peritoneum using a purse-string suture. Uterine morcellation is
carried out with a 10-, 15-, or 20-mm electric morcellator
through the dilated left lower quadrant port.
During the observation period from June 1998 to October
2004, 2334 LASH operations were performed at MICKlinik, Berlin. In the same period, 14 AHs, 1 TLH, and 77
LAVHs were performed. A questionnaire was sent at a
minimum of 6 months after the operation to all 2334
women.
We used Pearson’s test for metric variables, Spearman’s
rank correlation test for ordinal data, as well as the
Mann-Whitney U test and Kruskal-Wallis test. A P
value ⬍ .05 was considered statistically significant. Data
were analyzed using SPSS version 13.0 (SPSS Inc./IBM,
Armonk, NY).
RESULTS
Of all 2334 questionnaires sent out, 1553 were returned
and 1431 (61.3%) of those could be analyzed. As shown in
Table 1, 1344 patients (93.9%) were highly satisfied with
their outcome after LASH. Eighty patients (5.6%) reported
medium satisfaction and 7 patients (0.5%) were not satisfied. There was no significant difference in patient satisfaction with regard to the different indication for LASH.
When the period between the date of LASH and the date
of questioning was classified into 6 subgroups (5 to 6
years, 4 to 5 years, 3 to 4 years, 2 to 3 years, 1 to 2 years,
and 6 to 12 months), no significant difference in patient
satisfaction could be found within the different subgroups
(Table 2).
Patients were asked about the occurrence of postoperative vaginal bleeding. There was no significant difference
in the percentages of postoperative bleeding with regard
to the indication for LASH (Table 3). As shown in Table 4,
288 of the 1344 patients (21.4%) who were highly satisfied with LASH had postoperative vaginal bleeding. Of
the 80 women reporting medium satisfaction, 41 (51.3%)
had vaginal bleeding, whereas in the group of 7 poorly
satisfied women, 5 (71.4%) had postoperative bleeding.
Table 1.
Postoperative Patient Satisfaction After LASH
Patient Satisfaction
Uterus Myomatosus
High, n (%)
1116 (94.6)
72 (90.0)
149 (92.5)
7 (70.0)
1344 (93.9)
Medium, n (%)
58 (4.9)
8 (10.0)
12 (7.5)
2 (20.0)
80 (5.6)
Poor, n (%)
6 (0.5)
0 (0.0)
0 (0.0)
1 (10.0)
7 (0.5)
108
Adenomyosis Uteri
Bleeding Disorders
JSLS (2013)17:107–110
Genital Descensus
All Indications
Table 2.
Postoperative Patient Satisfaction at Different Time Points of Follow-up After LASH
Patient Satisfaction
6 mo to 1 y
1 to 2 y
2 to 3 y
3 to 4 y
4 to 5 y
5 to 6 y
High, n (%)
362 (92.8)
453 (93.4)
212 (94.6)
191 (95.5)
97 (97.0)
29 (90.6)
Medium, n (%)
26 (6.7)
29 (6.0)
12 (5.4)
7 (3.5)
3 (3.0)
3 (9.4)
Poor, n (%)
2 (0.5)
3 (0.6)
0 (0.0)
2 (1.0)
0 (0.0)
0 (0.0)
Table 3.
Postoperative Bleeding After LASH
Patient Satisfaction
Table 5.
Influence of Postoperative Bleeding on Quality of Life
Postoperative Bleeding
No
Yes
Negative Influence of
Postoperative Bleeding on
Quality of Life
Uterus myomatosus, n (%)
901 (76.4)
279 (23.6)
No
Yes
Adenomyosis uteri, n (%)
61 (76.2)
19 (23.8)
Bleeding disorders, n (%)
126 (78.3)
35 (21.7)
Uterus myomatosus,n (%)
227 (79.4)
59 (20.6)
Genital descensus, n (%)
9 (90.0)
1 (10.0)
Adenomyosis uteri, n (%)
8 (53.3)
7 (46.7)
All indications, n (%)
1097 (76.7)
334 (23.3)
Bleeding disorders, n (%)
18 (54.5)
15 (45.5)
Table 4.
Postoperative Bleeding and Patient Satisfaction
Patient Satisfaction
Postoperative Bleeding
No
Yes
High, n (%)
1056 (78.6)
288 (21.4)
Medium, n (%)
39 (48.8)
41 (51.2)
Poor, n (%)
2 (28.6)
5 (71.4)
A significant correlation between patient satisfaction
and postoperative vaginal bleeding could be observed
(P ⬍ .05).
Another question evaluated whether postoperative vaginal bleeding had a negative influence on quality of life.
Differences in patient satisfaction between women having
answered this question with “yes” or with “no” are highly
significant (P ⬍ .0004). Table 5 shows the influence of
postoperative vaginal bleeding on quality of life with
regard to the indication for LASH. Of the 286 women with
postoperative vaginal bleeding when LASH was indicated
because of uterus myomatosus, 59 patients (20.6%)
claimed that the bleeding had a negative influence on
their quality of life. This was also reported by 7 of the 15
women with adenomyosis uteri (46.7%). When LASH was
indicated because of bleeding disorders, 33 women still
had postoperative bleeding. Here, the bleeding negatively
Indication for LASH
influenced quality of life in 15 women (45.5%). The percentages of women in whom postoperative bleeding negatively influenced quality of life significantly differed with
regard to the respective indication for LASH (P ⬍ .0004).
DISCUSSION
This retrospective analysis of patient satisfaction in women
after LASH shows that most patients are highly satisfied with
their postoperative outcome, which is in line with smaller
studies.10 –12 Postoperative satisfaction was constantly high
after the different indications for LASH and did not depend on the duration of the observation period and the
date of LASH, respectively. The latter fact might be of
particular interest for gynecologists deciding to establish
laparoscopic operation techniques in their departments
because early LASH operations performed 6 years ago
were also considered.
Approximately one-quarter of the women had postoperative bleeding. This is not a result of too-high amputation
rates. As the cervical mucus recovers after surgery, it may
react to hormonal changes in the area of the ovaries. In the
future, we will try to resolve this problem by sufficient duration of coagulation. The rate of postoperative bleeding
published is between 1% and 25%, whereby this discrepancy
might be explained by different case numbers, operation
techniques, or observation periods.11,13–16 Patient satisfaction
correlated with these postoperative vaginal bleeding occurrences. This was even more pronounced when quality of life
JSLS (2013)17:107–110
109
Postoperative Patient Satisfaction After Laparoscopic Supracervical Hysterectomy, Tchartchian G et al.
was decreased by postoperative bleeding. With regard to
the different indications for LASH, postoperative bleeding
was found to have a mostly negative influence on quality
of life in women who had LASH for adenomyosis uteri or
for preoperative bleeding disorders. This underlines the
importance of choosing the right indication for LASH. In
particular, women with bleeding disorders or dysmenorrhea should be carefully counseled that postoperative
(cyclic) bleeding might persist. An influence of the operation technique on postoperative bleeding was demonstrated by others, and the height of uterus amputation, as
well as coagulation of the endocervical canal, is considered to play an important role.17,18 Future prospective
trials should be conducted to evaluate patient satisfaction
with regard to different operation techniques or modifications.
CONCLUSION
This study demonstrates high postoperative patient satisfaction in women after LASH. The rate of highly satisfied
women might be increased by carefully choosing the right
indications for LASH and improving operation techniques.
This is important for widening acceptance of this innovative new operation standard.
References:
1. Richardson EH. A simplified technique for abdominal panhysterectomy. Surg Obstet Gynecol. 1929;48:248 –251.
2. Reich H. New techniques in advanced laparoscopic surgery.
Baillieres Clin Obstet Gynaecol. 1989;3(3):655– 681.
3. Pelosi MA, Pelosi MA 3rd. Laparoscopic supracervical hysterectomy using a single-umbilical puncture (mini-laparoscopy).
J Reprod Med. 1992;37(9):777–784.
4. Hasson HM. Cervical removal at hysterectomy for benign
disease. Risks and benefits. J Reprod Med. 1993;38(10):781–790.
5. Lyons TL. Laparoscopic supracervical hysterectomy. A comparison of morbidity and mortality results with laparoscopically
assisted vaginal hysterectomy. J Reprod Med. 1993;38(10):763–
767.
110
6. Mettler L, Semm K. Subtotal versus total laparoscopic hysterectomy. Acta Obstet Gynecol Scand Suppl. 1997;164:88 –93.
7. Kilkku P, Gronroos M. Peroperative electrocoagulation of
endocervical mucosa and later carcinoma of the cervical stump.
Acta Obstet Gynecol Scand. 1982;61(3):265–267.
8. Kilkku P, Grönroos M, Taina E, Söderström O. Colposcopic,
cytological and histological evaluation of the cervical stump 3
years after supravaginal uterine amputation. Acta Obstet Gynecol
Scand. 1985;64(3):235–236.
9. Bojahr B, Raatz D, Schonleber G, Abri C, Ohlinger R. Perioperative complication rate in 1706 patients after a standardized
laparoscopic supracervical hysterectomy technique. J Minim Invasive Gynecol. 2006;13(3):183–189.
10. Kilkku P, Lehtinen V, Hirvonen T, Grönroos M. Abdominal
hysterectomy versus supravaginal uterine amputation: psychic
factors. Ann Chir Gynaecol Suppl. 1987;202:62– 67.
11. van der Stege JG, van Beek JJ. Problems related to the
cervical stump at follow-up in laparoscopic supracervical hysterectomy. JSLS. 1999;3(1):5–7.
12. Okaro EO, Jones KD, Sutton C. Long term outcome following laparoscopic supracervical hysterectomy. BJOG. 2001;
108(10):1017–1020.
13. Schwartz RO. Laparoscopic hysterectomy. Supracervical vs.
assisted vaginal. J Reprod Med. 1994;39(8):625– 630.
14. Lyons TL. Laparoscopic supracervical hysterectomy. Baillieres Clin Obstet Gynaecol. 1997;11(1):167–179.
15. Learman LA, Summitt RL Jr, Varner RE, et al. A randomized
comparison of total or supracervical hysterectomy: Surgical complications and clinical outcomes. Obstet Gynecol. 2003;102(3):
453– 462.
16. Hasson HM, Rotman C, Rana N, Asakura H. Experience with
laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc. 1993;
1(1):1–11.
17. Donnez J, Nisolle M. Laparoscopic supracervical (subtotal)
hysterectomy (LASH). J Gynecol Surg. 1993;9(2):91–94.
18. Ghomi A, Hantes J, Lotze EC. Incidence of cyclical bleeding
after laparoscopic supracervical hysterectomy. J Minim Invasive
Gynecol. 2005;12(3):201–205.
JSLS (2013)17:107–110
SCIENTIFIC PAPER
Total Microlaparoscopic Radical Hysterectomy in
Early Cervical Cancer
Francesco Fanfani, MD, Valerio Gallotta, MD, Anna Fagotti, PhD, Cristiano Rossitto, MD,
Elisa Piovano, MD, Giovanni Scambia, MD
ABSTRACT
INTRODUCTION
Background and Objective: In less than 2 decades,
laparoscopy has contributed to modification in the management of early cervical cancer patients, and all comparisons between open and laparoscopic-based radical operations showed an identical oncological outcome. The
aim of this study is to describe surgical instrumentations
and technique to perform total microlaparoscopy radical
hysterectomy in early cervical cancer patients and report
our preliminary results in terms of operative time and
perioperative outcomes.
In less than 2 decades, laparoscopy has definitely contributed to modification in the management of cervical cancer
patients. After laparoscopy’s introduction in 1990,1 several
studies have documented the safety and feasibility of
laparoscopic radical hysterectomy in early-stage cervical
cancer patients (ECC).1–10 In the first period, laparoscopy
was considered assistance to a radical vaginal approach
(LARVH), whereas more recently there is general agreement about the achievability to perform all of the procedures by laparoscopy (TLRH).2,3 All comparisons between
open and laparoscopic-based radical operations for the
treatment of women with ECC show an identical oncological outcome.2,4,6,8
Methods: Between January 1, 2012, and March 25, 2012,
4 consecutive early cervical cancer patients were enrolled
in this study.
Results: We performed 3 type B2 and 1 type C1-B2 total
microlaparoscopy radical hysterectomy, and in all cases
concomitant bilateral salpingo-oophorectomy and pelvic
lymphadenectomy were carried out. Median operative
time was 165 minutes (range: 155 to 215) (mean: 186), and
median estimated blood loss was 30 mL (range: 20 to 50).
Median number of pelvic lymph nodes removed was 12
(range: 11 to 15). All procedures were completed without
5-mm port insertion and without conversion. No intraoperative or early postoperative complications were reported.
Conclusions: This report suggests a role of microlaparoscopy in the surgical management of early cervical cancer with adequate oncological results, superimposable
operative time, and perioperative outcomes with respect
to standard laparoscopy.
Key Words: Microlaparoscopy, Radical hysterectomy,
Cervical cancer.
Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome,
Italy
Address correspondence to: Francesco Fanfani, Department of Obstetrics and
Gynecology, Division of Gynecologic Oncology, Catholic University of the Sacred
Heart, Largo Agostino Gemelli 8, 00168 Rome, Italy. Telephone and fax: ⫹39 – 0630156332, E-mail: [email protected]
DOI: 10.4293/108680812X13517013318319
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
In recent years, many efforts have been made by laparoscopic surgeons to further reduce the surgical invasiveness of minimally invasive approaches by reducing the
trauma of access ports by reducing their diameter to 3 mm
or performing single-port surgery. The evolution of even
more minimally invasive surgery toward microlaparoscopy (M-LPS) and single-port laparoscopy (LESS) has
been supported by different goals: (1) To extend to even
more minimally invasive techniques the benefits already
realized for laparoscopy versus laparotomy in terms of
postoperative pain, recovery time, and cosmetic results;
and (2) to perform laparoscopic procedures with the leastinvasive approach with the assumption of minimizing the
risk of incisional complications.
Recently, different studies showed an early postoperative
benefit in terms of pain for patients who underwent hysterectomy by LESS with respect to patients treated using
standard laparoscopy (S-LPS).11,12 Regarding M-LPS hysterectomy, Ghezzi et al13,14 recently found that ports can
be safely reduced in size without a negative impact on the
surgeon’s ability to perform total hysterectomy and that
M-LPS appears to have no advantage over S-LPS in terms
of postoperative pain. We have recently shown that both
M-LPS and LESS hysterectomy can be performed safely
and seem to be associated with halving of early postoperative pain, with a lower request of analgesia compared
with standard laparoscopy.15
JSLS (2013)17:111–115
111
Total Microlaparoscopic Radical Hysterectomy in Early Cervical Cancer, Fanfani F et al.
To our knowledge, there are no reports about total M-LPS
radical hysterectomy. The following are our preliminary
results and surgical technique obtained with total M-LPS
radical hysterectomy in ECC patients.
MATERIALS AND METHODS
Between January 1, 2012 and March 25, 2012, 19 cervical cancer
patients were referred to the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart in Rome, Italy. All of these patients
were prospectively evaluated for M-LPS treatment. Inclusion
criteria were FIGO stage IA2-IB1 cervical cancer with no evidence of lymph node and/or adnexal and/or corpus uteri involvement at computed tomography/magnetic resonance imaging; uterine size ⬍12 weeks’ gestation; no history of previous
xifo-pubic abdominal major laparotomic surgery (laparotomy
for peritonitis, bowel resection, etc); body mass index (BMI)
⬍35; and American Society of Anesthesiologists score ⬍II.
Our institutional review board approved the study, and
patients were informed about the M-LPS technique and
signed a written informed consent acknowledging the risk
of standard laparoscopic and/or laparotomic conversion.
The same surgical team (1 experienced surgeon, 1 fellow,
and 1 resident) performed all of the interventions.
Patient demographic (age, race), surgical (type of hysterectomy, operative time, blood loss), and postoperative
(complications, discharge, bladder voiding function, ileus) data were prospectively collected. Clinical (BMI, previous neoplasms) and diagnostic information regarding
actual disease (stage, grade, histotype, lymph nodes, residual disease) were also noted from paper patient charts
and electronic medical records. Operative time (OT) was
defined as the interval between incision start and closure.
Operative complications were defined as bowel, bladder,
ureteral, or vascular injuries, and an estimated blood loss
(EBL) ⱖ500 mL. Anemia was considered when hemoglobin level was ⬍8 g/dL, and fever was considered when
body temperature was at least 38 °C in 2 consecutive
measurements at least 6 hours apart, excluding the first
day after surgery.
Patients were discharged home when they were fully
mobile, apyrexial, and could pass urine satisfactorily.
Early postoperative complications were defined as any
adverse event that occurred within 30 days after surgery,
and they were considered severe if they resulted in unplanned readmission, blood transfusion, or a secondary
surgical procedure.
112
Surgical Instruments and Technique
Surgical procedures were performed with one disposable
optic-view transumbilical 10-mm port (Endopath Xcel
10-mm optic-view; Ethicon Endo-Surgery, Cincinnati,
OH). A 10-mm 0 ° HD-videolaparoscope (Endoeye; Olympus Winter & Ibe GmbH, Hamburg, Germany) was inserted in the umbilical port. Patients under general anesthesia were positioned in the dorsal lithotomic position
with both legs supported in Allen stirrups with a Trendelenburg tilt. A reusable intrauterine manipulator (Karl
Storz, Tuttlingen, Germany) was used to move the uterus.
Once pneumoperitoneum (12 mm Hg) was achieved, 3
additional 3.5-mm reusable ports with conical tip were
inserted, and 3-mm operative instruments (Karl Storz)
were used (Figure 1) from choices of dissecting and
grasping forceps, monopolar scissors or spatula, suction
and irrigation tube (Karl Storz), and 2 types of bipolar
coagulator (Take-Apart bipolar coagulating forceps [Karl
Storz] and PK Molly forceps [Gyrus ACMI, Hamburg, Germany]. Monopolar scissors/hook/spatula were inserted
into the suprapubic port; bipolar forceps were inserted
into the left port; and the right port was used for grasping
or as a suction/irrigation device. The disposition of the
instruments did not change during the intervention. After
pelvic and abdominal exploration and washing, the operations started with opening of the pelvic retroperitoneal
spaces. Paravesical and pararectal spaces were developed
with blunt dissection. Systematic removal of external iliac
and obturator nodes was performed by a combination of
bipolar forceps and monopolar scissors/spatula (Figure 2). A
free endo-bag was inserted through the umbilical port
Figure 1. External vision of the surgical field: one 10/12-mm
umbilical port and three 3-mm ancillary ports.
JSLS (2013)17:111–115
Figure 2. Right pelvic lymphadenectomy. EIA ⫽ external iliac
artery; EIV ⫽ external iliac vein; GN ⫽ genitofemoral nerve;
ON ⫽ obturator nerve, OUA ⫽ obliterated umbilical artery,
PM ⫽ psoas muscle.
Figure 4. Dissection of the right paracervix after uterine artery
section and ureteral tunnel development. P ⫽ paracervix; U ⫽
ureter; UVL ⫽ uterovesical ligament.
nopolar and bipolar devices with the “vessel by vessel”
technique. Dissection of the ureteral tunnel and vesicovaginal spaces was accomplished with monopolar and blunt
technique and with the aid of bipolar coagulation (Figure 4).
At that point, the vaginal wall was identified and transected with a monopolar hook using pure section energy
to avoid postoperative ureteral and bladder complications. The specimens were removed vaginally. The vaginal cuff was then closed by laparoscopy with 0 polyglactin
running sutures using a 3-mm needle holder (Karl Storz).
A hydropneumatic test for bladder integrity was performed at the end of the procedure. The laparoscopic
access point was not sutured but was closed only with
steri-strips. Radical hysterectomy was classified according
to Querleu and Morrow classification.16
Figure 3. Dissection of the posterior paracervix. HN ⫽ hypogastric nerve; R ⫽ rectum; U ⫽ ureter; US ⫽ uterosacral ligament; V ⫽ vagina.
after removing the camera; then after replacing the camera, lymph nodal specimens were put into the endo-bag,
removed throughout the umbilical port after removing the
camera again, and sent for frozen section analysis. The
uterine artery was identified, coagulated, and sectioned at
the origin from the umbilical artery with bipolar forceps.
The uterosacral ligament was transected after separation
of the hypogastric nerve after Okabayashi’s pararectal
space development with combination of mono- and bipolar instruments (Figure 3). The paracervical tissue and
the uterosacral ligaments were transected combining mo-
RESULTS
During the study period, 4 of 19 consecutive cervical
cancer patients (20.1%) met all the inclusion criteria and
were enrolled in this trial. None of the candidate patients
refused to be enrolled in the study.
Table 1 shows the clinicopathological and procedural
characteristics of the study population. All patients were
Caucasian. The median/mean age was 46/52 years (range:
45 to 70), and the median/mean BMI was 22.2/23.4 kg/m2
(range: 20 to 28.5). Three patients were staged as FIGO
1A2 (2 of these had positive margins after cone biopsy),
and the remaining patient was staged as FIGO 1B1. Three
women had squamous histology, and 1 had an adenocarcinoma. Two patients had a moderate (G2) differentiated
JSLS (2013)17:111–115
113
Total Microlaparoscopic Radical Hysterectomy in Early Cervical Cancer, Fanfani F et al.
Table 1.
Patients and Procedural Characteristics of the Study Population
Characteristics
Results
patient with FIGO stage IIA endometrial cancer underwent adjuvant radiotherapy. At this time (median follow-up time 7 months [range: 6 to 9]), no recurrences were
registered.
Age (y), median/mean (range)
46/52 (45–70)
BMIa (kg/m2), median/mean
(range)
22.2/23.4 (20–28.5)
DISCUSSION
Operative time (min), median/mean
(range)
165/186 (155–215)
Estimated blood loss (mL), median/
mean (range)
30/32 (20–50)
Intraoperative complications
0
In the recent years, more attention has focused on the role
of new endoscopic techniques aimed to further minimize
the invasiveness of surgical treatment and minimize possible morbidity. In this context, M-LPS and LESS could
represent an upgrade of standard laparoscopy in terms of
surgical trauma, postoperative pain, and less damage to
women’s body image with visible scars.11–14
Postoperative complications
0
Conversion to LPS/LPTa during
hysterectomy
0
Ileus (days), median/mean (range)
1/1 (1–1)
Time to discharge (days), median/
mean (range)
2/2.2 (1–3)
BMI ⫽ body mass index; LPS ⫽ laparoscopy; LPT ⫽
laparotomy.
a
cervical cancer. In the other 2 patients, these data were
not available before surgery, and definitive pathology
found only intraepithelial neoplasia or carcinoma in situ.
We performed 3 type B2 and 1 type C1 on the left and B2
on the right paracervix total M-LPS radical hysterectomy,
and in all cases concomitant bilateral salpingo-oophorectomy and systematic removal of external iliac and superficial obturator nodes were performed.
The median/mean EBL and OT were 30/32 mL (range: 20
to 50) and 165/186 minutes (range: 155 to 215), respectively. No minor or major intraoperative complications
were registered. All of the procedures were completed
without 5-mm port insertion and without conversion.
Foley catheter was removed 24 to 32 hours after surgery,
and postmintional residual was ⬍100 mL in all cases. Postoperative ileus was 1 day in all patients. The median time to
discharge was 2 days from surgery (range: 1 to 3). No
postoperative complications and readmissions were registered in the early (within 30 days after surgery) postoperative
period, nor during the first follow-up visit (3 months after
surgery). Definitive pathology confirmed clinical stage in 3
cases, and in one case, diagnosed endometrioid endometrial
adenocarcinoma extended to the endocervix. The median
number of pelvic lymph nodes removed was 12 (range: 11 to
15). Definitive histology confirmed frozen section analysis
on pelvic nodes as all negative. The median/mean length of
vaginal margin was 1.5/1.6 cm (range: 1.3 to 1.9). Resection margins were free of disease in all cases, and only the
114
In this preliminary study, we describe surgical instrumentations and technique to perform total M-LPS radical hysterectomy in ECC patients. As previously reported by
Ghezzi et al,14 for total hysterectomy, our study suggests
that ports can be safely reduced in size without a negative
impact on the surgeon’s ability to perform radical hysterectomy. Also, considering that this is a very preliminary
experience, we observed no longer OT for M-LPS with
respect to standard laparoscopic radical hysterectomy and
superimposable perioperative outcomes.2,6,8 The similar
OT between M-LPS and standard laparoscopy could be
justified by the fact that the reduction of port and instrument size from 5 to 3 mm does not influence the surgical
technique. These peculiarities of M-LPS could offer some
advantages of this approach with respect to single-port
surgery when performing advanced surgery as radical
hysterectomy and pelvic lymphadenectomy—in particular
(1) different from single-port, the surgical field is the same
of standard laparoscopy, maintaining the triangularization
between the instruments; and (2) the third operative instrument, managed by the second surgeon, can reduce the
loss of time in some specific surgical steps. It is conceivable that, different from single-port surgery, the M-LPS
technique does not require a specific learning curve.
Moreover, the smaller trocars require less force to penetrate the abdominal wall, and this allows a more controlled entry and consequently the reduction of the risk of
port-related injury to both the abdominal wall and the
intraabdominal organs. Nevertheless, the scar-free procedure could potentially have a significant impact on patients’ body image, which is not only a cosmetic result, but
is also an aid to cope with a past cancer diagnosis. Other
remarkable considerations have to be taken from the
oncological point of view: this preliminary experience
suggests that M-LPS appears to have an adequate onco-
JSLS (2013)17:111–115
logical performance in terms of type of hysterectomy and
number of pelvic lymph nodes removed.
As far as technical limits are concerned, we can hypothesize
that the smaller (3 mm vs 5 mm) bipolar grasp dimension
could be insufficient to control severe hemorrhage during
paracervical vessel dissection. In our previous retrospective
study comparing M-LPS, single-port, and laparoscopic hysterectomy, we reported 2 cases of additional 5-mm port
insertion to control a severe hemorrhage; one of these was in
the M-LPS group and the other was in the single-port
group.15 Thus, waiting for more effective 3-mm new generation devices, preventive hemostasis (ie, uterine artery closure at the beginning of the procedure), and gentle surgical
technique should be recommended. Moreover, the high
flexibility of such little instruments could limit the capability
to perform an adequate retroperitoneal dissection in the
presence of fibrosis. In this study, patients’ average BMI was
low, and it is possible that in the surgical management of
obese patients, the reduced strength of the instruments could
be a limit compared with standard laparoscopy, especially
for large and small bowel traction.
In this preliminary experience, we found that in wellselected cases, M-LPS radical hysterectomy seems safe and
may offer a new tool in minimally invasive surgery for
ECC patients. Further large and prospective, randomized
trials are needed to confirm these results and to compare
this technique with standard laparoscopy to identify potential advantages for the patients.
CONCLUSION
lymphadenectomy in patients with stage I cervical cancer: Surgical morbidity and intermediate follow-up. Am J Obstet Gynecol. 2002;187:340 –348.
5. Ramirez PT, Slomovitz BM, Soliman PT, Coleman RL, Levenback C. Total laparoscopic radical hysterectomy and lymphadenectomy: The M.D. Anderson Cancer Center experience.
