Abstract

Many techniques have been analysed to reduce the risk of perioperative anastomotic leakage and bleeding. No specific resection technique with either linear or circular stapling devices has been shown to be superior in preventing these complications. Reinforcement of staple lines with various buttressing materials is a new strategy used to diminish or eliminate anastomotic leaks and haemorrhage. In this chapter, varying reinforcement techniques with different materials are compared. The available literature has been reviewed thoroughly for relevant data regarding stapled reinforcement techniques and minimizing anastomotic leaks and haemorrhage. Reported data show non-absorbable, semi-absorbable, and bioabsorbablematerials available for gastrointestinal (GI) resections. Semi-absorbable xenomaterials (Bovine Pericardial Strips and Bovine Collagen Strips; Shellhigh No-Reaction Vascupatch, Milburn, NJ, USA), non-absorbable expanded polytetrafluoroethylene (ePTFE; W.L. Gore, Elkton, MD, USA) and absorbable poly (L-lactic acid-co-epsilon-caprolactomne) film are compared. Non-absorbable and semi-absorbable materials show many differences. Absorbable polymer membranes demonstrate marked benefits. Staple-line reinforcement used for laparoscopic GI surgery is a relatively new strategy, most probably improving perioperative outcome only if proper buttressing material is used. To decrease anastomotic complications, using an absorbable polymer membrane as staple-line reinforcement material is reliable and efficacious.

Abstract

Following tissue disruption, whether operative or traumatic, the priorities of any organism are cessation of hemorrhage, prevention of infection, and restoration of tissue integrity and function. Several hemostatic techniques achieve the goal of hemorrhage cessation. One evolving technique is the use of fibrin sealants (FSs) as a surgical tissue adhesive. The different and most common applications of fibrin glue in open and laparoscopic surgery are reviewed.

Abstract

The role of liver resection for benign and malignant hepatobiliary diseases is expanding because of the markedly reduced operative mortality in recent years, as the result of better patient selection, improved surgical techniques, and better perioperative management. The major technical challenge of liver resection is control of bleeding during transection of liver parenchyma. Ultrasonic dissector and clamp crushing are the two techniques used most frequently in liver transection. In recent years, new instruments have been developed for liver transection with an aim to reduce bleeding. Other important advances in liver surgery that have contributed to improved perioperative outcomes include intraoperative ultrasound (IOUS), use of vascular staplers, and reduced bleeding by the development of low central venous pressure anesthesia. Laparoscopy is useful for staging purposes, and laparoscopic liver resection is gaining popularity due to the availability of new laparoscopic instruments for liver transection. Development of local ablative therapies for liver tumors, such as radiofrequency (RF) ablation, is posing a competition to liver resection. However, such techniques also have allowed expansion of indication for hepatic resection to patients with bilobar tumors, and thermal ablative technologies have been used for liver transection. This chapter reviews the current techniques of liver resection.

Abstract

The prevalence of obesity in the United States (U.S.) is increasing to epidemic proportions. Currently, more than 60% of Americans and 51% of Germans are overweight. Whereas a variety of medications are available for treatment of obesity, none results in the long-term loss of more than 10% of body weight. The current standard for treatment of severe obesity, defined as a body mass index (BMI) of greater than 35 kg/m2 with comorbidities and generally greater than 40 kg/m2, is surgical. Several surgical procedures are currently available, including gastric bypass, biliopancreatic diversion (BPD) with duodenal switch, and the adjustable gastric band. These operations may be performed using laparoscopic surgical techniques to minimize perioperative morbidity and postoperative recovery time. To optimize the outcome of this type of procedure, bariatric surgery should be performed on carefully selected patients, in bariatric centers specially equipped to care for the obese, within a broadly based, multidisciplinary setting that provides lifelong postoperative care.