Gynecol Oncol. 2006;102:252–255.
6. Frumovitz M, dos Reis R, Sun CC, et al. Comparison of total
laparoscopic and abdominal radical hysterectomy for patients with
early- stage cervical cancer. Obstet Gynecol. 2007;110:96–102.
7. Nam JH, Park JY, Kim DY, Kim JH, Kim YM, Kim YT.
Laparoscopic versus open radical hysterectomy in early-stage
cervical cancer: Long-term survival outcomes in a matched cohort study. Ann Oncol. 2012;23(4):903–911.
8. Pellegrino A, Vizza E, Fruscio R, et al. Total laparoscopic
radical hysterectomy and pelvic lymphadenectomy in patients
with Ib1 stage cervical cancer: Analysis of surgical and oncological outcome. Eur J Surg Oncol. 2009;35(1):98 –103.
9. Malzoni M, Tinelli R, Cosentino F, Fusco A, Malzoni C. Total
laparoscopic radical hysterectomy versus abdominal radical hysterectomy with lymphadenectomy in patients with early cervical
cancer: Our experience. Ann Surg Oncol. 2009;16(5):1316 –1323.
10. Naik R, Jackson KS, Lopes A, Cross P, Henry JA. Laparoscopic assisted radical vaginal hysterectomy versus radical abdominal hysterectomy—a randomised phase II trial: Perioperative outcomes and surgicopathological measurements. BJOG.
2010;117(6):746 –751.
11. Fanfani F, Rossitto C, Gagliardi ML, et al. Total laparoendoscopic
single-site surgery (LESS) hysterectomy in low-risk early endometrial
cancer: A pilot study. Surg Endosc. 2012;26(1):41–46.
This report suggests a role of M-LPS in the surgical management of ECC with adequate oncological results and
specific advantages of a further less invasive surgery than
standard laparoscopy.
12. Fagotti A, Boruta DM 2nd, Scambia G, Fanfani F, Paglia A,
Escobar PF. First 100 early endometrial cancer cases treated with
laparoendoscopic single-site surgery: A multicentric retrospective study. Am J Obstet Gynecol. 2012;206(4):353.e1– e6.
References:
13. Ghezzi F, Cromi A, Siesto G, Zefiro F, Franchi M, Bolis P.
Microlaparoscopy: A further development of minimally invasive
surgery for endometrial cancer staging—initial experience. Gynecol Oncol. 2009;113(2):170 –175.
1. Canis M, Mage M, Wattiez A, Pouly JL, Manhes H, Bruhat MA.
Does endoscopic surgery have a role in radical surgery of cancer of
the cervix uteri? J Gynecol Obstet Biol Reprod (Paris). 1990;19:921.
2. Koehler C, Gottschalk E, Chiantera V, Marnitz S, Hasenbein
K, Schneider A. From laparoscopic assisted radical vaginal hysterectomy to vaginal assisted laparoscopic radical hysterectomy.
BJOG. 2012;119(2):254 –262.
3. Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander
CE. Laparoscopic radical hysterectomy with para-aortic and pelvic node dissection. Am J Obstet Gynecol. 1992;166:864 – 865.
14. Ghezzi F, Cromi A, Siesto G, et al. Minilaparoscopic versus
conventional laparoscopic hysterectomy: Results of a randomized trial. J Minim Invasive Gynecol. 2011;18(4):455– 461.
15. Fanfani F, Fagotti A, Rossitto C, et al. Laparoscopic, minilaparoscopic and single-port hysterectomy: Perioperative outcomes. Surg Endosc. 2012 Jun 8. [Epub ahead of print].
16. Querleu D, Morrow CP. Classification of radical hysterectomy. Lancet Oncol. 2008;9(3):297–303.
4. Spirtos NM, Eisenkop SM, Schlaerth JB, Ballon SC. Laparoscopic radical hysterectomy (type III) with aortic and pelvic
JSLS (2013)17:111–115
115
SCIENTIFIC PAPER
Comparison of Robotic, Laparoscopic, and
Abdominal Myomectomy in a Community Hospital
Joseph M. Gobern, MD, C. J. Rosemeyer, DO, James F. Barter, MD, Albert J. Steren, MD
ABSTRACT
Background and Objectives: To evaluate the operative
outcomes between robotic, laparoscopic, and abdominal
myomectomies performed by a private gynecologic oncology practice in a suburban community hospital.
Methods: The medical records of 322 consecutive robotic, laparoscopic, and abdominal myomectomies performed from January 2007 through December 2009 were
reviewed. The outcomes were collected from a retrospective review of patient medical records.
Results: Records for 14/322 (4.3%) patients were incomplete. Complete data were available for 308 patients, including 169 (54.9%) abdominal, 73 (23.7%) laparoscopic,
and 66 (21.4%) robotic-assisted laparoscopic myomectomies. Patients were similar in age, body mass index, parity, and previous abdominopelvic surgery. Median operative time for robotic surgery (140 min) was significantly
longer (P⬍.005) compared to laparoscopic (70 min) and
abdominal (72 min) myomectomies. Robotic and laparoscopic myomectomies had significantly less estimated
blood loss and hospital stay compared to abdominal myomectomies. There was no significant difference in complications or in the median size of the largest myoma
removed between the different modalities. However, the
median aggregate weight of myomas removed abdominally (200g; range, 1.4 to 2682) was significantly larger
than that seen laparoscopically (115g; range, 1 to 602) and
robotically (129g; range 9.4 to 935). Postoperative transfusion was significantly less frequent in robotic myomecDepartment of Obstetrics and Gynecology, Walter Reed National Military Medical
Center, Bethesda, MD, USA (Drs Gobern, Rosemeyer); Women’s Health Specialist,
Holy Cross Hospital, Silver Spring, MD, USA (Drs Barter, Steren).
The opinion or assertions contained herein are the private views of the authors and
are not to be construed as official or as reflecting the views of the Department of
the Army or the Department of Defense.
The authors thank Robin S. Howard, MA, for her assistance in data analysis and
manuscript review.
Address correspondence to: COL Joseph M. Gobern, Department of Obstetrics and
Gynecology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave,
Bethesda, MD 20889, USA. Phone: (301) 295-4394, Fax: (301) 295-0764, E-mail:
[email protected]
DOI: 10.4293/108680812X13517013317473
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
116
tomies compared to laparoscopic and abdominal myomectomies.
Conclusion: While robotic-assisted laparoscopic myomectomies had longer operative times, laparoscopic and roboticassisted laparoscopic myomectomies demonstrated shorter
hospital stays, less blood loss, and fewer transfusions than
abdominal myomectomies. Robotic myomectomy offers a
minimally invasive alternative for management of symptomatic myoma in a community hospital setting.
Key Words: Myomectomy, Robotic surgery, Laparoscopic, Laparoscopy, Fibroids.
INTRODUCTION
Fibroids are the most common benign tumor of the uterus
and are present in up to 80% of women. Although only
25% of women are affected by symptoms like pelvic pain,
pressure, heavy menses, recurrent pregnancy loss, and
infertility, it remains the leading indication for hysterectomy
and a common women’s health concern.1,2 Treatment alternatives include medical management with oral contraceptives, nonsteroidal anti-inflammatory medications, or GnRH
agonists. Additionally, evolving technology continues to expand the conservative options available for women desiring
uterine preservation to include uterine artery embolization,
MRI-guided high frequency ultrasound, and radio frequency
ablation. Myomectomy, however, remains the gold-standard
for women affected by symptoms of a fibroid uterus who
desire uterine preservation.3
Myomectomy has traditionally been managed by laparotomy and has demonstrated effective clinical outcomes for
symptoms as well as fertility.4,5 Comparison of outcomes
for laparoscopic and robotic-assisted laparoscopic myomectomy (RALM) has demonstrated comparable clinical outcomes for blood loss, hospital stay, and complications despite longer robotic operative times.6,7 The feasibility of the
adoption of robotic-assisted surgery by the community gynecologist has been discussed by Payne et al.8 The authors
concluded that the length of stay and decrease in blood loss
seen with robotic-assisted surgery “hold true not only for
academic centers but also in community settings involving
JSLS (2013)17:116 –120
the general gynecologist.” However, the data regarding myomectomies have primarily been reported from university
teaching hospitals and regional medical centers. Considering
the limited adoption of these techniques in the community
hospital setting, this study sought to evaluate operative outcomes of abdominal, laparoscopic, and RALM performed in
a community hospital.
METHODS
All myomectomies performed consecutively in a single
gynecology practice from January 2007 through December 2009 were identified. All procedures were performed
by 1 of 2 gynecologic oncologists in a single community
hospital. Both surgeons were experienced advanced laparoscopists. The same providers performed the preoperative
evaluation and counseling for each patient to determine the
indication and route of surgery. The hospital electronic medical record was used to review and collect data from each
patient’s chart including scanned outpatient encounters and
imaging reports presented as part of the preoperative admission documentation. All patients with documented removal
of at least 1 myoma were included. Patients were excluded if
no record was available or no documentation of myoma
removal was evident in the record.
Demographic data, including age, race, body mass index
(BMI), and parity were collected. Additionally, baseline
clinical data including indication for surgery, symptomatology, number of myoma, size of largest myoma, American Society of Anesthesiologists (ASA) physical status
classification, and history of prior abdominal or pelvic
surgery was recorded. Perioperative outcomes, which included operative time, length of hospital stay, estimated
blood loss, packed red blood cell (PRBC) transfusion, and
intraoperative and postoperative complications, as well as
aggregate myoma weight, were collected for comparison
among operative groups.
Surgical indications were categorized into symptoms of
bleeding, pain or pressure, fertility, and other. The largest
myoma was documented as the greatest diameter of the
single largest myoma reported on preoperative imaging
by ultrasound or magnetic resonance imaging (MRI). The
myoma weight was determined as the aggregate weight of
tissue reported from the pathology report. Operative time
and estimated blood loss was extracted from the anesthesia record. Length of hospital stay was documented as
date of discharge less date of admission, whereas 0 d
indicates same day surgery. The primary outcomes were
identified as length of hospital stay, estimated blood loss,
and operative time. Finally, intraoperative or postopera-
tive complications, transfusions, and myoma characteristics were secondarily compared among groups.
Symmetrically distributed numerical variables were summarized with means and standard deviations while other
variables were summarized with medians and ranges. Appropriate parametric tests were utilized where data demonstrated normal distribution, and nonparametric tests were
used for alternative parameters. For numerical variables,
univariable comparisons were conducted with either analysis of variance or Kruskal-Wallis analysis of ranks (for
non-normal data). ␹2 and Fisher exact test were used for
categorical data. Statistical analysis was performed using
SPSS for Windows Inc. version 16 (Nov 2007). Differences
were considered significant at P⬍.05. This protocol was
granted exempt status by the Holy Cross Hospital Institutional Review Board.
RESULTS
A total of 322 records were analyzed with 14/322 (4.3%)
records excluded for incomplete or absent data. Complete
data were available for 308/322 (95.7%) patients including
169 (54.9%) abdominal, 73 (23.7%) laparoscopic, and 66
(21.4%) robotic-assisted myomectomies. Patients in each
category were similar in age, BMI, parity, and previous
abdominopelvic surgery (Table 1). Patients who reported
their race as black, however, more often underwent abdominal myomectomy (Table 2). Additionally, evaluation
of baseline clinical characteristics revealed no statistically
significant difference in patients with prior myomectomy,
ASA classification, or presenting symptoms of pain, pressure, and bleeding (Tables 1 and 2). Patients with a
fertility indication more frequently had an abdominal
myomectomy (Table 2).
Operative time for robotic surgery (140 min; range, 55 to
328) was longer compared to laparoscopic (70 min; range,
17 to 218) and abdominal myomectomy (17 min; range, 13 to
185; P⬍.005). Laparoscopic and robotic myomectomy had
significantly (P⬍.005) less estimated blood loss as well as
shorter hospital stay compared to abdominal myomectomy
(Table 3). Among secondary outcomes, there was no significant difference between all modalities of surgery for postoperative complication or between laparoscopic and robotic
surgery for conversion to laparotomy. However, postoperative transfusion was significantly (P⬍.005) less frequent in
robotic myomectomy compared to laparoscopic and abdominal myomectomy (Table 3).
The characteristics of myomas between the operative
groups were compared. There was no significant differ-
JSLS (2013)17:116 –120
117
118
108 (70%)
47 (71%)
1 (60%)
33 (21%)
18 (27%)
13 (31%)
13 (8%)
37 (2%)
6 (10%)
ASA 2
[n (%);
p⫽0.13]
ASA 1
[n (%);
p⫽0.13]
20 (12%)
2 (3%)
5 (8%)
70 (42%)
30 (41%)
24 (36%)
26 (15%)
16 (22%)
18 (27%)
12 (7%)
7 (10%)
9 (14%)
169
73
66
Abdominal
Laparoscopic
Robotic
39 (27–50)
39 (23–56)
40 (26–51)
27 (18–46)
25 (19–52)
27 (19–53)
103 (61%)
23 (32%)
28 (42%)
38 (22%)
31 (42%)
22 (33%)
16 (10%)
12 (16%)
7 (11%)
Prior
Myomectomy
[n (%);
p⫽0.063]
Prior
Surgery
[n (%);
p⫽0.74]
Prior
Parity
[n (%);
p⫽0.053]
Other
Race
[n (%);
p⫽0.001]
Asian
[n (%);
p⫽0.001]
White
[n (%);
p⫽0.001]
Black
[n (%);
p⫽0.001]
BMI
(p⫽0.067)
n
Age [(yrs)
Median
(range)]
p⫽0.69
ence in the median size of the largest myoma removed
robotically (6.1 cm; range, 1.8 to 18.4), laparoscopically
(6.4 cm; range, 1 to 14), or abdominally (6.1 cm; range, 2.2
to 15; P⫽.13), although most myomas ⬎10 cm were removed abdominally (Figure 1). The median aggregate
weight of myoma removed abdominally (200g; range, 1.4
to 2682), however, was significantly (P⬍.005) larger than
that of myomas removed laparoscopically (115g; range, 1
to 602) and robotically (129g; range, 9.4 to 935).
DISCUSSION
Type of
Myomectomy
Table 1.
Operative Outcomes of Abdominal, Laparoscopic, and Robotic Assisted-Laparoscopic Myomectomy in a Community Hospital
Comparison of Demographic Data
ASA 3
[n (%);
p⫽0.13]
Comparison of Robotic, Laparoscopic, and Abdominal Myomectomy in a Community Hospital, Gobern JM et al.
Myomectomy is performed commonly for women with
symptomatic fibroid uterus desiring uterine preservation and
future fertility. Laparoscopic myomectomy was first reported
in 1979.9 This technique has been performed safely and has
consistently demonstrated advantages, such as decreased
blood loss, shorter hospital stay, less postoperative disability,
and comparable complications compared to abdominal
myomectomy.10 –17 Clinical outcomes for fertility and obstetrical outcomes are also comparable to abdominal myomectomy.18 Comparison of outcomes for laparoscopic and roboticassisted laparoscopic myomectomy has demonstrated
comparable clinical outcomes for blood loss, hospital stay, and
complications despite longer robotic operative times in university hospitals and medical centers.6,7 The American College of
Obstetricians and Gynecologist and the American Association
of Gynecologic Laparoscopist have confirmed the advantages
of laparoscopy over laparotomy. Despite advances in laparoscopic technique, as well as the advantages of laparoscopic
myomectomy reported over 30 y, most gynecologic procedures
are still performed through abdominal incisions.8,19
The technical skill required for excision of myoma and lack
of surgeon experience are considered significant limiting
factors to the wide acceptance of this technique.18,20 Technical advantages of robotic-assisted laparoscopic surgery
may help overcome these challenges and perhaps improve
the adoption of the laparoscopic technique.8,11 These advantages include 3-dimensional visualization, instrument articulation, improved dexterity, and the elimination of tremor and
counterintuitive movements.21,22 Specifically, these advantages offer the community-based gynecologist greater facility
with which to suture and surgically dissect laparoscopically.
Specifically, this study demonstrated primary surgical outcomes of operative time, decreased hospital stay, and decreased estimated blood loss with robotic-assisted laparoscopic myomectomy that were consistent with published
reports in university-based teaching hospitals and regional
medical centers. These findings, coupled with the demonstrated advantages of robotic-assisted laparoscopic surgery,
JSLS (2013)17:116 –120
Table 2.
Comparison of Preoperative Symptoms/Indications
Type of Myomectomy
n
Pain/Pressure
[n (%); p⫽0.072]
Bleeding
[n (%); p⫽0.64]
Fertility
[n (%); p⫽0.0005]
Other
[n (%); p⫽0.003]
Abdominal
169
55 (33%)
66 (39%)
92 (54%)
5 (3%)
Laparoscopic
73
35 (48%)
24 (33%)
19 (26%)
10 (14%)
Robotic
66
23 (35%)
23 (35%)
23 (35%)
7 (11%)
Table 3.
Comparison of Perioperative Outcomes
Type of
Myomectomy
n
Procedure Time
[(min) Median
(range)
p⬍0.0005]
Hospital Stay
[(days) Median
(range)
p⬍0.0005]
EBL [(mL)
Median (range)
p⬍0.0005]
Post-op
Complications
[n (%) p⫽0.58]
Transfusion
[n (%) p⬍0.0005]
Conversions to
Laparotomy
[n (%) p⫽0.5]
Abdominal
169
72 (13–185)
2 (0–12)
200 (10–2500)
17 (10%)
43 (26%)
N/A
Laparoscopic
73
70 (17–218)
0 (0–6)
100 (10–1800)
5 (7%)
9 (12%)
6 (8%)
Robotic
66
140 (55–328)
1 (0–17)
100 (10–1000)
8 (12%)
4 (6%)
3 (5%)
Largest Myoma
Maximum Myoma Size
Robotic-assisted laparoscopy has been proposed as a way to
overcome many of the technical challenges to traditional
laparoscopy through improved imaging as well as enhanced
dexterity of surgical instruments.8,11 While these characteristics have been demonstrated in university-based teaching
hospitals and medical centers, this is the first comparison of
abdominal, laparoscopic and RALM in a community hospital.10 This study demonstrated reduced blood loss and
shorter hospital stay consistent with previously published
reports. Additionally, the differences in operative times and
comparable rates of complications in our community hospital were similar to those of university-based teaching hospitals and medical centers with experienced surgeons.
Figure 1. Largest myoma on preoperative imaging, which was
removed by abdominal, laparoscopic, or robotically assisted laparoscopic myomectomy.
Strengths of this study include the large, continuous case
series with a high rate of complete patient data sets in a
single community hospital with access to all routes of surgery. Limitations of this study include all those inherent to
the retrospective design. A statistical difference was demonstrated in clinical outcomes although the descriptive nature
of the study results may reflect some differences from the
preselection process and individual patient characteristics. P
values were reported, nonetheless, as a direct comparison to
studies reported from medical centers and university-based
hospitals.
may improve the adaptation of this technique by general
gynecologists desiring to offer a more minimally invasive
approach to their patients in a community-based practice.
Concerns over increased costs, operating times, and number
of laparoscopic ports associated with robotic surgery continue to be addressed. New evidence suggests comparable
costs and operating times for robotic-assisted laparoscopy
Type of Surgery
JSLS (2013)17:116 –120
119
Comparison of Robotic, Laparoscopic, and Abdominal Myomectomy in a Community Hospital, Gobern JM et al.
compared with conventional laparoscopy, especially when
performed by experienced robotic surgeons.6,23–25
CONCLUSION
Laparoscopic and robotic-assisted myomectomies performed in this community hospital demonstrated clinical
outcomes consistent with those published from universitybased teaching hospitals and medical centers in the hands of
experienced laparoscopist. Further prospective randomized
studies evaluating whether the same outcomes are observed
with general gynecologists trained in robotic surgery are
warranted. This is especially true in the community hospital
setting. Regardless, robotic-assisted laparoscopic myomectomy offers a minimally invasive alternative for management
of symptomatic myoma and may expand the adoption of the
laparoscopic technique in the community hospital setting.
References:
1. Laughlin SK, Stewart EA. Uterine Leiomyomas: Individualizing the Approach to a Heterogenous Condition. Obstet Gynecol.
2011;117(2):396 – 403.
2. Agdi M, Tulandi T. Minimally invasive approach for myomectomy. Semin Reprod Med. 2010;28(3):228 –234.
3. Bonney V. The techniques and results of myomectomy.
Lancet. 1931;220:171–177.
4. Babaknia A, Rock JA, Jones HW Jr. Pregnancy success following abdominal myomectomy for infertility. Fertil Steril. 1978;
30(6):644 – 647.
5. Parker WH. Uterine myomas: management. Fertil Steril.
2007;88(2):255–271.
6. Bedient CE, Magrina JF, Noble BN, Kho RM. Comparison of
robotic and laparoscopic myomectomy. Am J Obstet Gynecol.
2009;201(6):566.e1–5.
7. Nezhat C, Lavie O, Hsu S, Watson J, Barnett O, Lemyre M.
Robotic-assisted laparoscopic myomectomy compared with
standard laparoscopic myomectomy–a retrospective matched
control study. Fertil Steril. 2009;91(2):556 –559.
8. Payne TN, Pitter MC. Robotic-assisted surgery for the community gynecologist: can it be adopted? Clin Obstet Gynecol.
2011;54(3):391– 411.
9. Semm K. New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy. 1979;11(2):85–93.
11. Barakat EE, Bedaiwy MA, Zimberg S, Nutter B, Nosseir M,
Falcone T. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol.
2011;117(2):256 –265.
12. Falcone T, Bedaiwy MA. Minimally invasive management of
uterine fibroids. Curr Opin Obstet Gynecol. 2002;14(4):401– 407.
13. Nezhat C, Nezhat F, Silfen SL, Schaffer N, Evans D. Laparoscopic myomectomy. Int J Fertil. 1991;36(5):275–280.
14. Miller CE, Johnston M. Laparoscopic myomectomy using
ultrasonic dissection. Surg Technol Int. 1995;(4):227–233.
15. Mais V, Ajossa S, Guerriero S, Mascia M, Solla E, Melis GB.
Laparoscopic versus abdominal myomectomy: a prospective,
randomized trial to evaluate benefits in early outcome. Am J
Obstet Gynecol. 1996;174(2):654 – 658.
16. Ascher-Walsh CJ, Capes TL. Robot-assisted laparoscopic
myomectomy is an improvement over laparotomy in women
with a limited number of myomas. J Minim Invasive Gynecol.
2010;17(3):306 –310.
17. Nash K, Feinglass J, Zei C, Lu G, Mengesha B, LewickyGaupp C, Lin A. Robotic-assisted laparoscopic myomectomy
versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs. Arch Gynecol Obstet. 2012;285(2):435–
440.
18. Sami WM, Heaton RL. The role of laparoscopic myomectomy in the management of uterine fibroids. Curr Opin Obstet
Gynecol. 2011;23(4):273–277.
19. Matthews CA. Applications of robotic surgery in gynecology.
J Womens Health (Larchmt). 2010;19(5):863– 867.
20. Lee CL, Wang CJ. Laparoscopic myomectomy. Taiwan J
Obstet Gynecol. 2009;48(4):335–341.
21. Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol. 2008;112:1369 –1384.
22. Robotic-assisted surgery. ACOG Technology Assessment in
Obstetrics and Gynecology No. 6. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114:1153–1155.
23. Shashoua AR, Gill D, Locher SR. Robotic-assisted total laparoscopic hysterectomy versus conventional total laparoscopic
hysterectomy. JSLS. 2009;13(3):364 –369.
24. Jonsdottir GM, Jorgensen S, Cohen SL, et al. Increasing
minimally invasive hysterectomy: effect on cost and complications. Obstet Gynecol. 2011;117(5):1142–1149.
25. Bush A, Morris SN, Millham FH, Isaacson KB. Women’s
preferences for minimally invasive incisions. J Minim Invasive
Gynecol. 2011;18(5)L:640 – 643.
10. Advincula AP, Xu X, Goudeau S 4th, Ransom SB. Robotassisted laproscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol. 2007;14(6):698 –705.
120
JSLS (2013)17:116 –120
SCIENTIFIC PAPER
Laparoscopic Ureteroneocystostomy for Ureteral
Injuries After Hysterectomy
Alexandre Pompeo, MD, Wilson R. Molina, MD, David Sehrt, BS, Marcos Tobias-Machado, MD,
Renato M. Mariano Costa Jr, MD, Antonio Carlos Lima Pompeo, MD, Fernando J. Kim, MD
ABSTRACT
Objectives: To examine the feasibility of early laparoscopic ureteroneocystostomy for ureteral obstruction due
to hysterectomy injury.
Methods: We retrospectively reviewed a 10-y experience
from 2 institutions in patients who underwent early (⬍30
d) or late (⬎30 d) laparoscopic ureteroneocystostomy for
ureteral injury after hysterectomy. Evaluation of the surgery included the cause of the stricture and intraoperative
and postoperative outcomes.
Results: A total of 9 patients with distal ureteral injury after
hysterectomy were identified. All injuries were identified and
treated as early as 21 d after hysterectomy. Seven of 9 patients underwent open hysterectomy, and the remaining
patients had vaginal and laparoscopic radical hysterectomy.
All ureteroneocystostomy cases were managed laparoscopically without conversion to open surgery and without any
intraoperative complications. The Lich-Gregoir reimplantation technique was applied in all patients, and 2 patients
required a psoas hitch. The mean operative time was 206.6
min (range, 120 –280 min), the mean estimated blood loss
was 122.2 cc (range, 25–350 cc), and the mean admission
time was 3.3 d (range, 1–7 d). Cystography showed no urine
leak when the ureteral stent was removed at 4 to 6 wk after
the procedure. Ureteroneocystostomy patency was followed
up with cystography at 6 mo and at least 10 y after ureteroneocystostomy.
Division of Urology, Department of Surgery, Denver Health Medical Center and
University of Colorado Health Sciences Center, Denver, CO, USA (Drs. A. Pompeo,
Molina, Sehrt, Kim).
Tony Grampsas Cancer Institute, Denver, CO, USA (Dr. Kim).
Division of Urology, ABC Medical School, São Paulo, Brazil (Drs. A. Pompeo,
Tobias-Machado, Mariano Costa, A.C.L. Pompeo).
Wilson R. Molina has a Fellowship Grant with Boston Scientific. Fernando J. Kim is a
Principal Investigator for Olympus, Covidien, Healthtronics, Amgem, and Cubist. Alexandre Pompeo, David Sehrt, Marcos Tobias-Machado, Renato M. Mariano Costa Jr, and
Antonio Carlos Lima Pompeo have no conflicts of interest or financial ties to disclose.
Address correspondence to: Fernando Kim, MD, Division of Urology, Denver
Health Medical Center, 777 Bannock St, MC 0206, Denver, CO 80204, USA. Telephone: (303) 436-6558, Fax: (303) 436-6572, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317437
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
Conclusion: Early laparoscopic ureteral reimplantation
may offer an alternative surgical approach to open surgery
for the management of distal ureteral injuries, with favorable cosmetic results and recovery time from ureteral
obstruction due to hysterectomy injury.