Abstract

Use of laparoscopic resection for colorectal malignancy has raised concerns regarding local cancer control and the lack of long-term results. Most reported data are preliminary and medium-term results, at best. The aim of this study is to analyse all patients who underwent a laparoscopic resection for colorectal cancer at our department between November 1992 and July 2003. The cohort comprised a total of 394 patients (194 rectal cancer and 200 colon carcinoma). The most common procedures were high and low anterior resection with total mesorectum excision (TME) (176), followed by sigmoidectomy (89), right hemicolectomy (57), and left hemicolectomy (42). Mean operating time was 176 minutes. Conversion was necessary in 4 of the patients. Mean number of lymph nodes removed was 27. The postoperative complication rate was 20.1% (rectum) and 12.5% (colon). One patient died of myocardial infarction. Mean follow up was 45 (0.3-135) months. Port site metastasis occurred in 2 patients. The local recurrence rate was 4.1% after curative rectum resection and 0.5% in the colon group. After curative resection, the overall 5-year survival rate was 76.9% (rectum), and 81.4% (colon). Cancer-related survival rate after 5 years was 87.7% (rectum), and 91.3% (colon). Our results demonstrate that laparoscopic resection for colorectal cancer is not associated with higher morbidity and mortality rates. Established oncological principles are respected and long-term results are at least as good as those after open surgery.

Abstract

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently the most common procedure performed for treatment of morbid obesity in the United States. The technique reported in this chapter requires mastering of extra-corporeal and intra-corporeal laparoscopic suturing, but is safe, cost effective, and technically feasible. Use of the straight needle eliminates the challenge of proper needle orientation encountered with a curved needle. The linear technique is used to construct the gastrojejunostomy because it is time saving and relatively simple. An endoscopic ruler and bougie are used to ensure a consistent pouch size and alimentary limb length. This chaper demonstrates the use of preoperative preparation, and a meticulous surgical technique using the linear stapler, to perform a combined total of more than 1800 cases.

Abstract

The SECCA (Curon Medical, Freemont, CA USA) device delivers temperature-controlled radiofrequency (RF) energy to the anorectal junction to treat fecal incontinence. The procedure is performed as an outpatient either in the endoscopy suite or ambulatory surgery center. After appropriate local block, the SECCA device is then inserted into the anal canal and submucosal RF energy is delivered circumferentially to the anorectal junction. A pilot trial in Mexico on 10 patients demonstrated a significant improvement in Cleveland Clinic Florida Fecal Incontinence Scores (CCF-FIS) from a pre-treatment score of 13.5 to 12-month post-treatment score of 3.8. These patients continued to have significantly improved continence with an average CCF-FIS of 7.3 at 24-month follow up. A multi-center, institutional review board-approved, open label, prospective trial that evaluates the efficacy and safety of the SECCA procedure has been completed in the United States (U.S.). Five centers prospectively enrolled 50 patients with greater than or equal to 3 months of weekly fecal incontinence who also had failed either medical or surgical interventions. Patients underwent anoscopy, anorectal manometry (ARM), endoanal ultrasound (EAUS), and pudendal nerve terminal motor latency (PNTML) at 0 and 6 months. The CCF-FIS scale, fecal incontinence-related quality of life score (FIQL), and SF-36 were administered at 0, 3, and 6 months. After conscious sedation and local perianal block, RF energy was delivered by way of the SECCA device. At 6 months, the mean CCF-FI score improved significantly (14.5 to 11.1, p < 0.0001). All FIQL parameters improved: lifestyle (2.5 to 3.1, p=0.0001), coping (1.9 to 2.3, p=0.005), depression (2.8 to 3.1, p=0.0008), embarrassment (1.9 to 2.5, p < 0.0001). Sixty-percent (n=30) of the patients improved after therapy, with 70% resolution of their symptoms. The SF-36 mental composite score (45.3 to 48.3, p=0.06) and social function sub-score (64.0 to 77.3, p=0.003) improved. No changes occurred in ARM, EAUS, or PNTML. Two major complications included two mucosal ulcerations. From these data, the authors concluded that RF energy delivered for treatment of FI safely improves CCF-FIS, FIQL, and quality of life.