Key Words: Laparoscopy, Ureteroneocystostomy, Ureteral reimplantation, Hysterectomy.
INTRODUCTION
Hysterectomy is the most frequent gynecologic procedure
for benign uterine disease.1 Unfortunately, because of the
close proximity of the ureter to the cervix and uterine
artery, unintended injury to the ureter may occur during
this procedure. Ureteral injury may occur because of suture, clip, or staple ligation; crush injury; or electrocautery
thermal spread, which can lead to the development of
hydronephrosis, loss of renal function, fistula formation,
and possible sepsis if not detected intraoperatively.2 Optimal management of distal ureteral stricture includes resection of the stenosis, spatulation of the healthy ureter,
and tension-free ureteroureteral anastomosis with optimal
ureterovesical mucosa apposition. Traditionally, these
procedures have been performed by an open approach
after the acute phase has passed (⬎6 wk), but laparoscopy has emerged as a minimally invasive option.3–5
In 1992 Nezhat and Nezhat6 reported the first laparoscopic
ureteroureterostomy for the repair of a ureteral injury during
a laparoscopic gynecologic procedure. Since then, laparoscopic ureteroneocystostomy has been reported, but the
reconstructive steps may be challenging to surgeons. We
evaluated a 10-y multi-institutional experience with early and
late laparoscopic ureteral reimplantation in patients who
were treated for distal ureteral injury after hysterectomy performed by surgeons (F.J.K. and M.T.-M.) at 2 institutions.
MATERIALS AND METHODS
We retrospectively reviewed the charts of patients who underwent laparoscopic ureteroneocystostomy after hysterectomy from 2002 to 2011 at Denver Health Medical Center
(Denver, CO, USA) and the ABC Medical School (São Paulo,
JSLS (2013)17:121–125
121
Laparoscopic Ureteroneocystostomy for Ureteral Injuries After Hysterectomy, Pompeo A et al.
Figure 1. Left distal hydronephrosis of left ureter at 2 y after hysterectomy (CT scan and ascendant pyelogram). (Arrow) stenosis of the
ureter.
Brazil). Data collection included demographics, cause of the
stricture, and intraoperative and postoperative outcomes.
Surgical Technique
Identification of the ureteral stricture was made preoperatively with computed tomography (CT)–intravenous pyelography and then intraoperatively with retrograde ureteropyelography (Figure 1). A council-tip Foley catheter (Bard,
Covington, GA) was then placed, followed by a 5-mm ureteral catheter, and then a Superstiff guidewire (Boston Scientific, Natick, MA) catheter was inserted. Laparoscopic ureteroneocystostomy was performed in a transperitoneal
manner with the Lich-Gregoir technique. The Kocher maneuver was performed after incision of the line of Toldt, and
the ureter was released, dissected above the stenotic area,
clipped distally, and sectioned (Figure 2A). The bladder
was mobilized to achieve a good length up to the incised
ureter without requiring insufflation of the bladder. By use of
laparoscopic scissors, the bladder was incised and dissected
with good mucosa exposure (Figure 2B). Mucosa-mucosa
anastomosis was performed with absorbable No. 3.0 Polysorb suture (Johnson & Johnson, New Brunswhick, NJ) starting at the 6-o’clock position after spatulation of the
distal ureter (Figure 2C). Before the ureterovesical
anastomosis was finalized, a ureteral stent was placed
with assistance from the Superstiff guidewire, and the
bladder anastomotic site was tested for watertightness
with irrigation and filling up the bladder with 250 cc of
sterile saline solution (Figure 2D).
122
A Foley catheter was removed 1 wk postoperatively.
Cystography was performed at 4 to 6 wk at the time the
double-J ureteral stent was removed if no extravasation
was identified. CT intravenous urography was performed
and serum creatinine levels were obtained at 3 mo to
reassess the ureteroneocystostomy. Renal nuclear (Mercaptoacetyltriglycine) scans were ordered for patients
who had questionable decreased renal function postoperatively.
RESULTS
A total of 9 patients with ureteral stricture due to iatrogenic
injury from hysterectomy were identified. A percutaneous nephrostomy tube was placed in 4 patients (44.4%) before the
ureteroneocystostomy. Interestingly, in 1 of these patients, the
ureter was medially deviated because of previous procedures
(Figure 3). In the 5 patients who did not have urinary diversion, hydronephrosis and ureteral obstruction with ipsilateral
flank pain developed at 7 d and 1, 2, 3, and 13 y after hysterectomy. Ureterovaginal fistula developed in 2 patients with
long-term obstruction. Preoperative creatinine levels were normal in all patients, ranging from 0.5 mg/dL to 0.9 mg/mL. The
mean patient age was 48.5 y (range, 30–76 y).
Table 1 shows patient demographics and preoperative
data. Seven patients (77.8%) underwent open hysterectomy: The procedure was performed in 5 patients (71.4%)
because of myoma and in 1 patient (14.3%) because of
cervical cancer; moreover, 1 patient (14.3%) underwent
JSLS (2013)17:121–125
Figure 2. (A) Resection of stenotic area.
(B) Mucosal exposure of the detrusor muscle of the bladder. (C) Ureterovesical anastomosis after ureteral spatulation. (D) Suture of muscular layer of the bladder wall
(detrusor).
Table 1.
Patient Demographics and Stricture Etiology
Patient Age BMIa
ASA
No.
(y) (kg/m2)
Side
Ureteral Etiology
Position
1
58
28.2
2
Left
distal
2
46
32.8
2
Right distal
OH, myoma
3
50
31.2
2
Left
distal
OH, myoma
4
43
21.5
3
Right distal
OH, myoma
5
42
35.1
3
Right distal
ORHa, cervical
cancer
6
76
20.7
3
Left
distal
VHa, myoma
7
30
25.3
1
Right distal
OH, myoma
8
55
18.9
1
Left
distal
LRHa, cervical
cancer
9
40
20.5
1
Left
distal
OH, uterine
atony
OHa, myoma
ASA ⫽ American Society of Anesthesiologists class; BMI ⫽ body
mass index; LRH ⫽ laparoscopic radical hysterectomy; OH ⫽
open hysterectomy; ORH ⫽ open radical hysterectomy; VH ⫽
vaginal hysterectomy.
a
Figure 3. Intraoperative pyelogram of ureter deviated past midsagittal plane.
emergent laparotomy and hysterectomy for bleeding due
to uterine hemorrhage and failure to coagulate after vaginal delivery. Vaginal hysterectomy was performed in 1
patient (11.1%), whereas 1 patient (11.1%) underwent
laparoscopic radical hysterectomy.
JSLS (2013)17:121–125
123
Laparoscopic Ureteroneocystostomy for Ureteral Injuries After Hysterectomy, Pompeo A et al.
Table 2.
Surgical Outcomes
Patient No.
ORTa (min)
EBLa (mL)
Procedure
Hospital Stay (d)
Complications
1
250
250
Ureteroneocystostomy
3
No
2
240
150
Ureteroneocystostomy
7
Transfusion reaction
3
200
25
Ureteroneocystostomy
2
No
4
280
25
Ureteroneocystostomy
3
No
5
220
100
Ureteroneocystostomy and psoas hitch
3
No
6
130
50
Ureteroneocystostomy
2
No
7
120
50
Ureteroneocystostomy
1
No
8
240
350
Ureteroneocystostomy and psoas hitch
7
Urinary tract infection
9
180
100
Ureteroneocystostomy
2
No
EBL ⫽ estimated blood loss; ORT ⫽ operative time.
a
All ureteroneocystostomies were successfully performed by a
laparoscopic approach without conversion to open surgery.
Surgical outcomes are summarized in Table 2. The mean operative time was 206.6 min (range, 120–280 min), and the mean
estimated blood loss was 122.2 cc (range, 25–350 cc). The
increased operating room time was because of intraperitoneal
adhesions from previous surgery including hysterectomy. The
mean hospital stay was 3.3 d (range, 1–7 d). Two patients were
hospitalized for 1 wk: 1 patient because of a blood transfusion
reaction (the patient who underwent emergent hysterectomy
and was repaired 7 d thereafter) and another as a result of a
complicated urinary tract infection. CT cystography or voiding
cystography showed no urine leak and a patent ureteroneocystostomy in all patients. In 2 cases the bladder received a psoas
hitch to allow for a tension-free ureterovesical anastomosis.
Postoperative creatinine levels were normal for all patients
(range, 0.7–1.1 mg/dL). In 1 patient with a psoas hitch, lowergrade ureterovesical reflux was observed without clinical repercussion on renal function (Figure 4).
DISCUSSION
Iatrogenic ureteral injury is a grave complication that can
occur during abdominal or pelvic surgeries. Ureteral injuries have a documented incidence of 0.3% to 1.5%.7 Fortunately, ureteral injuries from open hysterectomy are also
rare and occur in 0.2% to 0.4% of these procedures.8,9
Leonard et al.1 published a series of 1300 laparoscopic
hysterectomies, with a ureteral injury rate of 0.3%, comparable with that in the published open series.
Unfortunately, our patients were diagnosed after the hysterectomy. Five patients had the repair within 30 d of
injury, showing that early repair is feasible and efficient
124
Figure 4. Postoperative aspect of CT cystogram after psoas hitch
with low-grade reflux.
contrary to the dogma that one should wait 3 to 6 mo after
injury for repair. Pathology reports from the injury sites
confirmed fibrotic tissue and complete obliteration of the
ureteral lumen.
Open surgical procedures have good long-term results
with reported success rates ⬎80%.2 However, open surgical procedures are associated with a longer hospital
stay, extra blood loss, and the need for additional pain
medication.4 Nevertheless, minimally invasive techniques
have gained in popularity in recent years.10 –20 Since the
first report of a laparoscopic ureteroneocystostomy was
published by Nezhat and Nezhat6 in 1992, only a few
JSLS (2013)17:121–125
reports with small sample sizes have been recorded in the
literature. Moreover, these reports were not limited only to
post-hysterectomy ureteral injuries and did not address
the optimal timing of the ureteral reimplantation. Our
series focused on patients who required ureteroneocystostomy after hysterectomy only. In addition, even more
extensive ureteric defects were successfully repaired with
the psoas-hitch technique and Boari flap laparoscopically.
5. Modi P, Goel R, Dodiya S. Laparoscopic ureteroneocystostomy for distal ureteral injuries. Urology. 2005;66(4):751–753.
Recently, robot-assisted techniques have been described
for ureteral reimplantation. However, robot-assisted ureteral reimplantation in adult patients is not a universal
reality because of the cost and inexperience of surgeons
in countries outside of the United States and a few Asian
and European countries. The laparoscopic approach certainly can be performed in most practices where a robot is
not available.
8. Harkki-Siren P, Sjoberg J, Mäkinen J, et al. Finnish national register
of laparoscopic hysterectomies. A review and complications of 1165
operations. Am J Obstet Gynecol. 1997;176(1 Pt 1):118–122.
This study has several limitations. It is retrospective and
limited by the small sample of patients. However, the
feasibility of performing the procedure early may offer
benefits to the patients who often may have a percutaneous nephrostomy tube placed and may decrease the anxiety level of the surgeon who caused the injury.
CONCLUSION
The laparoscopic technique of early ureteral reimplantation for the repair of ureteral obstruction due to hysterectomy injury may be challenging, but it is feasible. Our 10-y
experience showed that early laparoscopic ureteroneocystostomy offers similar success rates compared with
open procedures, decreasing issues associated with delayed repair of injuries.
References:
1. Leonard F, Fotso A, Borguese B, Chopin N, Foulot H,
Chapron C. Ureteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: a 13-year experience in a continuous series of 1300 patients. Hum Reprod.
2007;22(7):2006 –2011.
2. Sakellariou P, Protopapas AG, Voulgaris Z, et al. Management of
ureteric injuries during gynecological operations: 10 years experience.
Eur J Obstet Gynecol Reprod Biol. 2002;101(2):179–184.
3. Simmons MN, Gill IS, Fergany AF, Kaouk JH, Desai MM.
Laparoscopic ureteral reconstruction for benign stricture disease.
Urology. 2007;69(2):280 –284.
4. Rassweiler JJ, Gözen AS, Erdogru T, Sugiono M, Teber D.
Ureteral reimplantation for management of ureteral strictures: a
retrospective comparison of laparoscopic and open techniques.
Eur Urol. 2007;51(2):512–522.
6. Nezhat C, Nezhat F. Laparoscopic repair of ureter resected during
operative laparoscopy. Obstet Gynecol. 1992;80(3 Pt 2):543–544.
7. Parpala-Sparman T, Paananen I, Santala M, Ohtonen P, Hellstrom P. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scand J Urol Nephrol. 2008;
42(5):422– 427.
9. Mäkinen J, Johansson J, Tomas C, et al. Morbidity of 10110
hysterectomy by type of approach. Hum Reprod. 2001;16(7):
1473–1478.
10. Phipps JH, Tyrrell NJ. Transilluminating ureteric stents for
preventing operative ureteric damage. Br J Obstet Gynaecol.
1992;99(1):81.
11. Paulson JD. Laparoscopically assisted vaginal hysterectomy.
A protocol for reducing urinary tract complications. J Reprod
Med. 1996;41(9):623– 628.
12. Ostrzenski A, Radolinski B, Oatrzenska KM. A review of
laparoscopic ureteral injury in pelvic surgery. Obstet Gynecol
Surv. 2008;58(12):794 –799.
13. Ehrlich RM, Gershman A, Fuchs G. Laparoscopic vesicoureteroplasty in children: initial case reports. Urology. 1994;43(2):255–261.
14. Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy.
J Urol. 1994;152(6 Pt 1):2057–2059.
15. Nezhat CH, Malik S, Nezhat F, Nezhat C. Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative endometriosis. JSLS. 2004;8(1):3–7.
16. Modi P, Gupta R, Rizvi SJ. Laparoscopic ureteroneocystostomy and psoas hitch for post hysterectomy ureterovaginal fistula. J Urol. 2008;180(2):615– 617.
17. Fugita OE, Dinlenc C, Kavoussi L. The laparoscopic Boari
flap. J Urol. 2001;166(1):51–53.
18. Smith RP, Oliver JL, Peters CA. Pediatric robotic extravesical
ureteral reimplantation: comparison with open surgery. J Urol.
2011;185(5):1876 –1881.
19. Marchini GS, Hong YK, Minnillo BJ, et al. Robotic assisted
laparoscopic ureteral reimplantation in children: case matched
comparative study with open surgical approach. J Urol. 2011;
185(5):1870 –1875.
20. Kasturi S, Sehgal SS, Christman MS, Lambert SM, Casale P.
Prospective long-term analysis of nerve sparing extravesical robotic assisted laparoscopic ureteral reimplantation. Urology.
2012;79(3):680 – 683.
JSLS (2013)17:121–125
125
SCIENTIFIC PAPER
Laparoscopic Surgery for Kidney Orthotopic
Transplant in the Pig Model
Bulang He, Gabby C. Musk, Lingjun Mou, Gerald L. Waneck, Luc Delriviere
ABSTRACT
Background and Objectives: Laparoscopic surgery has
rapidly expanded in surgical practice with well-accepted
benefits of minimal incision, less analgesia, better cosmetics, and quick recovery. The surgical technique for kidney
transplantation has remained unchanged since the first
successful kidney transplant in the 1950s. Over the past
decade, there were only a few case reports of kidney
transplantation by laparoscopic or robotic surgery. Therefore, the aim of this study is to develop a laparoscopic
technique for kidney transplantation at the region of the
native kidney.
Methods: After initial development of the laparoscopic
technique for kidney transplant in cadaveric pigs, 5 live
pigs (Sus scrofa, weighing 45–50 kg) underwent laparoscopic kidney transplant under general anesthesia.
First, laparoscopic donor nephrectomy was performed,
and then the kidney was perfused and preserved with
cold Ross solution. The orthotopic auto-transplant was
subsequently performed using the laparoscopic technique. The blood flow of the kidney graft was assessed
using Doppler ultrasonography, and urine output was
monitored.
Results: The laparoscopic kidney transplant was successful in 4 live pigs. Immediate urine output was observed in
3 pigs. The blood flow in the kidney was adequate, as
determined using Doppler ultrasonography.
Conclusion: It has been shown that laparoscopic kidney
orthotopic transplant is feasible and safe in the pig model.
Immediate kidney graft function can be achieved. A further study will be considered to identify the potential
Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, Australia (Messrs He, Mou, Delriviere).
surgical morbidity and mortality after recovery in a pig
model before translating the technique to clinical human
kidney transplantation.
Key Words: Laparoscopic surgery, Orthotopic kidney
transplant, Pig model.
INTRODUCTION
The use of laparoscopic surgery has been widely expanded in clinical surgical practice. In the kidney transplant field, it is well accepted that laparoscopic donor
nephrectomy has equal kidney graft function with minimal incision, less analgesia, better cosmetic appearance,
and quick recovery.1–5 The surgical technique for kidney
transplantation has remained unchanged since the first
successful kidney transplant in the 1950s.6 The kidney is
routinely placed in the iliac fossa with the renal artery
being anastomosed to the iliac artery and the renal vein
end being anastomosed to the side of the external iliac
vein. The disadvantage of this technique is that the kidney
graft is vulnerable to injury or trauma because it is exposed to the front of the pelvis. It also becomes very
challenging when a third or fourth subsequent kidney
transplant is required because of adhesions around the
iliac vessels from previous transplant surgery. Therefore,
the aim of this study is to develop a laparoscopic technique for orthotopic kidney transplant. We predict that
laparoscopic kidney transplant will have the advantages
of equal graft function, a smaller incision, less pain, a
better cosmetic appearance, a quicker recovery, and a
shorter hospital stay compared with conventional open
surgery.
Animal Care Service, The University of Western Australia, Perth, Australia (Musk).
Transplant Immunology Laboratory, The University of Western Australia, Perth,
Australia (Mr. Waneck).
Research funding was received from Western Australian Transplant Service.
Address correspondence to: Bulang He, MBBS, MS, FRACS, Telephone: 0061-893464055, Fax: 0061-8-93467442, E-mail: [email protected]
DOI: 10.4293/108680812X13517013318021
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
126
METHODS
The study was approved by the animal ethics committee
of the university. The study consists of 2 parts. In part 1
the laparoscopic technique for kidney transplant was developed on 10 cadaveric pigs that were used for other
studies. The technique development included the justification of port position and vessel anastomosis. In part 2
JSLS (2013)17:126 –131
the laparoscopic kidney transplant was performed in live
pigs.
geal temperature, and electrocardiogram. The parameters
were recorded every 5 minutes.
Animals
Surgical Procedure
Ten cadaveric pigs were used after a study conducted by
the department of respiratory medicine. The lungs of the
pigs were removed by the respiratory medicine team for
histopathology. Approval was obtained from the animal
ethics committee of the university for this secondary
study. Five live pigs (Sus scrofa, 2 male and 3 female pigs),
weighing 45 to 50 kg, were transported to the Large
Animal Facility of the university 2 weeks before surgery
for acclimatization. The pigs were housed in a pen above
the floor. They were fed a maintenance diet (Grower;
Westfeeds Pty Ltd, Bentley, Australia) and allowed free
access to tap water. Daily care was provided by the staff of
the Large Animal Facility. The pigs were euthanized by
intravenous injection of pentobarbital (160 mg/kg) at the
end of the study.
After general anesthesia, the pig was placed in the right
decubitus position. The camera port was inserted via a
small open incision (1.5 cm) at a site to the left of midline
and above the umbilicus. The other ports were placed
under vision; the sites of the ports are shown in Figure 1.
The left kidney was identified and the bowel dissected
medially. The renal artery and vein and ureter were exposed and dissected. The renal artery was dissected to the
origin of the aorta and the renal vein to the origin of the
vena cava to obtain the best possible vessel exposure.
This facilitated the subsequent auto-transplant. The left
kidney was mobilized free from its attachments. The ureter was divided first at the level of the lower pole. At this
point, 1,500 IU of heparin was given intravenously. A
small low midline incision (6 cm) in the abdomen was
created by longitudinally cutting the skin and fascia at the
midline. Then, the muscular layer was opened through
the left para-midline (Figure 2). The peritoneal layer
remained intact at this stage. The renal artery and vein
were clamped with an endoscopic Bulldog device (B.
Braun Melsungen AG, Melsungen, Germany) and divided.
The kidney was then delivered by opening the peritoneum via the incision and perfused on the back table
immediately with cold (4°C) Ross perfusion fluid (Orion
Laboratories, Balcatta, Australia) (1 L of Ross solution plus
10,000 IU of heparin). The kidney graft was prepared on
the back table. No. 6-0 Prolene stitches (Ethicon, Somerville, New Jersey) were placed at the upper and lower
Anesthesia
Food was withheld for 12 hours before anesthesia and
surgery, but the pigs were allowed free access to water.
Anesthesia was induced with a combination of Zoletil (4.4
mg/kg) and xylazine (2.2 mg/kg) by intramuscular injection in the neck. An auricular vein was cannulated, and
propofol (1 mg/kg) was administered intravenously to
achieve an adequate depth of anesthesia for tracheal intubation. The trachea was intubated with a cuffed endotracheal tube (Portex Soft Seal Cuff, 8.0-mm inner diameter; SIMS Portex Ltd, Hythe, United Kingdom). Anesthesia
was maintained with isoflurane delivered in 100% oxygen.
Mechanical ventilation was commenced immediately after
oral intubation of the trachea with a tidal volume of 10 to
15 mL/kg and peak inspiratory pressure ⬍25 cm of water.
The respiratory rate was adjusted to achieve normocapnia
(end-tidal carbon dioxide level, 35– 45 mm Hg). The
depth of anesthesia was assessed subjectively by a veterinary anesthetist throughout the procedure and altered
accordingly. The auricular artery was also cannulated
for direct blood pressure measurement. In addition, a
central line catheter was inserted into the left jugular
vein (7-French, 2-lumen catheter; Arrow International,
Reading, Pennsylvania) for measurement of central venous pressure and delivery of intravenous fluid therapy
(Hartmann solution and Gelofusin). Pancuronium was
administered (0.1 mg/kg intravenously) for neuromuscular blockade. The observations were continuous including
oxyhemoglobin saturation, end-tidal carbon dioxide level,
invasive blood pressure, central venous pressure, pharyn-
Figure 1. Positions of ports.
JSLS (2013)17:126 –131
127
Laparoscopic Kidney Orthotopic Transplant, He B et al.
Figure 2. Small midline incision for delivery of kidney graft.
Figure 4. Renal vein end-to-end anastomosis.
RV anastomosis
RA anastomosis
Figure 5. Renal graft reperfused rapidly and uniformly. The
arrows show renal artery (RA) and renal vein (RV) anastomosis
by running suture.
Figure 3. Renal artery end-to-end anastomosis.
corners of the renal vein as marking stitches, thus facilitating the manipulation of the vessel during the anastomosis. The kidney was preserved in the cold perfusion
fluid until implantation.
The kidney was then implanted at the orthotopic location
by a laparoscopic technique. The kidney graft was continuously flushed with cold (4°C) normal saline solution
via an extra 5-mm port during the period of vessel anastomosis. The renal artery was anastomosed end to end to
the renal artery stump and the renal vein was anastomosed end to end to the renal vein stump by No. 6-0
Prolene running sutures (Figures 3, 4, and 5) in the first
4 pigs and by interrupted stitches in the fifth pig (Figure 6).
The venous running suture was tied with a growth factor
margin allowing distension of the venous anastomosis
128
after reperfusion. The kidney graft was reperfused by
removing the venous Bulldog device, followed by the
arterial Bulldog device. Forty milligrams of furosemide
was given intravenously after kidney reperfusion. The
ureteral catheter that was inserted into the ureter was
brought out via the laparoscopic port for observation of
urine output.
Postoperative Course
The pig remained under anesthesia during the period of
observation. The vital signs were recorded every 5 minutes. The urine output was monitored. Doppler ultrasonography was performed to check the blood flow in the
kidney graft. Graft nephrectomy was performed by a laparoscopic technique at the end of the observation period.
The pig was then euthanized according to the study pro-
JSLS (2013)17:126 –131
RV
Figure 6. Renal graft reperfused rapidly and uniformly. The
arrow shows renal vein (RV) interrupted stitches.
tocol. The vessel anastomoses were examined on the
bench table.
Figure 7. Removed kidney graft after transplantation. The renal
artery and vein anastomoses are patent.
RESULTS
technique for kidney transplant has remained unchanged
since the first successful kidney transplant in the 1950s.6
Basically, an open incision is needed at the lower abdomen and the kidney graft is placed at the iliac fossa in a
heterotopic position. In this open surgery, the incision is
approximately 15 to 20 cm long and cutting of the muscular layers is unavoidable. Recently, there have been few
reports of heterotopic kidney transplant by laparoscopic/
robotic surgery, which could minimize the incision for
placement of the kidney graft.9 –14 However, the disadvantage of these techniques is that the kidney graft is located
at the pelvis, where it is relatively superficial and susceptible to injury during contact sports or trauma. Moreover,
a third or fourth kidney transplant can also be very difficult because of the formation of adhesions surrounding
the iliac vessels from previous transplant surgery. Open
surgery for orthotopic kidney transplant has been reported in the literature as an effective alternative for those
recipients in whom a heterotopic transplant was inappropriate, such as patients with a retained iliac fossa from a
former graft, thrombosis of the iliac vein, or severe arthromatosis on the iliac artery.15–18 The long-term patient and
graft survival rates are comparable with those for conventional heterotopic kidney transplant.18 However, open orthotopic kidney transplant has not been the favored approach because it is more difficult when compared with
conventional heterotopic kidney transplant. It usually requires a longer midline incision or use of a posterolateral
lumbotomy, in which massive muscles will be cut.17,18 As
a result, more analgesia is required and the recovery takes
longer. This study has shown that orthotopic kidney transplant can be performed safely by a laparoscopic ap-
The vital signs of all pigs were stable during the surgery
and postoperative observation period. The blood pressure
was stable from 100 mm Hg/60 mm Hg to 140 mm Hg/80
mm Hg. There were no intraoperative complications and
no conversion to open surgery. There was minimum
blood loss in 4 pigs, and 1 pig had more blood oozing
during the anastomosis. The operative time for laparoscopic donor nephrectomy ranged from 1 hour 20 minutes
to 1 hour 50 minutes (mean, 1 hour 30 minutes). The time
for renal artery anastomosis ranged from 30 to 40 minutes,
whereas the time for renal vein anastomosis ranged from
25 to 35 minutes. The graft warm ischemic time ranged
from 3 to 5 minutes. The graft cold ischemic time ranged
from 1 hour 50 minutes to 2 hours 20 minutes. Four of five
grafts were reperfused rapidly and uniformly (Figures 5
and 6). Urine output was immediately seen in 3 pigs. The
blood flow in the kidney grafts was satisfactory on Doppler ultrasonography; the arterial waveforms in the kidney
parenchyma were normal, as was venous flow. On postmortem examination, the vessel anastomosis was shown
to be widely patent in 3 pigs (Figure 7), whereas there
was narrowing at the anastomoses of the renal artery and
vein in the other 2 pigs.
DISCUSSION
The use of laparoscopic surgery has expanded rapidly in
clinical surgical practice, replacing conventional open surgery. A laparoscopic technique has also been successfully
used for vessel anastomosis with satisfactory results and
significant benefits to patients.7,8 However, the surgical
JSLS (2013)17:126 –131
129
Laparoscopic Kidney Orthotopic Transplant, He B et al.
proach, in which only a small midline (6-cm) incision is
needed. The application of the laparoscopic technique for
human orthotopic kidney transplant could facilitate the
consideration in selected recipients. In particular, it could
be useful for younger recipients who wish to enjoy active
sports and those who have an unsuitable pelvic condition
for heterotopic kidney transplant.
To our knowledge, this is the first report of laparoscopic
kidney orthotopic transplant in a pig model. Obviously, in
this experiment, laparoscopic kidney transplant only requires a small incision (6 cm) in the lower midline for
delivery of the kidney graft in and out. The incision was
created by opening the skin and fascia at the midline and
opening the muscular layer in the para-midline, which
makes the incision function like a valve to effectively
reduce gas leak. This incision is time and cost saving
because it does not need to be closed or sealed to prevent
gas leak, and it thus minimizes the warm ischemic time of
the graft. In this study, we have learned that the laparoscopic vessel anastomosis for kidney transplant is safe and
feasible. The quality of vessel anastomosis by the laparoscopic technique is reliable on postmortem examination.
Nevertheless, the anastomotic stenosis tends to occur in
the fashion of a continuous anastomosis because the renal
vein wall is very thin and the renal artery is very small in
caliber. This phenomenon was also reported in open
kidney orthotopic transplant in a pig model.19 The interrupted stitch for vessel anastomosis could be considered
in a future study when the laparoscopic suture technique
is improved (Figure 6). This could prevent the possibility
of anastomotic stenosis in this model. Alternatively, the
sutures can be tied after the Bulldog device has been
repositioned, allowing the blood flow through the anastomosis in the renal artery and the growth factor created at
the renal vein anastomosis to prevent the anastomotic
stenosis. It was noticed that the vessel anastomotic time
was longer by the laparoscopic technique. However, this
is a fairly new technique. The laparoscopic instruments
used in this experiment were not fine enough because the
renal artery was usually smaller in caliber (⬃2–3 mm in
diameter) than those in the human kidney. We believe the
laparoscopic vessel anastomotic time will be reduced dramatically with further practice over time and modification
of the laparoscopic instruments. Robotic surgery may
have advantages in vessel anastomosis because of its 3-D
view of the system compared with laparoscopic surgery.11,13,14 It may shorten the vessel anastomotic time,
improve the quality of vessel anastomosis, and minimize
the ischemic-reperfusion injury to the graft. Further stud130
ies will also be of value in determining the technique for
endoscopic vessel anastomosis.
Regarding animal welfare concerns, this model of laparoscopic kidney transplant could be applied to other research projects in which the kidney transplant model is
involved, such as ischemic-reperfusion injury with benefits of smaller incision and less requirement for analgesia.
This model could also provide an opportunity for surgeons who wish to perform human laparoscopic kidney
transplant to obtain the skill.
A limitation of this study is that the observation of graft
function was performed for only up to 4 hours after
kidney transplant. Further studies have been approved by
our animal ethics committee to investigate the impact of
laparoscopic kidney transplant on morbidity and mortality
in a survival pig model. The pigs and kidney graft function
will be observed for 4 weeks after transplant using the
laparoscopic technique. The graft function will be monitored by regular testing of the serum creatinine level after
laparoscopic kidney transplant. Further information on
safety and feasibility will be provided before application
to human clinical kidney transplant with the laparoscopic
technique. Nevertheless, our initial experience suggests
that the use of the laparoscopic technique could facilitate
orthotopic kidney transplant in selected recipients.
References:
1. Tooher R, Boult M, Maddern GJ, Rao MM. Final report from
the ASERNIP-S audit of laparoscopic live-donor nephrectomy.
ANZ J Surg. 2004;74(11):961–963.
2. Merlin TL, Scott DF, Rao MM, et al. The safety and efficacy of
laparoscopic live donor nephrectomy: a systematic review.
Transplantation. 2000;70(12):1659 –1666.
3. Melcher ML, Carter JT, Posselt A, et al. More than 500 consecutive laparoscopic donor nephrectomies without conversion
or repeated surgery. Arch Surg. 2005;140(9):835– 839; discussion
839 – 840.
4. Hadjianastassiou VG, Johnson RJ, Rudge CJ, Mamode N.
2509 living donor nephrectomies, morbidity and mortality, including the UK introduction of laparoscopic donor surgery.
Am J Transplant. 2007;7(11):2532–2537.
5. He B, Mitchell A, Delriviere L, et al. Laparoscopic donor
nephrectomy. ANZ J Surg. 2011;81(3):159 –163.
6. Murray JE, Merrill JP, Harrison JH. Kidney transplantation
between seven pairs of identical twins. Ann Surg. 1958;148(3):
343–359.
7. Chung BI, Gill IS. Laparoscopic splenorenal venous bypass
for nutcracker syndrome. J Vasc Surg. 2009;49(5):1319 –1323.
JSLS (2013)17:126 –131
8. Bruls S, Quaniers J, Tromme P, Lavigne JP, Van Damme H,
Defraigne JO. Comparison of laparoscopic and open aortobifemoral bypass in the treatment of aortoiliac disease. Results of a contemporary series (2003–2009). Acta Chir Belg. 2012;112(1):51–58.
9. Hoznek A, Zaki SK, Samadi DB, et al. Robotic assisted kidney
transplantation: an initial experience. J Urol. 2002;167(4):1604–1606.
10. Rosales A, Salvador JT, Urdaneta G, et al. Laparoscopic
kidney transplantation. Eur Urol. 2010;57(1):164 –167.
11. Giulianotti P, Gorodner V, Sbrana F, et al. Robotic transabdominal kidney transplantation in a morbidly obese patient.
Am J Transplant. 2010;10(6):1478 –1482.
12. Modi P, Rizvi J, Pal B, et al. Laparoscopic kidney transplantation: an initial experience. Am J Transplant. 2011;11(6):1320 –1324.
13. Boggi U, Vistoli F, Signori S, et al. Robotic renal transplantation: first European case. Transpl Int. 2011;24(2):213–218.
14. Benedetti E. Robotic intra-peritoneal kidney transplant in
obese recipients. Presented at: American Transplant Congress;
April 30-May 4, 2011; Philadelphia, PA.
15. Ferri M, Russell JD, Whelan JP. Orthotopic renal transplantation in a patient with a massive pelvic arteriovenous malformation. J Urol. 2000;163(3):899.
16. Rodrigues P, D’Imperio M, Campagnari M, Azevedo LA,
Campagnari JC, van Bellen B. Alternative grafting technique for
patients unsuited to heterotopic transplantation due to diseased
pelvic conditions. Urol Int. 2004;73(4):316 –319.
17. Paduch DA, Barry JM, Arsanjani A, Lemmers MJ. Indication,
surgical technique and outcome of orthotopic renal transplantation. J Urol. 2001;166(5):1647–1650.
18. Musquera M, Peri LL, Alvarez-Vijande R, Oppenheimer F,
Gil-Vernet JM, Alcaraz A. Orthotopic kidney transplantation: an
alternative surgical technique in selected patients. Eur Urol.
2010;58(6):927–933.
19. Jochmans I, Lerut E, Heedfeld V, Wylin T, Pirenne J, Monbaliu D. Reproducible model for kidney autotransplantation in
pigs. Transplant Proc. 2009;41(8):3417–3421.
JSLS (2013)17:126 –131
131
CASE REPORT
Laparoscopic Excision of Splenic Artery Aneurysm
Youngjin Kim, MD, Samir Johna, MD
ABSTRACT
INTRODUCTION
Introduction: Splenic artery aneurysm is more frequently
diagnosed today with the advancement and liberal use of
imaging modalities. A symptomatic aneurysm, an aneurysm of any diameter in a pregnant woman or a woman of
childbearing age, and an aneurysm ⬎2 cm are all strong
indications for surgery because of a significantly increased
risk for splenic artery rupture.
Splenic artery aneurysm (SAA) is the most common
splanchnic arterial aneurysm, accounting for approximately 60% of all visceral aneurysms, and is the third most
common abdominal aneurysm, after aortic and iliac artery
aneurysms.1,2 The incidence of SAA has been reported to
be between 0.02% and 10.4% in the general population,
with a prominent occurrence in multiparous women.1 The
increase in the incidence of SAA in the past decade can be
attributed to the technical advancement and more frequent use of imaging modalities. Most patients with SAAs
are asymptomatic. However, a symptomatic aneurysm, an
aneurysm of any diameter in a pregnant woman or a
woman of childbearing age, and an aneurysm ⬎2 cm are
all strong indications for surgery because of a significantly
increased risk for splenic artery rupture.1 Various treatment options for SAA include endovascular management,
laparoscopic surgery, and open surgery.3 We report the
successful laparoscopic surgical treatment of a 2.5-cm SAA
near the splenic hilum by en bloc resection of the SAA and
the spleen.
Case Description: A 35-year-old, morbidly obese, African American woman presented with constant left flank
pain for 4 weeks. Angiography confirmed a 2.5-cm splenic
artery aneurysm near the splenic hilum. Because angioembolization was unlikely to succeed because of extensive collaterals and the aneurysm’s proximity to the
splenic hilum, laparoscopic excision of the aneurysm with
splenectomy was performed.
Discussion: We report the successful laparoscopic surgical treatment of a 2.5-cm splenic artery aneurysm. Any
splenic artery aneurysm with a significantly increased risk
of rupture requires a prompt intervention. Although percutaneous embolization of the splenic artery is the most
frequently applied therapy today, surgical repair is preferred for all symptomatic aneurysms because of the
greater likelihood of success.
Key Words: Aneurysm, Laparoscopy, Splenic artery, Rupture.
Department of General Surgery, Arrowhead Regional Medical Center/Kaiser Permanente Fontana Medical Center, Fontana, CA, USA (Drs. Kim, Johna).
Address correspondence to: Youngjin Kim, MD, Department of General Surgery,
Kaiser Permanente Fontana Medical Center, 9985 Sierra Ave, Fontana, CA 92335,
USA. Telephone: (909) 427-5626, Fax: (909) 427-4065, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317392
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
132
CASE REPORT
A 35-year-old, morbidly obese, African American woman
presented with constant left flank pain, which she had had
for 4 weeks. She had no significant medical history and no
family history of aneurysm or connective tissue disorder.
Physical examination was benign. Computed tomography
showed no obvious disease processes except a questionable aneurysm of the splenic artery, and subsequent computed tomography angiography confirmed a 2.5-cm SAA
near the splenic hilum (Figure 1). A multidisciplinary
discussion among the primary admitting team, the vascular surgeon, the general surgeon, and the interventional
radiologist resulted in a recommendation of angioembolization as the treatment of choice. However, after visceral
angiography, the interventional radiologist believed that
angioembolization was unlikely to succeed in this case
because of extensive collaterals. Surgical options, including open aneurysm excision or laparoscopic en bloc resection with the spleen because of the hilar location of the
aneurysm, were discussed with the patient. The laparoscopic approach was offered based on reports of success-
JSLS (2013)17:132–134
Figure 1. Coronal computed tomography image showing large
aneurysm of splenic artery.
ful treatment of SAA with the risk of rupture, which is
difficult to treat with interventional radiology therapy.4 On
laparoscopy, the aneurysm was found to be partly embedded in the tail of the pancreas and the hilum of the
spleen. The spleen appeared to be normal in size and
texture. The aneurysm was excised en bloc with the
spleen because the aneurysm was too close and tethered
to the hilum, where isolation of the aneurysm would be
dangerous and ultimately unnecessary. The SAA was identified and dissected ex vivo to confirm the removal of the
aneurysm (Figure 2). The surgery was complicated by
the patient’s shortness of breath due to pulmonary atelectasis. She eventually recovered and was discharged home
on postoperative day 5.
DISCUSSION
SAA is the most frequently encountered type of splanchnic artery aneurysm and is the third most common abdominal aneurysm, after aortic and iliac artery aneurysms.1 Female patients are 4 times more likely to have
SAAs than male patients. An increased incidence of SAAs
has been associated with several conditions, including
pregnancy, degenerative atherosclerosis, portal hypertension, medial fibrodysplasia, arteritis, collagen vascular disease, ␣1-antitrypsin deficiency, and pancreatitis. Less
common causes include idiopathic dissection, septic emboli, essential hypertension, polyarteritis nodosa, systemic
lupus erythematosus, Ehlers-Danlos syndrome, and neurofibromatosis. Pseudoaneurysms of the splenic artery are
most often caused by chronic pancreatitis or by trauma.5
More than two-thirds of aneurysms of the splenic artery
are true aneurysms. They are usually saccular and occur at
a bifurcation in the splenic hilum.6 The true cause of SAA
formation is unclear. However, an increase in splenic
Figure 2. Isolated SAA after en bloc resection of aneurysm and
spleen.
blood flow may play a role in the development of SAA in
patients with portal hypertension due to liver cirrhosis or
transplantation. In addition, the increased prevalence in
multiparous women may be related to increased splenic
blood flow and the effects of estrogen on the elastic tissue
of the tunica media.7
SAA rupture has been associated with aneurysm size ⬎2
cm, pregnancy, history of liver cirrhosis or transplantation,
and ␣1-antitrypsin deficiency. The overall risk for rupture
is 5%. Evidence in the literature indicates that pregnant
patients are at high risk for rupture of SAAs, with a maternal mortality rate near 70% and an even more devastating fetal mortality rate of 90% to 95%.8 SAA, once mostly
found incidentally at autopsy, is more frequently diagnosed with the technical advancement of diagnostic imaging, prompting an earlier intervention for those at an
increased risk for SAA rupture.
Traditionally, open laparotomy with either aneurysm ligation alone or splenectomy with ligation was the gold
standard for the management of SAA. Today, various therapeutic options are available for SAA, including noninvasive endovascular management and laparoscopic or open
surgery with or without splenectomy.9 Percutaneous embolization of the splenic artery is the most frequently
applied therapy. It may be performed for all SAAs except
those located at the splenic hilum.10 Aneurysm of the
proximal splenic artery can be treated with simple ligation
JSLS (2013)17:132–134
133
Laparoscopic Excision of Splenic Artery Aneurysm, Youngjin K et al.
or aneurysmectomy, but those involving the hilum require
splenectomy.3 Most recently, stent grafts and covered
stents have been used with success, especially in the
presence of portal hypertension, because the extensive
collateral circulation that develops with portal hypertension makes surgery more difficult.11 Surgical repair is preferred for all symptomatic aneurysms because of the
greater likelihood of success.5 Rarely, aneurysmectomy
with end-to-end anastomosis may be used when the SAA
is not intrasplenic or in the hilum.
Since the first successful laparoscopic-assisted SAA resection performed in 1993 by Saw et al.,12 simple laparoscopic ligation of the artery proximal to the SAA and SAA
resection with or without splenectomy have been conducted with increasing frequency. In experienced hands,
laparoscopic surgery is a simple, safe, minimally invasive
technique, with rapid recovery, decreased postoperative
pain, and shorter hospital stay compared with the open
technique.13 Some authors have advocated a tangential
stapler resection of sacciform aneurysms to preserve
splenic flow, but others worry that this type of laparoscopic treatment leaves behind part of the aneurysmal
artery and therefore might contribute to recurrence.14,15
Ligation of the proximal and distal segment is considered
safer in lesions of the medial third, because these are often
adherent to the pancreas. However, the risk of pancreatic
injury during the laparoscopic dissection of an SAA is
more theoretical than real because the splenic artery runs
separate from the pancreatic parenchyma and a plane can
always be found between the two. Ligation is feasible in a
mid-SAA by stapling or clipping the inflow and outflow.
Preservation of the spleen should be attempted unless the
SAA is located deep within the splenic hilum.16 Most
recent reviews of laparoscopic surgery for SAAs show
successful laparoscopic treatment of hilar SAAs with splenectomy and some even with distal pancreatectomy for
SAAs too difficult to treat with interventional radiology
therapy.4 In case of splenic artery pseudoaneurysm, most
often caused by chronic pancreatitis or trauma, SAA resection with splenectomy with or without distal pancreatectomy is recommended because of the higher risk of
recurrence and complications.17
1. Abbas MA, Stone WM, Fowl RJ, et al. Splenic artery aneurysms: two decades experience at Mayo Clinic. Ann Vasc Surg.
2002;16(4):442– 449.
2. Trastek VF, Pairolero PC, Joyce JW, Hollier LH, Bematz PE.
Splenic artery aneurysms. Surgery. 1982;91(6):694 – 699.
3. Hashizume M, Ohta M, Ueno K, Okadome K, Sugimachi K.
Laparoscopic ligation of splenic artery aneurysm. Surgery. 1993;
113(3):352–354.
4. Obuchi T, Sasaki A, Nakajima J, Nitta H, Otsuka K, Wakabayashi G. Laparoscopic surgery for splenic artery aneurysm.
Surg Laparosc Endosc Percutan Tech. 2009;19(4):338 –340.
5. Pasha SF, Gloviczki P, Stanson AW, Kamath PS. Splenic
artery aneurysm. Mayo Clin Proc. 2007;82(4):472– 479.
6. Carr SC, Pearce WH, Vogelzang RL, McCarthy WJ, Nemcek
AA Jr, Yao JS. Current management of visceral artery aneurysms.
Surgery. 1996;120(4):627– 633.
7. Hallett JW Jr. Splenic artery aneurysms. Semin Vasc Surg.
1995;8(4):321–326.
8. Cailouette JC, Merchant EB. Ruptured splenic artery aneurysm in pregnancy: twelfth reported case with maternal and fetal
survival. Am J Obstet Gynecol. 1993;168(6 Pt 1):1810 –1813.
9. Kokkalera U, Bhende S, Ghellai A. Laparoscopic management of splenic artery aneurysms. J Laparoendosc Adv Surg Tech
A. 2006;16(6):604 – 608.
10. Reidy JF, Rowe PH, Ellis FG. Splenic artery aneurysm embolization—the preferred technique to surgery. Clin Radiol.
1990;41(4):281–282.
11. Arepally A, Dagli M, Hofmann LV, Kim HS, Cooper M, Klein
A. Treatment of splenic artery aneurysm with use of a stent-graft.
J Vasc Interv Radiol. 2002;13(6):631– 633.
12. Saw EC, Ku W, Ramachandra S. Laparoscopic resection of a
splenic artery aneurysm. J Laparoendosc Surg. 1993;3(2):167–171.
13. Ha JF, Sieunarine K. Laparoscopic splenic artery aneurysm
resection: review of current trends in management. Surg Laparosc Endosc Percutan Tech. 2009;19(2):e67– e70.
14. Matsumoto K, Ohgami M, Shirasugi N, Nohga K, Kitajima M.
A first case report of the successful laparoscopic repair of a
splenic artery aneurysm. Surgery. 1997;121(4):462– 464.
15. Lai PB, Leung KL, Lau WY. Laparoscopic repair of a splenic
artery aneurysm. Surgery. 1998;123:247–248.
CONCLUSION
SAA requires prompt attention for patients at increased
risk for rupture. Endovascular management is the least
invasive and most applied therapy. However, for more
complicated cases, laparoscopic surgery should be considered as the next best option.
134
References:
16. Pietrabissa A, Ferrari M, Berchiolli R, et al. Laparoscopic treatment
of splenic artery aneurysms. J Vasc Surg. 2009;50(2):275–279.
17. Tessier DJ, Stone WM, Fowl RJ, et al. Clinical features and
management of splenic artery pseudoaneurysm: case series and
cumulative review of literature. J Vasc Surg. 2003;38(5):969 –974.
JSLS (2013)17:132–134
CASE REPORT
Transvaginal Liver Surgery Using a Tethered Magnet
and a Laparoscopic Rein
Daniel Alberto Tsin, MD, Guillermo Dominguez, MD, Fausto Davila, MD,
Juan Manuel Alonso-Rivera, MD, Brad Safro, MD, Andrea Tinelli, MD
ABSTRACT
INTRODUCTION
Introduction: A novel technique was used to remove a
large liver cyst via culdolaparoscopy.
A transvaginal approach with assisted minilaparoscopy in
the removal of benign liver lesions has previously been
reported in the surgical literature. In one case, culdolaparoscopy with a liver biopsy was an incidental finding1; the
other 2 cases reported2 and the case here presented were
programmed liver cyst interventions. We used laparoscopy reins and a magnetic grasper in single-port laparoscopy surgery and in transvaginal cholecystectomies.3,4
The transvaginal approach is a safe method with better
aesthetic results than prior laparoscopic procedures we
had performed, resulting in less patient discomfort and
potential risk for abdominal incision site hernias. The
initial findings of this approach in the removal of hepatic
benign lesions look promising.
Case Description: We used laparoscopic instruments, a
gastroscope, a laparoscopic rein, and magnets. The magnets consist of an external magnet and a specially modified tethered neodymium internal magnet, safe for use in
transvaginal endoscopic surgery.
Discussion: These technologies offer some advantages
when they are used together: magnets and the rein to aid
in exposure, traction–retraction, and triangulation. Previous reports have been published on the removal of benign liver lesions transvaginally, but none to date has
involved the use of magnets. This article reports on the
role of magnets and reins in an incision reduction approach to the removal of a liver cyst.
Key Words: Magnets, Culdolaparoscopy, Liver, Laparoscopy, NOTES.
The Mount Sinai Hospital of Queens. Long Island City, NY, USA (Drs. Tsin, Safro).;
Fundación Hospitalaria, Buenos Aires, Argentina (Dr. Dominguez).; Sesver Regional Hospital, Poza Rica City, Veracruz, Mexico (Drs. Davila, Alonso-Rivera).;
Vito Fazzi General Hospital, Lecce, Italy (Dr. Tinelli).
Dr. Guillermo Dominguez, founder of IMANLAP, reports that this financial relationship had no influence on the outcome or content of this paper. Other authors
have no financial interests to disclose.
Address correspondence to: Daniel Alberto Tsin, MD, The Mount Sinai Hospital of
Queens, Long Island City, NY, USA. Telephone: 718-899-7878 Fax: 718-899-0865
E-mail: [email protected]
DOI:10.4293/108680812X13517013317239
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
CASE REPORT
The surgery was performed in May 2008 at Hospital Regional,
Poza Rica, SESVER in Veracruz, Mexico after being approved by
the Institutional Review Board for Minilaparoscopy Assisted
Natural Orifice Surgery (MANOS) and Natural Orifice Translumenal Endoscopic Surgery (NOTES) using rigid, flexible, and
magnetic technologies, with Dr. Fausto Davila as the principal
investigator.5 A 32-y-old multiparous female with a body mass
index of 35 presented with right upper-quadrant abdominal
pain and jaundice. Additional sonogram and computed tomography scan findings showed a simple liver cyst measuring
12.2cm by 12.3cm. Preoperative laboratory results showed a
total bilirubin of 9.29 mg/dL (normal, 0.3 to 1.9) a direct
bilirubin of 6.86 mg/dL (normal, 0 to 0.3), an alanine
transaminase (ALT; serum glutamic pyruvate transaminase
[SGPT]) of 116 IU/L (normal, 7 to 56), and an aspartate aminotransferase (AST; serum glutamic oxalacetic transaminase
[SGOT]) of 85 IU/L (normal, 5 to 40). The elevated bilirubin was
due to pressure from a large simple cyst over the biliary tract.
The patient was given a dedicated informed consent for this
procedure and was scheduled for surgery after risk and
benefits were carefully explained, as was done in previous operations.6 She received intravenous antibiotic prophylaxis with metronidazole and cephalosporins and had
undergone bowel preparation starting the night before the
procedure. The procedure was done with the patient
under general anesthesia with endotracheal intubation.
JSLS (2013)17:135–138
135
Transvaginal Liver Surgery Using a Tethered Magnet and a Laparoscopic Rein, Tsin DA et al.
The patient was placed in the European position for laparoscopy. In the operating room, one monitor was placed
by the patient’s right shoulder, the other by her left foot.
The vagina was cleansed with 10% povidone iodine; pelvic examination was done while the patient was anesthetized to assess the pelvis for mobility and potential for
obstruction of the posterior cul-desac. After placing a
Foley catheter in the urinary bladder, a uterine manipulator (ZUMI-4.5; Circon Cabot, Racine, WI) was inserted,
and a weighted vaginal speculum was used to allow
proper exposure of the posterior fornix. Pneumoperitoneum was induced with a Verses needle inserted in the
umbilical area. The 5-mm umbilical port was placed and a
5-mm laparoscope with camera was inserted. The posterior cul-desac was visualized with the laparoscope. A
plastic, 12-mm diameter, 15-cm long armed trocar was
placed against the posterior fornix. The weighted speculum was removed and the uterine manipulators together
with the trocar were pushed upward and anteriorly. The
point of pressure was identified with the laparoscope, and
under laparoscopic surveillance, the trocar was inserted
into the posterior cul-desac. The armed trocar was removed and the external cannula remained as a vaginal
port.7 A set of magnets was used that consisted of a larger
external magnet and a smaller intraabdominal magnet,
which was an 11 mm in diameter neodymium magnet
with an alligator grasper in tandem and an alligator clip
applier (IMANLAP, Buenos Aires, Argentina). This intraabdominal magnet was modified with a tether of 0 polypropylene suture, 75cm long. The intraabdominal magnet
was introduced via the vaginal port with a Maryland
grasper. The free end of the tether remained outside the
vaginal port and was held with a Kelly clamp. The external magnet was placed inside a sterilized Ziploc bag. The
bagged magnet was introduced into a sterilized tubular
stockinet. The stockinet was closed at both ends with
knots. The external magnet was used to attract the intraabdominal magnet to the anterior peritoneum in the pelvis. The surgeon then moved the internal magnet by
sliding the external magnet along the patient’s abdomen
(Figure 1). The magnet was brought to the designated
area of the anterior abdominal wall near the cyst and was
kept in place.4 A gastroscope (Excera GIF-160 Olympus,
Center Valley, PA) was introduced into the abdominal
cavity for visualization through the vaginal port with the
patient in the Trendelenburg position. The gastroscope
was brought to the umbilical line, approximately 10cm
away from the liver, and the patient’s position was
changed into a reverse Trendelenburg for better visualization. The umbilical port was used to place a 5-mm laparoscope and instruments, e.g., laparoscopic scissors, nee136
Figure 1. The external magnet inside a tubular stockinet.
dle holder, and aspiration needle, as well as a rein. The
rein consisted of a straight, 6-cm, cutting-edge needle, 2-0
polypropylene (Prolene, Ethicon, Somerville, NJ) 75cm in
length with a stoppage at the end made of silastic, measuring 3 ⫻ 2x1mm.7
While viewing the cyst from the vaginal port with a gastroscope, an aspiration needle was placed via the umbilical port for drainage. After the collapse of the cyst wall,
an alligator clip applier was used to grasp the back of
the alligator clamp attached to the internal neodymium
magnet, opening its jaws and grasping the cyst. The
internal magnet and the external magnet were then
coupled and moved to the desired location by sliding
the external magnet along the skin. This technique
allowed for retraction of the cyst wall while keeping it
under tension (Figure 2). With this exposure, the roof of
the cyst was removed using a 5-mm laparoscopy scissor
placed in the umbilical port. The rein was introduced into
the abdomen via a 5-mm umbilical port. Once the abdomen was accessed, the needle was passed through the
cyst wall at the strategic point with relation to the internal
magnet to provide better exposure and triangulation. The
rein was held as a marionette or at the skin level to anchor
the cyst with a Kelly clamp. The rein needle was cut and
disposed of safely (Figure 3).7 The removed portion of
the cyst was brought to the pelvic area by using the
magnets for mobilization. The laparoscopy rein held the
specimen as a marionette while allowing traveling from
the upper abdomen to the pelvis. A 5-mm laparoscope
was placed in the umbilical port. A 10-mm laparoscopic
clamp was placed via the vaginal port to grab the specimen. The external magnet was removed. The Kelly
JSLS (2013)17:135–138
Figure 2. Tethered magnet holding the cyst wall.
Figure 4. Transvaginal magnet and cyst wall extraction.
hospital for laparoscopic cholecystectomies. She resumed
sexual activities 40 d after surgery without dyspareunia.
She was followed for 1 wk and 3 mo after surgery she had
no complications.
DISCUSSION
Figure 3. A magnet, rein exposure.
clamps holding the end of the tether and the end of the
rein were released and in a coordinated manner, the
specimen, the magnet, the rein, and the vaginal port were
removed together vaginally (Figure 4). The vaginal port
was reintroduced to place a catheter for drainage in the
right upper flank. The colpotomy incision was closed with
2-0 chromic sutures placed vaginally. Two hours after
surgery the patient was sitting, eating, and with pain of
2cm as measured on her visual analogue scale. Thirty-six
hours after surgery, her jaundice began to clear, the total
bilirubin was 3.2 mg/dL, the direct bilirubin was 2.1 mg/
dL, the ALT (SGPT) was 59 IU/L, the AST (SGOT) was 24
IU/L and the vaginal drainage was removed. She was
discharged 2 d after surgery, which is customary in this
Hybrid transvaginal endoscopic surgery can be facilitated
with additional instruments, techniques, and a flexible
video endoscope. Retraction and exposure are done with
magnets and a laparoscopic rein, instead of using additional abdominal ports, which lead to added patient discomfort and unnecessary scaring.7 Magnets have been
investigated for their use in the transvaginal approach.3,8,9
The magnets are used through a natural orifice to retract
tissues by aligning them with external magnets to avoid
additional trocar placement.10 The function of the tether is
to localize an out-of-sight or dislodged intraabdominal
magnet. The tether should not be used indiscriminately,
because pulling may cause injury to adjacent tissues.3
Although the rein can move the target in one direction, the
magnet has the option in most cases to move freely via
the anterior peritoneum, and the ability to reposition the
graspers offers a range of movements beyond the rein.
Secured independent tools (SIT) not used in this case are
different from the rein; the SIT provides more range of
movement without target perforation but has less mobility
than the magnets.11 The use of 2 magnets creates a risk of
collision of the internal or external magnets; we avoid this
event in our approach by combining one set of magnets
with a rein.
JSLS (2013)17:135–138
137
Transvaginal Liver Surgery Using a Tethered Magnet and a Laparoscopic Rein, Tsin DA et al.
CONCLUSION
We modified an internal laparoscopic magnet grasper by
adding a 75-cm tether. This change was originally recommended for transvaginal cholecystectomies as a way to secure or retrieve the internal magnet in case of misplacement
during natural orifice surgery. The tether is left inside the
vaginal port, held externally, and removed with the magnet
at the end of the procedure. Furthermore, the use of the
laparoscopy rein in combination with magnets avoids the
risk of collision when more than one internal or external set
of magnets is used. The cumulative experience in culdolaparoscopy, a hybrid transvaginal endoscopic surgery, suggests benefits with less pain, fewer hernias, and definitely
better cosmetics results. To our knowledge, this is the first
report of the use of magnets for the transvaginal treatment of
a liver cyst in humans. This concept has the potential to
change the way we approach minimally invasive surgery in
the abdomen by using different instruments or techniques
and combining them with the use of magnets.
References:
1. Tsin DA, Bumaschny E, Helman M, et al. Culdolaparoscopic
oophorectomy with vaginal hysterectomy: an optional minimalaccess surgical technique. J Laparoendoscope Adv Surg Tech A.
2002;12:269 –271.
2. Castro-Pérez R, Dopico-Reyes E, Acosta-González LR. Minilaparoscopic-assisted transvaginal approach in benign liver lesions. Rev Esp Enferm Dig. 2010;102(6):357–364.
sented at: 37th Annual Meeting of the American Association of
Gynecologic Laparoscopists; October 28-November 1, 2008; Las
Vegas, NV.
4. Padilla BE, Dominguez G, Millan C, Martinez-Ferro M. The
use of magnets with single-site umbilical laparoscopic surgery.
Semin Pediatr Surg. 2011;20(4):224 –231.
5. Davila FJ, Tsin DA, Gutierrez LS, Lemus J, Jesus R, Davila
MR, Torres-Morales J. Transvaginal single port cholecystectomy
surgical laparoscopy. Surg Laparosc Endosc Percutan Tech.
2011;21(3):203–206.
6. Tsin DA, Tinelli A, Malvasi A, Davila F, Jesus R, Castro-Perez
R. Laparoscopy and natural orifice surgery: first entry safety
surveillance step. JSLS. 2011;15(2):133–135.
7. Tsin DA, Davila F, Dominguez G, Tinelli A. Laparoscopy rein
and a backward needle entrance. J Laparoendosc Adv Surg Tech
A. 2011;21(6):521–523.
8. Park S, Bergs RA, Eberhart R, Baker L, Fernandez R,
Cadeddu JA. Trocar-less instrumentation for laparoscopy: magnetic positioning of intra-abdominal camera and retractor. Ann
Surg. 2007;245:379 –384.
9. Cho YB, Park CM, Chun HK, et al. Transvaginal endoscopic
cholecystectomy using a simple magnetic traction system.
Minim Invasive Ther Allied Technol. 2011;20(3):174 –178.
10. Scott DJ, Tang S, Fernandez R, et al. Completely transvaginal
NOTES cholecystectomy using magnetically anchored instruments. Surg Endosc. 2007;21:2308 –2316.
11. Tsin DA, Davila F, Dominguez G, Manolas P. Secured independent tools in peritoneoscopy. JSLS. 2010;14:258.
3. Tsin DA, Dominguez G, Jesus R, Aguilar S, Davila F. Transvaginal cholecystectomy using magnetic graspers. Paper pre-
138
JSLS (2013)17:135–138
CASE REPORT
Gallstone-Related Abdominal Abscess 8 Years After
Laparoscopic Cholecystectomy
Andrew Dobradin, MD, PhD, Stephanie Jugmohan, BS, Luis Dabul, BS
ABSTRACT
INTRODUCTION
Background: A common intraoperative complication
during laparoscopic cholecystectomy is gallbladder perforation with spillage of gallstones. The undesirable consequence of spilled gallstones is the formation of abscesses
months or years after an operation.
The beginning of the era of laparoscopic cholecystectomy
started on September 12, 1985 in Germany by Prof DrMed
Erich Muhe (or since its introduction in France in 1987 by
Dubois et al).1 Laparoscopic cholecystectomy is now considered the gold standard of surgical intervention for the
treatment of symptomatic cholelithiasis and gallbladder
disease.2,3
Case Description: Our clinical report describes an intraabdominal abscess formation in an 82-year-old man that
developed 8 years after a laparoscopic cholecystectomy. A
computed tomography scan of the abdomen showed an
elongated fluid collection in the right abdominal compartment musculature at the level of the internal oblique
muscle. Abdominal ultrasonography confirmed a large
fluid collection, with 2 echogenic masses in the dependent portion. Incision and drainage of the abscess were
performed, and 2 gallstones were found.
Conclusion: Any unusual collection of fluid in the perihepatic space and abdominal wall in the area of the
surgical incision in a patient with a remote history of
cholecystectomy should be evaluated for abscess related
to retained gallstone. Early abscess formation is usually
diagnosed and treated by the surgeon. However, the late
manifestation might be a clinical problem seen in the
primary care physician’s office. Therefore, the primary
care physician should incorporate diagnosis of gallstonerelated abscess in patients with abdominal abscess formation of unknown etiology.
Key Words: Laparoscopic cholecystectomy, Retained
gallstones, Abdominal abscess, Gallstones.
Winter Park, Florida, USA (all authors).
Address correspondence to: Andrew Dobradin, MD, PhD, 320 North Edinburgh
Drive, Suite B, Winter Park, FL 32792, USA. Telephone: 407-647-3460, E-mail:
[email protected]
DOI:10.4293/108680812X13517013317518
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
This commonly performed and well-established minimally invasive surgery is still associated with adverse effects and complications. The most feared complication of
laparoscopic cholecystectomy is injury to the common
bile duct. The initial high occurrence rate (1.9%) of this
type of injury during the early era of laparoscopic surgery
has since decreased and stabilized to 0.5%.4,5 Surgeons
take precautions to avoid and detect this type of injury by
using the “critical view” technique and intraoperative
cholangiography.5 Other common complications include
retained common bile duct stones, bile leaks, and superficial wound infections. The complications that occur
more often with laparoscopic cholecystectomy are perforations of the gallbladder during laparoscopic surgery and
spillage of gallstones.6 In their review of the scientific
literature, Papasavas et al7 found that in contrast to 127
case reports of complications secondary to dropped gallstones during laparoscopic cholecystectomy, only 2 such
events have been described for open cholecystectomies
since the year 1963. This is obviously a matter of concern
because additional studies reported incidents of gallbladder perforation during laparoscopic surgery varying from
10% to 40%, a 7.3% incidence of gallstone spillage, and an
estimated 33% of unretrieved gallstones.8 –13,14
In rare instances, postoperative residual gallstones can
contribute to associated abscess formation.14 The formation of abscesses occurs in remote locations to the site of
the gallbladder fossa, making diagnosis and causation
difficult to establish after the index operation.14 Most of
these abscesses have been reported to manifest during the
first 4 to 9 months after the initial operation, whereas only
a few can be detected as late as 15 years after laparoscopic
cholecystectomy.15 In our case, the time between laparoscopic cholecystectomy and abdominal wall abscess formation was 8 years.
JSLS (2013)17:139 –142
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Gallstone-Related Abdominal Abscess 8 Years After Laparoscopic Cholecystectomy, Dobradin A et al.
CASE DESCRIPTION
An 82-year-old man was admitted to the clinic with complaints of right upper quadrant abdominal pain and soreness in the right subcostal area lasting 2 months. He
described the pain as constant and rated it a 5 on a
10-point scale, where 10 represents the worse pain ever.
He denied any nausea, vomiting, fever, or chills. His past
medical history was significant for hypertension, coronary
artery disease, dyslipidemia, Crohn disease, diverticulosis,
osteoarthritis, benign prostatic hypertrophy, depression,
sleep apnea, and environmental allergies. Eight years
prior, he had undergone an uncomplicated laparoscopic
cholecystectomy with intraoperative cholangiography.
The medical records and operative report were reviewed
and there was no description of gallbladder perforation or
spillage of stones. Electrocautery and blunt dissection
were used to mobilize the gallbladder, and an Endobag
was used for gallbladder removal.
On physical examination, the patient’s pulse rate was 72
bpm, blood pressure was 110/60 mm Hg, temperature
was 97.6°F, and respiratory rate was 16 breaths/minute.
On palpation of the abdomen, the patient indicated right
subcostal tenderness.
The initial laboratory tests revealed a hemoglobin level of
14.3g/dL and white blood cell count of 10.5 ⫻ 1000
cells/␮L. A computed tomography scan of the abdomen
performed both before and after intravenous administration of contrast showed an elongated fluid collection with
an enhancing mature wall under the right abdominal musculature compartment (Figure 1). The fluid collection
was elongated in the cephalocaudal plane and measured
11 cm in height, 8 cm in maximal depth, and 3 cm in width
(Figure 2). Ultrasonography of the right upper quadrant
of the abdomen performed in the clinic showed a large
volume of fluid collection 6 cm in length and 2 cm in
depth, extending from the subdiaphragmatic space toward the iliac wing on the right side. Ultrasonography also
revealed 2 echogenic structures on the dependent portion
of the cavity with posterior shadowing (Figure 3), one of
which measured 9.4 ⫻ 5.3 mm.
A diagnosis of abdominal wall abscess was suspected, and
ultrasonography-guided aspiration was performed in the
clinic. The aspiration returned 70 mL of white purulent
material. A Gram stain of the collected fluid showed 1⫹
white blood cells, and the culture did not grow any organisms after 3 days. Two weeks later, incision and drainage of the abdominal wall abscess were performed with
the patient under general anesthesia at the hospital. Ultrasonography was used to identify the area of the abscess
140
Figure 1. Gallstone-related abdominal abscess. Computed tomography depicting right flank fluid collection with surrounding
inflammatory changes.
Figure 2. Gallstone-related abdominal abscess. Computed tomography image of the abdominal abscess.
on the right upper abdominal quadrant, which was approximately 2 cm deep, 8 cm wide, and 10 cm long. In the
dependent portion of this space, 2 shadowing 5-mm objects were seen. In this area, the incision was made down
to the subcuticular tissue, and the muscle of the abdominal wall was split to enter the abscess cavity. A collection
of white pus was seen and evacuated with a suction
JSLS (2013)17:139 –142
Figure 3. Gallstone-related abdominal abscess. Ultrasonographic study showing a gallstone in the abscess cavity with
typical posterior shadowing.
device. Two stones were found and one was sent for
pathologic examination. The other remained with the suction material. The cavity was irrigated with saline solution,
and a 19-Fr Blake drain was placed in the most dependent
part of the abscess. The pathology report of the stone
described a single, medium, orange/tan irregular calculus,
with a 44-mg mass and a size of 5 mm to 9 mm, that was
composed primarily of cholesterol.
There were no complications from the surgery, and the
patient was discharged home on the same day of the
operation. On the first clinic follow-up visit, 5 days postoperatively, the drain was removed. One month later, the
patient remained in good condition without any complaints. During the same visit, abdominal ultrasonography
was performed and revealed a small amount of fluid in the
abdominal wall.
Abscess formation caused by intraoperative spilled gallstones may occur weeks, months, or even years after
cholecystectomy. In a retrospective review, the median
and mean times from laparoscopic cholecystectomy until
the first onset of symptoms were 3 months and 5.5
months, respectively.14 Brueggemeyer et al6 described a
case of the right flank and retroperitoneal abscess after 72
months; however, their extensive review of the literature
did not show any such case later than 12 months after
laparoscopic cholecystectomy in 23 cases reported from
1992 to 1996. The longest reported abscess formation was
20 years after an open cholecystectomy.15 The longest
interval documented between previous laparoscopic cholecystectomy and abscess formation was 15 years.15 In the
case presented here, an abdominal wall abscess developed as a result of the 2 retained gallstones after a laparoscopic cholecystectomy performed 8 years earlier. In
this particular patient, the late presentation of symptoms
of the abscess formation could have been masked by the
chronic abdominal pain related to colitis.
In laparoscopic cholecystectomies, perforation of the gallbladder may occur during grasping, traction, dissection,
and extraction of the gallbladder. The quality of the gallbladder wall is also a contributing factor to gallbladder
perforation. Currently, graspers are used to hold the gallbladder wall, and if they are used with too much traction,
gallbladder perforation and spillage of stones can result.15
However, traction of the gallbladder during operation is
indispensable for proper dissection from its bed. Therefore, the question remains whether it is best to replace
graspers with a different gentler instrument with which
adequate traction can be addressed for proper exposure.15
If perforation does occur during grasping and traction, the
spilled material should be evacuated and the perforation
site controlled by clips, by an endoloop, or by placing the
grasper in such a way that it closes the perforation.6
DISCUSSION
Gallbladder perforations followed by bile leak and gallstone spillage are potential intraoperative events. However, complications caused by gallstone spillage are rare.9
These complications differ in manifestation, location, and
onset of symptoms after laparoscopic cholecystectomy.
The most frequent complication of residual gallstones
after cholecystectomy is abscess formation.16 –18 The abscess location includes the intraperitoneal and extraperitoneal spaces. The most common areas of intraperitoneal
abscesses are in the subhepatic and subphrenic spaces.14
Extraperitoneal locations of infections include abdominal
wall ports and incision sites.14
During extraction, the gallbladder is squeezed through an
abdominal incision, which can cause it to rupture and spill
stones. For this reason, surgeons may use a sterile retrieval
bag for extraction of the gallbladder. In addition, the
retrieval bag facilitates manual breakdown of large gallstones that are often unable to be extracted through the
small incisions made during laparoscopic cholecystectomy. The bag prevents spillage of the gallbladder contents into the abdominal cavity and the abdominal wall.
If there is spillage of gallstones, it can be addressed during
the operation with suitable surgical instruments, application of a suction-irrigation system, stone forceps, a disposable bag, or a combination of these.6
JSLS (2013)17:139 –142
141
Gallstone-Related Abdominal Abscess 8 Years After Laparoscopic Cholecystectomy, Dobradin A et al.
An outpatient ultrasonogram of the abdominal wall/cavity
was helpful in the initial evaluation of a patient who was
suspected of having an abscess related to possible retained gallstones. It is advisable that health care providers
include this complication on their list of differential diagnoses when an unusual abdominal wall or cavity abscess
develops in a postcholecystectomy patient.
CONCLUSION
Abdominal cavity abscess formation secondary to retained
gallstones after cholecystectomy is a rare condition that
can manifest itself many years after an initial operation.
Gallbladder perforation and retained or unretrieved gallstones after spillage need to be carefully recorded for later
review and for help with diagnosis of the complication in
the future. Universal use of a protective bag for gallbladder removal might decrease the chance of a trocar site
abscess and superficial site infection. Presence of the
highly reflective echoes with posterior shadowing in the
abscess cavity can be pathognomic for gallstone abscess
in patients with known histories of cholecystectomy, especially those performed with the laparoscopic technique.
References:
1. Dubois F, Icard P, Berthelot G, Levard H. Coeliscopic cholecystectomy. Preliminary report of 36 cases. Ann Surg. 1990;211(1):60–62.
2. Litynski GS. Highlights in the History of Laparoscopy. Frankfurt, Germany: Barbara Bernert Verlag; 1996:165–168.
3. Zehetner J, Shamiyeh A, Wayand W. Lost gallstones in laparoscopic cholecystectomy: all possible complications. Am J Surg.
2007;193(1):73–78.
4. Buddingh TK, Weersma R, Savenije RA, van Dam GM, Nieuwenhuijs V. Lower rate of major bile duct injury and increased
intraoperative management of common bile duct stones after
implementation of routine intraoperative cholangiography. J Am
Coll Surg. 2011;213(2):267–274.
5. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem
of biliary injury during laparoscopic cholecystectomy. J Am Coll
Surg. 1995;180(1):101–125.
6. Brueggemeyer M, Saba A, Thibodeaux L. Abscess formation
following spilled gallstones during laparoscopic cholecystectomy. JSLS. 1997;1(2):145–152.
142
7. Papasavas PK, Caushaj PF, Gagné DJ. Spilled gallstones after
laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A.
2002;12(5):383–386.
8. Schäfer M, Suter C, Klaiber C, Wehrli H, Frei E, Krähenbühl
L. Spilled gallstones after laparoscopic cholecystectomy. A relevant problem? A retrospective analysis of 10,174 laparoscopic
cholecystectomies. Surg Endosc. 1998;12(4):305–309.
9. Memon MA, Deeik RK, Maffi TR, Fitzgibbons RJ Jr. The
outcome of unretrieved gallstones in the peritoneal cavity during
laparoscopic cholecystectomy. A prospective analysis. Surg Endosc. 1999;13(9):848 – 857.
10. Rice DC, Memon MA, Jamison RL, et al. Long-term consequences of intraoperative spillage of bile and gallstones during
laparoscopic cholecystectomy. J Gastrointest Surg. 1997;1(1):
85–91.
11. Sarli L, Pietra N, Costi R, Grattarola M. Gallbladder perforation during laparoscopic cholecystectomy. World J Surg. 1999;
23(11):1186 –1190.
12. Kimura T, Goto H, Takeuchi Y, et al. Intraabdominal contamination after gallbladder perforation during laparoscopic
cholecystectomy and its complications. Surg Endosc. 1996;10(9):
888 – 891.
13. Diez J, Arozamena C, Gutierez L, et al. Lost stones during
laparoscopic cholecystectomy. HPB Surg. 1998;11(2):105–108,
discussion 108 –109.
14. Woodfield JC, Rodgers M, Windsor JA. Peritoneal gallstones
following laparoscopic cholecystectomy. Surg Endosc. 2004;
18(8):1200 –1207.
15. Arishi AR, Rabie ME, Khan MS, et al. Spilled gallstones: the
source of an enigma. JSLS. 2008;12(3):321–325.
16. Horton M, Florence MG. Unusual abscess patterns following
dropped gallstones during laparoscopic cholecystectomy: etiology and sequelae. Am J Surg. 1998;175(5):375–379.
17. Whiting J, Welch NT, Hallissey MT. Subphrenic abscess
caused by gallstones “lost” at laparoscopic cholecystectomy one
year previously: management by minimally invasive techniques.
Surg Laparosc Endosc. 1997;7(1):77–78.
18. Wilton PB, Andy OJ Jr, Peters JJ, Thomas CF, Patel VS,
Scott-Conner CE. Laparoscopic cholecystectomy. Leave no
(spilled) stone unturned. Surg Endosc. 1993;7(6):537–538.
JSLS (2013)17:139 –142
CASE REPORT
Laparoscopic Completion Cholecystectomy and
Common Bile Duct Exploration for Retained
Gallbladder After Single-Incision Cholecystectomy
Matthew Kroh, MD, Sricharan Chalikonda, MD, Bipan Chand, MD, R. Matthew Walsh, MD
ABSTRACT
Background: Recent enthusiasm in the surgical community for less invasive surgical approaches has resulted in
widespread application of single-incision techniques. This
has been most commonly applied in laparoscopic cholecystectomy in general surgery. Cosmesis appears to be
improved, but other advantages remain to be seen. Feasibility has been demonstrated, but there is little description in the current literature regarding complications.
Patient and Methods: We report the case of a patient
who previously underwent single-incision laparoscopic
cholecystectomy for symptomatic gallstone disease. After
a brief symptom-free interval, she developed acute pancreatitis. At evaluation, imaging results of ultrasonography
and magnetic resonance cholangiopancreatography demonstrated a retained gallbladder with cholelithiasis. The
patient was subsequently referred to our hospital, where
she underwent further evaluation and surgical intervention.
Results: Our patient underwent 4-port laparoscopic remnant cholecystectomy with transcystic common bile duct
exploration. Operative exploration demonstrated a large
remnant gallbladder and a partially obstructed cystic duct
with many stones. Transcystic exploration with balloon
extraction resulted in duct clearance. The procedure took
75 minutes, with minimal blood loss. The patient’s postoperative course was uneventful. Final pathology results
demonstrated a remnant gallbladder with cholelithiasis
and cholecystitis.
Conclusion: This report is the first in the literature to
describe successful laparoscopic remnant cholecystectomy and transcystic common bile duct exploration after
previous single-port cholecystectomy. Although inadvertent partial cholecystectomy is not unique to this techDepartment of General Surgery, Digestive Disease Institute, Cleveland Clinic,
Cleveland, Ohio, USA (all authors).
Address correspondence to: Matthew Kroh, MD, Department of General Surgery,
Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA. Telephone:
(216) 445-9966, Fax: (216) 444-2153, E-mail: [email protected]
DOI:10.4293/108680812X13517013317356
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
nique, single-port laparoscopic procedures may result in
different and significant complications.
Key Words: Single-port laparoscopy, Complications, Retained gallbladder.
INTRODUCTION
New technologies and surgical approaches continue to
advance the field of minimally invasive surgery. Laparoscopy has revolutionized approaches to general surgical
problems with improved outcomes of decreased postoperative pain and patients’ quicker return to work. In large
part because of these successes, natural orifice and singlesite approaches have been adopted. Although enthusiasm
for transvisceral approaches has waned, single-site operations have increased significantly. A PubMed search for
“single-port laparoscopic surgery” generated 202 peerreviewed articles in the past year, 163 articles in the year
prior, and only 8 publications during the intervening 5
years from 5 to 10 years ago. Although many procedures
have been described, it appears that the most common
application for single-port surgery within general surgery
is transumbilical cholecystectomy. Trials are currently underway and certain benefits have been suggested, but the
only clear advantage at this time appears to be cosmesis.1
Difficulties with single-port access procedures include external clashing secondary to lack of triangulation and
possibly alterations in surgical approaches. As such, complications associated with this technique are now being
described and include common bile duct injury, subcapsular hematoma, and incisional hernia.2,3 We describe a
case of laparoscopic completion cholecystectomy with
transcystic common bile duct exploration for incomplete
cholecystectomy after single-port cholecystectomy resulting in retained gallbladder and postoperative gallstone
pancreatitis.
PATIENTS AND METHODS
A 51-year-old woman with symptomatic cholelithiasis underwent a single-port cholecystectomy using a single-port
device at an outside hospital. The presence of gallstones
JSLS (2013)17:143–147
143
Laparoscopic Completion Cholecystectomy and Common Bile Duct Exploration, Kroh M et al.
was confirmed by preoperative ultrasonography, and the
patient did not have a prior history of pancreatitis or
jaundice. The operative report from the outside hospital
was reviewed. The operation was performed with a commercially available single-port trocar with 3 trocars for
instruments and camera access. The report described dissection within Calot’s triangle and securing both the cystic
duct and cystic artery with clips. There was no specific
description of removal of the adventitial tissue from
Calot’s triangle to obtain a critical view of safety. There
was also no description of difficulties or unusual circumstances during the operation. Cholangiography was not
performed during this operation, and the patient was
subsequently discharged from the facility on postoperative day 0. On postoperative day 14, she presented to the
same hospital emergency department with back and flank
pain. She was found to have elevated amylase and lipase
levels, so right upper quadrant ultrasonography was performed, which demonstrated an echogenic foci of stones
in what appeared to be a cystic structure, or a dilated
cystic duct. Ultrasonography also demonstrated a common bile duct dilated to 1.2 cm, but no distal stone was
visualized. The patient was admitted and treated for acute
pancreatitis with intravenous fluid resuscitation, analgesics, and slow reinstitution of diet. She was discharged
after 3 days and was then referred to our facility as an
outpatient for a retained remnant or duplicate gallbladder.
As part of her workup, magnetic resonance cholangiopancreatography (MRCP) was performed (Figure 1), which
demonstrated a large gallbladder remnant with gallstones
and normal caliber extrahepatic biliary tree. The patient
was advised to undergo completion cholecystectomy with
intraoperative cholangiogram.
At operation, the patient was placed supine on a radiolucent bed. Entrance into the peritoneal cavity was obtained
with a 5-mm optical trocar in the right subcostal region,
given her previous intraumbilical incision. After abdominal insufflation, 2 additional 5-mm trocars were placed,
one in the epigastrium and one in the right lower quadrant. After a brief sharp adhesiolysis, a 10-mm trocar was
placed at the umbilicus. Inferior margin of the liver was
carefully elevated, and a large dilated gallbladder remnant
was identified (Figure 2). The gallbladder remnant was
retracted lateral and cephalad toward the right shoulder.
The peritoneum overlying the cystic duct and gallbladder
junction was opened, and the cystic artery and cystic duct
were dissected out circumferentially. The hepatocystic
plate was also partially mobilized, and a critical view of
safety with normal hepatic parenchyma behind this structure was obtained (Figure 3). One distal and two proxi144
Figure 1. MRCP. Arrow points to the remnant gallbladder with
filling defects and normal extrahepatic biliary tree.
Figure 2. Laparoscopic view of remnant gallbladder during
adhesiolysis. Black arrows denote the border of the gallbladder.
mal clips were placed across the artery, a single clip was
placed on the duct, and a small cystic ductotomy was
made. The cystic duct was gently compressed, and several
stones were removed retrograde through the cystic ductotomy. Cholangiography was performed and showed a
normal-caliber common bile duct and common hepatic
JSLS (2013)17:143–147
guidance, a balloon extraction catheter was used to successfully remove several small stones retrograde through
the dilated ductotomy incision. After several sweeps
through the common bile duct, completion cholangiography was performed that showed complete clearance of
the stones. The cystic duct was controlled with a suture
tie, and both the cystic duct and artery were transected.
The remnant gallbladder was dissected off the gallbladder
fossa and removed in the standard manner. Examination
of the gallbladder was performed immediately after its
removal (Figure 5a and 5b).
RESULTS
Figure 3. Critical view of safety. The cystic duct (white arrow)
and the cystic artery (black arrow) seen to be the only 2 structures entering into the remnant gallbladder with normal liver
demonstrated behind them.
The procedure took 75 minutes, with minimal blood loss.
No drain was left. The patient was discharged home on
postoperative day 0. Follow-up in the office at 2 weeks
Figure 4. Laparoscopic transcystic common bile duct exploration with a balloon extraction catheter in the cystic duct. The
white arrow depicts the cannula in the cystic duct; the black
arrow shows the remnant gallbladder.
duct without filling defects, as well as free contrast flow
into the duodenum. There were, however, several filling
defects within the cystic duct at its insertion into the
common bile duct. A transcystic common bile duct exploration was then performed using a commercially available
kit. After dilation of the cystic duct, the access cannula was
placed into the duct and a guidewire was inserted through
this into the duodenum (Figure 4). Under fluoroscopic
Figure 5. A, Gross specimen. The white solid arrow marks clips
from the previous operation; the black thin arrow marks the clip
on the cystic duct. B, The gross specimen, opened, demonstrating retained stones.
JSLS (2013)17:143–147
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Laparoscopic Completion Cholecystectomy and Common Bile Duct Exploration, Kroh M et al.
and by phone at 2 months showed the patient to be
symptom free. Final pathologic results were consistent
with chronic cholecystitis and cholelithiasis. The presence
of the previously placed clips on the gallbladder fundus
confirmed the diagnosis of retained gallbladder versus a
duplicate or accessory gallbladder.
DISCUSSION
Minimally invasive surgery and its applications continue
to progress. New techniques have been introduced to
deliver equal surgical results in a less invasive manner.
Single-port laparoscopy is an extension of this phenomenon. Advantages have been suggested and these may
include less pain, but until more stringent trials are completed, cosmesis and potential complications from additional trocar sites appear to be the main differences. Drawbacks of this technique, unique from standard multitrocar
laparoscopy, have also been identified. This is inherent to
the single portal of access and may be related to technical
considerations including external clashing of instruments,
poor visualization of critical structures, and surgeon fatigue. Complications from single-port cholecystectomy
have been described, although whether these are the
result of the surgical approach or isolated events is unclear, and large-scale comparative trials against standard
laparoscopic approaches have not been performed. In
addition, the learning curve for these techniques has not
been described. Currently, opportunities for training in
single-site surgery are limited but include formal and
informal fellowship training, continuing medical education courses sponsored by surgical societies, and industry-sponsored events including laboratory work and
proctoring.
Planned partial cholecystectomy is a described technique
when dissection is inhibited by severe inflammation, and
it may prevent biliary injury in the setting of cholecystitis.
Incomplete cholecystectomy may also arise inadvertently
with incomplete dissection of Calot’s triangle, resulting in
transection of the gallbladder fundus instead of the cystic
duct. Although inadvertent partial cholecystectomy was
initially thought to have increased with the widespread
adoption of laparoscopy, increased rates have not been
seen in the surgical literature.4 Retained gallbladder after
cholecystectomy can manifest with symptoms similar to
primary gallstone-related disease. Biliary symptoms after
cholecystectomy are evaluated with ultrasonography, and
typically in these cases this will demonstrate a cystic lesion
containing stones.5 MRCP can further delineate biliary
anatomy, and it is considered a definitive test for diagno146
sis. Completion cholecystectomy, by means of laparotomy
or laparoscopy, is the definitive treatment.4,6
As with all new technologies, single-port access procedures have inherent limitations. Request for patient consent for single-port techniques should include full disclosure of the risks, benefits, and alternatives to the
procedure. Although there are not absolute contraindications to this technique, patient selection should be left to
the surgeon’s discretion. With the adoption of multitrocar
laparoscopic cholecystectomy, there was a significant increase in common bile duct injuries. Although this rate
improved with increased surgeon experience, the overall
rate is still higher than with the open technique. Standardized techniques for safe laparoscopic cholecystectomy
have been developed and have resulted in decreased rates
of major biliary complications. Techniques of routine
cholangiography to identify aberrant biliary anatomy and
demonstration of the critical view of safety have improved
the overall conduct of cholecystectomy. If single-port applications are to become widespread for cholecystectomy,
the operation must not deviate from these protocols.
Cholangiography can and should be used routinely to
demonstrate biliary anatomical variants, strictures or
stones, or to identify structures for safe gallbladder removal. Dissection in Calot’s triangle must be complete to
achieve a critical view of safety both to prevent major
biliary injury and to perform a complete operation. This
visualization may be compromised by a single port of
access originating from the umbilicus by not allowing
cephalad and lateral retraction of the gallbladder. The
result may be biliary injury or, as in this case, incomplete
cholecystectomy secondary to failure to remove all adventitial tissue in Calot’s triangle.
Using different techniques including improved commercial access devices and instruments, as well as robotics,
may improve retraction and/or dissection and may represent an improvement in conduct and safety over current
manual single-port techniques.7 Surgeons should also
have a low threshold to add additional trocars to recreate
relationships seen in standard laparoscopy or convert to
open procedures as dictated on an individual patient basis. Recreation of a safe cholecystectomy technique, either
laparoscopic or open, must be paramount for single-port
procedures, especially in light of the relative improvement
over standard laparoscopy. In this particular case, incomplete cholecystectomy resulted in acute gallstone pancreatitis requiring hospitalization and then an additional surgical procedure for definitive care.
JSLS (2013)17:143–147
CONCLUSION
This detailed report is the first in the literature to describe
successful laparoscopic remnant cholecystectomy and
transcystic common bile duct exploration after previous
single-port cholecystectomy. Although inadvertent partial
cholecystectomy is not unique to single-port techniques,
careful attention to performing the appropriate procedure,
regardless of technique, must be achieved in the face of
applying new technologies.
References:
1. Philips MS, Marks JM, Roberts K, et al. Intermediate results of
a prospective randomized controlled trial of traditional fourport laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy. Surg Endosc. 2012;26(5):1296 –1303.
2. Krajinovic K, Ickrath P, Germer CT, Reibetanz J. Trocar-site
hernia after single-port cholecystectomy: not an exceptional
complication? J Laparoendosc Adv Surg Tech A. 2011;21(10):
919 –921.
3. Hansen AJ, Augenstein J, Ong ES. Large subcapsular liver
hematoma following single-incision laparoscopic cholecystectomy. JSLS. 2011;15(1):114 –116.
4. Pernice LM, Andreoli F. Laparoscopic treatment of stone
recurrence in a gallbladder remnant: report of an additional case
and literature review. J Gastrointest Surg. 2009;13(11):2084 –
2091.
5. Demetriades H, Pramateftakis MG, Kanellos I, Angelopoulos
S, Mantzoros I, Betsis D. Retained gallbladder remnant after
laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A.
2008;18(2):276 –279.
6. Walsh RM, Ponksy JL, Dumot J. Retained gallbladder/cystic
duct remnant calculi as a cause of postcholecystectomy pain.
Surg Endosc. 2002;16(6):981–984.
7. Kroh M, El-hayek K, Rosenblatt S, et al. First human surgery
with a novel single-port robotic system: cholecystectomy using
the da Vinci single-site platform. Surg Endosc. 2011;25(11):
3566 –3573.
JSLS (2013)17:143–147
147
CASE REPORT
Catastrophic Bleeding From a Marginal Ulcer After
Gastric Bypass
Shafik Sidani, MD, Ehab Akkary, MD, Robert Bell, MD, MA
ABSTRACT
INTRODUCTION
Marginal ulceration at the gastrojejunal anastomosis is a
common complication following Roux-Y gastric bypass
(RYGB). Hemodynamically significant hemorrhagic marginal ulcers are usually treated either endoscopically or
surgically. We describe a unique case of life-threatening
hemorrhagic marginal ulcer eroding into the main splenic
artery. This condition was initially managed with angiographic embolization, followed by surgical intervention.
It is well established that Roux-Y gastric bypass (RYGB)
causes significant weight loss and aids resolution of obesity related comorbidities.1 The surgery is also associated
with a low incidence of early and late complications,
including anastomotic leak, pulmonary embolism, small
bowel obstruction, anastomotic stricture, gastrointestinal
hemorrhage, and marginal ulceration (MU).2 Although a
relatively minor complication, MU commonly occurs during the early or late postoperative period. The reported
incidence of MU after RYGB ranges between 0.6% and
16%, and is more frequently diagnosed in smokers than
nonsmokers.3,4 The true incidence of MU is difficult to
assess, because many patients are asymptomatic. Management of MU varies from medical treatment with proton
pump inhibitors, H2-receptor blockers, and sucralfate, to
endoscopy or surgery, depending on the cause and complications.5 In the case of hemorrhagic MU, endoscopic
control or laparotomy is usually the standard of care.4,6
Bleeding marginal ulcers following gastrojejunostomy are
usually supplied by jejunal branches of the superior mesenteric artery or gastric branches of the celiac artery.7 We
present a case of life-threatening hemorrhagic MU 18
months after conducting open RYGB. The bypass eroded
into the main splenic artery and was managed with angiographic embolization followed by surgery.
Key Words: Marginal ulcer, Gastric bypass, Embolization,
Morbid obesity.
CASE REPORT
Department of Surgery, Yale University, New Haven, Connecticut, USA (all authors).
Address correspondence to: Robert Bell, MD, Department of Surgery, Yale University School of Medicine, 40 Temple St, New Haven, CT 06510, USA. Telephone:
(203) 764-9060, Fax: 203-764-9066, E-mail: [email protected]
DOI: 10.4293/10860812X13517013318274
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
148
A 65-year-old male with a history of diabetes and hyperlipidemia underwent an open RYGB at an outside institution 18 months prior to presentation. He was not on
chronic acid suppression therapy. At the emergency
room, the patient presented with hematemesis and orthostatic hypotension. In the supine position, his blood pressure was 109/66 with a heart rate of 77. Orthostatic measurements were 86/54 and 89, respectively. His hematocrit
was 21%. After initial fluid resuscitation and blood transfusion, the patient underwent esophagogastroduodenoscopy (EGD) that revealed large blood clots in the gastric
pouch and bright red blood oozing from a marginal ulcer
at the gastrojejunal (GJ) anastomosis. The patient received
multiple transfusions of packed red blood cells and a
pantoprazole infusion. Adequate visualization and endo-
JSLS (2013)17:148 –151
Figure 1A. Mesenteric angiography
revealing gross extravasation from
the mid splenic artery. Figure 1B.
The distal splenic artery is not visualized following embolization.
scopic hemostasis could not be performed and repeat
endoscopy was also unsuccessful. Urgent angiography
did not reveal any active bleeding. Subsequently, the
hematocrit stabilized, and the patient seemed to recover
for the next 5 days. At that point, the patient developed an
abrupt onset of severe hematemesis. EGD showed recurrent bleeding from the GJ anastomosis. Mesenteric angiography revealed gross extravasation from the mid
splenic artery (Figure 1A), which was successfully embolized. Following embolization, the distal splenic artery
could not be visualized, and the splenic parenchyma
could not be seen due to poor collateral flow (Figure 1B).
Within 8 hours of embolization, the patient developed
abdominal pain, distention, and lactic acidosis. An abdominal CT scan revealed pneumoperitoneum with high
attenuation ascites representing contrast and hemorrhage
(Figure 2). The patient was urgently taken to the operating room for exploratory laparotomy. Approximately 2.5
liters of blood and clots were evacuated from the peritoneal cavity. With the aid of intraoperative endoscopy, a
large defect was found in the gastric remnant, the gastric
pouch, and the proximal Roux limb of the jejunum. The
Roux limb was completely detached from the gastric
pouch. Gelfoam and coils were visualized in the lesser
sac, and the splenic artery was non-pulsatile. The spleen
appeared dusky; hence, splenectomy was performed. The
gastric remnant, gastric pouch, and Roux limb of the
jejunum (that included the perforations) were resected
back to viable tissue. The remaining gastric pouch and the
proximal Roux limb of the jejunum were subsequently
reanastomosed utilizing a circular stapling technique. Intraoperative endoscopy revealed a patent, leak-free, anastomosis. The patient was discharged on the ninth postoperative day, after a negative Gastrografin swallow
Figure 2. Abdominal CT scan revealing pneumoperitoneum
with high attenuation ascites representing contrast and hemorrhage.
evaluation. At discharge, he tolerated an oral liquid diet.
During the postoperative course, he developed a left upper quadrant intraabdominal abscess requiring percutaneous drainage and intravenous antibiotics.
DISCUSSION
Marginal ulceration at the gastrojejunal anastomosis is the
most common cause of early and late upper GI bleeding
following RYGB. Although gastrin levels are decreased
following gastric bypass, vagal stimulation is preserved, as
is the gastric pouch’s ability to produce acid. Unlike the
JSLS (2013)17:148 –151
149
Catastrophic Bleeding from a Marginal Ulcer after Gastric Bypass, Sidani et al.
duodenum, the jejunum’s ability to buffer acid via bicarbonate secretion is poor, further contributing to the risk of
gastrojejunal marginal ulcers.5,8 The risk of postoperative
MU is also increased by factors such as H. pylori infection,
nonsteroidal anti-inflammatory drugs (NSAID), anticoagulation, and smoking. Technical factors that increase the
risk of MU formation include a large gastric pouch, nonabsorbable sutures, and tissue ischemia at the staple
line.3,9 –11 Patients suffering from MU following RYGP usually present with epigastric pain and occasional nausea
and emesis. Clinically significant upper GI hemorrhage is
not usually observed.3,4,12 The diagnosis of MU is performed endoscopically. Uncomplicated MU is generally
managed with high-dose proton pump inhibitor (PPI)
therapy. Preventive low-dose PPI or H2-blocker therapy is
a common practice following RYGB.5,6,11,13 Triple therapy
is usually started in case of H. pylori infection. Cessation of
smoking is mandatory and NSAIDS should be discontinued, if possible. Hemodynamically significant upper GI
bleed secondary to MU is managed endoscopically or
surgically, after initiating intravenous formulations of proton pump inhibitor therapy. At our institution, an 80-mg
intravenous bolus of pantoprazole followed by an infusion at a rate of 8mg/hr is used. Endoscopic options
include heater probe coaptive coagulation, bipolar probe
coaptive coagulation, chemical sclerosant, epinephrine
injection, laser therapy, and hemostatic clip placement.
Surgical management is usually required if endoscopic
therapy fails to adequately control the bleeding. Angiographic interventions are generally considered for bleeding secondary to traditional peptic ulcer disease, especially when patients are at high risk for surgery.14 There
are no reports in the literature describing angiographic
intervention for the control of bleeding marginal ulcers. In
a series of 18 patients, Ljungdahl et al15 reported successful management of massive gastric and duodenal bleeding
with transcatheter selective arterial embolization in 17 of
those patients. All cases involved bleeding from the left
gastric or gastroduodenal arteries or their branches. No
case involved the splenic artery, nor was marginal ulceration a cause of the bleeding in any of the reported cases.
When needed, surgical management can be performed
using the open or laparoscopic technique and involves
excision of the gastrojejunostomy, including the ulcerated
areas and construction of a new gastrojejunostomy.6 During the procedure, the bleeding vessels must be meticulously identified and ligated. The current case, reports a
novel approach to the management of clinically significant hemorrhagic MU, involving the splenic artery. Preoperative control of bleeding is a key step given the
amount of inflammation present in patients with MU.
150
Attention should be paid to collateral circulation causing
hemorrhage following embolization of a visceral artery,
requiring trial of different embolic agents for adequate
bleeding control or immediate surgery.16,18
CONCLUSION
We describe a unique life-threatening complication of
marginal ulceration following RYGB. We also propose a
novel approach to its management. Massive upper GI
bleeding, due to marginal ulcer eroding into the main
splenic artery, can be controlled preoperatively with angiographic selective embolization to allow successful surgical repair. This strategy should also be considered in
patients with hemodynamic instability.
References.
1. Pories WJ. Bariatric surgery: risks and rewards. J Clin Endocrinol Metab. 2008;93(11 Suppl 1):S89 –96.
2. Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and outcomes. Gastroenterology. 2007;132:2253–2271.
3. Jordan JH, Hocking MP, Rout WR, et al. Marginal ulcer
following gastric bypass for morbid obesity. Am Surg. 1991;57:
286 –288.
4. Sapala JA, Wood MH, Sapala MA, et al. Marginal ulcer after
gastric bypass: a prospective 3-year study of 173 patients. Obes
Surg. 1998;8:505–516.
5. Gumbs AA, Duffy AJ, Bell RL. Incidence and management of
marginal ulceration after laparoscopic Roux-Y gastric bypass.
Surg Obes Relat Dis. 2006;2:460 – 463.
6. Nguyen NT, Hinojosa MW, Gray J, et al. Reoperation for
marginal ulceration. Surg Endosc. 2007;21:1919 –1921.
7. Oglevie SB, Smith DC, Mera SS. Bleeding marginal ulcers:
angiographic evaluation. Radiology. 1990;174:943–944.
8. Demaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281
consecutive total laparoscopic Roux-en-Y gastric bypasses to
treat morbid obesity. Ann Surg. 2002;235:640 – 645.
9. Pope GD, Goodney PP, Burchard KW, et al. Peptic ulcer/
stricture after gastric bypass: a comparison of technique and acid
suppression variables. Obes Surg. 2002;12:30 –33.
10. Siilin H, Wanders A, Gustavsson S, et al. The proximal gastric
pouch invariably contains acid-producing parietal cells in Rouxen-Y gastric bypass. Obes Surg. 2005;15:771–777.
11. Frezza EE, Herbert H, Ford R, et al. Endoscopic suture
removal at gastrojejunal anastomosis after Roux-en-Y gastric
bypass to prevent marginal ulceration. Surg Obes Relat Dis.
2007;3:619 – 622.
JSLS (2013)17:148 –151
12. Sanyal AJ, Sugerman HJ, Kellum JM, et al. Stomal complications of gastric bypass: incidence and outcome of therapy. Am J
Gastroenterol. 1992;87:1165–1169.
16. Goldman ML, Skorapa V, Jr., Galambos JT, et al. Intra-arterial
tissue adhesives for medical splenectomy in dogs. Am J Gastroenterol. 1978;70:489 – 495.
13. Schirmer B, Erenoglu C, Miller A. Flexible endoscopy in the
management of patients undergoing Roux-en-Y gastric bypass.
Obes Surg. 2002;12:634 – 638.
17. Goldman ML, Freeny PC, Tallman JM, et al. Transcatheter
vascular occlusion therapy with isobutyl 2-cyanoacrylate (bucrylate) for control of massive upper-gastrointestinal bleeding.
Radiology. 1978;129:41– 49.
14. Millward SF. ACR Appropriateness criteria on treatment of
acute nonvariceal gastrointestinal tract bleeding. J Am Coll Radiol. 2008;5:550.
15. Ljungdahl M, Eriksson LG, Nyman R, et al. Arterial embolisation in management of massive bleeding from gastric and
duodenal ulcers. Eur J Surg. 2002;168:384 –390.
18. Morse SS, Siskind BN, Horowitz NR, et al. Splenic arteriogastric fistula from plication of a gastric ulcer. Therapeutic embolization. J Clin Gastroenterol. 1987;9:480 – 482.
JSLS (2013)17:148 –151
151
CASE REPORT
Endoclip Closure of a Large Colonic Perforation
Following Colonoscopic Leiomyoma Excision
Vamsi R. Velchuru, MD, FRCS, Marek Zawadzki, MD, Amy L. Levin, MD,
Christine M. Bouchard, MD, Slawomir Marecik, MD, Leela M. Prasad, MD, John J. Park, MD
ABSTRACT
INTRODUCTION
Background and Objective: Endoscopic removal of
large colonic submucosal lesions can lead to a higher risk
of perforation. Although not as common following diagnostic and therapeutic colonoscopy, it does occur more
often following therapeutic colonoscopy. We present a
case of a large submucosal mass excised endoscopically,
resulting in a large perforation that was closed using
endoclips. While endoclips are typically used for smaller
perforations, we have found that they can be used safely
on a larger defect.
Surgical resection has been the mainstay of treatment for
large colonic lesions. Unfortunately, even with the introduction of laparoscopy, significant morbidity still exists.
Endoscopic removal of large benign colonic submucosal
lesions has been successfully performed, although it
brings with it an increased risk of bleeding and perforation. In fact, reports show significant operative morbidity
(36%) and mortality (7%).1 Traditionally, these complications have been addressed with a laparotomy,1 but recently laparoscopic2 and endoscopic techniques3,4 have
been used successfully to close perforations.
Methods: A 68-y-old woman presented with a 2.9-cm
benign submucosal mass found in the hepatic flexure. It
was removed via endoscopic polypectomy, leaving a perforation of 3cm x 3cm. The perforation was closed with
endoscopic clips.
Results: Histology of the specimen showed clear margins.
At 4-wk follow-up, the patient had no complications. A
colonoscopy at 6-mo follow-up showed only a scar at the
procedure site with no complaints.
Conclusions: Large iatrogenic colonic perforations can
be managed successfully using endoclips, particularly in a
prepped colon.
Key Words: Colonic submucosal lesions, Perforation,
Therapeutic colonoscopy, Endoclip.
Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park
Ridge, IL, USA (all authors).; Division of Colon Rectal Surgery, University of Illinois
of Chicago, Chicago, IL, USA (Drs. Velchuru, Zawadzki, Prasad).
Presented as a poster at SAGES 12th World Congress of Endoscopic Surgery
Landover, MD, USA, April 14 –17, 2010.
Address correspondence to: Vamsi R. Velchuru, MD, FRCS, Division of Colon and
Rectal Surgery, University of Illinois Medical Center at Chicago, 840 S. Wood Street,
MC 958 #518, Chicago, IL 60612, USA. Telephone: (312) 996-2061, Fax: (312)
996-1214, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317554
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
152
The incidence of colonic perforation following colonoscopy can vary between 0.03% and 2%.4 – 6 Perforation rates
increases with therapeutic interventions7 and the size of
the polyp.6 We present a case of a large submucosal mass
that was excised endoscopically, resulting in a 3-cm x
3-cm perforation that was closed using endoclips. Typically, these clips are used for smaller perforations2; however, we have found that they can be used safely on a
larger defect. Endoclips have been used to clip a vessel in
a bleeding ulcer or to achieve hemostasis from the base of
a polyp after polypectomy.
MATERIALS AND METHODS
A 68-y-old woman presented with a 3-cm mass at the
hepatic flexure (Figure 1), which was found during a
routine outpatient colonoscopy. The mass was submucosal and the overlying mucosa was ulcerated. The lesion
was firm. Biopsy of the lesion showed colonic mucosa
with inflammatory changes. A subsequent CT scan of the
abdomen confirmed that it was a 3-cm submucosal mass
with benign features. The patient was taken for planned
endoscopic resection with primary closure. The operating
room was on standby in the event the resulting defect
could not be closed endoscopically. A snare polypectomy
was successfully performed that resulted in a 3-cm perforation (Figure 2). Seven endoclips (Resolution Clip; Boston Scientific, Natick MA) were placed in order to seal the
colotomy (Figure 3). A frozen section of the specimen
showed a benign stromal neoplasm.
JSLS (2013)17:152–155
Figure 1. Hepatic flexure mass as seen on colonoscopy.
Figure 3. Endoclips closing the perforation site.
Figure 2. Perforation after Snare Polypectomy.
RESULTS
A postprocedure abdominal X-ray revealed expected free
air (Figure 4), and the patient was admitted for observation. On postprocedure day 1, the patient’s examination
was unremarkable. She was started on a clear liquid diet.
On postprocedure day 2, she advanced to a soft diet and
was discharged home.
Final pathology revealed a 2.9-cm submucosal leiomyoma
with clear margins. The patient returned to the office 4 wk
later without complaints. A colonoscopy at 6 mo showed
a scar at the site.
DISCUSSION
Colonic leiomyomas are rare benign stromal tumors that
can cause gastrointestinal bleeding,8 obstruction,9 and, in
Figure 4. Postprocedure X-ray showing free air. Note the endoclips in the right upper quadrant.
rare instances, progress to a sarcoma.10 Large benign colonic lesions have been removed by colonic resection and
anastomosis, although recently they have been managed
via an endoscopic mucosal resection11 and endoscopic
polypectomy.12 The size, type (pedunculated or sessile),
configuration, and site of the lesion all determine the type
of procedure to be performed.
Pedunculated lesions13 and those over 2cm12 have been
dealt with using endoloops or hemoclips. One report12
showed a 3.5-cm lipoma that was excised by endoscopic
JSLS (2013)17:152–155
153
Endoclip Closure of a Large Colonic Perforation Following Colonoscopic Leiomyoma Excision, Velchuu VR et al.
polypectomy with no complications. Endoloops can also
be used to resect large colonic lipomas to prevent bleeding and perforation.14 Perforation risk increases with therapeutic colonoscopy,4,7,15 polyps ⬎ 2cm,16 in the elderly
(⬎75yrs),15 and in female patients.17 Full-thickness endoscopic removal should be contemplated only after the
lesion is proven benign either by imaging or histopathology, as a malignant lesion can potentially convert an early
disease to stage 4 disease leading to bad prognosis.
Depending on the size of the perforation and clinical
condition, treatment strategies vary. Small perforations
can be managed conservatively with a success rate of 33%
to 73%.18 Operative intervention can be managed by simple closure of the perforation15 or via a bowel resection
with or without anastomosis.1 Colonic perforations have
been dealt with laparoscopically leading to shorter hospital stay and decreased postoperative morbidity.19
Endoscopic closure of colonic perforation has been performed using endoclips, particularly when the perforation
is ⬍ 1cm.4 Few authors3,20 have used the endoclips for
perforations ⬎ 1 cm. Trecca et al.3 reported 2 perforations ⬎ 3cm that were managed using endoclips successfully. In both patients, 3 TriClips (Cook Medical, Bloomington, IN) were used. In our case, the perforation was
3cm in size, and 7 clips were used to close the defect. The
patient was discharged on the second day. Of course, the
number of clips used can vary, depending on the size of
the perforation.3
Endoscopic closure of an iatrogenic colonic perforation at
colonoscopy is feasible, because it is a prepped colon and
there is minimal contamination. Closure should, however,
be undertaken using minimal to no air insufflation.3 This
helps with approximation of the edges and prevents fecal
spillage. An experienced colonoscopist is the most important factor as the endoclip application can be technically
challenging, and also depends on the site (hepatic flexure
in our case) and size of the perforation.
Reports21,22 have shown clip closure to be successful in
69.2% to 92.6% of cases. Still, 2 of 27 patients who underwent clip application needed surgery, making it vitally
important to monitor patients for complications following
the procedure.21 We did not perform follow-up examination with X-ray for the clips3 or immediate colonoscopy,23
because the patient was clinically well. A follow-up endoscopy 6 mo postprocedure revealed a scar. Intravenous
antibiotics and serial examinations are paramount in the
postprocedure period to identify any leaks that can lead to
peritonitis. Our patient made a remarkable recovery and
was sent home in 2 d.
154
In our practice, therapeutic colonoscopy for large polyps
is managed in the operating room with the patient anesthetized. We often perform diagnostic laparoscopy in suspicious cases to confirm that there is no leak at the site.
CO2 colonoscopy is often performed to minimize intraabdominal free air, and to minimize distension of the colon,
in the event that we need to convert to a laparoscopic
procedure. Colonic perforations that are 3cm x 3cm following a benign excision can be closed using endoclips,
which is possible in view of the prepped colon, with
immediate identification of the perforation and with minimal contamination. Laparoscopic repair of an iatrogenic
colon perforation has been shown to be feasible with
decreased morbidity and shorter hospital stay compared
to the open approach.24 Delayed diagnosis is associated
with higher morbidity1 and can be dealt with by laparoscopy or with laparotomy.
To date, 3 cases have been reported in the literature with
successful outcomes for perforations of 3cm3,20 that have
been closed with endoclips. The case reported herein is
about the largest perforation managed following a leiomyoma excision from the colon.
Immediate identification of the perforation is critical to
using the endoscopic technique. Endoclip application can
be challenging, and the success rate can depend on the
colonoscopist, presence of fecal contamination, and the
size and site of the perforation. An experienced colonoscopist with vast experience in therapeutic procedures is
the most important factor for a successful outcome. Other
factors are clean bowel with minimal contamination, the
site of the perforation, and the availability of operating
room facility. While endoscopic removal of 1-cm to 2-cm
lesions has been reported, we believe this is the first
reported case of an endoscopically resected 3-cm leiomyoma leading to perforation that was successfully repaired
using endoclips. Immediate thorough evaluation of the
polypectomy site for both bleeding and perforation is a
good practice, particularly in high-risk cases and this
avoids delayed diagnosis. Serial clinical examination following the procedure is very important to help identify
any signs of sepsis. As endoscopic technology continues
to evolve, and its use increases, we believe this method
will become the standard of care.
References:
1. Iqbal CW, Cullinane DC, Schiller HJ, Sawyer MD, Zietlow SP,
Farley DR. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg. 2008;
143(7):701–707.
JSLS (2013)17:152–155
2. Kilic A, Kavic Stephen. Laparoscopic colotomy repair following colonoscopic polypectomy. JSLS. 2008;12(1):93–96.
3. Trecca A, Gaj F, Gagliardi G. Our experience with endoscopic repair of large colonoscopic perforations and review of
the literature. Tech Coloproctol. 2008;12:315–322.
4. Jovanovic I, Zimmermann L, Fry LC, Monkemuller K. Feasibility
of endoscopic closure of an iatrogenic colon perforation occurring
during colonoscopy. Gastrointest Endosc. 2011;73(3)550 –555.
5. Korman LY, Overholt BF, Box T, Winker CK. Perforation
during colonoscopy in endoscopic ambulatory surgical centers.
Gastrointest Endosc. 2003;58(4):554 –557.
6. Ahlawat S, Gupta N, Benjamin SB, Al-Kawas FH. Large
colorectal polyps: endoscopic management and rate of malignancy: does size matter? J Clin Gastroenterol. 2011;45:347–354.
7. Damore LJ 2nd, Rantis PC, Vernava AM 3rd, Longo WE.
Colonoscopic perforations. Etiology, diagnosis, and management. Dis Colon Rectum. 1996;39(11):1308 –1314.
8. Moussi A, Nouira R, Bourguiba B, Daldoul S, Zaouche A.
Rare cause of a lower gastrointestinal bleeding. Tunis Med.
2010;88(12):961–963.
9. Padberg BC, Emmermann A, Zornig C, Germer M, Schroder
S. Leiomyomatosis of the colon: Case report and literature review. Pathologe. 2007;28(2):161–165.
10. Agaimy A, Wunsch PH. True smooth muscle neoplasms of
the GIT: morphological spectrum and classification in a series of
85 cases from a single institute. Lagenbecks Arch Surg. 2007;
392(1):75– 81.
11. Repici A, Tricerri R. Endoscopic polypectomy: techniques,
complications and follow-up. Tech Coloproctol. 2004 Dec;8
Suppl 2:s283–290. Review.
12. Geraci G, Pisello F, Antonio S, Modica G, Sciumè C. Endoscopic resection of a large colonic lipoma: case report and review of
the literature. Case Rep Gastroenterol. 2010 Feb 3;4(1):6 –11.
13. Luigiano C, Ferra F, Ghersi S, et al. Endoclip–assisted resection of large pedunculated colorectal polyps: Technical aspects
and outcome. Dig Dis Sci. 2010 Jun;55(6)1726 –1731.
14. Jansen JB, Temmerman A, Tjhie-Wensing JW. Endoscopic
removal of a large colonic lipomas. Ned Tijdschr Geneeskd.
2010;154:A2215. Dutch.
15. Lohsiriwat V, Sujarittanakarn S, Akaraviputh T, Lertakyamanee N, Lohsiriwat D, Kachinthorn U. What are the risk factors of
colonoscopic perforation? BMC Gastroenterol. 2009;24:9:71.
16. Pèrez Roldán F, González Carro P, Legaz Huidobro ML et al.
Endoscopic resection of large colorectal polyps. Rev Esp Enferm
Dig. 2004;96:36 – 47.
17. Anderson ML, Pasha TM, Leighton JA. Endoscopic perforation of the colon: lessons from a 10-year study. Am J Gastroenterol. 2000;95(12):3418 –3422.
18. Lohsiriwat V. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010;
16(4):425– 430.
19. Bleier JI, Moon V, Feingold D, et al. Initial repair of iatrogenic colon perforation using laparoscopic methods. Surg Endosc. 2008;22:646 – 649.
20. Barbagallo F, Castello G, Latteri S, et al. Successful endoscopic repair of an unusual colonic perforation following
polypectomy using an endoclip device. World J Gastroenterol.
2007;13(20):2889 –2891.
21. Magdeburg R, Collet P, Post S, Kaehler G. Endoclipping of
iatrogenic colonic perforation to avoid surgery. Surg Endosc.
2008;22:1500 –1504.
22. Taku K, Sano Y, Fu KI, et al. Iatrogenic perforation associated with therapeutic colonoscopy: A multicenter study in Japan.
J Gastroenterol Hepatol. 2007;22:1409 –1414.
23. Kirschnaik A, Kratt T, Stüker D et al. A new endoscopic over
the scope clip system for the treatment of lesions and bleeding in
the GI tract: first clinical experiences. Gastrointest Endosc. 2007;
66(1):162–167.
24. Bleier JI, Moon V, Feingold D, et al. Initial repair of iatrogenic colon perforation using laparoscopic methods. Surg Endosc. 2008;22(3):646 – 649.
JSLS (2013)17:152–155
155
CASE REPORT
Robotic Repair of Uterine Dehiscence
Mauricio Francisco La Rosa, MD, Shirley McCarthy, MD, PhD, Christine Richter, MD,
Masoud Azodi, MD
ABSTRACT
INTRODUCTION
Background and Objectives: During the past few decades, there has been a significant increase in the number
of cesarean deliveries, and thus an increase in the number
of complications. A common complication of multiple
cesarean deliveries is symptomatic uterine scar dehiscence, for which there are no treatment guidelines available. We report a case of uterine scar dehiscence—the
repair of it by robotic surgery—and review the literature
on this defect.
During the last few decades, there has been a significant
increase in the number of cesarean deliveries, hence,
complications including uterine scar dehiscence, whose
incidence was previously rare but is now increasing.1
Case: The patient was a 39-year-old woman, gravida 4
para 2022, complaining of persistent vaginal spotting for
the prior 5 months with a history of a cesarean delivery 3
months before the onset of the symptoms.
Discussion: We report a case of a successful robotic
repair of a symptomatic cesarean scar defect.
Conclusion: We propose further studies that include
more patients so this technique may become the standard
for cesarean scar defect.
Key Words: Cesarean scar defect, Uterine dehiscence,
Robotic repair.
Lima, Peru (Dr. La Rosa).
Department of Radiology, Yale-New Haven Hospital, New Haven, CT, USA (Dr.
McCarthy).
Gynecologic Oncology Section, Department of Obstetrics Gynecology and Reproductive Science, Yale University School of Medicine, New Haven, CT, USA (Drs.
Richter, Azodi).
Address correspondence to: Masoud Azodi, MD, Department of Obstetrics Gynecology and Reproductive Science, Gynecological Oncology Section, Yale University School of Medicine, 333 Cedar St., FMB 332, New Haven, CT 06510, USA.
Telephone: (203) 785-4013, Fax: (203) 785-6782, E-mail: [email protected]
Robotic surgery is becoming the repair technique of choice
for some types of surgery such as myomectomy. Currently,
no guidelines are available for the treatment of symptomatic
uterine dehiscence at the cesarean scar. We report a case of
uterine scar dehiscence repair by robotic surgery, review the
literature, and suggest this entire technique as the possible
new gold standard for the repair of this defect.
CASE REPORT
A 39-year-old woman, gravida 4 para 2022, presented to the
gynecologic oncology clinic complaining of persistent vaginal
spotting for the prior 5 months. She had a cesarean delivery 3
months before the onset of symptoms. Three months before
her presentation, the patient resumed normal menses, which
was associated with persistent spotting. She denied abdominal
or vaginal pain, dyspareunia, fever, nausea, vomiting, or vaginal
discharge. During these months, she also complained of progressive fatigue and exercise-induced shortness of breath.
Her obstetric history was significant for 2 cesarean deliveries,
the first in 2006 and the last 3 months before the onset of her
symptoms. The indication for both surgeries was failure to
progress. During the last cesarean delivery, the obstetrician
reported that the subcutaneous tissue was very thin but densely
adherent to the fascia, with significant scarring. Also, the bladder
was densely adhered to the uterus. The uterine incision was
low transverse, just above the lower uterine segment. Uterine
closure was performed in 3 layers. The postoperative period
was uncomplicated. The patient had a laparoscopic ovarian
cystectomy in 2008. Her last Pap smear, 6 months earlier, had
normal findings.
Her past medical history was positive for iron deficiency
anemia and migraine headaches. She reported being allergic to nabumetone. She was taking 325 mg of ferrous
sulfate twice per day.
DOI: 10.4293/108680812X13517013317996
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
156
On physical examination, the patient had stable vital
signs. Her weight was 63.9 kg, height was 1.7 m, and body
JSLS (2013)17:156 –160
mass index was 22.1. The pelvic examination revealed
normal external female genitalia and some dark blood in
the vagina vault, but no visible cervical or vaginal lesions.
The uterus was mobile without any masses or nodularity.
As part of the patient’s work-up, a magnetic resonance imaging (MRI) scan and an ultrasonogram were obtained and
showed dehiscence at the lower uterine segment, with a
collection of blood in the area of the dehiscence and hematocolpos (Figure 1). These findings led to the diagnosis of
abnormal uterine bleeding secondary to uterine scar dehiscence. Treatment options with associated risks and benefits
were discussed with the patient, and she opted for a da
Vinci–assisted laparoscopic repair of the lesion.
After general anesthesia, the patient was placed in a low
lithotomy position, and an 8-mm skin incision was made in
the umbilical area. A pneumoperitoneum was created, and
three 5-mm incisions were made—2 pediatric da Vinci ports
and 1 assistant port were placed. The uterus was densely
adhered to the abdominal wall, so adhesiolysis was performed using sharp dissection and electrocautery. The bladder flap was developed using sharp dissection, mobilizing
the bladder from the lower uterine segment. The defect in
the lower uterine segment was identified. At this point, hysteroscopy was initiated, and the hysteroscopic view showed
an approximately 3-cm defect in the lower uterine segment
and a thin scarlike membrane covering it; however, during
the hysteroscopy, the laparoscopic view showed a bulging
lower uterine segment (Figure 2). The intrauterine cavity
appeared to be normal. A uterine incision was made using
electrocautery and the blood was removed. The edges of the
defect were freshened using unipolar electrocautery. The
uterus was closed using 0-Vicryl sutures in 2 layers. The
sutures were inspected hysteroscopically. After copious irrigation and evacuating the pneumoperitoneum, the trocars
were removed and the skin was closed using 4 – 0 Caprosyn
sutures. Blood loss was ⬍50 mL. The patient was discharged
home on postoperative day 1.
Three months later, she had her first follow-up examination and was asymptomatic. She had spotting for about 2
weeks after surgery but has since had no problems. Menses were adequate with no intermenstrual spotting.
DISCUSSION
Cesarean delivery is the most common obstetric surgery in
the United States, with an increasing incidence of up to
25% of all births.2,3
Figure 1. (A) A sagittal T2-weighted scan demonstrates a large
clot (arrow) at the level of the internal os. Note that no overlying
myometrium or fibrous stroma is seen. Dense adhesions involving the anterior uterine wall (arrowhead) attach to the abdominal wall on other images (not shown). (B) Fat-suppressed T1weighted scan demonstrates high signal at cesarean delivery scar
site consistent with hematoma (short arrow). Long arrows indicate blood in the endocervical canal and vagina.
A meta-analysis of birth after a previous cesarean delivery
found that the incidence of cesarean scar dehiscence, also
JSLS (2013)17:156 –160
157
Robotic Repair of Uterine Dehiscence, La Rosa MF et al.
Figure 2. (A and B) Hysteroscopic view of uterine scar dehiscence and (C) the suture post repair of the cesarean scar defect.
known as cesarean scar defect (CSD), was 1.9%.4 OfiliYebovi et al found uterine scars in 99.1% of patients with a
history of a cesarean delivery, but 19.4% had a defect in their
scars; 9.9% of the CSDs were severe, defined as the loss of
⬎50% of myometrial mantle at the scar level.1 Other studies
have reported rates of CSD between 0.6% and 3.8%.5,6
Cesarean scar dehiscence is typically defined as discontinuity of the myometrium at the site of a previous cesarean
delivery incision or as a subperitoneal separation of the
uterine scar in the lower uterine segment, with the chorioamniotic membrane visible through the peritoneum.3,4
Risk factors for CSD are a history of multiple prior cesarean deliveries, a retroflexed uterus, and the inability to
visualize the entire cesarean scars by ultrasonography.4
Uterine healing is a complex process that depends on several
biochemical variables, such as transforming growth factor–␤
family, tumor necrosis factor–␣, platelet-derived growth
factor, fibroblast growth factor, and vascular endothelial
growth factor. All of these factors control the production
of collagen in the healing area.7,8 Pollio et al9 reported
higher collagen content in the areas of CSD compared
with the well-healed cesarean scars. This finding was
attributed to lower-than-normal transforming growth factor–␤3 and connective tissue growth factor. These defects
showed increased expression of fibroblast growth factor,
vascular endothelial growth factor, platelet-derived growth
factor, and tumor necrosis factor–␣.9
One of the principal concerns with uterine dehiscences is
their possible association with uterine rupture. Several
studies have found that no relationship exists between
these 2 variables. However, one study reported a positive
association between uterine dehiscence and uterine rupture, but it was not statistically significant, probably because of the low power of the study, given the rareness of
the condition.10 Thus, there is no consensus about screening nonpregnant women for uterine scar defects.
The width and depth of the defect is proportional to the
number of previous cesarean deliveries. The width is also
158
greater in patients who have a retroflexed uterus, maybe
a result of the reduced vascular perfusion. The width of
the defect is greater in patients who present with vaginal
spotting, dyspareunia, and chronic pelvic pain.6
Cesarean scar dehiscence is asymptomatic in most patients
but can cause symptoms, such as dysmenorrhea11 and intermenstrual bleeding.12,13 In a 3-year study,14 Wang et al found
that among the 293 patients diagnosed with CSD by transvaginal sonography, the most common symptom was intermenstrual spotting (64%), followed by dysmenorrhea (53%),
chronic pelvic pain (40%), and dyspareunia (18%).
Some mechanisms that could explain these symptoms have
been proposed; for example, vaginal bleeding could be the
result of the presence of congested endometrial folds (61%
of the cases) or the presence of a polyp in the scar recess
(16% of the cases). A lack of coordinated muscular contractions around the CSD can also contribute to the collection of
debris and therefore cause intermenstrual spotting. Chronic
pelvic pain and dyspareunia can be caused by a lymphocytic
infiltration (65% of the cases) or a distortion of the lower
uterine segment (75%). Finally, the presence of dysmenorrhea in these patients could be produced by iatrogenic adenomyosis.1
In addition, the cesarean scar dehiscence can also be the site
of implantation in an ectopic pregnancy,15 increasing the
prevalence of this disease during the last decade of life.16,17
In an ultrasonography study,18 it was reported that the risk
of a defective scar is directly related to the degree of
thinning of the lower uterine segment at 37 weeks of
pregnancy. The sensitivity and negative predictive value
of ultrasonography for the diagnosis of scar dehiscence in
pregnant patients was 88.9% and 96.2%, respectively. Retention of blood in the scar dehiscence was also found,
likely accounting for intermenstrual spotting.
MRI has been shown to be the most definitive modality to
evaluate uterine incision healing after cesarean deliveries.19,20 It has the advantage of superior contrast resolution, enabling detailed visualization of tissue planes. Fur-
JSLS (2013)17:156 –160
thermore, MRI is not impeded by body habitus or bowel
gas. The size of the defect can be better estimated by using
MRI. In a case of posterior wall dehiscence from laparoscopic myomectomy, MRI was able to clearly depict the
defect, whereas the initial ultrasonographic evaluation did
not.21 Hemorrhage or hematomas have a characteristic
signal on MRI and therefore can be readily distinguished
from other fluid collections or masses. One study suggested that the presence of a bladder flap hematoma ⬎5
cm should prompt a careful search for dehiscence.22
In expectant management of uterine dehiscence during
pregnancy, MRI can be used to confirm the diagnosis, and
then the lesion can be followed by ultrasonography if it is
adequately visualized by the latter modality.23
There are no guidelines for the treatment of intermenstrual bleeding caused by CSD. Nevertheless, multiple
techniques had been proposed for the repair of uterine
scar dehiscence—for example, hysteroscopic resection of
the fibrotic tissue5 or the technique proposed by Donnez
et al,24 who reported 3 cases of satisfactory laparoscopic
repair of uterine scar dehiscence.
Regarding the type of suture used, Greenberg et al25
conducted a small pilot study in ewes and concluded that
the absorbable knotless barbed suture was equivalent to
knotted smooth sutures for closing of the uterus.19
CONCLUSION
To our knowledge, this is the first reported case of a CSD
repair using a pediatric robot that uses 5-mm trocars. The
surgical result was excellent. Postoperatively, the patient’s
symptoms resolved and she is asymptomatic. This technique
has been used for treatment of several other diseases, but
never previously for CSD. We believe that this technique can
become, after further studies, the gold standard surgery for
this specific defect.
4. Blanco JD, Collins M. Willis D, Prien S. Prostaglandin E2 gel
induction of patients with a prior low transverse cesarean section.
Am J Perinatal. 1992;9:80 – 83.
5. Bromley B, Pitcher BL, Klapholz H, Lichter E, Benacerraf BR.
Sonographic appearance of uterine scar dehiscence. Int J Gynaecol
Obstet. 1995;51:S3–S6.
6. Tahara M, Shimizu T, Shimoura H. Preliminary report of treatment
with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar. Fertil Steril. 2006;86:477–479.
7. Werner S, Grose R. Regulation of wound healing by growth
factors and cytokines. Physiol Rev. 2003;83:835– 870.
8. Singer AJ, Clark RAF. Cutaneous wound healing. N Engl J Med.
1999;341:738 –746.
9. Pollio F, Staibano S, Mascolo M, et al. Uterine dehiscence in
term pregnant patients with one previous cesarean delivery:
Growth factor immunoexpression and collagen content in the
scarred lower uterine segment. Am J Obstet Gynecol. 2006;194:
527–534.
10. Vikhareva O, Valentin L. Clinical importance of appearance of
Cesarean hysterotomy scar at transvaginal ultrasonography in nonpregnant women. Obstet Gynecol. 2011;117:525–532.
11. Morris H. Surgical pathology of the lower uterine segment
cesarean section scar: is the scar a source of clinical symptoms? Int
J Gynecol Pathol. 1995;14(1):16 –20.
12. Thurmond AS, Harvey WJ, Smith SA. Cesarean section scar as
a cause of abnormal vaginal bleeding: diagnosis by sonohysterography. J Ultrasound Med. 1999;18:13–16.
13. Fabres C, Arriagada P, Fernandez C, Mackenna A, Zegers F,
Fernandez E. Surgical treatment and follow-up of women with
intermenstrual bleeding due to cesarean section scar defect. J
Minim Invasive Gynecol. 2005;12(1):25–28.
14. Wang CB, Chiu WW, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean scar defect: correlation between Cesarean section number,
defect size, clinical symptoms and uterine position. Ultrasound
Obstet Gynecol. 2009;34(1):85– 89.
References:
15. Ito M, Nawa T, Mikamo H, Tamaya T. Lower segment uterine
rupture related to early pregnancy by in vitro fertilization and
embryo transfer after previous cesarean delivery. J Med. 29(1–2):
85–91, 1998.
1. Ofili-Yebovi D, Ben Nagi J, Sawyer E, et al. Deficient lowsegment cesarean section scars: prevalence and risk factors. Ultrasound Obstet Gynecol. 2008;31:72–77.
16. Wang CB, Tseng CJ. Primary evacuation therapy for Cesarean
scar pregnancy: three new cases and review. Ultrasound Obstet
Gynecol. 2006;27:222–226.
2. Seffah JD. Re-laparotomy after cesarean section. Int J Gynaecol
Obstet. 2005;88:25:3–7.
17. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies. Obstet Gynecol. 2006;170(6):1373–1381.
3. Betrán AP, Merialdi M, Lauer JA, et al. Rates of caesarean
section: analysis of global, regional and national estimates. Paediatr
Perinat Epidemiol. 2007;21:98 –113.
18. Rozenberg P, Goffinet F, Philippe HF, Nisand I. Ultrasonographic measurement of lower uterine segment to assess risk of
defects of scarred uterus. Lancet. 1996;347(8997):281–284.
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19. Woo GM, Twickler DM, Stettler RW, Erdman WA, Brown CEL.
The pelvis after cesarean section and vaginal delivery: normal MR
findings. AJR Am J Roentgenol. 1993;161(6):1249 –1252.
20. Dicle O, Kucukler C, Pirnar T, Erata Y, Posaci C. Magnetic
resonance imaging evaluation of incision healing after cesarean
sections. Eur Radiol. 1997;7(1):31–34.
21. Humar BD, Levine D, Katz NL, Lim KH. Expectant management of uterine dehiscence in the second trimester of pregnancy.
Obstet Gynecol. 2003;102(5 Pt 2):1139 –1142.
22. Hasbargen U, Summerer-Moustaki M, Hillemanns P, Scheidler J,
Kimmig R, Hepp H. Uterine dehiscence in a nullipara, diagnosed by
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MRI, following use of unipolar electrocautery during laparoscopic
myomectomy: case report. Hum Reprod. 2002;17:2180–2182.
23. Maldjian C, Adam R, Maldjian J, Smith R. MRI appearance of the
pelvis in the post cesarean-section patient. Magn Reson Imaging.
1999;17:223–227.
24. Steenfos HH. Growth factors and wound healing. Scand J Plast
Reconstr Surg Hand Surg. 1994;28:95–105.
25. Greenberg JA, Walden S, Hammer CM, Grazul-Balska AT, Vonnahme KA. A comparison of barbed and smooth sutures for ovine
cesarean delivery. Int J Gynecol Obstet. 2011;113:215–217.
JSLS (2013)17:156 –160
CASE REPORT
Laparoscopic Removal of Abdominal Cerclage at 19
Weeks’ Gestation
James F. Carter, MD, Ashlyn Savage, MD, David E. Soper, MD
ABSTRACT
INTRODUCTION
We discuss laparoscopic removal of an abdominal cerclage in a 39-year-old woman, gravida 4, para 0, abortus 3,
who presented at 19 weeks’ gestation with ruptured membranes. This patient had a failed previous vaginal cerclage.
An abdominal cerclage was performed at the time of
abdominal myomectomy. A subsequent pregnancy was
diagnosed, with ruptured membranes at 19 weeks’ gestation, and the patient opted for pregnancy termination.
After laparoscopic removal of the cerclage, cervical laminaria were placed, and the patient underwent an uncomplicated dilation and curettage procedure the following
day.
Abdominal cerclage was originally described by Benson and
Durfee1 in 1965. Most patients who have had recurrent second trimester pregnancy loss as a result of an incompetent
cervix, now termed cervical insufficiency, can be treated
successfully with a transvaginal cerclage. A select group of
patients who have recurrent pregnancy loss despite a transvaginal cerclage or who have an anatomically physically
disabled cervix, making vaginal cerclage placement impossible, may benefit from the transabdominal approach.2– 4
Key Words: Laparoscopic, Abdominal, Cerclage, Pregnancy, Intrauterine.
In the past, the major disadvantage of the transabdominal approach has been the necessity of 2 laparotomies: one associated
with placement of the cerclage and the other with cesarean
delivery.5 We recently reported our series of successful abdominal cerclage procedures performed laparoscopically.6
Some disorders of pregnancy in the second trimester, before
fetal viability, warrant delivery. Previously, these women
required either a laparotomy to remove the cerclage to allow
vaginal delivery or a hysterotomy for delivery while leaving
the cerclage in situ. We describe a successful laparoscopic
removal of an abdominal cerclage in a patient with ruptured
membranes at 19 weeks’ gestation. To date, removing a
cerclage suture laparoscopically at this gestational age has
been accomplished only one previous time.7
CASE REPORT
Department of Obstetrics and Gynecology, Medical University of South Carolina,
Charleston, SC, USA (all authors).
Address correspondence to: James F. Carter, MD, MUSC, Ob/Gyn, 96 Jonathan
Lucas Street, Suite 634, Charleston, SC, 29425, USA. Telephone: (843) 792-4500, Fax
(843) 792-0053, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317194
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
The patient was a 39-year-old woman, gravida 4, para 0,
abortus 3, who presented at 19 weeks’ gestation with spontaneous ruptured membranes. She had a poor pregnancy
history, including a spontaneous miscarriage at 8 weeks with
her first pregnancy and a loss at 16 weeks in her second
pregnancy that was attributed to cervical insufficiency. In her
third pregnancy, despite a prophylactic McDonald cerclage
that was placed early in pregnancy, she had another loss at
16 weeks.
The decision was made to place an abdominal cerclage
before another pregnancy. The patient was noted to have
multiple uterine fibroids, including one 3 ⫻ 3– cm fibroid at
the cervical isthmus. At the time of laparotomy, a myomectomy was performed to remove the 2 fibroids, and the abdominal cerclage was placed using a 5-mm Mersilene band.
JSLS (2013)17:161–163
161
Laparoscopic Removal of Abdominal Cerclage at 19 Weeks’ Gestation, Carter JF et al.
The patient conceived within 3 months of her cerclage
placement and had an uneventful early pregnancy. Obstetric ultrasonongraphy at 17 weeks revealed a cervical
length of 47 mm and no funneling. At 19 weeks, spontaneous ruptured membranes were confirmed. She was
counseled about the options of pregnancy termination
versus expectant management. She elected pregnancy termination and preferred dilatation and curettage over induction of labor. To achieve adequate cervical dilation,
removal of the abdominal cerclage was necessary. We
scheduled the patient for a laparoscopic removal of the
cerclage to be followed by placement of a cervical laminaria and a dilation and curettage procedure the following
day after sufficient time had elapsed for the laminaria to
affect cervical dilation.
Figure 1. Dense adhesions in deep pelvis.
Operative Procedure
While under general anesthesia, the patient was placed in
a lithotomy position. The patient’s uterus was 1 cm below
the umbilicus. A 10-mm incision was made vertically in
the navel, and a Hasson trocar was placed through the
umbilicus under direct visualization. We placed two 5-mm
trocars bilaterally, slightly above the level of the umbilical
incision, and a single accessory port was placed suprapubically. Initial survey of the abdomen revealed moderate
adhesions, which were lysed (Figure 1). A 5-mm, 3-blade
laparoscopic fan was instrumental for retraction and manipulation of both the bowel and the uterus because this
uterus was soft as would be expected in a 19-week gravid
uterus. The entire pelvis was filled with the gravid uterus,
and we needed all of the ports. The port positions were
instrumental in finding the proper angle to dissect and
locate the previously placed abdominal cerclage.
After displacement of the uterus to the right and somewhat posteriorly and advancing the laparoscope anterior
to the uterine fundus, we identified the vesicouterine
reflection at the level of the internal cervical os. It required
careful dissection with laparoscopic scissors and Maryland
forceps along the left lateral vesicouterine reflection, undermining and lifting the bladder off of this portion of the
lower uterine segment. Proceeding posteriorly was not an
option because of the size of the uterus. This dissection
uncovered the Mersilene knot that was positioned just
anterolateral to the left uterine artery. We mention this to
emphasize that at this gestation age, the lower uterine
segment is soft and difficult to manage without incising
into either the bladder or the uterine artery laterally. The
knot was then grasped with a blunt grasper to elevate the
suture. Laparoscopic scissors were gently placed under the
single strand of the suture and the suture was transected.
162
Figure 2. Uterus at 19⫹ weeks (our patient).
We removed the suture and knot. Blood loss was minimal
and we ended her surgery. We then placed 10 laminaria in
her cervix in preparation for her dilation and curettage procedure that was scheduled for the following day.
DISCUSSION
We have previously published a case report11 of a successful laparoscopic removal of an abdominal cerclage in
a 17-week-gestation pregnancy. We reconfirm in this case
report that in an even larger uterus at 19 weeks, an
operative laparoscopy is a viable alternative for removing
a cerclage previously placed by laparotomy.
An important technical aspect of the case was placement
of the trocars.10,11 We placed the lateral trocars at least as
high as the navel incision (Figures 2, 3, and 4). This
allowed us to achieve the proper angle to address the
JSLS (2013)17:161–163
rior area between the uterosacral ligaments. We mention
this because at the time of this surgery (10/27/2010), we
were reporting the second case of removal of an abdominal cerclage as far as 19 weeks’ gestation.7 This dissection
was difficult to perform, and we would not recommend
the posterior approach at 19 weeks’ gestation.
CONCLUSION
An abdominal cerclage can be removed laparoscopically
in the second trimester of pregnancy. At 19 weeks’ gestation, this surgery requires a clear operative strategy and
superior laparoscopic skills.
References:
Figure 3. Example of uterus at 16 weeks.
1. Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for treatment of cervical incompetency.
Obstet Gynecol. 1965;25:145–155.
2. Novy MJ. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. Am J Obstet Gynecol.
1991;164:1635–1642.
3. Cammarano CL, Herron MA, Parer JT. Validity of indications
for transabdominal cerclage for cervical incompetence. Am J
Obstet Gynecol. 1995;172:1871–1875.
4. Leiman G, Harrison NA, Rubin A. Pregnancy following
conization of the cervix. Complications related to cone size. Am J
Obstet Gynecol. 1980;136:14 –18.
5. Lesser KB, Childers JM, Surwit EA. Transabdominal cerclage:
a laparoscopic approach. Obstet Gynecol. 1998;91:855– 856.
6. Carter J, Soper D, Goetzl L, Van Dorsten J. Abdominal cerclage
for the treatment of recurrent cervical insufficiency: laparoscopy or
laparotomy? Am J Obstet Gynecol. 2009;201:111.e1– e4.
Figure 4. Example of uterus at 20 weeks.
depth and width of the larger uterus, which can block the
visualization of the camera and trocars when they are
placed through an infraumbilical port. In this case, we
were able to displace the uterus posteriorly and lateral
enough to develop a bladder flap, accessing the space of
Retzius to ensure we had palpated and located the area of
the suture and the knot. We were able to grasp the knot
and elevate and transect the suture while firmly holding
the knot. We then removed the entire knot and suture
with good hemostasis. The lateral ports had been placed
at a level slightly higher than the umbilicus under direct
visualization to gain access to the cervical isthmus and
bladder flap. In an earlier article,12 in a pregnancy at 17
weeks, a posterior approach was discussed. In this case, at
19 weeks’ gestation, the uterus was too large to displace
anteriorly or laterally enough to gain access to the poste-
7. Agdi M, Tulandi. Placement and removal of abdominal cerclage
by laparoscopy. Reprod Biomed Online. 2008 Feb;16(2):308–310.
8. Scarantino SE, Reilly JG, Moretti ML, Pillari VT. Laparoscopic
removal of a transabdominal cervical cerclage. Am J Obstet
Gynecol. 2000 May;182(5):1086 –1088.
9. McComiskey M, Dornan JC, Hunter D. Removal of transabdominal cerclage. Ulster Med J. 2006;75(3):228.
10. Carter JF, Soper DE. Laparoscopy in pregnancy. JSLS. 2004;
8:57– 60.
11. Carter JF, Soper DE. Laparoscopic abdominal cerclage: a
case report. JSLS. 2005;9:491– 493.
12. Carter JF, Soper DE. Laparoscopic removal of abdominal
cerclage: a case report. JSLS. 2007;11(3):375–377.
JSLS (2013)17:161–163
163
CASE REPORT
Single-Incision Laparoscopic Adnexectomy in an
Obese Patient with Previous Laparotomies
Francesco Sesti, MD, Claudio Boccia, MD, Giuseppe Sorrenti, MD, Alberto Baffa, MD,
Emilio Piccione, MD
ABSTRACT
INTRODUCTION
Introduction: No case of single-incision laparoscopic
surgery in obese patients who had previously undergone
multiple midline vertical laparotomies has been described
in the literature to date. Hence we report the first case of
single-port laparoscopic salpingo-oophorectomy in an
obese patient who was affected by a left adnexal mass and
who had previously undergone 3 midline vertical laparotomies.
Laparoscopic surgery with a single access site, known as
single-incision laparoscopic surgery (SILS), laparoendoscopic single-site surgery, or single-port access surgery,
represents a new frontier of minimally invasive surgery. Its
feasibility in gynecologic surgery has been shown by
various authors who performed salpingo-oophorectomies, uterine myomectomies, hysterectomies, and more
recently, radical surgeries with pelvic lymphadenectomy.1–3 Interest in this technique is based on its many
benefits over traditional laparoscopy, such as decreased
operative time, reduced incidence of intraoperative complications, improvement of cosmetics results, and shorter
length of hospital stay.2– 4
Case Description: A postmenopausal 57-year-old woman
with a body mass index of 31.2 kg/m2 and a history of 3
midline vertical cesarean deliveries and a right salpingooophorectomy was diagnosed with a left adnexal mass and
underwent a single-incision laparoscopic salpingo-oophorectomy.
Discussion: The patient was treated successfully. The
operative blood loss was minimal. The postoperative hospital stay lasted 18 hours, and postoperative pain was
short-lasting. No early or long-term postoperative complications were registered. On histopathologic examination,
a diagnosis of ovarian serous cystadenoma was made.
Even though this unique case is the first to be reported in
the literature, its encouraging results suggest the use of
this new surgical technique in similar clinical situations to
verify whether the feasibility and safety reported in this
article are confirmed.
Key Words: Single-incision laparoscopic surgery, Salpingo-oophorectomy, Benign adnexal mass, Midline vertical
laparotomies, Obesity.
In defining the inclusion and exclusion criteria for SILS in
patients, several authors considered obesity, previous abdominal surgeries, and early-stage gynecologic cancer as
relative contraindications to this surgical approach
whereas patients who had previously undergone ⬎2 midline vertical laparotomies or panniculectomies, who did
not possess a native umbilicus, or who had a diagnosis of
advanced malignancy were judged unsuitable candidates
for SILS.3,5,6
To our knowledge, no case of SILS in obese patients who
had previously undergone multiple midline vertical laparotomies has been described in the literature. Hence we
report the first case of single-port laparoscopic salpingooophorectomy in an obese patient who was affected by a
left adnexal mass and who had been previously undergone 3 midline vertical laparotomies.
CASE REPORT
Section of Gynecology and Obstetrics, Department of Biomedicine & Prevention,
Tor Vergata University Hospital, Rome, Italy (all authors).
Address correspondence to: Francesco Sesti, MD, School of Medicine, Department
of Biomedicine & Prevention, Tor Vergata University Hospital, Viale Oxford,
81– 00133, Rome, Italy. Telephone: ⫹39 06 20 902 921, Fax: ⫹39 06 20 902 924
E-mail: [email protected]
DOI: 10.4293/108680812X13517013317158
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
164
A postmenopausal 57-year-old woman, gravida III, para
III, with a body mass index of 31.2 kg/m2 presented to our
institution with a diagnosis of left adnexal mass. In 2004
she had undergone a right quadrantectomy for breast
cancer that, at present, was in remission. The patient
reported 3 previous cesarean deliveries performed
through midline vertical umbilical-pubic incisions. During
the last cesarean delivery, she had also undergone right
salpingo-oophorectomy because of a benign ovarian cyst.
Transabdominal and transvaginal ultrasonography showed a
JSLS (2013)17:164 –166
34 ⫻ 27 ⫻ 23–mm left ovarian cyst with no peripheral
vascularity, no septa, and no echogenic signs. Ovarian markers were negative.
RESULTS
The patient received general anesthesia and was placed in
a dorsal lithotomic position. After the uterine manipulator
was inserted, a 2.5-cm intraumbilical vertical incision was
carried out, in part, overlying the old scar. After an open
laparoscopy was performed, a SILS multiple-instrument
access port device was inserted (Covidien, Mansfield, MA)
and pneumoperitoneum was established. We used two
5-mm cannulas for introducing the laparoscopic instruments (Johann forceps [Karl Storz, Tuttlingen, Germany]
and 5-mm LigaSure Advance [Covidien]) and a 12-mm
cannula for insertion of a 5.5-mm-diameter, 30°, 50-cmlong rigid laparoscope (Storz Hopkins II; Karl Storz). After
the entire abdominal cavity had been observed, which
appeared normal except for a few tenuous peritoneal
adhesions, we visualized the left adnexa that appeared to
be of increased size because of the presence of an ovarian
cyst with a smooth and even wall (Figure 1). We carried
out left salpingo-oophorectomy using a 5-mm LigaSure
Advance device (Figure 2). The whole specimen was
extracted through the umbilicus by use of an Endobag
(Covidien) after partial withdrawal of the port device
(Figure 3). The operative time, from the incision of the
skin to its complete closure, was 30 minutes (Figure 4).
No intraoperative or postoperative complications were
observed, and blood loss was minimal. Postoperative pain
was assessed at 20 minutes and at 2, 4, and 8 hours by a
visual analog scale represented by a line 10 cm long,
ranging from 0 (no pain) to 100 (pain as bad as it could
be). The score ranged between 6 (20 minutes after surgery) and 0 (8 hours after surgery). The postoperative
hospital stay was 18 hours. On histopathologic examination, a diagnosis of ovarian serous cystadenoma was
Figure 2. Image after salpingo-oophorectomy was performed
with 5-mm LigaSure Advance.
Figure 3. Specimen including left ovarian cyst and tube.
Figure 4. Incision site at end of skin closure.
made. At 3 months after surgery, the scar healing was optimal and no incisional hernia was observed (Figure 5). We
acquired institutional review board approval from the local
ethics committee and written informed consent from the
patient before reporting this case.
DISCUSSION
Figure 1. Left ovarian cyst with smooth and even wall.
SILS is a novel technique that has become progressively
more accepted and applied as data supporting its safety and
JSLS (2013)17:164 –166
165
Single-Incision Laparoscopic Adnexectomy in an Obese Patient with Previous Laparotomies, Sesti F et al.
that this technique was carried out rapidly and without
any intraoperative and postoperative complications in
an obese woman who had previously undergone ⬎2
midline vertical laparotomies. Even though this unique
case is the first to be reported in the literature, its
encouraging results suggest the use of this new surgical
technique in similar clinical situations to verify whether
the feasibility and safety reported in this article are
confirmed.
References:
1. Fader AN, Escobar PF. Laparoendoscopic single-site surgery
(LESS) in gynecologic oncology: technique and initial report.
Gynecol Oncol. 2009;114:157–161.
Figure 5. Incision site at 3 months after surgery.
enhancements in use have accumulated. A few authors emphasize the advantages of this approach over traditional
laparoscopy, such as improved cosmetic results, decreased
operative time, and reduced postoperative pain.7–9 This case
confirms those favorable results. Indeed, postoperative pain
analysis shows that at 8 hours after surgery, the patient
reported no pain. Probably the minor invasiveness of this
approach causes less and rapidly decreasing pain, allowing a
faster recovery time and, consequently, a shorter hospitalization. Unlike the conventional laparoscopy, another advantage is the possibility of extracting the whole adnexal
specimen into a 12-mm Endobag through the unique umbilical incision after partial withdrawal of the port device. This
is of great importance especially in cases of suspected adnexal masses because a whole specimen facilitates the histopathologic diagnosis.
However, no case of SILS in an obese patient who had
previously undergone multiple midline vertical laparotomies
has been described in the literature. Fader et al.6 advised
against executing the SILS technique in women with ⬎2
previous midline vertical laparotomies and suggested that
patient selection should initially be geared toward simple
cases because learning these ergonomically challenging
techniques may be less technically demanding in these
cases. Moreover, a body mass index ⬎30 kg/m2 was considered an absolute contraindication to SILS.8
CONCLUSION
2. Uppal S, Frumovitz M, Escobar P, Ramirez PT. Laparoendoscopic single-site surgery in gynecology: review of literature and
available technology. J Minim Invasive Gynecol. 2011;18:12–23.
3. Fader AN, Rojas-Espaillat L, Ibeanu O, Grumbine FC, Escobar PF. Laparoendoscopic single-site surgery (LESS) in gynecology: a multi-institutional evaluation. Am J Obstet Gynecol. 2010;
203:501.e1–501.e6.
4. Fader AN, Cohen S, Escobar PF, Gunderson C. Laparoendoscopic single-site surgery in gynecology. Curr Opin Obstet Gynecol. 2010;22:331–338.
5. Fagotti A, Fanfani F, Rossitto C, et al. Laparoendoscopic
single-site surgery for the treatment of benign adnexal disease: a
prospective trial. Diagn Ther Endosc. 2010;2010:108258.
6. Fader AN, Levinson KL, Gunderson CC, Winder AD, Escobar
PF. Laparoendoscopic single-site surgery in gynaecology: a new
frontier in minimally invasive surgery. J Minim Access Surg.
2011;7:71–77.
7. Yim GW, Jung YW, Paek J, et al. Transumbilical single-port
access versus conventional total laparoscopic hysterectomy: surgical outcomes. Am J Obstet Gynecol. 2010;203:26.e1–26.e6.
8. Escobar PF, Bedaiwy MA, Fader AN, Falcone T. Laparoendoscopic single-site (LESS) surgery in patients with benign adnexal disease. Fertil Steril. 2010;93:2074.e7–2074.e10.
9. Fagotti A, Fanfani F, Marocco F, et al. Laparoendoscopic
single-site surgery for the treatment of benign adnexal diseases:
a pilot study. Surg Endosc. 2011;25:1215–1221.
The present case, which was performed by surgeons
who had little experience with this procedure, shows
166
JSLS (2013)17:164 –166
CASE REPORT
Small Bowel Injury During Laparoendoscopic
Single-Site Surgery for Simple Nephrectomy
Shreyas S. Joshi, MD, Chandru P. Sundaram, MD
ABSTRACT
INTRODUCTION
Background and Objectives: A 71-year-old man underwent a right simple nephrectomy via the laparoendoscopic single-site surgery (LESS) approach for intractable
right flank pain and gross hematuria. A postoperative
diagnosis of duodenal injury was suspected by physical
findings and confirmed by computed tomography imaging.
The use of laparoscopic nephrectomy has blossomed
since its initial description by Clayman et al.1 Many advances have made this procedure one of the standards of
urologic surgery. Substantial gains have been made in
lowering morbidity rates and convalescence time while
improving the cosmetic results of these surgeries. In particular, the creation of laparoendoscopic single-site surgery (LESS) has made real the possibility of safe scarless
umbilical nephrectomy.2,3 Although much research has
been done to elucidate the complication rates of regular
and hand-assisted laparoscopic renal surgery,4 the newer
single-port approach still requires more clinical data to
address efficacy and complication rates. We report the
successful completion of a single-port laparoscopic right
nephrectomy that was complicated by a duodenal perforation diagnosed postoperatively.
Methods: Emergency exploratory laparotomy revealed a
⬍5-mm full-thickness perforation of the duodenum and
an accompanying 1-cm seromuscular injury.
Results: The subsequent postoperative course was unremarkable except for a right intraabdominal seroma that
resolved without intervention.
Conclusion: LESS nephrectomy is an effective surgical
approach, but more data are needed regarding its surgical
outcomes and complications. This case shows that the
LESS approach is not without the risk of life-threatening
complications, and it must be performed by experienced
surgeons in select patients who are notably interested in
improved cosmesis, after an informed consent that includes the potential for complications.
Key Words: Laparoscopy, Nephrectomy, Single-incision
surgery, Intraoperative complications.
Department of Urology, Indiana University School of Medicine, Indianapolis, IN,
USA (all authors).
Address correspondence to: Chandru P. Sundaram, MD, Department of Urology,
Indiana University School of Medicine, Indiana Cancer Pavilion, 535 N. Barnhill Dr.,
Suite 420, Indianapolis, IN 46202, USA. Telephone: (317) 278-3098, Fax: (317)
274-0174, E-mail: [email protected]
DOI: 10.4293/108680812X13517013317112
© 2013 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
CASE REPORT
A 71-year-old white man was observed for several months
by urology staff for severe right-sided flank pain and gross
hematuria with no definitive diagnosis aside from confirmation of a gross hematuria at the right ureteral orifice.
Ureteroscopic examination revealed severe inflammation
of the pelvicaliceal urothelium without any evidence of
malignancy. After conservative management failed, the
patient was scheduled for a laparoscopic right nephrectomy via the LESS approach.
The patient was placed in the left lateral position. A 2-cm
periumbilical vertical incision was made, in which a Triport (R-Port, Advanced Surgical Concepts, Dublin, UK)
single-port trocar was inserted, as has been previously
described.5 We performed the remainder of the operation
using a flexible tip Olympus 5-mm laparoscope (Olympus, Center Valley, PA), a Cambridge Endo-hook electrode (Cambridge Endoscopic Devices, Framingham,
MA), surgical scissors (United States Surgical, Norwalk,
CT), an Endo-GIA stapler (United States Surgical), and a
Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati,
OH). No trocar except for the single-port trocar was used.
Two renal arteries were identified posterior and inferior to
the renal veins. Both renal arteries were controlled with
JSLS (2013)17:167–169
167
Small Bowel Injury During Laparoendoscopic Single-Site Surgery for Simple Nephrectomy, Joshi SS et al.
Hem-o-lok polymer clips (Weck-Teleflex, Research Triangle Park, NC).
One of the 12-mm port openings was cut open, and a
15-mm EndoCatch retrieval bag (Auto Suture, Norwalk,
CT) was inserted through this incision. The entrapment of
the mobilized kidney was difficult because of leakage of
pneumoperitoneum through the trocar site. A fresh R-port
device was placed through this incision, and the laparoscope was reinserted to confirm that there was no bleeding and no visible bowel injury. The R-port was removed
and the incision was closed.
The patient was stable until 10:00 PM on the same day of
surgery, when a sudden onset of severe abdominal pain
developed. The patient was treated with intravenous morphine and observed overnight. Physical examination at
7:00 AM on the following day revealed significant abdominal guarding and rebound tenderness. Computed tomography (CT) of the abdomen and pelvis with oral diatrizoic
acid suggested a duodenal injury and spillage of oral
contrast into the renal fossa (Figure 1).
An emergency exploratory laparotomy revealed a ⬍5-mm
full-thickness perforation of the duodenum and an accompanying 1-cm seromuscular injury. A primary 2-layered repair of the injury and peritoneal lavage with normal saline
solution were performed by the general surgeons. The patient was discharged home on postoperative day 12.
At the 2-month follow-up, the patient was noted to be
recovering well but admitted to some right flank discomfort and was subsequently found to have an intraabdominal seroma after CT imaging. The seroma was conservatively observed without intervention and it resolved
completely by the 4-month follow-up visit.
DISCUSSION
Laparoscopic nephrectomy provides a profound step forward in reducing patient morbidity associated with surgery when compared with the open approach. As such,
research has been conducted to attempt to elucidate the
major complications associated with laparoscopic surgery.
A meta-analysis of laparoscopic renal surgery series studies between 1995 and 2004 was conducted by Pareek et
al,4 showing an overall major complication rate of 9.5%.
This included small bowel injury, which ranged between
0.5% and 2.3% of the overall complication rate, depending
on the laparoscopic approach that was used.
Bowel injury is a well-known potential complication of
intraperitoneal surgery. Laparoscopic bowel injury has
168
Figure 1. CT reveals spillage of enteric contrast material (white
arrows) into the right renal fossa, suggesting duodenal injury.
been characterized for more than a decade, beginning
with the seminal evaluation by Bishoff et al,6 who reported a laparoscopic bowel perforation rate of 0.2%,
more than half of which occurred in the small bowel. As
has been previously suggested for multiport laparoscopic
nephrectomy, inadvertent bowel injury during dissection
may be averted by the visualization of instruments at all
times and by paying particular attention to adjacent structures. It is further recommended that the surgeon remain
on the plane between Gerota’s fascia and the bowel mesentery, thus minimizing the risk of bowel injury.7
The presentation of bowel injury after laparoscopy differs
from those that present after laparotomy. These symptoms
are described as persistent pain at a single trocar site
without erythema or purulence, abdominal distention, diarrhea, and leukopenia. There is also a notable lack of
ileus, diffuse abdominal pain, nausea, and vomiting.6
The ability to provide a scar-free surgery with decreased
pain and postoperative morbidity was examined using the
LESS technique by Gill et al,2 who had an excellent surgical outcome in their initial cases. However, little is currently known about the likelihood of encountering various surgical complications as a result of single-port
surgery.
Apart from improved cosmesis with a single incision in the
umbilicus compared with multiple visible incisions during
conventional laparoscopy, there is little benefit for the
patient.8,9 The learning curve and limitations of LESS,
including the lack of triangulation of instruments, inadequate retraction and exposure, and instrument collision,
could result in inadvertent injury to neighboring struc-
JSLS (2013)17:167–169
tures, as demonstrated in the patient presented here. This
complication occurred after we had completed 7 LESS nephrectomies at our institution by a single surgeon who had
previously performed more than 1000 laparoscopic renal
surgeries. As more institutions and surgeons begin their experience with LESS nephrectomy, the risk of similar complications increases. The LESS nephrectomy is therefore not
without the risk of life-threatening complications and must
be performed only by highly experienced surgeons in carefully selected patients who are particularly interested in improved cosmesis, after an informed consent that includes the
potential for complications.
To our knowledge, this is the first published report of a major
bowel complication resulting from LESS nephrectomy. Further research and clinical experience will help elucidate the
balance between potential benefits and the potential for
major complications in single-port nephrectomy.
References:
1. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic
nephrectomy: initial case report. J Urol. 1991;146(2):278 –282.
2. Gill IS, Canes D, Aron M, et al. Single port transumbilical
(E-NOTES) donor nephrectomy. J Urol. 2008;180(2):637– 641,
discussion 641.
3. Raman JD, Bensalah K, Bagrodia A, Stern JM, Cadeddu JA.
Laboratory and clinical development of single keyhole umbilical
nephrectomy. Urology. 2007;70(6):1039 –1042.
4. Pareek G, Hedican SP, Gee JR, Bruskewitz RC, Nakada SY.
Meta-analysis of the complications of laparoscopic renal surgery:
comparison of procedures and techniques. J Urol. 2006;175(4):
1208 –1213.
5. Desai MM, Rao PP, Aron M, et al. Scarless single port transumbilical nephrectomy and pyeloplasty: first clinical report. BJU
Int. 2008;101(1):83– 88.
6. Bishoff JT, Allaf ME, Kirkels W, Moore RG, Kavoussi LR,
Schroder F. Laparoscopic bowel injury: incidence and clinical
presentation. J Urol. 1999;161(3):887– 890.
7. Siqueira TM Jr, Kuo RL, Gardner TA, et al. Major complications in 213 laparoscopic nephrectomy cases: the Indianapolis
experience. J Urol. 2002;168(4 Pt 1):1361–1365.
8. Raybourn JH 3rd, Rane A, Sundaram CP. Laparoendoscopic
single-site surgery for nephrectomy as a feasible alternative to
traditional laparoscopy. Urology. 2010;75:100 –103.
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